Qus & Ans: Polycystic Ovarian Syndrome (PCOS)

Qus and Ans: Polycystic Ovarian Syndrome (PCOS)

I am on a PCOS mailing list. Recently there has been mention that the use of Clomid for seven days (starting cycle day 1 instead of cd 3 or cd 5) instead of five days is better for PCOS women. Is this true? If so could you give me a link to some written information on the subject.

Different doctors use Clomid in different ways. In general, prudence dictates that one should use the lowest possible dose of a medicine to achieve the desired therapeutic effect. If you are ovulating with five days of Clomid (as most patients do), there is no need to take seven days of the drug. However, if five days is not enough, then you may need to increase the amount of Clomid you take - either by increasing the daily dosage or by taking it longer.

Dr. Malpani
Malpani Infertility Clinic, Bombay, India
http://www.drmalpani.com

Hello. I have been told by my RE that unless I lose weight I will most likely not conceive or ever have regular cycles return. I have anovulation problems, and don't have periods without Provera. Is it true that women with this condition must lose weight to better their chances for ovulation and conception? I have been pregnant once (February 1999) but miscarried at 8 weeks. I currently weigh 294 lbs and am on a diet and exercising, attempting to lose weight. I have battled the bulge all my life and have been losing, especially after I finished college. I have gained about 100 lbs. in quick spurts of time since 1992. Please help. All I want is a chance at a healthy term pregnancy! Thank you. -- R.

Losing weight may help patients with PCOS, but as I stated in my answer to the first question above, not always. There are lean women with PCOS. Weight loss may help reduce insulin resistance, resulting in spontaneous or improved ovulation. Quick weight loss may cause more harm than good, so slow weight loss is best. Therefore, go easy on the weight loss and work with your RE very closely in order to treat your difficulties effectively with the prospects of getting a pregnancy established, soon. I wish you all the best.

Pette N. Zarmakoupis, M.D.
Director, Kentucky Center for Reproductive Medicine
Lexington, Kentucky

I was diagnosed with PCOS five years ago. We are trying to conceive now, and I just started taking Clomid. I am wondering how effective it is. Also, since I usually have a 30-40 day cycle, when is it likely that I will ovulate? Will it be around day 14? Would you advise an ovulation kit for me? Thank you. -- Michelle.

Clomid may work for PCOS women, but only about 40 percent of those who ovulate on it will get pregnant. A good trial is three to four ovulatory cycles. Most doctors would recommend not doing more a total of six cycles of Clomid, and I personally prefer even less than that, going as low as four cycles.

Your cycle length will most likely change when you start taking Clomid and should get a bit shorter, so it would be premature to speculate when you might be ovulating. It is obviously very important that your physician should not only attempt to get you to ovulate but also to make sure that he/she can predict your ovulation properly. Proper ovulation prediction coupled with either intercourse or IUI should maximize your prospects for pregnancy. An ovulation predictor kit should be helpful in predicting your ovulation but, especially under PCO conditions where the blood LH concentrations may be slightly higher than normal, ultrasound information must and should be used by your physician to complement and confirm your ability to ovulate. Any ovulation predictor kit should be adequate. Please follow the manufacturer's instructions and specifications. Good luck to you.

Pette N. Zarmakoupis, M.D.
Director, Kentucky Center for Reproductive Medicine
Lexington, Kentucky

I am 22 and have both PCOS and endometriosis. I was diagnosed about a year and a half ago. We have tried up to 250 mg of Clomid and dieting, but I can't seem to keep the weight off -- I am now at 285. What is the next step with everything? Thank you. -- Kristie.

Losing weight may help patients with PCOS, but not at all times. There are lean women with PCOS. Weight loss may help reduce insulin resistance, resulting in spontaneous or improved ovulation. However, please note that quick weight loss may cause more harm than good, so slow weight loss is best.

Clomid may work for PCOS women, but only about 40 percent of those who ovulate on it will get pregnant. A good trial period is three to four ovulatory cycles with intense ovulation prediction via ultrasound. Most doctors would recommend not doing more than a total of six cycles of Clomid. If this is still unsuccessful, then injectable medication (FSH or HMG) may be a recommended choice of treatment, again with intense ovulation prediction via ultrasound. Kristie, please don't give up and continue to try. You are too young to get frustrated and either put a lot of stress on your self or quit!

Pette N. Zarmakoupis, M.D.
Director, Kentucky Center for Reproductive Medicine
Lexington, Kentucky

After being on Clomid, I may have to have a surgery called "ovarian drilling." Can you give me some details? Specifically, what exactly is the procedure, will I be in pain, and will I need to be off from work? Thank you. -- Amy.

The purpose of ovarian drilling is to reduce androgens and restore menses. Ovarian drilling (via microcautery or laser) is done by outpatient laparoscopic surgery. A small needle is used to make four to 20 punctures in the ovary. An electric current is passed through the needle and a small portion of the ovary destroyed. Often a small amount of cyst fluid can be seen escaping as the puncture is made onto the ovaries.

The success rate for ovarian drilling is generally less than 50 percent, maybe even less than 25 percent. One advantage to ovarian drilling is that the surgery may be combined with diagnostic laparoscopy, chromotubation (also called chromopertubation or hydrotubation) and/or hysteroscopy. Disadvantages include adhesion formation and decreased ovarian reserves ( follicles and the oocytes contained within) at an earlier age. Surgical therapy for PCOS should not be considered as a first step in treatment in part because it is unclear what the long-term effects might be. Please make sure that your physician has had some experience and knowledge in performing such procedures. Your ovaries are very important to you.

