High Responder Fails Two IVM and Two IVF Cycles: PCOD & Follicle Maturation Issues

QUESTION: Hello,

During the last year we did two IVM (in vitro maturation) and two IVF (in vitro fertilization) cycles at different clinics at Montreal, Canada. All failed. I'm 39 years old and my husband is 40. My FSH was 11.1 and AMH 2.2 two years ago. The first IVM was without stimulation, I was triggered when the lead follicle was 13mm, 11 eggs were collected, 7 managed to mature in the lab and 4 fertilized. By the day 3 we had transferred 2 embryos 6 and 8 cells (they did not give us their grade). Endometrium was 6.8mm by the day of collection. No pregnancy...

The second IVM I had 3 days light stimulation (about 150UI Puregon days 3-5 + Estrace from day 6). I was not aware of my hormone test that shown the E2 level fell on day 6. We had collected only 8 immature eggs from 17 follicles, the only egg fertilized and on the second day the weak embryo was transferred. Endometrium was 7.3mm. Of cause, no pregnancy.

We moved to another clinic and did there two IVFs. The first one I had stimulation from the second day: 225 Gonal-F + 75 Luveris. After 4 days dosage was increased up to 300 Gonal-F + 150 Luveris. On the day 13 I was triggered when I had one follicle about 22mm, 2 about 18mm, and many smaller ones. We collected 16 eggs, 12 were mature, 9 fertilized. My doctor decided to wait till day 5 for the transfer. We had one blast, the other embryos stopped developing. The lining was 8.2mm at the day of transfer. No pregnancy.

As the clinic doesn't work during weekends, the stimulation for our second IVF started on day 4 and lasted 9 days. It was more aggressive: 300 Gonal-F + 150 Luveris from the start and about 200 Gonal-F + 150 Luveris at the end as I had developed mild OHSS. I was triggered when my follicles were 1-19mm, 1-18mm, 3-16mm, and many 15mm and less. As I said the clinic doesn't work weekends. My collection was Friday. I asked to wait for follicle growing bigger and the answer was: no, they are big enough. We collected 25 eggs, only 13 were mature, and only 5 fertilized. They were stopping developing one after another. The last one stopped at day 6 on the morulae stage. The lining was perfect: 13.5mm. It was an epic failure: nothing to transfer... I was told that the issue is my egg quality (my husband has no issues with his sperm).

I see that I had the only follicle bigger 20mm at the collection and we had the only blast. So I really would like to understand whether it's not a coincidence? If there is a way to have more equal size of follicles by changing the protocol? If I'm a good responder and have many eggs and they usually fertilize good (if they are mature) but they stop developing - does it mean they are poor quality? Or they were not fully mature at the day of collection? As I'm getting older and we have no time to experiment with different protocols I would like to maximize our chances by using more effective protocol for our next attempt. It would be great to hear your opinion on it. Could the change in protocol give us better chance for success?

Thank you in advance! O. from Canada.

ANSWER: Hello O. from Canada,

I can't give you specific protocol recommendations because each doctor and each clinic do different things. There is no one way to do IVF as you have found out.

The latter stimulation cycles show that you are NOT a poor responder but a high responder with PCOD tendencies. That means your ovaries are very sensitive to stimulation and that is a good thing. Yes, your age and therefore your egg quality are issues. However, hope is not lost because there is a chance that you still have a few good eggs left. As long as your ovaries respond well to stimulation, your chances of finding the good eggs are high. However, it also means that you need to find the right clinic because pregnancy rates will vary highly depending on the skill of the clinic and factors such as when to retrieve. I think it is a mistake to go to a clinic that only does egg maturation, and a clinic that doesn't work weekends. Both clinics are short changing you. It's time to find a better clinic.

It is also known that when OHSS develops, the pregnancy rates also drops. Probably because the majority of the eggs are not adequately matured. So one goal would be to decrease the stimulation and try for fewer eggs and a longer stimulation to get higher quality eggs. That is my goal with patients that are high responders. One method I use to try to even out the stimulation is to use the "sandwich protocol" which is to use 2-3 days of antagonist prior to starting the stimulation (I don't use the long Lupron protocol)to suppress the ovaries so that the follicles all start at the same point. Not all doctors use this protcol.

