What You Need to Know About PCOS, Fertility, & Pregnancy [Podcast] - PCOS Diva
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What You Need to Know About PCOS, Fertility, & Pregnancy [Podcast]

PCOS Podcast 118 - PCOS, Fertility, & Pregnancy“If you, as a PCOS patient, do not feel that your healthcare provider is taking ownership in your problem, get someone else. You have been frustrated long enough, you have been overwhelmed long enough, and you need someone to be your advocate, to answer your questions, to provide you with options as opposed to only one way, to be cost-conscious, and to be your ally- to work with you along your journey. However long it takes to find the right doctor, I think you need to do that.” – Dr. Mark Trolice

If you’ve been diagnosed with PCOS, you may have been told, “It’s going to be very difficult for you to have children,” or even, “You won’t have children.” Dr. Mark Trolice is here to tell you that is not necessarily true. Dr. Trolice is the Director of Fertility Care at the IVF Center in Winter Park, Florida, and is a double board-certified doctor in reproductive endocrinology and fertility as well as an OB/GYN. He spends a lot of time advocating for women with PCOS on a national level as well as helping them to conceive and have healthy pregnancies. On this podcast, we discuss fertility challenges for women with PCOS and how to overcome them. Listen in (or read the transcript) as we discuss:

  • Causes of PCOS and criteria for PCOS diagnosis
  • Why you have excess hair growth and when to consider electrolysis or laser hair removal
  • Things to consider (other than PCOS) if you are having trouble conceiving
  • What to do before you try to get pregnant
  • Letrozole vs. Clomid
  • Pros and cons of ovarian drilling
  • Special considerations for women with PCOS undergoing IVF

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Mentioned in this podcast:

Full Transcript:

Amy:                                     Today I have the pleasure of speaking with Dr. Mark Trolice. He is the Director of Fertility Care the IVF Center in Winter Park, Florida, and he is a double board-certified doctor in reproductive endocrinology and fertility as well as an OB/GYN. In 2018 I had the pleasure of meeting him in person as he was awarded the Social Responsibility Award by PCOS Challenge. His practice was a very wonderful sponsor of the PCOS Challenge symposium and walk, and I have a lot of appreciation for Dr. Mark, and I’m just so glad that he’s come on the PCOS Diva Podcast to talk about fertility challenges for women with PCOS.

Amy:                                     So welcome, Dr. Trolice.

Dr. Trolice:                          Oh, thank you Amy. Thank you for the invitation, and kudos to you for all the wonderful work that you’re doing to empower women about PCOS. I really admire how much effort you’ve put into this, and you’re a great resource.

Amy:                                     Thank you. I can’t believe it has been 10 years since I started PCOS Diva, and as you mentioned, empowering women with PCOS with the knowledge they need to go and advocate for themselves. A lot of women listening are just probably now starting their fertility journeys. They’re looking to try to conceive, they may have been told by doctors, I share about this all the time, that, “You have PCOS, it’s going to be very difficult for you to have children,” or, “You won’t have children.” You feel like you’re up against a huge mountain, you have a huge mountain to climb when you have PCOS when it comes to fertility.

I always advocate that women go and find a good reproductive endocrinologist, and you are just that. I would love for you to kind of help educate us on what some of the fertility challenges are for women with PCOS.

Dr. Trolice:                          Sure, I’ll be glad to. Well, you hit it on the head about the frustration. It begins not only with the symptoms, Amy, but at least a third of women wait greater than two years, and almost half need to see three or more health professionals, like myself, before they are diagnosed with PCOS. I mean just imagine going through the discomfort of having irregular cycles, not knowing what’s going on there, why they’re having the hair growth and things like that. It’s just such a shame in that respect. I try to make PCOS really simple in terms of being able to explain it to the patient. They did nothing wrong. They were born with this to some degree.

So, where does it come from, Amy? Well while the woman was inside her mom as a baby, she was exposed to some increase in male hormone, either from mom’s higher levels of testosterone because she had PCOS, and/or mom had some elevated anti-mullerian hormone, which we see with PCOS, or AMH. That’s the ovarian age test. And when baby is exposed to that inside mom, that seems to set the stage for PCOS. We don’t completely understand what causes this. That’s the premise that we have to go by. But we know what the signs and symptoms are. And women can present as girls. They have earlier onset of secondary characteristics, in terms of the hair growth, the pubic hair, axillary hair.

So, the diagnosis, at least as an adult, is based on having two out of three criteria. That’s really what we all ascribe to now. It’s the Rotterdam Criteria way back in 2003, and we’ve really kept up with that. One of the criteria is irregular cycles, clearly. Women with PCOS can bleed every few months, once every six months, a year, never, or every day. And all of that is seen in PCOS.

