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Polycystic Ovarian Syndrome (PCOS) and Infertility
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Polycystic Ovarian Syndrome (PCOS) occurs in 5-10% of women of reproductive age. The condition is characterized by abnormal ovarian function (irregular or absent periods, abnormal or absent ovulation and infertility), androgenicity (increased body hair or hirsutism, acne) and increased body weight/body mass index or BMI. The ovaries of women with PCOS characteristically contain multiple micro-cysts often arranged like a “string of pearls” immediately below the ovarian surface (capsule), interspersed by an overgrowth of ovarian connective tissue (stroma).
PCOS women often have a family history of diabetes and demonstrable insulin resistance (evidenced by high blood insulin levels and an abnormal 2-hour glucose tolerance test). This underlying diabetic profile could play a role in the development of PCOS and contribute to the development of obesity, an abnormal blood lipid profile, and a predisposition to coronary vascular disease. Women with PCOS are also slightly more at risk of developing uterine, ovarian and possibly also breast cancer in later life and accordingly should be evaluated for these conditions on a more frequent basis than non-PCOS women.
Most women with PCOS either do not ovulate at all or they ovulate irregularly. As a consequence, they usually experience delayed, absent or irregular menstruation. In addition, an inordinately high percentage of the eggs produced by PCOS women following ovulation induction tend to be chromosomally abnormal (aneuploid). Rather than being due to an intrinsic egg defect or being inherent in PCOS women, the poor egg quality is more than likely the result of overexposure to male hormones (predominantly testosterone) produced by the ovarian stroma. These two factors (ovulation dysfunction and poor egg quality) are the main reasons for the poor reproductive performance (infertility and an increased miscarriage rate) in PCOS women.
PCOS patients are also at an inordinate risk of severely over-responding to injectable fertility drugs such as Follistim, Puregon,Bravelle, Gonal F and Menopur. In such cases a very large number of ovarian follicles are formed and blood estrogen levels go sky high. In some cases this can lead to life endangering complications. When this happens, the condition is referred to as severe ovarian hyperstimulation syndrome (OHSS). In addition, PCOS women receiving fertility agents followed by the “hCG trigger” shot, they often release several eggs at a time (i.e multiple ovulation). This can lead to about a 40 % chance of a multiple pregnancy and a 10-20% chance of high order multiples (i.e. triplets or greater) with often devastating consequences.
VARIETIES OF POLYCYSTIC OVARIAN SYNDROME:
1) Hypothalamic-pituitary-PCOS: This is the commonest form of PCOS. It is often genetically transmitted and is characteristically associated with uncharacteristically high blood Luteinizing Hormone (LH) levels. In such cases the LH is usually much higher than the Follicle Stimulating Hormone (FSH) level. In non PCOS women, the FSH is usually higher than the LH concentration. PCOS is also associated with high-normal blood androgen (male) hormone concentrations e.g. androstenedione, testosterone and dehydroepiandrosterone – (DHEA). Hypothalamic-pituitary-ovarian PCOS is commonly associated with insulin resistance (in about 40%-50% of cases).
2) Adrenal PCOS: Here, the excess of androgen (male) hormones is derived from overactive adrenal glands rather than from overactive ovaries. Blood levels of testosterone and/or androstenedione are raised, but with this variety of PCOS, characteristically the blood level of dehydroepiandrosterone (DHEAS), only produced only by the adrenals is also raised, thereby clinching the diagnosis.
3) PCOS associated with severe pelvic adhesive disease: here the multiple ovarian cysts are thought to be due to prolonged ovarian engorgement with blood…the result of severe pelvic adhesions. The condition is sometimes seen with severe endometriosis, chronic pelvic inflammatory disease and/or extensive pelvic surgery: In contrast with ovarian or adrenal PCOS, these women tend not to hyperstimulate with fertility drugs. In contrast they are often even “poor responders”.
