PCOS – What you should know
As a fertility doctor, I see women who are troubled by Polycystic ovary syndrome (PCOS) on a daily basis. Most of them come to see me because they have difficulty in trying to conceive and some of them have irregular menses, but many of them are unaware of their condition. Polycystic ovary syndrome (PCOS) is a relatively common health problem, affecting an estimated 1 out of 10 women of childbearing age. However, many women who come to see me are either unaware or misinformed about PCOS. To help dispel some of the misconceptions about PCOS, in today’s blog I’ll be explaining what PCOS is, what causes it and how it can be treated.
What is PCOS?
PCOS is a condition whereby small ‘cysts’ develop on a woman’s ovaries. In actual fact, these ‘cysts’ are not actually cysts per se, but are ovarian follicles which contain eggs. A healthy young woman will usually have about 5-10 follicles in each ovary, however, in the case of PCOS, each of the ovaries contain more than 10-12 follicles. Although these follicles are a sign of abundance in egg numbers, they cause the body to have hormone imbalances. Because hormones are chemical messengers, responsible for triggering various different processes in our bodies, when a hormone imbalance occurs it causes detrimental chain reactions.
For example, PCOS can cause the ovaries to produce more androgens (male sex hormones), which disrupts ovulation, causes irregular periods, as well as causes acne and extra body or facial hair. PCOS can also cause insulin resistance, which increases blood sugar levels and can cause diabetes over time.
Other health issues caused by PCOS are metabolism problems, heart disease and infertility. If you have a family history of PCOS, on either your mother or father’s side, your chance of getting it is much higher.
Most women with PCOS share a number of common symptoms such as weight gain or trouble losing weight; extra facial or body hair (especially on the face, chest, belly and back); hair thinning on the scalp; irregular, few or no periods; heavy periods; fertility problems and depression. You may have many or just a few of these symptoms.
In order to diagnose PCOS, your doctor will begin by asking you a series of questions about your health, symptoms and menstrual cycles. This will be followed by a physical exam, which will look for excessive body hair and high blood pressure, as well as take note of your body mass index (BMI). Next, some of your blood will be drawn to test your blood sugar, insulin and other hormone levels. Finally, you may have a pelvic ultrasound to look for cysts on your ovaries. Early diagnosis and treatment is crucial, as it can help you to control the unpleasant symptoms of PCOS, as well as prevent long-term health problems.
Positive lifestyle changes can have a profound effect in treating PCOS. They not only reduce the unpleasant symptoms that you may experience, but also help prevent long-term health issues. To kick start your PCOS treatment, fit in moderate to vigorous exercises to your daily routine, such as walking, swimming, aerobic dancing and bicycling.
You should also eat a healthier diet, comprising of lots of vegetables, fruits, nuts, beans and whole grains. You should also reduce your intake of high calorie food which are high in saturated fat and carbohydrate. These life style changes will improve your weight and reduces insulin resistance. If you are a smoker, quite smoking as it causes you to have higher androgen levels. Most polycystic women will also benefit from weight loss, which can help balance out your hormones and regulate your ovulation and menstrual cycle.
In addition to lifestyle changes, your doctor may prescribe you with medication to help reduce any symptoms you might be suffering, as well as to help you get pregnant. The common medications are ovulation inductions drugs, such as Clomiphene Citrate (Clomid) or FSH hormones injections. This will help you to ovulate naturally and increase your chance of pregnancy. Your doctor may also prescribe Metformin, which is a medication to reduce insulin resistance. This in turn will help to reduce weight, increase natural ovulations and reduces the androgenic effects of PCOS.
Laparoscopic ovarian drilling was once a popular surgery in reducing the effect of high androgens in PCOS patients. However, recent studies revealed that the effect of laparoscopic ovarian drilling is short-lived, i.e. the menstrual irregularity returns after a few months. On top of that, laparoscopic ovarian drillings has other adverse effects on women’s fertility, such as premature ovarian failure, adhesion formations causing tubal obstructions etc. Laparoscopic ovarian drilling is invasive and expensive especially in private settings. Therefore, it has become difficult to justify its cost against its effectiveness.