I describe the bleeding that patients have as overflow bleeding. So, they’re not ovulating, they don’t have that hormonally controlled withdrawal bleed after ovulation. Estrogen builds up your lining, then after ovulation, progesterone kicks in, stabilizes the lining. If you’re not pregnant, both those hormones go down and you shed your lining. PCOS bleeding is if you get a hose, put it into a pool, and forget to turn it off. And you overflow. It’s not hormonally controlled. It’s just havoc, haphazard and miserable for patients. So abnormal uterine bleeding, we’ve got that.

Number two, hair growth or some elevated male hormone measure, typically total testosterone. Up to 70% of patients with PCOS are going to have some hair growth. What women don’t really know is that they’re not growing new hair. Women are born, like men, with all the hair follicles they’re ever going to have. So, when they get some elevated male hormone … And by the way, I have estrogen, you have testosterone, Amy, but we have a lot more of what we need. Women with PCOS have relative elevations in testosterone. Not to the degree of men, but higher than most women.

So, the hair follicles that they are born with, they get turned dark because of circulating testosterone. Actually, it gets converted to dihydrotestosterone or DHT, but it gets dark. And once it gets dark Amy, that’s it. You’re not going to get that hair to go back. Plucking, pulling, shaving, any of those depilatory methods, are just going to make it potentially worse by inflaming the hair follicle.

How do you get rid of the hair? Electrolysis or laser. But, and a big but here, don’t start that process until you stop the conversion of the hair that you have. In other words, if you don’t do anything else, and just go to electrolysis because of the hair, you’ll be being in and out of the doors of the electrolysis constantly, for a long time, going back every few weeks or months or so and so forth, because you’re not doing anything to stop it. So how do you stop it, birth control pills and anti-male hormone. So, once you stop the conversion of the light to dark hair, then after about six months or so, then you could get the electrolysis or laser to stop the hair that you have, and get rid of that hair, and your hormone medication is preventing new hair.

So, you’ve got those two things now, we’ve got the ovulation dysfunction, irregular cycles, you got the hair, elevated testosterone. The last one is polycystic ovaries. The name polycystic ovary syndrome is really a misnomer. Because you don’t have to have multicystic ovaries to make the diagnosis, you only need two out of these three criteria.

But the other thing Amy, is that patients, when they hear the word “cyst,” I don’t know about you, but when I tell a patient they have cysts in their ovaries, it’s panic. But it’s not bad cysts. I mean there’s good cysts and bad cysts, but it’s not bad cysts with PCOS. You have these little tiny, tiny little cysts that just surround the ovary, and there’s a lot of them. Now these cysts you need because they have eggs, but PCOS patients have a lot more, and the configuration of that, and how the ovary looks in ultrasound, puts it at one of the criteria. So, two out of these three criteria make the diagnosis of PCOS.

Amy:                                     So, let me ask you a question about the cysts. I am sort of under this belief that PCOS, in and of itself, is not a painful syndrome. There are other issues … If a woman is experiencing a lot of pain then there’s something else going on in addition. A lot of women in PCOS have cysts that burst, and they experience a lot of pain. How is that similar or different to those multiple small follicle cysts that you described?

Dr. Trolice:                          Perfect question. The small little follicles, or follicular cysts, little baby cysts in the ovary, are safe, and they are not of concern. Cysts can get large, they can rupture and cause bleeding and pain, or you could have different types of cysts. I’ve seen patients with PCOS who have endometriosis. Endometriosis is typically what we call is due to incessant, or nonstop, menstrual cycles, not interrupted by pregnancy or the birth control pills, and the blood flows out through the vagina and back through the tubes, which happens in a lot of women. But some women, it sticks to the ovaries or the pelvic cavy. Endometriosis is the lining of the uterus anywhere it’s not supposed to be. So, patients with PCOS could even have endometriosis.

But to your point, PCOS patients, do they have pelvic pain? Typically, no. Can they get gynecologic problems like other women? Yes, but women with PCOS, they can have pain, or discomfort if you will, because they feel like they’re always going to get their period. I have patients describe feeling premenstrual, like they’re going to be getting their period, and premenstrual, unfortunately, hormonally and emotionally.

And by the way, which we’ll talk about in a little while, anxiety and depression are one of the side effects and risks of having PCOS. So, it definitely can lead to discomfort and disruption of a woman’s life, without a doubt.

Amy:                                     Okay, so the three criteria, maybe you could just recap that for us quickly?

Dr. Trolice:                          Sure. PCOS is diagnosed by having two out of these three criteria: one of them is ovulation dysfunction. You can have irregular menstrual periods anywhere from every day, two weeks, several months apart, six months, or never. Or, I’ve seen patients who have monthly cycles and don’t ovulate by doing blood testing. We check them for progesterone. So, you can have monthly cycles and not ovulate, particularly in PCOS patients. So that’s number one.

Number two, some measure of elevated male hormone. And that’s by having hair growth, dark hair, in what we call sex dependent, or male pattern, areas. Upper lip, chin, sideburns, neck. Chest, around the breast, nipple area, lower belly, upper belly, upper inner thigh, lower back, upper back. Male pattern areas. The other is an elevation in testosterone. Total testosterone elevations are often seen. Testosterone is also in the blood as a free testosterone, a little bit more difficult to calculate, but you really would only need a testosterone level if you were concerned, if somebody has something more serious going on.