One final note: I let my follicles reach 20 mms before trigger. In some cases, I'll go up to 24 mms on the lead follicles if there is some unevenness, the goal of which is to try to get as many mature eggs as possible. Again, these things/variations are what make clinics and doctors different. You need to find a clinic that has a respectable pregnancy rate for your age group (and that will stay open on the weekends) so that you don't waste any more IVF cycles.

FOLLOW-UP QUESTION:

Dr. Ramirez,

At first, thank you very much for your fast and detailed response.

I've forgot to mention that our infertility is unexplained and I always have a lot of follicles at any given cycle (the first time we asked medical help for infertility 4 years ago).

Today I've got some new details about my IVFs: first time the E2 was about 8000 at the day of trigger and progesterone was about 4. The second time E2 was more than 22000 and progesterone was 6.4 so that my doctor didn't wait anymore and triggered me when the lead follicle was still 19mm (and not because they do not work weekends, as he explained). Is it possible that the E2 level could compromise egg quality the second time?

My doctor told me that assisted hatching is not possible for a blast as it can be easily damaged. Do you agree with that? Is assisted hatching used for day 3 embryos only?

Also my doctor is tended to wait for a blast and do 5-day transfer as he believes it would give stronger embryo and higher chances of implantation. As I see we had many good-looking embryos on day 3 and 1 or no blast at day 5. Would it better to transfer at day 3 instead?

Thanks again for sharing your knowledge

Regards, O. from Canada.

FOLLOW-UP ANSWER:

Hello again,

You have to understand that my advice is my personal opinion and not necessarily the gold standard or generally accepted standard because there are many many variations in the stimulation portion of the IVF cycle. But let me give you my opinion.

Both cycles led to overstimulated cycles. If the peak E2's are correct, you went very very high and in the U.S., in general, we don't like the E2 to go above 4000. Yes, it has been shown that when hyperstimulation occurs, i.e. the E2 goes above 4000, there seems to be a decline in egg quality and pregnancy rates.

You don't necessarily have a diagnosis of "unknown" infertility. You have the "age factor" which means that your egg quality could be compromised based on your age. That is a diagnosis. My approach to transfer is to use D#3 transfers unless I have so many good D#3 embryos that it is harder to determine which ones to transfer. In that case I will proceed to D#5. I am not a big D#5 person because I don't think that it is an absolutely perfect technology and we probably lose some good embryos because of it (that has been shown by genetic testing of the embryos on D#3). Not all blastocysts are genetically good embryos. Because of your age, I don't think it makes any difference which day you transfer, but I would prefer to put back more and let nature decide that the lab. YES, assisted hatching can be done on blastocysts.

The only other option that might help you, is to consider preimplantation genetic screening so that only normal embryos are replaced. I would also recommend tranferring at least 4 embryos because of your age. PGS might decrease your pregnancy chances a little, depending on the expertise of the clinic, but can help you to distinguish the genetically normal from the abnormal. PGS can be done on D#3 or D#5.

Good Luck,

Dr. Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.com

Comment: Dr. Ramirez gives detailed and clear answers. He is extremely helpful and very knowledgeable.

Possible PCO Patient Adjusting IVF Antagonist Protocol For Fear Of OHSS: Decrease Gonal-F Dosage?

Question:

I am about to start my first IVF protocol (today is CD2). I am concerned about the recombinant FSH dosage prescribed and would like your opinion regarding appropriate dosage. I believe I am at higher risk for OHSS for several reasons (described below), however my recent ultrasounds are not showing definitive signs of PCO. Here is the protocol prescribed by my doc:

No pre-cycle BCPs (they make me very ill)
CD2: gonal-f 225
CD3: gonal-f 225
CD4: gonal-f 150
CD5: gonal-f 150
ultrasound on day 6
addition dosing determined following this ultrasound
Gonarilex to prevent premature ovulation

I called the doctor today because I was nervous about taking the first two days of 225IU gonal because of the risk of OHSS. After very little discussion, he switched me to 150IU for 4 days.

The difference between 225 and 150 is a big change. I wonder if I will get good results with a dosage that is this low. What is your opinion? I feel like there might be some sort of middle ground that is more appropriate? I would appreciate any thoughts. I would like to get the "best" results without complications of OHSS.