In some women, whereby there are other associated problems such as tubal obstructions or husbands’ sperms are weak or low in numbers, an IVF (In-vitro Fertilisation) treatment may be necessary and cost effective to achieve a pregnancy
Should you have any questions or concerns about PCOS and how it is affecting your health and chances of conceiving, as always, don’t hesitate to speak to your fertility consultant.
The loss of a pregnancy or miscarriage is something that most couples rather not think of. However, it’s important for couples to understand why miscarriages can happen, especially as it can be caused by various factors and steps can be taken to lower the risks. The common causes of miscarriage are anatomical causes (like uterine abnormality), genetic causes, immunological disorders and hormonal imbalance. In this article, I will address one of the most common types of hormonal imbalance known today – insulin resistance.
Insulin resistance is a condition whereby levels of sugar, estrogen and testosterone in the blood are raised, while progesterone levels are lowered. The result is an excess of glucose in the bloodstream, which leads to prediabetes, diabetes and other serious health disorders. In pregnancy, insulin resistance causes a variety of concerns, such as delayed fetal growth and gestational diabetes.
Several scientific studies have also found that insulin resistance can lead to miscarriage. One such study was carried out by a team of researchers at the Reproductive Medical Centre, Peking University, People’s Hospital, Beijing, China. After examining 107 patients that achieved their first pregnancy after infertility treatment, they came to the conclusion the risk of miscarriage can be directly linked to insulin resistance.
A team from the Obstruction & Gynecology Department, Babol University of Medical Science, Babol, Iran offered similar findings, when they proved that women with elevated insulin levels are at a higher miscarriage risk. As worrying as this is, it must be noted that insulin resistance doesn’t just heighten the risk of miscarriage; in fact, it has been shown to increase the risk of multiple miscarriages.
Several published studies have confirmed this, such as one by a team from the Department of Obstetrics and Gynecology at Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou. After investigating the differences in insulin resistance between women with recurrent miscarriage and those with normal pregnancy, they concluded that insulin resistance increases the risk for recurrent miscarriage during the first trimester of pregnancy.
The crucial link between insulin resistance and recurrent miscarriage was echoed in a prospective clinical study by a team of researchers from the Department of OB & GYN, Shiraz Medical University, Iran. Their study found that 39% of women with recurrent miscarriage have abnormal oral glucose tolerance test (OGTT) results. The OCTT, which measures the body’s ability to use glucose, is often used to check for insulin resistance and gestational diabetes.
Meanwhile, a team from the Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology, University of Tennessee Health Science Center, Memphis, USA concluded that 27% of women with repeat miscarriage have high fasting insulin, despite normal glucose levels.
Insulin resistance is also associated with Polycystic Ovarian Syndrome or PCOS, which is why women with PCOS struggle with infertility. The condition raises levels of estrogen and testosterone in the body, while lowering progesterone levels. This interferes with the normal development of follicles in the ovaries, causing problems with ovulation.
However, if you have PCOS or insulin resistance and wish to undergo infertility treatment, hope is not lost. There are steps you can take to improve your insulin resistance sensitivity through lifestyle changes or medical intervention, before you undergo infertility treatment. Please don’t hesitate to speak to your infertility consultant should you have any concerns about insulin resistance. Your doctor can advise you on ways to reduce your risks and increase your chances for a safe pregnancy.
The link between Vitamin D and fertility
Caucasian women love showing off a sun-kissed tan, so much so they would dedicate a good portion of their holidays to sunbathing. We Asian women, however, are the exact opposite, preferring to keep out of the sun, sometimes taking considerable pains to do so. This aversion to the sun is largely due to the desire to maintain a fair complexion, but is driven in part by concerns over harmful UV rays. This penchant for shunning the sun, however, has had an undesirable side effect on Asian women, as we are known to have lower levels of Vitamin D despite living in tropical climates.
Few people realise that vitamin D plays a significant role, not only in their general health, but their fertility as well. It has been shown that people living in countries with strong seasonal contrasts have always had fewer pregnancies during winter and more in summer, resulting in a baby boom around spring. Scientists have discovered that this ebb and flow has to do with exposure to the sun.
Over the years, this link between Vitamin D and fertility has been extensively investigated, but it has been further detailed in a systemic review published in 2012 by the European Journal of Endocrinology. The review, by Elisabeth Lerchbaum and Barbara Obermayer-Pietsch from the Medical University of Graz, Austria, assessed studies that evaluated the relationship between vitamin D and fertility in women and men, as well as in animals.