TREATMENT OF INFERTILITY DUE TO ASSOCIATED OVULATION DYSFUNCTION:
Hypothalamic-pituitary-/ovarian PCOS:Ovulation induction [with or without intrauterine insemination (IUI) is often successful in establishing pregnancies in PCOS women. However, it has one significant draw back , namely that it is associated with an inordinately high risk of multiple pregnancies (often triplets or greater). IVF, by allowing purposeful limitation of the number of embryos reaching the uterus, prevents this risk and at the same time is several times more effective than IUI in resulting in pregnancy. It is in my opinion that IVF represents the treatment of choice (see below).
The oral diabetes medication, Glucophage (syn. Metformin) administered to PCOS women who have hyperinsylinism will within 3 months of startingtreatment result in a significant drop in blood insulin and a 40% reduction of the blood testosterone level. This can lead to an improvement in ovulatory function, and es a degree of suppression of androgenous symptoms and signs.
Surgical treatment:
- 1.”Ovarian drilling”: In this process multiple holes are made in the ovarian surface, ostensibly to drain the micro-cysts. Unfortunately this is usually wishful thinking because if there is any benefit at all, it will certainly be very short lived.
- Ovarian Wedge resection: This traditional surgical “aproach” designed to remove androgen hormone producing tissue fro the ovaries often at times result in reinstatement of regular ovulation and can result in pregnancies. However it notoriously also often results ibn the development of extensive post-surgical adhesions adding an anatomical barrier to fertility to an existing ovulatory dysfunction.
Adrenal PCOS: This form of PCOS is often successfully treated with cortisone-like steroids such as prednisone or dexamethasone to reducing the realease of male hormones by the adrenal glands. Over a period of several weeks, regular spontaneous ovulation often is reinstated. In some cases the additional use of fertility drugs will be needed.
PCOS due to Pelvic Adhesive Disease: This is an atypical variety of the condition because unlike other varieties of PCOS it is often associated with reduced ovarian reserve, a raised FSH blood level and a reduced response to fertility drugs. In such cases, high dosages of gonadotropins (FSH-dominant) with “estrogen priming” will be needed to induce appropriate follicle growth. Neither steroids nor Metformin are helpful in most such cases.
SEVERE OVARIAN HYPERSTIMULATION SYNDROME (OHSS):
As stated above, there is an inordinate propensity for women with PCOS to hyper-respond to gonadotropin fertility drugs and in the process produce large numbers of ovarian follicles and dangerously high blood estrogen (estradiol) concentrations. If left unchecked, this can lead to OHSS, a potentially life endangering condition.
So, the onset of OHSS is signaled by the development of a large number of ovarian follicles (usually, > 25 in number) accompanied by rapidly rising plasma estradiol (E2) levels, often exceeding 3,000 pg/ml within 7 or 8 days of initiating ovarian stimulation. The E2 level will usually peak above 6,000 pg/ml prior to hCG administration (In fact I have often encountered blood E2 levels rising to more than double this level). When the E2 rises above 6,000 pg/ml, the risk of OHSS occurring (with life-endangering complications) is above 80%.
Symptoms and signs of OHSS include: abdominal distention due to excessive fluid accumulation in the abdominal cavity (i.e. ascites), fluid in the chest cavity (i.ehydrothorax), rapid weight gain (of a pound or more per day) due to tissue fluid retention, abdominal pain, lower back ache, nausea, diarrhea, vomiting, visual disturbances, a rapidly declining urine output, vascular collapse and failure of blood to clot resulting in severe bruising (echymosis) etimes frank bleeding and multiple organ failure. These symptoms and signs usually start developing even before pregnancy is diagnosed.
Once pregnancy occurs, the OHSS condition will rapidly worsen progressively over a period of 3-5 weeks whereupon it will suddenly resolve spontaneously over a few days. If no pregnancy occurs the condition is self-limiting with symptoms and signs usually all disappearing spontaneously within 10-12 days of the “hCG trigger” shot.
When the amount of fluid collecting in the abdominal cavity gets so severe as to make breathing difficult or it causes a lot of discomfort, some or all of the fluid can readily and safely be drained through sterile needle introduced into the abdominal cavity (usually via the vagina), thereby improving the situation significantly. Fluid drainage might have to be repeated intermittently.
