Fertility assessment for patients with PCOS (Polycystic Ovary Syndrome)

I guess that they’re doing an ultrasound of your ovary or noticing maybe if you’re in menopause. Your FSH and LH levels are elevated, and we don’t see that with PCOS. I think what’s happening is a combination of things. There’s some diminished ovarian reserve, and that’s a fancy word for a reduction in the quality and quantity of the follicles you have remaining. If they are saying that you’re menopausal, that’s probably what’s happening. If you were diagnosed with PCOS using the criteria that we discussed, so it’s a true diagnosis, and they ruled out all the other conditions that can cause the same effects, then you have to assume is PCOS that you still have this propensity toward insulin resistance. It’s not curable, but it still means, in my opinion, that you should be careful with the way that you’re eating, and consider the exercise, first, it’s just a good way to live, but it can prevent or delay other conditions that can affect your quality of life later.

It’s over-diagnosed for sure in teenagers and young women because people look at these ovaries, and you only need to have one ovary like that ultrasound knowledge they should, it doesn’t need to be both. Many young healthy women have that, so that ultrasound picture in itself is not diagnostic. To underscore this diagnosis there has to be some ovulatory dysfunction, it’s very rare for someone with PCOS to have hyperandrogenism and polycystic ovaries and not have ovulatory dysfunction. The typical scenario is that somebody doesn’t get regular cycles or doesn’t get cycles at all. They come in, we do an ultrasound, we see PCOS appearing on ovaries or PCOS ovarian morphology, which is the other name, then we draw their blood, and we see elevated antigens. We don’t even need to see that because if they have that ultrasound that shows a very active ovary often enlarged with irregular cycles, PCOS is sort of as that’s where we’re thinking that’s happening. There’s a couple of other conditions that we need to make sure it’s not going on, like hypothalamic amenorrhoea. I mentioned some people are very rigorous exercisers, they have very active ovaries, it’s just that they’re not making their own FSH and LH stimulate the follicles. There can be some confusion in terms of a lean PCOS patient and a kind of rigorous exercise hypothalamic amenorrhoea patient, you have to be careful.

PCOS affects the quantity of eggs or follicles that you have. The biggest correlation between the quality is age. Keeping with that, 36 is not bad, in terms of what’s going on with fertility. Over 35, there’s a little of a difference, but if you get blood work and ultrasound done, and we look at your or diagnose your ovarian reserve at age 36. Your FSH and LH levels and AMH are normal, and you have active ovaries which I’m assuming you do with PCOS then you should have a pretty good chance with IVF with your own eggs. The challenge is if you’re 36 with active ovaries, and we find an elevated FSH, we see a low AMH, then the concern is yes, you have lots of follicles, but we’re a little worried about their quality. The good news is that if you have lots of follicles, and do IVF, in terms of egg quality, there are lots of choices because there are so many follicles. When people don’t have many follicles and have poor quality, we just have to go with what we have. In PCOS, as I said, at least we’re getting a lot of follicles or hopefully eggs at retrieval, but then we need to determine the quality. We can look at them under the microscope for quality, and then we can also do genetic testing on them because as we know pretty embryos or blastocyst under the microscope can be genetically abnormal, have an abnormal chromosome number. If you are worried at all, and your ovarian testing is normal or ovarian testing is a little concerning, you might want to combine the IVF if you can afford it with the genetic testing. That we’re only transferring back genetically normal embryos, and that’s not 100 chance of pregnancy, but it will increase the chance of pregnancy greatly, and also reduce the chance of pregnancy loss due to something we call aneuploidy.