Pette N. Zarmakoupis, M.D.
Director, Kentucky Center for Reproductive Medicine
Lexington, Kentucky

I hear that with PCOS, the ovaries get enlarged. As a patient already diagnosed with PCOS and considering ART, my question is, if I pursue superstimulation, will it make my ovaries *much* bigger? Is there some control over how big the ovaries get with treatment? If they get to be very big will I need surgery? Will I loose the ovaries? Which treatments help people with PCOS? Thanks for your time and input. -- B.

Because of the tendency for women with PCOS to produce many small follicles, the trick to avoiding hyperstimulation is getting a few follicles to mature without an army of smaller ones, which, incidentally are not performing the same function or role as the few mature ones. Caution should be used with medications, starting at the lowest doses, and follicle production should be monitored by ultrasound and estradiol hormone levels.

Ovarian Hyperstimulation Syndrome (OHSS) is a condition which can occur when the response to injections to stimulate egg production is greater than normally would be expected. Symptoms associated with OHSS usually begin four to five days after the eggs have been collected or released. In the mild to moderate form, symptoms may include enlarged ovaries, tenderness in the areas of the ovaries, and a feeling of discomfort in the abdomen and nausea. If the syndrome is severe, patients may also experience swelling of the abdomen causing shortness of breath and a reduction in the amount of urine produced. This severe form of OHSS only occurs in less than 1 percent of women affected. In cases where the OHSS is very severe, hospitalization may be necessary. Again, please make sure that you are in good hands with your physician that has had some experience and knowledge in performing such procedures and understands the types of risks that are mentioned above. Keep up the faith and please be strong.

Pette N. Zarmakoupis, M.D.
Director, Kentucky Center for Reproductive Medicine
Lexington, Kentucky

What is the connection between PCOS & Dermoid Cysts? I was infertile, the doctor found & removed a dermoid cyst with the ovary & falliopan tube about 3 1/2 years ago. A year later, I was pregnant. Now I am trying to get pregnant again and have tried for 8 months. I am currently 37 yrs. old. & am wondering if/how the two conditions are related. Thanks, Elizabeth

Dear Elizabeth: There is not a real relationship between PCOS and dermoid cysts. A patient may, however, have both of these conditions. Apparently your dermoid cyst was removed three and a half years ago, and the fact that you have not been able to get pregnant for the last eight months requires further and more aggressive evaluation. Some of the issues that need to be addressed are: 1. Assuming that you have PCOS, you likely will require medication to help you ovulate. 2. You are now 37 years old and need more aggressive treatment because of your age. Determination of Cycle Day 3 FSH and estradiol levels would also be helpful. Women who have undergone ovarectomy tend to demonstrate diminished ovarian reserve earlier than others. Good luck with your efforts in getting pregnant again.

Pette N. Zarmakoupis, M.D.
Director, Kentucky Center for Reproductive Medicine
Lexington, Kentucky

My husband and I have been trying to conceive for over a year and I am starting my 3rd month of clomid. I have not ovulated yet and I am very frustrated with my gyn. I have told him that I thought I had many symptoms of PCOS after reading about it but he didn't want to do anything with this. I have not had a biopsy of the endometrial lining or any other kind of test. I do get my blood tested around 3 weeks after completing the clomid but that is it. I am very frustrated and don't know if I am being impatient or if I should find another doctor. Thanks for your help. Sincerely, B.

Dear B.: The diagnosis of PCOS has not yet been established with your case. It is very important that a definite diagnosis be made before undertaking any kind of treatment. Anovulation can be due to many different causes. You definitely need a thorough work-up before being given Clomid. Assuming that you have PCOS, the issues to be addressed would be: 1. Do you also have insulin resistance? 2. Is your DHEAS (male hormone secreted by the adrenal gland) level high? We know that not all PCOS patients will respond to Clomid. If any of the two issues above are positive, there are adjacent treatments that can be added to the Clomid to help response. If those fail, then the patient will have to take injectable medication to respond. I do not think that you are being impatient. If your questions are not being addressed, maybe you should consider finding another physician. We wish you good luck in your efforts. Keep up the spirits.

Pette N. Zarmakoupis, M.D.
Director, Kentucky Center for Reproductive Medicine
Lexington, Kentucky

I was diagnosed with polycystic ovarian syndrome and have already done 6 rounds of Clomid with no ovulation. We have no other fertility barriers. I am supposed to start my first round of injectibles this month butI have seen many reports regarding the use of Metformin or Rezulin to help PCOS sufferers and it has, in some cases, restored ovulation. I will turn 34 this month and my question is: at my age, should I even consider using this unproven method (Metformin) or be more aggressive and start using injectibles?

Recent studies on the Metformin and Rezulin have been promising, especially in patients with polycystic ovaries who are overweight and insulin-resistant. The "gold standard" for Clomid- resistant patients, however, is still ovulation induction with injectable fertility drugs. Good luck.

Alan B. Copperman, M.D.
Director, Mount Sinai ART Program
New York, NY

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i am 32, the dr said one tube is blocked and i have ovarian cyst.my period is irregular. can i do hydrotubation? will it help, please reply.

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