In all cases of OHSS, the ovaries will invariably become markedly enlarged. Unless the ovary twists on its axis, cutting off the blood supply (ovarian torsion) the ovarian enlargement is temporary and somewhat inconsequential. Ovarian torsion is fortunately an extremely rare complication of OHSS, but when it occurs, it represents a surgical emergency.
It is important to know that because the symptoms and signs of OHSS are aggravated by rising hCG levels, such patients should never be given additional hCG injections.
Does PCOS cause poor egg/embryo quality?
It is undeniable that women with PCOS undergoing IVF commonly produce a disproportionate number of poor quality eggs with reduced fertilization potential and which upon fertilization can produce embryos with poor developmental potential. However, rather than being due to the eggs of PCOS women having an intrinsic defect, such poor embryo quality is much more likely to be the consequence of excessive local varian production of androgen hormones, aggravated by severe ovarian hyperstimulation.
Increased androgen hormone production can be limited through the selective use of customized low-gonadotropin dose ovarian stimulation protocols. This will reduce exposure of developing follicles (and the eggs they harbor) to excessive ovarian androgens. Such protocols should be designed to suppress the woman’s LH production throughout the duration of ovarian stimulation with gonadotropins. This in turn will reduce androgen hormone release by the ovarian stroma. At the same time, administration of high LH-containing gonadotropins such (e.g. Menopur) should kept to a minimum. Finally those women at imminent risk of developing OHSS must be treated by “prolonged coasting” (see below).
In the past, even a threat of the dreaded development of OHSS often prompted the treating physician to abruptly cancel the cycle or prematurely administer the “hCG trigger” in an attempt to arrest the process and so limit the risk to the patient. But, while premature administration of hCG does abruptly arrest progression of follicle growth, there is always the risk that if hCG is given too prematurely the eggs might not have have had sufficient time to develop adequately beforehand. In such cases, very premature administration of the “hCG trigger” will increase the risk of numerical egg chromosomal abnormalities (aneuploidy) and thereby set the scene for poor embryo quality.
In women with PCOS, the connective tissue that surrounds the follicles (ovarian stroma) is often characteristically overgrown (stromal hyperplasia). It is this stroma that produces androgen hormones (mainly testosterone) in response to LH stimulation. PCOS women who often have elevated blood LH concentration are thus predisposed to have excessive production of androgen hormones (mainly testosterone) and as a result, compromised egg/can also impair endometrial response to estrogen.leading to poor endometrial thickening (often seen in association with ovarian stimulation of PCOS women).
The obvious remedy to such adverse effects on egg/embryo and endometrial development is to prescribe a stimulation protocol that regulates and limits ovarian over-exposure to LH and at the same time allows sufficient time for the follicles/eggs to develop optimally, prior to administering the “hCG trigger” shot. It is in regard to the latter, that the precise timing for initiating “Prolonged Coasting” (PC) becomes a critical consideration.
What is Prolonged Coasting and how does it work?
In the early 90’s, we were the first to report on “prolonged coasting” (PC), a novel approach that helps to protect egg quality while preventing the development of OHSS. PC has since gained universal acceptance as a method of choice for preventing OHSS.
Prolonged coasting involves withholding gonadotropin therapy while continuing the administration of the GnRHa and then waiting until the plasma estradiol concentration drops low enough to insure that the woman is out of danger. Only then is the “hCG trigger” initiated. In such cases, the correct application of PC will prevent severe OHSS, regardless of the number of prior developed follicles or the number of eggs retrieved.
Some have suggested that PC leads to poor quality eggs that upon being fertilized produce poor quality embryos. This, is not so! PC itself is not a cause of poor egg quality unless the timing with which the “coasting” process is implemented is wrong. If PC is initiated too early, follicle growth and development may stop. If started too late, the follicles will become over-ripe (often cystic) leading to poor quality eggs/embryos. Thus, precise timing of the initiation of PC is critical.
Prolonged coasting virtually eliminates the risk of OHSS. When properly implemented, it will not significantly compromise egg development and maturation. Because of this, it prevents canceled IVF cycles and with it……..“canceled dreams”.