I believe I am at higher risk for OHSS than the normal woman for many reasons:

1) my ultrasound yesterday (on CD1) shows 9 follicles on right and 16 on left

2) I responded well to low doses of gonadotropins (6 IUI cycles some with letrozol/femera at 5mg/day?, others with clomid at 25mg/day all cycles gave 3-5 mature follicles on CD12),

3)I am petite (5'2", 100 lb.s)

4) in 2006 a doctor told me I had PCOS based on ultrasound results, a history of severe PMS, and moderate acne(two additional doctors I consulted with gave no diagnosis - I am not hairy or pear-shaped)

5) cancelled IUI due to elevated estrogen associated with a small complex cyst on cd2 (and another very uncomfotable IUI cycle when a different OBGYN proceeded with an IUI when I had a cyst at the start of my cycle).

6) grandma had type 2 diabetes

7)early male baldness runs in my family.

Answer:

Hello J. from the U.S.,

First of all, I have to caution you about trying to second guess your doctor. Sometimes that may not be good. I would presume that your doctor had a logical reason for selecting your protocol.

You were originally scheduled to be on a 3 down protocol (75IU x 3 for two days then decrease). That is a standard protocol and is on the low side. Because of your concern, your doc decreased you to 150IU and will make adjustments based on the response. The only down side to the lower protocol is that you may not recruit as many follicles as the higher dose, but there is no way to know this when it is the very first cycle. In most cases we determine the protocol based on an educated guess. The adjustment at CD#6 is still early enough to increase the dosage and recruit more follicles if necessary, and if you are indeed a PCO, then you will already have an increased number of follicles and the decreased dosage will be safer for you.

I am glad to see that your doc is using the "antagonist" protocol with ganerelix. I am a firm believer in this medication and its ability to decrease the risks of OHSS. With the antagonist, instead of using HCG to trigger ovulation, Lupron can be used to trigger and because of its shorter half-life, the risk of OHSS is dramatically reduced. This is the protocol I use with my PCOD patients to reduce their risk, in addition to careful monitoring, lowered FSH dosage, Drifting (if necessary) and Coasting (if necessary). My goal is to keep the Estradiol level less than 4000 at the time of trigger. With this protocol, I have had no incidence of OHSS in my center for the past 5 years. Most the reasons that you gave for being PCOD are not valid criteria, but my concern would be the same as yours based on the high number of antral follicles seen on ultrasound. I treat patients as a PCO patient if they have PCO-appearing ovaries even if they don't meet the strict criteria for PCO. And, I find that they do stimulate like a PCO ie have a high number of follicles (>25).

In your case, I think that being safe is better than being sorry and the lower dose is probably the way to go. I call your new protocol a 2up protocol and it is a standard protocol that I use with my PCO patients. I check estradiols at CD#5, however, and adjust from there.

Good Luck,

Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.com

Monterey, California, U.S.A.

The Fertility Chase: PCOS - Polycystic Ovarian Syndrome and Fertility

Back in May 2010, we were privileged to make a movie with The Fertility Chase which aired on the We Network. This short, 7 minute movie is an intimate look at how PCOS, polycystic ovarian syndrome, has affected two women who happen to be patients of our center. They frankly discuss their frustrations and pain over their struggle with infertility. We are grateful to them for having the courage to step forward to talk about this distressing syndrome with the hope of letting others know that they are not alone and that there is hope. In addition, you will have the opportunity to meet me! Perhaps my brief overview of this syndrome will clear up some misconceptions and pave the way for those of you who are struggling with this disorder to begin to formulate a treatment path that will aid in bringing resolution to your problem.

One moving quote from the movie by our patient, Brandi: "...Being a family doesn't mean you have to have children. You're a family when you're a daughter, you're a family when you're a wife, and you don't have to have children to be a family. It's been comforting to know that, hey, I'm not the only one..."

September is PCOS Awareness Month. Other worthwhile sites to look at for more information include: PCOS Challenge, founded by Sasha Ottey (http://www.pcoschallenge.com/) and the PCOS Association, founded by Christine DeZarn (http://www.pcosupport.com/).

Young PCOD Patient With Tubal Blockage Unable To Conceive: Surgery or IVF?