The other myth with PCOS is that you have to be on a low or no-carb or keto diet which I always like to address. That is not the case, low-carb or no-carb diets may help initial weight loss, but they’re very difficult to sustain so often that weight comes back and can come back even more than before. With that in mind, I think that anyone with insulin resistance, whether you have PCOS or not, should be careful with carbs and what I mean by careful is that you want to have what’s called a slow-carb, a carb that doesn’t make your blood sugar spike. When your blood sugar spikes, your insulin spikes and then what happens is your blood sugar drops. You get shaky, starving, all those symptoms that we get with hypoglycaemia, then you reach for carbs like orange juice, cracker, or a cookie because you’re shaky or hungry, and the whole thing perpetuates itself. The first thing in terms of being careful with carbs is to make sure the carb that you have is a slow-carb, so it’s closest to its natural form as possible. It is usually not white, so brown rice, multi or whole grain pasta, quinoa is a superb carb that also has protein. The other way to be careful with carbs to mitigate or temper that big spike is to combine them with a protein. Whenever you have a snack or a meal, the first thing that goes on the plate is a protein, not a carb, you pick your protein, and there are lots of options, then having a healthy fat, olive oil, avocado, nuts, nut butter, the yolk and eggs, cheese that also can mitigate that quick spike of the carb. Then you can have the carb, but it should be a carb that’s closest to its natural form as possible that takes your body a long time to digest, so that is what I call the perfect plate. I always recommend colour on a plate which is vegetables and fruit. When I’m talking about in terms of completeness for the plate, I would be remiss not to mention that it has to have some colour, so never have a carb by itself, always prepare it if you go to work, or you’re at home to have these staples in your house, nuts, nut butter, cheese, eggs. I always tell my clients to have hard-boiled eggs, make a whole pot of quinoa and always make sure that you’re combining them, so if you have an apple, make sure you have it with a cheese stick if you want to have a banana, make sure you have it with nut butter, that is the best advice. I think that keeping that spike, not like this but a little more like this, you’re also going to feel better during the day, and you’re not going to have so many cravings.

I’ve seen people with anti-inflammatory diets, and by diet, I mean way of eating, not restricting food that would say no sugar, no alcohol, no dairy, no nuts. These things in some people can be inflammatory. If people are not sure how they respond to food, then what I tell people is to limit meat, alcohol, sugar, dairy and then reintroduce it after like 3 weeks. I’ve seen people do that, I don’t personally recommend that because I haven’t seen that in the literature that says that’s the case, and I find that it’s very restrictive, and I don’t want people to feel like they feel deprived when they eat. I want there to be common foods that you can eat without feeling like you not have the stuff. That being said, I always tell people I want to desensitize them to sugar because and what that means is that I want them to get used to not having sugar, it usually takes about 3 to 4 weeks, so that when you have sugar, it feels too sweet. I tell people to go sugar-free, and I mean in terms of added sugar. If you have fruit and there’s sugar in it, that doesn’t count, as far as I’m concerned, but in terms of added sugar for about 3 to 4 weeks, so that you can get that sugar taste, that craving for sugar out of your system. It’s not necessarily because it helps with the PCOS, of course, overdoing sugar can make things worse. I also prefer almond butter over peanut butter, and that’s just a preference, and it takes a little to get used to that taste. For some reason, people have told me to try almond butter instead of peanut butter. Almond butter doesn’t seem to have that same allergic or uncomfortable effect, whether that’s the stomach, whether you’re hungry sooner, so I usually tell people to give almond butter a try wherever they would use peanut butter and see how it goes. I find that most people after they get used to it like how it makes their body feel. To me, that’s the whole goal.

I had ovarian drilling done myself. Ovarian drilling is called diathermy or drilling where through laparoscopy, through the belly button and a small incision is made and laser the ovaries. It does brown dots. It’s almost like when you see, like in the movies, where you shock somebody’s heart, and it kind of gets to reset, ovarian drilling might do that. In women with ovarian drilling, it actually might restore menstrual cycle cyclicity without any medications, and it can improve that androgen or hormone profile. It doesn’t make it great, but it can be really helpful. To do ovarian drilling, though, you need to have a laparoscopy, and the other issue is you need to understand that we’re not sure by doing ovarian drilling if there’s a potential for damaging the ovaries, so it’s usually not a first-line offering with people for that reason. I’m in the medical field, and I ended up being born with an issue with my uterus where I can’t carry more than one baby, so it’s very difficult to stimulate me with medications and keep that from happening unless I went to IVF. Because I understood the consequences of ovarian drilling and I needed a laparoscopy due to the ovarian issue, they consulted with me about this, and I decided to have it done. Because the ovarian stimulating medications are so good and so prevalent, we usually end up going to use those as a first-line as opposed to drilling.