28 Responses to “Polycystic Ovarian Syndrome (PCOS) and Infertility”
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Ask Our DoctorsA Question
Hello Dr.
Thanks for such a good article and the overall blog,I do read them all. My wife(26 Yrs) has lean PCOS(110 lbs) and recently we had First IVF at SHER but it was not successful. She produced 10 eggs and E2 levels was 2300 before Hcg but she had OHSS and even had paracentesis to drain the fluid with couple of emergency room visits to suppress symptoms.
We came across a site which seems to be giving promising option to avoid OHSS
http://www.drmalpani.com/ohss.htm. They say…."using a special technique during egg collection with a double lumen needle, which allows us to remove all the granulosa cells from each follicle at the time of egg retrieval, by flushing each follicle meticulously. "….
1. In your opinion does this work and if yes do we have such option at SHER or some other clinics in USA.
2. What are the chances that she might get OHSS if we go for next IVF Cycle? What is the best option for us to avoid OHSS.
Thank you!
If the dosage of the drugs is lowered, the "coasting" is started at precisely the right time and the "hCG trigger" is delayed until the E2 drops below 2500pg/ml. severe ovarian hyperstimulation syndrome (OHSS) should not occur. Ovarian hyperstimulation (OHS) can and as you nknow does at times still happen but not the very severe life-endangering vatriety (OHSS). The development of ascites alone is not OHSS. There needs to be oliguria (very profound reduction in urine output, and specific hematologic and metabolic changes to make the diagnosis of OHSS. Hyperstimulation with ascites can be easily controlled and yes, sometimes even paracentesis (drainage) might be needed.But this should not be a dangerous situation.
The idea that one can prevent this by scraping out granulosa cells with a needle tip (even if it is a double bore, is so far fetched as to border on the ridiculous. This is just fancy foot work. Please do not buy into it.
Geoff Sher
Hello doctor. I recently underwent my second IVF cycle. I am PCOS and have had an issue with about half of my eggs being multinucleated. My doctor didn't seem to have a problem transferring-saying that they weren't ideal to use, but could result in pregnancy. Afterwards, I researched multinuclei and found that most doctors don't transfer them. What is your opinion of this? And are my embryos' quality linked in some way to my PCOS?
Thank you.
No doubt for the reasons I tried to outline in my blog, women with PCOS are much more at risk of egg aneuploidy and this can explain what you reported in your comment. The remedy is what I explained as being essential, i.e a very individualized aproach to stimulation using fertility drugs. This will go a long way towards preeventing/limiting the problem.
I respectfully disagree with the doctor that told you that such multinucleate (polyploid) embryos can make a healthy baby. That is not accurate!
Geoff Sher
First and foremost, THANK YOU for not only this blog, but also your wonderful book and all of the ways in which you've changed the face of ART as we know it.
Your book was the first time I read about the correlation between PCOS and pelvic adhesive disease; you expanded on that topic here in your post and I'd like to see what you think about my situation. When I was 13 I suffered from ovarian torsion and ended up loosing a tube and most of one ovary via exploratory surgery. It appears that left me with extensive adhesions (found via FUS), as my only true remaining ovary has adhered to my uterus.
In addition to this history, I suffer from PCOS. My most recent bloodwork showed my FSH at 5.5 and my LH at 23.7. My ovary has lots of follicles (antral count is 15+) and I exhibit signs of excess androgens by way added hair growth and mild hirsutism. As it goes with PCOS, not all the "classic" symptoms fit – I am 27 years old, my BMI is 18 and my insulin(<2), fasting glucose(77) and testosterone levels are all within range (total 36, free 3.2).
Would you say that I suffer from more of a classic "Hypothalamic-pituitary-PCOS" or is the "PCOS associated with severe pelvic adhesive disease" more of a factor here? I'm inclined to think the first because of all of my symptoms, but I would like your opinion as we will be doing our first IVF cycle this August. Any comments you have on how my factors might affect our success would be greatly appreciated.
Thanks very much and, again, thank you for your continued commitment to the infertility community!!
Cathy
In my opinion, yours sounds like a typical Hypothalamic-Pituitary-Ovarian PCOS.