Question:

I'm really searching for some advice. I was diagnosed with PCOS (not insulin resistant) this month (after four years of "maybe yes") as well as finding out I have a blocked fallopian tube.

I'm seeing an IVF specialist who recommended having hysteroscopy and laparoscopy surgery to clear the blockage and determine if there is scar tissue or endometriosis that can be fixed. I've suffered from very heavy irregular periods for the last 4 years.

I was told that if I chose not to go with the surgery the next step will probably be IVF. I thought IVF was a little extreme, completely skipping over Clomid and other fertility drugs. I know it's possible to get pregnant with one working tube, and I really don't want to do surgery unless it's absolutely necessary. I've been told by family I should get a second opinion, that sometimes surgeries are recommended when it's not really needed, because of money, etc. My Dr office did tell me I have excellent health insurance coverage. I don't think that's the case but it just seems like 2 extreme methods. I'm at one of the best fertility clinics in South Florida and feel like they should know better than me.

I'm 26 and not overweight (I lost 40 pounds 3.5 years ago), I've been off birth control for 5 years, and we've actively been Trying to conceive for over 8 months. My husband's sperm count is great. I used ovulation kits for 3 months but was never able to get a positive result. Is surgery the only way to tell if I have endometriosis?Would it be more beneficial to have the surgery then to start IVF without it?Is it usual to skip all other fertility medications in situations like mine and just use IVF? Is this a situation that you would recommend getting a second opinion?

Any advice you can shed is greatly appreciated.

Thank you, S. from Palm Beach County, FL

Answer:

Hello S. from Florida,

I guess I can be your second opinion. As you have described, you have two problems thus far: PCOD and tubal blockage. Certainly if PCOD were the only problem, ovulation induction with Clomid, Femara or injectables would be an option and could be combined with intercourse or IUI. However, keep in mind that most PCOD patients do not respond well to these medications and many (up to 85%) end up having to go to IVF because of this. However, if this were the only problem, then you would have more options.

Tubal blockage is another problem. The more problems you have, the worst the prognosis for achieving a natural pregnancy and the more you need to consider IVF. Tubal blockage by itself is enough to consider IVF, however. You don't describe where the tube is blocked but the only situation where surgery might help with tubal blockage is if it is blocked at the very end AND there has been no internal tubal damage, such as is caused by endometriosis. If the tube is blocked anywhere along the tube, it cannot be repaired and surgery would therefore not be indicated. The most common cause of tubal blockage is some form of inflammatory disease that ascended into the tube via the vagina and uterus. Because both tubes open to the uterus, this inflammation/infection problem got into both tubes but affected them unevenly such that only one tube is completely blocked. That does not mean that the other tube is normal, however. It could mean that the other tube was affected and damaged but did not scar enough to block completely. Usually when I see one side blocked, I make the assumption that the other tube is also not functional based on the fact that if it were, the patient would probably have achieved pregnancy on their own. Considering how long you have been trying, that makes me suspicious that the open tube is not functional. In that case, the ONLY treatment option is IVF because that is the only way to bypass the tubes. Remember that the internal part of the tube cannot be repaired and repair of the tube at the very end of the tube does not work well (1% pregnancy rate).

So, now, if you combine these two problems, then you can see that IVF is the treatment of choice for you. In that case, why have the surgery? Any other problems found, like endometriosis, will just be additional reason to do IVF. It does not affect your IVF chances. The only reason to have a laparoscopy if you are considering IVF is if the tube is swollen with fluid, called a hydrosalpinx, in which case that tube either needs to be removed or severed from the uterus to prevent the fluid within from leaking into the uterus. Studies have found that IVF pregnancy rates decrease by 50% when a hydrosalpinx is present. The only other reason is if you had any kind of ovarian mass or cyst. That would need to be removed prior to IVF as well. Remember, the treatment has to treat and overcome the problems.

Just choosing a treatment arbitrarily, like fertility medications, does not necessarily overcome all the problems present.

I hope that answers your questions.

Good Luck,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, U.S.A.

Twitter with me at @montereybayivf, and follow me on Facebook at http://bit.ly/9Iw9oV

Patient Had Laparoscopic Ovarian Drilling & Damaged Tubes, What To Do Next?

