26 June 2015

PCOS and Pregnancy – How to Manage Polycystic Ovarian Syndrome

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Webinar Q & A Session

Dr. John Kennedy, Consultant at Sims IVF answers a number of questions from his webinar audience on the subject of PCOS.

Q.  How can you determine the quality of an egg?

A.  The best way to determine the quality of eggs is to see what type of embryos they make.  During the IVF procedure, the egg and sperm are combined to create embryos and the success of an embryo is very often based on the quality of the egg.  If eggs are poor quality, this can be a difficult scenario to manage.

Metformin can be used.
You can try a second batch of eggs (ie a further cycle of IVF, perhaps with a different protocol)  in the hope that they are better quality.

Q.  How long can you stay on Metformin?

A.  There is no upper limit for taking Metformin as long as you can tolerate it.

Most people  tolerate Metformin well but in can cause gastrointestinal upset in a few.

There is a possibility that it  can reduce the risk of miscarriage – so it is recommended for the first 6-12 weeks of pregnancy.

Q.  My LH is consistently double my FSH. Testosterone is low. Does high LH lead to miscarriage?

A.  A high LH and high FSH may lead to difficulty conceiving.

However, high LH does not lead to miscarriage.

Q.  I have PCOS and a BMI above 35.   I am concerned about being judged for this.

None of us have a right to judge others and if you are being judged or in fat dismissed for your weight, in relation to fertility treatment, then you need to try a different doctor. 

Our role is not to judge but to find solutions – whether they be fertility treatment, lifestyle management or a realistic conversation about the chances of success, given your current circumstances.

Let’s look at solutions, and not problems.

Q.  What type of diet will help PCOS?

Avoid sugar.  PCOS is negatively impacted by a high sugar, high glycaemic diet.   Hyper-glycaemia causes high insulin levels and ultimately can lead to diabetes.

We don’t advice crash diets, because weight can creep up over time to above the level it started at.  There is no such thing as ‘too slow’ a weight loss programme.  Aim to move down consistently and modify your lifestyle.

Identify eating triggers, many of us eat to change our emotional state, not because we’re hungry.

Q.  How can you avoid OHSS – Ovarian Hyperstimulation Syndrome during IVF?

Awareness of the risk of OHSS is absolutely key to managing it.  You have to be able to predict the possibility and be aware of the signs.

Monitor the ovaries carefully.  Check the AMH.  Log a careful patient history.  Those with PCOS are at most risk. 

We manage OHSS with lower stimulating hormone doses.  We use a special protocol – a short or antagonistic protocol which reduces risk of OHSS.

This can change how we trigger the maturation and release of eggs towards the end of the cycle.  Managing OHSS is mostly about awareness and anticipating the problem, so that you can anticipate and treat it before it becomes an issue.

Q.  We have trying to conceive for 8 years.  When on Clomiud, we didn’t have scans.  Could we have missed a fertile window?

A.   Yes – this is quite possible.  Scans are extremely important when on Clomid.  You need to have scans to see when the follicles are ripe and ovulating.  This can vary from person to person and some ovulate on day 14 while other ovulate on day 21.  When they are around 17mm – 20mm then the release of an egg occurs.  This information can only be gleaned with the use of scans. 

Q.  How do you overcome Underactive Thyroid and DNA Fragmentation?

The Thyroid gland is responsible for metabolism and energy.  Very often PCOS and underactive thyroid go hand in hand.  Underactive thyroid can cause weight gain.   Eltroxin is the medication most often used to manage an underactive thyroid gland.
DNA Fragmentation relates to sperm quality.  There is a simple test that can be used to evaluate the fragility of the DNA within the sperm.  If there are issues with sperm a number of steps can be taken:

Lifestyle management may be important – decreasing caffeine, and alcohol.  Cutting out smoking.  Managing diet including increasing Vitamin D, E, C, Zinc and Selenium in the diet.

ICSI may be used during the IVF process which means we inject the sperm directly into the egg.

Q.  We have been using TSI – Timed sexual intercourse for 12 months.  I over-stimulated because I have large cysts.  Should I consider IVF?

The problem about TSI and IUI is that they don’t give you information on why you are having problems conceiving. 

IVF even if it is a failed cycle, can give us information on why infertility is present, which helps us to improve the chances of conception.

I would need to see other markers such as AMH in order to make a judgement on whether you should try IVF.

Q.  Is AMH of 2.4 poor for a 38 year old?  What are the chances of conceiving naturally?

The normal range for AMH is 12-35.  So a reading of 2.4 is low.  However, it is often about the quality of eggs not the quantity, so don’t be discouraged.  My advice is to BE PROACTIVE.  At age 38, your AMH will diminish further and it is critical that if you want a family, you act now.  You may not get a lot of eggs through an IVF cycle – that is an issue.  Again, quality will be the important aspect. 

Your chances of conception are OK – but time is critical.

Q.  I have been diagnosed with PCOS and am not overweight.  I have acne.  What would you recommend?

A.  If you are not trying for a family, then I would recommend a pill called Dianette.  However, you may have to wait 12 months before you see the full benefit.  Sometimes, Dianette can be associated with weight gain.

Q.  Is there a risk of higher gestational diabetes with PCOS?

Yes.  Once you have PCOS and are pregnant, then you should be carefully monitored for gestational diabetes.

Q.  Do you suggest beginning investigations with a GP or can you go directly to Sims IVF?

You are very welcome to call Sims IVF directly at 01 208 0710 or visit our website www.sims.ie

We don’t just do IVF – we do the whole spectrum of fertility management – diet and nutrition, TSI, IUI, IVF, a full range of tests and in particular the AMH test.

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