Good luck!
Geoff Sher
First of all Thank You for all of this wonderful information! I am glad you have not only recognized that those faced with infertility issues seem to be limited with information but you have acted and given us these great resources.
A quick question that I have not been able to find much about is the relationship between PCOS and ovulation. I have been diagnosed with PCOS by ultrasound without any other abnormal lab values and have had problems conceiving for approximately 4 years. There are no existing issues with my husband. Currently my husband and I are strongly considering IVF. Based on lab results I have been ovulating but have not been able to conceive. A doctor told me that they are able to get 80% of woman to ovulate and only 40% pregnant. He said there is an unknown factor preventing pregnancy. What is your insight to this type of dilemma? Is IVF the way to go?
Lindsay
Thanks!
Women with PCOS are very vulnerable to the wrong stimulation protocol. Because of all the ovarian hormonal influences mentioned in this article and in 2 other blogs (on "Factors affecting egg/embryo quality")it is imperative to customize the protocol of stimulation otherwise the yield of "competent" eggs/embryos will be poor.
Might I also suggest that you go to the http://www.haveababy.com site and post on the SIRM-Las Vegas discussion board where i will pick you up again and give more direct advice.
Geoff Sher
hello dr sher! i have never missed a period but my cycles are longish, between 30-33 days long. I am thin, normal BMI, but do have stray hairs in the chin area that I pluck. Also when a day 3 FSH was tested, my LH was higher than my FSH. Is that enough to draw the conclusion that I have PCOS?
It sounds very much like PCOS. You don't have to have all the features.
Geoff Sher
I have PCOS, am 43 and have been lean – as I swam competitively for 20 yrs. I recently completed a cycle- 17 embryos, 15 morphologically normal at day 5. We chose to implant the 2 best ones based on PGD analysis.The pregnancy did not take. Is there something we can go better
Sorry for the delay in responding. I have been abroad…
Of course there is a far better alternative to PGD/FISH which is hopelessly inadequate when it comes to identifying "competent" embryos. The reason…FISH canonly reliably access 8-12 or the 23 chromosome pairs, You need CGH to fully assess all chromosomes(read elsewhere on this blog to get this information).
Also in women over 40, it is critical to design a very individualized protocol of stimulation to protect egg quality that is so vulnerable to the biologiocal clock.
Go to our website http://www.haveababy.com and set up a free consultation by phgone with me to discuss.
Geoff Sher
Hi,
I recently came here and read this post because my wife had a diagnosis that are:
AMH: 12
FSH: 5.6
LH: 10.7
E2: 28.9
Her doctor did not indicate she was PCOS, but all of our research says she is and I am nervous about problems with fertility and OHSS with her IVF cycle.
IS this PCOS levels ?
Thanks.
First of all, I would say Thanks that your blog has cleared the picture of infertility which my wife is having. Her FSH level is 3.4 and LH level is 13.2. She is completely unable to ovulate. She has treated by Laproscopy & all other infertility treatments but still no positive response. Now we are going for our Ist IVF, her age is 30 only so I would like to know- is there any other option available for us or ivf would be the last one?
Thanks you in advance for reply…
IVF is not the only option for PCOS but it is the safest, for the reasons outlined abortive. One of the problems in dealing with ovarian stimulation in cases such as yours, is that the women tends to overstimulate and thus the protocol must be carefully fashioned to avoid severe ovarian hyperstimulation syndrome (OHSS).
Please read up on OHSS elsewhere on this site.
Good luck!
Geoff Sher
Dr,
Are there any cases in which you would recommend IVM in place of IVF? I'm a lean PCOS patient, and been TTC for 5 years. Had one healthy boy before I even knew I had issues. Now my testosterone level is over 100, although i have no symptoms of suck. Clomid was a fail, and i'm debating between finding a doctor who would do IVM and just trying IVF.
