Guest post by Rashmi Kudesia, MD MSc
Today we bring you the third and final section of our series on optimizing pregnancy outcomes for women with polycystic ovary syndrome (PCOS). Though the PCOS diagnosis can all too often make a woman feel that her body is out of control, here we address some concrete actions women can take to improve pregnancy outcomes. Without question, the first step is knowledge. Do you understand what PCOS really means – for your fertility, a pregnancy that is hopefully soon to be on the way, and your long-term health? Remember, knowledge is empowerment, and that’s definitely action item number one. Make an appointment to talk to your gynecologist or a reproductive endocrinologist about every possible impact of this diagnosis.
Part of the knowledge phase is understanding that even if your cycles are very irregular, and you don’t routinely ovulate (release an egg), for PCOS women there is always a chance of a random spontaneous ovulation – accidental pregnancies occur frequently! Until you’re ready to be pregnant, stay on some form of contraception. When you know you are ready to conceive, or even just trying to get things in order for conception, here are some important considerations.
Most importantly, start a prenatal vitamin. By the time you can confirm a pregnancy, you are already about 4 weeks along, and the folate in prenatal vitamins is critical to the earliest stages of development.
Next, think hard about where your health status is. In our prior posts, we reviewed the data about optimizing weight prior to conception – there is definitely a benefit! If you are in your 30s or younger with a body mass index falling in the obese category, there is good data to suggest that taking 3-6 months to improve your diet and exercise regimens can improve your fertility, chances at a healthy pregnancy, and the health of your child. Even if you think your weight is where it should be, get screened for diabetes. Even lean women with PCOS have an elevated rate of insulin resistance and diabetes in pregnancy, so it’s best to know where you stand prior to pregnancy. This all is hard time and effort well spent! Line up a healthcare team that is supportive and upfront about your health goals, including a nutritionist and a trainer or exercise coach as fits your needs.
Third, get the rest of your health lined up for pregnancy! Make sure you’ve seen your primary care provider, and you’re up-to-date on your vaccinations and don’t have any other outstanding medical problems. Pregnancy tends to exacerbate many medical diagnoses, so getting a good handle on your health prior to pregnancy is crucial.
- Consider alternate treatment options. Though Western medicine has a rather effective way of managing fertility for PCOS women, many women would prefer a more long-term approach that helps normalize their cycle and symptoms. Though insurance coverage is going to be limited for alternative options, your options include herbal medicine, acupuncture and supplements (inositols) that can help some PCOS women achieve a more regular cycle. These approaches are not for everyone, and unfortunately many Western medicine providers will not be very knowledgeable about these options. Try to find a specialist or virtual community who can help you understand and explore these options, if you’re so inclined!
- Make sure you’ve had your thyroid levels checked. There is conflicting data on the relationship between thyroid abnormalities and PCOS, but some studies suggest a correlation. Elevated thyroid levels (with stricter criteria than we use for general medical purposes) may be associated with reduced fertility and an increased miscarriage rate, so it’s worth making sure your levels are optimal.
Alright – congratulations – you’re really ready now! Here are a few last tips as you actively pursue fertility treatments.
- Keep track of your menstrual pattern (using a mobile application can be extremely helpful!), and make sure you understand what your bleeding patterns means, and that you’re not going too long (>3 months) without a bleed.
- Make sure that you’ve stopped any potentially harmful medications, including those for acne or extra body hair that PCOS women often take (Accutane, spironolactone, and so forth).
- If you don’t ovulate regularly, and are being prescribed “ovulation induction” medication, critically assess your options. The large multi-center trial PPCOS II demonstrated that letrozole was a better option for PCOS women than clomiphene citrate (Clomid). Despite this, many women are still initially prescribed clomid by their general gynecologist. Now, Clomid could definitely work. However, keep in mind, when I see patients that have a history of unmonitored clomid cyles (no ultrasound after medication to gauge response), I end up just disregarding those cycles, because I don’t know how the uterine lining looked, or how many follicles grew in response. If your healthcare provider doesn’t explain to you properly how to use the medication, offer letrozole and monitoring options, or give you realistic success rates (20% or less per cycle), then consider seeking consultation with a fertility specialist.
- Be particularly wary of any recommendations to proceed quickly to injectable medications – the indications for that regimen are few and far-between, and injectables definitely increase the risks of cycle cancellation and multiple gestation (though twins are adorable, twin pregnancies are associated with higher rates of pretty much every pregnancy complication, most importantly prematurity!).
- Finally, there is some evidence to suggest that PCOS women have lower luteal progesterone levels (progesterone supports the uterine lining and a healthy implantation in the second half, or luteal, phase of the menstrual cycle), so in a monitored cycle, you can get your levels checked to ensure that there is no need for supplementation.
The hard work here is really in trying to make sure your lifestyle is as optimal as possible. This effort is to be praised, and though it often seems unfair that your PCOS diagnosis makes this harder, the payoff is truly there! Beyond that, your other big assignment is to make sure you have assembled a care team that takes the time to explain your options carefully and implement treatment regimens that have your best interests at heart. You can definitely do this – good luck!
Dr. Kudesia is a board-certified Reproductive Endocrinology and Infertility specialist, practicing at Houston IVF in Houston, Texas. She joined Houston IVF in 2018 after practicing in New York City, where she was named a “New York Super Doctors Rising Star” in 2016 and 2017.
After completing her Baccalaureate degree in Biology & Medicine magna cum laude from Brown University, she received her M.D. with honors from the Duke University School of Medicine, where she was selected into a clinical research training program co-sponsored by the National Institutes of Health. Her residency training in Obstetrics & Gynecology at the New York Hospital-Weill Cornell Medical Center was followed by subspecialty training in Reproductive Endocrinology and Infertility (REI) at the Albert Einstein College of Medicine-Montefiore Medical Center, alongside a Masters’ of Science degree in Clinical Research Methods. She subsequently served as a Clinical Assistant Professor at the Icahn School of Medicine at Mount Sinai, as well as the Research Rotational Director for the REI fellowship, and Medical Director of the Brooklyn office of the Reproductive Medicine Associates of New York.
Dr. Kudesia is a Fellow of the American College of Obstetricians and Gynecologists, and an active member of the American Society for Reproductive Medicine (ASRM), Society for Reproductive Endocrinology and Infertility, Androgen Excess & Polycystic Ovary Syndrome Society, and American Medical Association (AMA). She has served in multiple local and national leadership roles in organized medicine, including her current positions as Secretary of the ASRM Women’s Council Executive Board and the ASRM delegate to the AMA Young Physicians’ Section.
Dr. Kudesia has also presented scientific research at national and international conferences, and has received multiple awards and grants for her work. She has published peer-reviewed articles and book chapters, including in leading journals such as Fertility & Sterility and the American Journal of Obstetrics & Gynecology, as well as editing a theme issue on reproductive medicine for the American Medical Association Journal of Ethics. Her current areas of focus include improving in vitro fertilization cycle prognosis, polycystic ovary syndrome, LGBT fertility, and fertility awareness, counseling, and access to care. She actively promotes women’s health and wellness on social media via Twitter, Facebook, and Instagram.