Question:

I am from the United Arab Emirates. I had problems with my periods earlier since beginning of my teenage, like the absence of periods for years. Then I started taking contraceptive pills for regularizing my periods but it didn't help me. After that I thought it would be ok after I got married but then I didn't get pregnant for 1 year. After that, I had Laparoscopic ovarian drilling done.

I take no medicine till now after the surgery I got my period twice on my own 28 days difference but on the 3rd month I didn't get my periods at all. I thought I got pregnant then but I had blood tests done twice but it showed me negative. Before the surgery I had taken injectables, Clomid and what not, but it didn't help me ovulate actually. Both of my tubes were blocked but now after the surgery one of them is working. The doctor said I have less hormone & right now I am on primolute to get periods. So after consuming primolute for 10 days when should I expect my periods???? and what has to be done for my hormones???

By the way my age is 21 and my height is 162 cm and have been married for 1 and half years . My husband's semen was tested and they said that it's normal. Thank you very much!

Answer:

It sounds like you have PCOD (polycystic ovarian disease). Ovarian drilling is a very, very old fashioned treatment for PCOD. It is a procedure whereby a laparoscope is inserted into the abdomen and a needle, electrode or laser is used to make holes (yes, holes) in the capsule of the ovary. In the past, it was used as the mainstay treatment for PCOS, and in some cases was successful in getting the ovaries to function normally, at least for a short while. But, it does not work in all cases, and the problem is that damage to the ovary can induce scar tissue around the ovary, tubes and pelvis, thereby rendering the patient infertile by obstructing movement of the egg to the tube. Contemporary fertility surgery preaches minimal tissue damage to prevent or reduce scar tissue formation. This procedure contradicts this philosophy, did not work in most cases and, in some cases, made the fertility problem worse. We don't use it very much in the U.S. any more, and I cannot recommend it.

You have two problems in regards to your fertility: (

Number One: because of the PCOD you don't ovulate and Number 2: you have a tubal problem.

First, let me deal with the tubal problem. In reality, there are NO surgeries that can correct a tubal problem. Surgery can be used to open the ends of the tubes, but the major damage is usually within the tube and this cannot be repaired. The fallopian tubes are not just pipes. Opening them is not enough. They are working organs with muscle layers and small hairlike cilia that help to move the egg and sperm together. Because this damage cannot be repaired, the only realistic treatment option is to proceed with IVF "in vitro fertilization". This allows us to bypass the tubes.

The second problem is PCOD. In this case the ovaries are difficult to ovulate safely (only allowing 2-3 eggs to ovulate). For that reason, the majority of PCOD women have to proceed with IVF. This is because we can extract all the eggs and control the number that are put back in. This is necessary because PCOD patients tend to over-respond to injectable medication, which is the only medication that will work to stimulate most PCOD ovaries. Clomid usually doesn't work.

So my recommendation is to see a fertility specialist and undergo IVF. The primolute is a progesterone, I believe, and is only being used to induce a period. It is not doing anything else.

Follow-Up Question:

So what do you say doctor, just Laparoscopic ovarian drilling and Clomid will not work after getting my periods thru primolute? I am waiting for my periods to come and so I can start with clomid and injections. This is the first clomid cycle after my surgery? Well, what I think is let me wait and see and then next we will go for IVF.

Follow-Up Answer:

Hello Again,

There is a good chance that the Clomid might stimulate your ovaries to ovulate. The ovarian drilling can sometimes make the ovaries more receptive to this medication. However, the chances are not good. The biggest problem that you have is a tubal problem. Because Clomid with either timed intercourse or IUI rely completely on the fact that there has to be normal tubes, if they are not, that is what will prevent you from getting pregnant.

In any case, miracles do happen and you may be the exception to the rule! So as long as you don't mind trying the Clomid, then it is okay to try.

Good Luck.

Sincerely,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

The Difference Between PCOD and PCOS, Fear of Birth Control Pill Protocol

Question:

Hi, thank you very much for your help in advance. I am 22 years old and not sexually active. I had my first period may be at about 16 yrs. of age. My period was always relatively irregular and it was normal for me to miss 2 to 4 months (4 months usually happened once a year in the spring). I have gone to a gynecologist several times and after the exams all have told me that I have irregular hormonal levels and should take birth control pills. As I have heard many times that such pills are bad for my health, I refused to follow that advice. The problem which greatly concerns me is that I now have not had a period for about 6 months (last time was in March).