Hi Dr Sher
I'm reading this with fascination! I am 37 and have an AMH at 3.74, but two years ago it was 6.3. I know this is high for my age, but it never occurred to me that I might have PCOS because I have regular cycles. I had a ruptured liver 13 years ago from a horse riding accident, and my surgeon from that time prefers that I don't even have a laparoscopy due to the chances of adhesions being so high. I chose (against my fertility specialist's recommendations) to have a mini IVF first time around, and I had three low quality embryos. Do you think this could be PCOS due to pelvic adhesive disease? Would that explain the high AMH and low quality embryos? Of course age could also be a factor, but there is nothing that can be done about that. Should I get testosterone levels tested together with LH/FSH just to eliminate the other two possibilities?
I would not diagnose PCOS on the basis of a high AMH and poor quality embryos, alone. The latter could have to do with the protocol of ovarian stimulation.
Might I suggest that you call 800-780-7437 and set up a free telephone consultation with me to discuss in more detail before you undergo further testing.
Geoff Sher
My sister is 30 years old and has PCOS. She and her husband have been trying to get pregnant since they had my nephew 8 years ago (after three years of trying to get pregnant with him). She recently got pregnant, but ended up loosing the baby. I am a healthy 24 year old with two girls of my own, and I had one miscarriage between my two full term pregnancies. I have offered to be a surrogate for them if they choose to go that route, but I am wondering if the eggs of women with PCOS are ‘good’ enough for surrogacy? Are there any risks additional risks to either of us?
Indeed the eggs could be fine, provided the stimulation protocol used is selected strategically.Please go to http://www.IVFauthority.com and when you get to the home page find the “search bar” in the right hand column. Type in the following subjects into the bar and it will take you to all the relevant articles I posted there.
1. “An Individualized Approach to Ovarian stimulation” (posted on November 22nd, 2010)
2. “PCOS”
3. “IVF success: Factors that influence outcome”
4. “Traveling for IVF from Out of State/Country– The Process at SIRM-Las Vegas” (posted on March, 21st 2012)
5. “A stepwise approach to IVF at SIRM” (posted March,9th, 2012)
6. “Gestational Surrogacy ”
You might also consider calling 800-780-7437 or 702-699-7437 to set up a telephone consultation with me (which is free if you reside in the U.S.A or in Canada) so we might discuss your case in detail.
Geoff Sher
Dr. Sher,
Hello there! My Husband and I have been wanting a baby for sometime now and I too was diagnosed with PCOS. A friend of mine is now doing IUI through your office and is extremely happy with the info she recieved and the service as well. I have read your websit inside and out and have learned SO much! Thank you! In my fertility adventures so far, I tried Oral CLomid once with no response so it was increased, and then again the response was, what I was told, good at first, but egg development stopped. Moving on in our adventures,we tried IUI going very slowly with FSH injections. Upon increasing the dosage, we finally got a response, but when I went in for the HCG Trigger Shot, and was told there were too many mature follicles that the Dr. recommended not continuing the treatment due to dangerous situations/outcomes. Just learning from your website today, there are different types of PCOS. I have always had abnormal and absent periods since starting at age 12, I have Excessive hair growth, a consistent high estrogen level, drastic weight gain starting at age 24 mainly in my midsection, and now only one to two cycles a year. My OBGYN has told me it is imparratiive to have a cycle at least every four months. About a two months ago I took Mediprogesterone (sorry the spellign is incorrect) for ten days to have a cycle which only lasted for about four days off and on. Also when ultrasounds were done, prior to begining IUI, I had an antrel count of 19 and 24 in my ovaries. With My PCOS diagnosis, I was also diagnosed as Anovulatory. I know you can’t tell me for sure which PCOS category I fall into, but which does it sound like? Oh and I have also been told I have a higher risk fo hyperstimulation since my ovaries look like full Easter Egg baskets. WOW I shared alot of information. I hope it was helpful to someone. So Dr, I am now 31 years old and fearing pregnancy is not an option????????????
Hi Stephanie,
It is not possible to say whether you have hypothalamic-pituitary-ovarian PCOS or adrenal without acces to all endocrine tests done…mainly: FSH, LH, DHEAS, Androstenedione, testosterone and 17-oh progesterone. If you send or post these results for me, I would be in a better position to offer that opinion. What I do know is that you need to sort this out. So, I strongly urge you to call 702-699-7437 and set up a Skype (or phone) consultation with me so we can discuss your case in detail.