Here’s what the review, entitled ‘Vitamin D and fertility: a systematic review,’ found:
- Vitamin D receptors (VDR) and vitamin D metabolising enzymes are present in the reproductive tissues of both men and women.
- Laboratory mice deprived of VDR tend to suffer significant gonad (sex gland) insufficiency, decreased sperm count and motility, and abnormalities in the microscopic structure of tissues in the testis, ovary and uterus.
- Vitamin D is involved in female reproduction including IVF outcome (clinical pregnancy rates) and polycystic ovary syndrome (PCOS).
- In PCOS women, vitamin D supplementation might improve menstrual frequency and metabolic disturbances.
- Vitamin D might influence steroidogenesis of sex hormones (estradiol and progesterone) in healthy women.
- In men, vitamin D is positively associated with semen quality and androgen status.
- Vitamin D treatment might increase testosterone levels.
While the results are encouraging, the researchers emphasise that vitamin D supplementation alone can’t improve fertility issues. However, what is certain is that it is a safe and inexpensive treatment that can be a boon to conception. So if you’re trying to conceive, don’t shy away from the sun! Instead, aim to get about 15 minutes of sun each day and take care not to overexpose yourself to UV rays.
In my next post, I’ll be discussing another topic related to fertility and nutrition – the findings of the Dutch Famine Birth Cohort Study. Stay tuned!
My New Year was filled with a few good news, which is definitely a good way to start a brand new year.
A patient of mine, Madam P, gave birth to a baby girl vaginally after an induction of labour. Madam P was a patient with severe Polycystic Ovary Syndrome, who had come to see me in a very depressed condition. She had consulted 5 different gynaecologists before, and was told that she will never get pregnant. At that time, she was already married for 7 years. She was obese, stressed and depressed. She hardly have any menses. Most of the time, she needed medication to induce menstruation.
She told me that she was discriminated from her relatives as she was not able to get pregnant. Relatives stopped inviting her to weddings and baby showers as they feel that she was infertile, which may bring bad luck to other couples.
One unique thing which strikes me about Madam P is her husband Mr A, a very loving and supportive husband, who literally stood by her throughout this special journey.
The first thing I told Madam P is that she needs to lose weight and bring down her sugar level. Madam P is a high-flying executive in a bank, and the pressure of work caused her to eat for comfort. This causes a spiraling vicious cycle on her body image and stressed her even more.
It took me a few months to convince her to see a dietitian to change her habit of eating and reluctantly she signed up for gym to lose some weight.
Along the way, she went into depression, requiring clinical psychologist’s support.
Six months along the way, she decided to quit her job and change her lifestyle. She started cooking at home so that she can eat healthily, spend more time with her dogs, exercise and to pursue fertility treatment.
She stopped seeing me for 4-5 months, and then one day she appeared at my clinic again.
At that time, her father had passed away unexpectedly at the age of 60 due to a heart attack. Suddenly, it threw things into perspective for her: She told me that she is going to go all out to have a baby, for the sake and the remembrance of her dad, who had supported her throughout this journey but have not lived to see this dream of hers coming true. She felt that this was the only thing she can do to keep her dad alive in her heart.
She gritted her teeth and started a weight loss programme with the help of a dietitian and a gym instructor, and managed to lose 15 kgs within 2-3 months. Her period started to become regular again. Upon her return from India for the prayers of her late father, we noticed that things beginning to change for her. She was also seeing an acupuncturist to prepare her body prior to an IVF.
I scanned her as part of my assessment prior to IVF, and I was delighted to see a growing follicle which was just about to ovulate. I suggested an IUI for that particular cycle.
Lo and behold, she got PREGNANT!!!!
We could not believe our eyes when we saw the urine pregnancy test, which was further confirmed by the blood test result.
P & A was over the moon, and of course the rest was history.
This whole journey took us two years and it ended up with a sweet victory.
The point I wish to bring forward to many of you who are out there and still struggling with trying to have a baby is: Nothing is impossible. The key thing is to keep moving forward and do the right thing. Like Madam P, she was told that she could never get pregnant but yet she did not give up, even though she have had some setbacks with Fertility Treatment.
The story of P had definitely inspired me, and taught me a good lesson about life. I hope it will be the same for you!