HOW TO DEAL WITH PCOS AND INFERTILITY

• MD/CEO, NORDICA FERTILITY CENTRE, DR. ABAYOMI AJAYI

Many women who are presently encountering Polycystic ovary syndrome, PCOS don’t realize it yet as they battle infertility, weight gain, and other concerns. They might not be getting the answers they need from their doctors. This informs why creating adequate awareness is needed.

Polycystic ovary syndrome is a common hormonal condition that affects women of reproductive age. It usually starts during adolescence, but symptoms may fluctuate over time. PCOS can cause hormonal imbalances, irregular periods, excess androgen levels and cysts in the ovaries. Irregular periods, usually with a lack of ovulation, can make it difficult to become pregnant. It is a leading cause of infertility.

One shocking fact about PCOS is that it’s a chronic condition and cannot be cured. However, some symptoms can be improved through lifestyle changes, medications and fertility treatments.

Joining the entire world in making September a significant month for PCOS awareness, a renowned Nigeria gynaecologist and fertility expert, Dr. Abayomi Ajayi in a media chat talked about what women should know pertaining PCOS, and how the health condition can be managed. Below are excerpts:

‘It’s said about 10 to 15% of women will encounter polycystic ovarian syndrome. Unfortunately, about 50% to 70% of them will not be diagnosed, so there’s still a lot of misdiagnosis and under-diagnosis going on, misdiagnosis in the sense that so many people are labelled to be PCOS when they are not, and the real people who have PCOS are not diagnosed most of the time, and so it’s important for us to be able to talk about this, ask questions, and be sure that information we’re passing across is the truth, and why do we have this misdiagnosis? Mostly because now many people just look at the scan report and say there’s polycystic ovarian syndrome from the scan alone, but we know that that might not be totally true, so the question is how do we diagnose polycystic ovarian syndrome? Now, it’s usually said that two out of three symptoms should be present before you can diagnose polycystic ovarian syndrome, the first one being that the woman will have irregular menstrual cycles, usually less than eight or nine a year. Why is this so? Because what we call polycystic ovaries are follicles arrested at different stages of development, which she did not ovulate, and therefore those months where they are arrested and she did not ovulate, she might not see her menses when it is due.

“We know that normal menstrual period should come 20 days plus or minus seven, so 21 days is normal, 35 days is normal, after 35 days it’s not normal, so most of these women will have menstrual periods, the duration will be more than 35 days, and that’s why they might not have more than eight periods in a year. Now, for the uterus to be healthy, when you are not on any form of contraception, you need to bleed at least four times in a year for the uterus to be healthy. We’ll see the consequence of this, they are not menstruating regularly with time.

“Now, that’s number one. The second thing is that because they have higher male hormones, they tend to have the male pattern hair growth, so it’s not unusual for you to see some of them having beards, some of them having hair on their chest, and even in the genital area, some of them will have the male pattern. The female pattern is usually an inverted triangle, the male is the one with the triangular pattern, so you see some of them having this triangular pattern of hair around their genitals.

“Some of them can be hairy generally, and then that’s with the male hormones, that they have excessive male hormones. They might have oily skin and they might have acne. Now, the other thing is that when you do a scan on them, you will see these so-called polycystic ovaries.

“It’s so-called because they are not really cysts, they are follicles arrested at different stages of development, and therefore, that’s one of the reasons when you give them drugs to ovulate, some of these drugs in some of these follicles just shout hallelujah, and then you have quite a number of them becoming active and getting to want to ovulate, and that’s also one of the complications that you can have from men who have polycystic ovarian syndrome. Now, the million-dollar question is what causes polycystic ovarian syndrome, and unfortunately, we still don’t know that yet, but we think there is definitely a genetic linkage because it runs in families. We also have been able to see some things that are like the pathology that might lead to polycystic ovarian syndrome.

“One of them is that we mentioned higher male hormones. So, this usually results from what we call insulin resistance. Now, this insulin is a hormone that releases sugar or energy in us.

“It’s the hormone that attracts glucose from the cells, from the blood. So, insulin is the hormone that attracts sugar from our blood into the cells. For example, after we have eaten and there is a bowl of a bowel, there is a lot of sugar in the blood.

“It’s insulin that drives the sugar into the cells, and that’s why we have energy to be able to do work. Now, if there is resistance, the sugar is not dragged into the blood, and therefore, because the body senses it, the body will tend to produce more insulin. And so, we have what we call, in a state we call hyperinsulinemia, the plenty, too much insulin in the body.

“What this does is that it makes also the, the insulin now makes the reproductive organs to produce more of the male hormone, and that’s why they have abnormal male hormone levels in their blood system, and also the symptoms of what we call estuarine, which is excessive hair growth, or male hair growth, like I described before. They have abnormal places for women. And now, the other thing is that we also have found out that this is also a tricky part, that they have a state of low level of inflammation, something similar to endometriosis. So, they have this low inflammation.

“For the state we call hyperinsulinemia, there is plenty or too much insulin in the body. What this does is that it also makes the insulin now makes the reproductive organs produce more of the male hormone. And that’s why they have abnormal male hormone levels in their blood system.