G-d bless and Merry Xmas!
Geoff Sher
Dr. Sher,
Thank you for your response. I am going to be putting in a request for my medical records and I will get you that information. I will definitely call after the holidays. Thanks again! God Bless and Merry Christmas to you too!
Merry Xmas and Happy New Year!
Geoff Sher
Dr. Sher,
I would like to share some background information before going into my current situation. About 4 years ago I started to experience irregularity in my periods and my cycles became very long (35 days maybe). Then about 3 years ago I went on birth control pills (Loestrin 24) for birth control purposes; after a few months of taking them I came off the pill. It took several months for my cycle to become more regular and finally a year after coming off the pill I had normal 28-30 day cycles for the first time in years. I was ovulating on cd13-15 with a luteal phase of about 13 or 14 days. With a sister who was diagnosed with pcos and my own symptoms of excess facial hair as well as tendency to gain weight around the midsection despite being very skinny, I feared that I might have PCOS. I was never officially diagnosed and last year in January I got pregnant, but unfortunately I had a second trimester loss.
Now several months post loss I am beginning to notice that I am ovulating very late into my cycle (cd22 or cd23) with a short luteal phase of 11 days. My FSH levels for cycle day 16 were 8.8 while LH levels were 13.7. I also had slightly elevated cholesterol levels and my glucose levels were slihtly elevated as well. My primary care doctor doesn’t think I have pcos since my ultrasound report did not show any cysts. Should I get further hormonal testing? Do my symptoms sound like pcos? The reason I am posting is here is because I am having trouble conceiving again and I believe my late ovulation might be pcos related.
The inverted FSH:LH ratio is reminiscent of PCOS but not absolutely diagnostic. The family history is another factor in favor of PCOS. The fact that you have ovulated on your own…even that you conceived, and the inability to clearly define subcapsular microcysts in your ovaries does by no means rule out PCOS. I would do hormone testimg, including (but not necessarily limited to: Testosterone, DHEAS, androstenedione and 17-OH progesterone. I would also have blood insulin measured.
Please go to the home page of this blog (www.IVFauthority.com ). When you get to the look for a “search bar” in the upper right hand corner. Type in the following subjects into the bar and it will take you to all the relevant articles I posted there.
“An Individualized Approach to Ovarian stimulation……” (posted on November 22nd, 2010)
“Ovarian Stimulation …….: Why is it important to down-regulate LH?”
“Agonist/Antagonist Conversion Protocol”
“Traveling for IVF from Out of State/Country– The Process at SIRM-Las Vegas” (posted on March, 21st 2012)
“A personalized, stepwise approach to IVF at SIRM”; Parts 1 & 2 (posted March, 2012)
Also read up on “PCOS” and on “IUI”
Consider calling 800-780-7437 or 702-699-7437 to arrange a telephone or Skype consultation (free of charge to those who reside in the United States or Canada) so we can discuss your case in detail.. While an audiovisual (Skype) interaction is much more personable and preferable than a discussion by telephone, either will suffice.
Geoff Sher
P.S. 11 day luteal phase is not a luteal defect
Big issues at my house. Morgan, my exquisitely beautiful cheerleader and gymnist has been diagnosed with PCOS. We have seen several specialists but have yet to get a handle on the weight gain. She gained 30lbs this past summer and she has dieted appropriately since with no results. She exercises regularly and maintains an active lifestyle. She is 5’2″ and is nearing the 150 mark. She eats few carbs and no fats. Where do we go from here. We are finding it difficult to find a physician that wants to do anything more than label her with the diagnosis. I need to find someone somewhere that will go the extra mile to get this deal manageable for her. We understand it will be hard work but after 9 months we feel as though we accomplished nothing.
I wish I had an answer…but this is a tough one. PCOS women have a hard time maintaining a normal BMI. The only hope is to enlist a dietician and trainer …and then to stick to a very rigid exercise and diet regime. BUT this will not be easy.
Good luck!
Geoff Sher