I am very worried and will go to the doctor, however, I would appreciate your opinion as well. I have a good figure, good eating habits, no excessive stress. What could this be? If this is PCOS would it have significant negative effects on my ability to get pregnant? Are hormonal pills really bad (weight gain, hair growth, adaptation of the body to constant supplements)? Could this be due to my lack of sexual experience/activity? If so, is this a problem? Is there a "body cleansing" pill that I could take to induce a period and see how things go without significant negative effects? Do you think that traditional Chinese medicine could be of help? In short, what is you opinion on this? I would appreciate as much detail as possible.

Thank you for taking the time to answer my questions.

Answer:

From your history, it sounds like you have PCOD (polycystic ovarian disease). This has not become the syndrome (PCOS) yet because the disease eventually turns into PCOS (polycystic ovarian syndrome) when it manifests by increased weight gain (obesity), excessive hair growth, increased male hormone, decreased voice, hair loss (male pattern loss), diabetes. This disorder is due to a dysfunction of the ovary, whereby the ovary does not process the FSH and LH from the brain appropriately so that ovulation does not occur. If the ovulatory process does not occur, the hormone precursors do not go down the estrogen/progesterone pathway to make those hormones and instead go down the testosterone pathway, leading to excess testosterone. This leads to the manifestations explained above. These are long term changes and occur slowly. They are not reversible, so you don't want to go down that road.

The other problem with not having a period regularly is that the endometrial lining can thicken leading to several problems: hemorrhagic bleeding when you do have a period requiring hospitalization and transfusion, a precancerous state and endometrial cancer. You also don't want to go down that road. Another problem is that with the lack of estrogen in your body, you can suffer other long-term consequences such as a very dry vagina, vaginal shrinkage, inadequate lubrication with intercourse, shrinking of the breasts, increased heart disease, bone loss, dryness of the skin.

If you are not intending to become pregnant, then the treatment of choice is to use the birth control pill. This is the recommendation that medical doctors in my field will give you. That is mainly because the pill/patch/ring are made of estrogen and progesterone and override your ovaries. It basically puts your ovaries at rest and gives you the hormones your body needs. Several studies have shown long term benefits from the pill including a significant decrease in ovarian cancer if used for greater than 7 years. I also believe that it helps to preserve your fertility longer because the ovary is quiescent. The things you heard that are "bad" about the pill are wives tales and not true. The one truth is that you may not be able to become pregnant after stopping the pill, but that is because you will go back to the way you were prior, which is not conducive to pregnancy because you are not ovulatory. So, my recommendation is to go on the pill.

In terms of sexual activity. The value of sex, if you are not trying to get pregnant, is for recreation. Because it feels good or gives other good feelings. It is not a physiologic requirement, so don't feel compelled to have sex just because you have to. It should be fun.

I cannot comment regarding Chinese medicine, as I have no knowledge of this subject. I have recommended acupuncture for my infertility IVF patients as a complimentary part of my protocol and have seen improved pregnancy results.

I hope this gives you the information that you were looking for.

Follow-up question:

I wonder if I can take up a bit more of your time by asking a follow-up question.

From what I understand, birth control pills do not treat the problem, they simply override it, for lack of a better term. At this stage in my life, I am not looking to become pregnant; however, this is a natural progression in life. As such the question is as follows: If I can't become pregnant without taking the pill due to the absence or scarcity of the ovulation process, and the pill while restoring that process, will be acting as a contraceptive, what are my options?

One of my concerns about the pill is that by taking it I will be decreasing the possibility of having natural period, as my body will become used to constant supplements. Consequently, my chances of ever becoming pregnant suddenly become almost null. As for sexual activity, I certainly understand the value thereof, I have been told, however, that sexually activity will stimulate the production of the hormones which are missing in my body. This was the assertion the validity of which I was looking to confirm. From what I understand, that belief is erroneous. Is that correct?

Furthermore, I was a bit unclear as to why you believe that I have not yet developed a "syndrome". You also mentioned that the pill will prolong my fertility. Are you then suggesting that I will likely lose fertility at some point due to PCOD?

Again, thank you for your time and assistance!