“And also the symptoms of what we call a cytosine, which is excessive air growth of male air growth like I described before. They hairs in abnormal places for women. So, and now the other thing is that we also have found out that this is also a tricky part, that they have a state of a low level of inflammation, something similar to endometriosis, you know. So, they have this low inflammation, level of inflammation going on. And this also contributes to the ovary to produce more androgens or the male hormone. So, but like I said, we don’t know exactly what is the, what triggers all these changes, but we think there’s a genetic composition to it. And because they have so many, they have this arrested, these follicles arrested at different stages. They also have higher levels of oestrogen. So that’s, but now how do we treat it? We know what the problem is.

“And this is also because they don’t ovulate regularly. This is why they can have infertility. So our main aim will be, if it is just PCOS, to make them ovulate. And that we do very well with drugs. But the fact that you have polycystic ovarian syndrome, because it takes two to tango, does not mean that your husband is completely free. And we know that male factor infertility is particularly very common in this part of the world.

“So the first thing to do with a patient who has infertility, even if you have diagnosed polycystic ovarian syndrome, is to do a proper evaluation of the infertility, which includes doing the seminar fluid analysis. And then you work out, you do a scan, you do HSG to be sure that the tubes are fitted, and then you do your hormone assay. When you have done this, then you already know she has polycystic ovaries, or you might be suddenly surprised to see that the man also is, there’s male factor infertility, and that immediately changes the picture.

“But if it’s just PCOS, then you can start with just trying to do ovulation induction with drugs. And there are many drugs that can be used. I don’t like mentioning the names of drugs so that patients don’t self-medicate, but the success with using drugs for ovulation induction is about 80%. So it’s very high. And if that is the only problem, don’t forget there’s also something called unexplained infertility. So you might have that and still have unexplained infertility.

“If that is the only problem, we just give them drugs and then watch them to ovulate. And then if every other thing is okay, then there’s pregnancy. But if they don’t get pregnant, then we go for that and go into this realm of assistive reproduction. Usually if the woman is less than 35, what we want to start with, and the tubes are fitted, we want to start with intrauterine insemination. And then, we get the sperm and use drugs to make her ovulate and then inject the sperm at the proper time into the uterus.

“And then hopefully there’s a pregnancy. But when all this doesn’t work, then we have to revert to IVF. Now, you know, we said that this, the peculiarity of this woman is that her follicles are extracted at different points of development. So when you give them any drug for ovulation induction, they should not be done by just ordinary doctors who are not gynaecologists because you need to monitor them because they run the risk of having this ovarian hyperstimulation. Okay. And this can be any drug.

“It does not have to be the high-falutin injectables. It’s been known that they can have hyperstimulation even with the commonest drug that we use for ovulation induction, which I don’t want to mention, which is a drug that people just use, it’s almost an over-the-counter drug in Nigeria. Though now a lot of things are being done to make it that it’s not an OTC.

“It’s a drug, it’s a prescription drug because it can be dangerous for this kind of woman because they can actually have ovarian hyperstimulation. Now what is ovarian hyperstimulation is an excessive reaction to ovulation induction drugs. So they’ll produce so many eggs and this sometimes can become very dangerous and can even be fatal because they can lose a lot of fluid into the system from the blood vessel.

“And if this is not taken care of, they could actually drown in this fluid that is in their system. So this is a very dangerous complication of ovulation induction, whether you are doing anything, either you are just doing standalone ovulation induction or you are using it for IUI or even when you are using it for IVF, especially when you are using it for IVF. So this is a very important thing to look out for in this group of women. And because of this, all this hormonal derangement, if you like, sometimes what we do is that we do what we call freeze-off for this patient. When we do IVF, we don’t transfer the embryos fresh.

“We now prepare the endometrium to receive the embryos that we have frozen or we have pulled. Another peculiarity is that despite the fact that they have many follicles, the majority of them, because the follicles are not of good quality, are old, they don’t produce good eggs. So if you have many follicles, you can be thrown into hyperstimulation, but the number of good eggs that we can get from the cycle might not be many.

“So sometimes we have to pull eggs or embryos for this kind of patient. And then we still do what we call the frozen embryo transfer for them. And this has very good results. Frozen embryo transfer is particularly important in these patients because don’t forget all the hormonal derangement I described earlier on. They have so much, the follicles are producing oestrogen. So the oestrogen level is very high in such patients.

“And you know the way ovulation happens is that when oestrogen reaches a particular level, it triggers some reaction and then we see that the patient can ovulate. So, you can see these patients ovulating even while you’re still stimulating them. And they might not, no matter how good your embryos, because you know that in reproduction, there is just a stage where the endometrium can receive the embryos.

“And while you are still trying to make R2s, you are stimulated to produce eggs, you have already passed your window of receptivity in the endometrium, so there is no work now. So that’s why it’s so important for us to collect the eggs and the embryos or the embryos and then transfer, freeze and transfer in another cycle. And what this does to us is that also we’re able to use some drugs that we started mainly because of these people, because of the hyperstimulation that has taken hyperstimulation completely, almost completely away from our lexicon.

“We are able to use a part of the kind of stimulation regime which we call the antagonist protocol. And then with that, it has reduced, limited the incidence of ovarian hyperstimulation to very minimal levels. And that’s why some of us have not seen ovarian hyperstimulation for 10 years, 10 years now. So, and that’s what is very important in this group of people, that such procedures are done for them to prevent hyperstimulation in this kind of patients.