I wonder if they think you have it just because of high AMH, and an ultrasound showed active ovaries. My thought is that if you’re 45 with active ovaries, and I’m not age shaming anyone, I’m actually over 45, but if you’re 45 with active ovaries, they might be thinking that’s so unusual that there could be PCOS or PCOS appearing ovaries. The issue is, if you don’t have elevated androgens either when we examine you, acne, hair growth, hair loss like I discussed or when they draw your blood and the blood androgens don’t come back elevated, then you don’t meet the criteria for PCOS. All you have are active ovaries because you don’t have ovulatory dysfunction if your periods are somewhere between 25 and 35 days even if they’re not always 25 or over 35, that’s not considered ovulatory dysfunction, that’s considered regular menstrual cycles. We always think 28 days, but very few women have regular 28-day cycles, they have to fall between 25 and 35 days. To me, it just seems like you have an active ovary, but you don’t need necessarily the other conditions or criteria to diagnose you with PCOS. Because you are in a good BMI category and because you’re active if you have insulin resistance, which is maybe the reason you want to know this. It’s a very difficult diagnosis, for some people, it’s very clear-cut, but other people like in your situation, you wouldn’t just have developed it. You would probably have had it your whole life, as I was explaining.

We’re missing 2 criteria, though. Irregular menstrual cycles and polycystic appearing ovaries. It sounds like you have insulin resistance if you’re pre-diabetic, and I’m not sure if they diagnosed that with the glucose and insulin test haemoglobin A1C or how they diagnosed you as being pre-diabetic, but it sounds like you have some form of insulin resistance which is incredibly common. Insulin resistance both makes it easy to gain weight, and then excess weight exacerbates in some resistance which is incredibly frustrating because it’s a vicious cycle. I wouldn’t say that your PCOS unless you have at least one of these other two criteria that I mentioned. Ambulatory dysfunction, to me, is the biggest one.  People with PCOS, even though there are two other criteria, androgens and PCO-appearing ovaries. I don’t know if you had an ultrasound to see if you have PCO-appearing ovaries, but you have insulin resistance, so it is possible. What I would do is since you’re pre-diabetic, or you’re in the impaired glucose tolerance part of the continuum, which is kind of the next step that you should work on insulin-sensitizing strategies, and it’s very difficult to lose weight. What works for other people in terms of healthy eating and losing weight doesn’t always work for people with insulin resistance. Sometimes it comes down to making your plate a certain way, increasing strength, not just cardio because of that muscle hypertrophy, with strength training that can help. I don’t know if they offered you Metformin, but a Myo Inositol sounds like it might be helpful for you, and I think it’s commonly found in Europe.  