Follow-up answer:

Hello Again,

The answer to your first question is that the pill will not inhibit your ability to become pregnant in the future. As you said, it overrides the ovary and puts it into a quiescent state. The active state returns after stopping the pill and you will return to where you were previously. That is, if you are not ovulating prior to the pill, you will still not ovulate after stopping the pill. Your body will not "become used to constant supplements" so you don't need to worry about that.

Sometimes, being on the pill causes the ovary to straighten itself out and I have had patients get pregnant immediately upon stopping the pill (the opposite reaction to what you are thinking.)Sexual activity has no influence on the regular hormones in your body. You can have many sexual encounters per day and your hormones and ovaries would still be abnormal from the PCOD. Of course, you will be exhausted every day too. :) Just kidding!

From how you described yourself in your first question, you do not seem to be exhibiting the "classic" symptoms of hirsuitism, weight gain etc. that manifest themselves with PCOS. That is why I am assuming that you have PCOD. I have had many patients that are PCOD with no symptoms whatsoever. To diagnose latent PCO you need to see an infertility specialist who will ultrasound you during your cycle to determine whether you are overproducing follicles.

Lastly, you will lose your fertility potential with increasing age, not because of PCOD. At age 30 the pregnancy rate is 85% per year, 35 PR is 30% per year, 40 yo PR is 10% per year.

Hope all this makes sense and answers your questions.

Sincerely,

Edward J. Ramirez, M.D.

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

www.montereybayivf.com

Polycystic Ovarian Disease In Young Woman

I have had many, many questions regarding Polycystic Ovarian Syndrome or Polycystic Ovarian Disease. As an infertility specialist, I see women every week that suffer from either the syndrome or the disease. If not treated, it can lead to serious health problems such as diabetes and heart disease. It can also cause infertility. PCOS or PCOD is common and affects as many as 1 in 15 women. Often the symptoms will begin in a woman's teen years, like the following questioner from Texas.

Question:

Hi Dr. Ramirez,

I am a 19 year old black female in Texas looking for answers. I started having periods at 12, but I have never had a normal, monthly cycle. I generally skip 3-6 months, after which I have a period lasting anywhere from 2 weeks to 3 months. At first, because I am hirsute and I was overweight, it was thought that I had polycystic ovarian syndrome, but I have been tested numerous times for such and I don't have that. During my long periods it was thought that I had uterine fibroids, for which I was also tested negative more than once.

I've lost 35 lbs. but I still have the same issue. Now I have a "bloodless period", with a brownish or clear fluid. I have been to 4 different ob/gyn's, non with a conclusive answer. The reason I post this in the infertility section is because I don't believe I am fertile, but I want to know what is causing my infertility so maybe I can go and get help to resolve the issue.

Thank you so much!

Answer:

You have PCOD. The is NO specific test for this disorder. It is a clinical diagnosis, which means that it is based on the signs and symptoms. If you have hirsutism, increased weight and very irregular periods, that is enough to make the diagnosis. PCOD has a wide variety of presentations. Some will have an FSH/LH imbalance on blood testing, but not all. Some will have irregular periods, but not all. Some will have increased hair growth, but not all. Some will have elevated insulin levels, but not all. The point is, your doctors are wrong. You have PCOD.

Therefore, you should be on the birth control pill to control your cycles. The problem with PCOD is that the ovary is dysfunctional and not processing FSH and LH correctly. Because of the dysfunction, it does not lead to ovulation and estrogen and progesterone are not produced. Instead, the precursors, the chemicals that usually are made into estrogen and progesterone, proceed to making testosterone, a male hormone. That leads to the increased hair growth, hair loss, obesity etc. By using the birth control pill, the ovaries are shut down, so that no testosterone is formed, and the estrogen and progesterone replace the hormone that you are not producing. The best pill for this purpose is Yasmin because the progesterone type, Drospirenone, blocks the testosterone receptors as well.

There are fertility issues with PCOD patients because they are not ovulating, which means, they are not giving off an egg each cycle. Those patients need to use fertility medication to get the ovaries to ovulate. Once ovulation is resumed, they have a normal chance of getting pregnant.

I hope this clarifies things for you. You might want to see a Reproductive Endocrinologist because this kind of doctor specializes in women's hormonal disorders and understands PCOD.

Sincerely,

Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
Monterey, California, U.S.A.

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