You have lots of follicles in a resting state, and you have an androgenic environment in the ovary which makes you more sensitive to stimulating medications. I love that you use the word prevent because once somebody has OHSS, we can’t fix it, we have to manage it and take care of that person. Preventing it is the best option, so one thing is to start with lower doses of stimulating medications, you don’t need the doses that somebody else your age who has PCOS probably doesn’t need. Another good option is if you can use an antagonist in the cycle, in the U.S., it’s  Cetrotide and Ganirelix, I‘m not sure what it is if you’re in Europe. An antagonist allows us to use a trigger shot which is the shot that ovulates called Lupron or Leuprolide acetate. It creates an LH surge and ovulation surge that doesn’t last as long and is not so pronounced and allows us to use the trigger shot of HCG less of a dose. What makes ovarian hyperstimulation worse or intensifies it or gives you more of a tendency to have it is a pregnancy hormone in your system. It’s either because you’re pregnant or because we gave you HCG to trigger you, so being on an antagonist to keep you from ovulating, starting with a low dose of medication and then giving you a combination of low HCG and that Lupron to trigger can help. The other thing is if there’s a concern that you’re hyper-stimulating, we don’t want to attempt pregnancy that cycle because once you’re pregnant, you can make it worse. We would freeze the embryos in that cycle, let everything calm down, and then once that calms down to give them back to you in a subsequent frozen embryo transfer cycle. If we don’t attempt pregnancy that month, we can give you a medication called Dostinex. It’s a pill we start around the time of the retrieval. It’s different when they start, and that also can help prevent or temper the symptoms of varying hyperstimulation, but we can’t give that to you if you’re attempting pregnancy and having a fresh transfer that month.  

I’m assuming that these are done on day three of a period, they’re not just randomly done. If that’s not the case, let me know, but I’m going to assume that these are done on day three of a period. I would need to know what your normal prolactin is because you might be measuring in pmol/L over there, we measure it in nanograms over here, so that prolactin level looks high, but if your prolactin and thyroid levels are normal. It is only valid to test someone’s FSH, LH and estradiol on day two, three or four of a period. AMH, prolactin, and TSH can be done at any point, but the FSH, LH and Estradiol should be done on day two, three or four. What is concerning to me is that the Estrogen level looks a little high depending on that lab, so that might make the FSH and LH levels lower because they have an opposite relationship, and we need to know what those true FSH and LH levels are, so they may need to repeat the estradiol level to get it to the normal if that’s not normal so that we can see what’s going on. Many women with PCOS have an LH, FSH ratio of two to one, it’s not necessary for diagnosis but remember, I said the LH effects or activity are usually stronger. Then what we would see with you would almost be a reverse in those, so the LH would be six, maybe the FSH 1.8, so that doesn’t make me think that’s what’s going on. The AMH of 2.9, I’m not sure of your age, but that’s a regular normal AMH level, in most labs over four puts people at risk for hyperstimulation, and you’re not there. There’s nothing here that’s making me think that you have PCOS, it sounds that you maybe just had active ovaries when they did your retrieval. I just think you know you have they’re surprised by the number of follicles that they made at your age. A lot of times, people have trouble with just IVF because they may make 10 eggs, they may make 15 eggs, so 34 eggs might make them think that’s what’s going on, but I don’t know that they would treat you any differently in an IVF cycle because you could have PCOS I think it’d be helpful to know in terms of your life, but I don’t know for IVF if they would do anything different unless you are hyper-stimulated that cycle, and then we need to treat you differently in a subsequent cycle, so you don’t hyper-stimulate.

CoQ10 is a supplement. The machinery in the cytoplasm of every cell. There are mitochondria, it’s a structure in the cytoplasm of the cell, and the mitochondria’s job is to produce the energy for cell division, which of course, we want when we want pregnancy. Cell division is really hard work, meaning it takes a lot of energy, it takes a lot for the body to go into cell division. The mitochondria need to be pretty powerful in terms of being able to make this cell division go efficiently, so as eggs age, we always think of the chromosomes, the chromosomes can be abnormal, but the other thing that ages are the cytoplasm and the mitochondria in the cytoplasm. There’s some supplement that we can give that might strengthen mitochondria, and CoQ10 is what they found. They did an animal study with coq10 the same facility where they discovered the use of Letrozole and what they found, in these animals as they had bigger litters, and they got pregnant quicker when they were on the CoQ10 because this is sort of like the spinach or kind of like special food for the mitochondria so that it can produce energy like it needs to. I think CoQ10 is helpful whenever you’re doing IVF whether you have PCOS or not, especially if you’re a little older. In many centres I work with, they put everyone that’s doing IVF on CoQ10 to help. In terms of the dose, it differs, so some people say 300 twice a day, some people say 300 three times a day.