Let me step aside for just a second. PCOS is a sign, or a condition, that can be caused from anything that increases male hormone in a woman. If you give a woman testosterone, they can start developing hair growth, as well as maybe getting some appearance on the ovaries, but they will start getting some irregular cycles as well. So, testosterone medication, sub-menstrual testosterone, or male hormone producing tumor, or other hormone producing problems, like Cushing syndrome, things that can increase male hormone, will give a polycystic ovary like picture. For our discussion today, when we talk about PCOS, we’re talking about the garden variety PCOS that is not other pathology, other concerns, it’s really ovulation dysfunction because of some elevations in male hormone, but not pathologic in terms of life threatening.

Now the third criteria, so we got ovulation, we got elevated male hormone, either hair growth or testosterone, the third is the issue of ultrasound. And the ultrasound appearance, you’ve got lots and lots of small little follicle cysts, and-or the ovarian volume, if you look at the volume of the ovary and calculate that. So, 10 centimeters cubed, or more than 20 small little baby cysts on the ovary, usually sub-capsule. We call that a pearl necklace appearance. More than 20 of those would meet the criteria.

Amy:                                     So, a patient comes to see you, and they’ve been diagnosed via this criteria, and they’ve been trying to get pregnant for quite a while, and nothing is happening. What would the first step be once you know that your patient has PCOS?

Dr. Trolice:                          Great question. Now we have a diagnosis of PCOS. So, what we do now is also … Well let me step aside just one second. Because somebody has PCOS, and that’s the most common, ovulation dysfunction in women, and as a result the most common reason for infertility in women, we don’t just put blinders on and say, “Oh yeah, PCOS, that’s why you can’t get pregnant.” Five to 10% of the time there could be a male factor, so we get a sperm analysis, and also do a complete history if they have a male partner. And five to 10% of the time or so they may have a tubal problem.

So I recommend, before we undergo ovulation inducing medication, is to do a Hysterosalpingogram, or an HSG. Now Amy, this is the procedure, very very common, a standard of fertility practice for decades, we inject dye up through the cervix into the uterus, patient’s awake, then under x-ray we can see that dye flow into the uterine cavity and backward through the fallopian tubes to see if the fallopian tubes are open. So, that’s the rest of the evaluation. Because in the fertility world we need three things: we need to know you’re releasing the egg, we need to know there’s an adequate amount of sperm, and we need to know those tubes are open and the uterus is normal. So that’s something, whether PCOS patient or not.

So, let’s say everything’s good. Let’s focus on PCOS here. I always tell my patients that PCOS is a reproductive problem and a metabolic problem. Metabolic is the machinery in your body that really runs so many different areas. And there’s a metabolic syndrome that is associated with PCOS. So, let’s just for a second talk about reproductive. We know you’re having abnormal uterine bleeding; we know that patients with PCOS could actually even present to the emergency room with hemorrhage because of the pool or flow, with the hose in the pool, remember I was talking to you about that, the pool or flows. They could have hemorrhage. And they sometimes need transfusion. So, anemia is a concern for patients who have continuous abnormal bleeding. They also have infertility, because you don’t know when and if they’re ovulating. These patients also have high risks of diabetes in pregnancy. They are predisposed to higher complications in pregnancy because of that. And a lot of times they’re overweight, and that’s a risk factor for infertility as well as pregnancy health.

So that’s reproductive. What about medical? So, we know that there’s this metabolic syndrome, and it is, up to 50% of PCOS women have this metabolic syndrome, and that’s a rate that’s two to four times higher than women who don’t have PCOS. So, what’s this metabolic syndrome all about? Well it’s part of insulin resistance, or pre-diabetes. Women with PCOS have a relative defect in their cells’ receptors for insulin. It takes higher levels of insulin to get the cells to take up blood sugar. And if there’s a defect in the insulin receptor, Amy, that means blood sugar circulates higher in the blood. If insulin is circulating higher in the blood, insulin, along with the pituitary gland, which is in the brain, LH, increases male hormone. So, you’re getting more of this vicious cycle of elevations in male hormone, and that increases the conversion to estrogen, which can increase the risk of pre-uterine cancer, it inhibits ovulation, it just goes around and around and around. So, insulin resistance.

Another part of the metabolic syndrome is obesity. And the fat cells in the PCOS patient usually center around the abdomen. I don’t know, your listeners may have heard about, when we talk about patients who are obese, some look like a pear and some look like an apple. The pair are more of obesity in the hip area, upper legs and the hip area; apple, mostly in the center. That is much more concerning for cardiovascular disease and insulin resistance. They also have, as part of this metabolic syndrome, abnormal lipids, which are the cholesterols and the triglycerides, which unfortunately increase the risk of heart disease too. Then lastly, high blood pressure.

So, these metabolic problems are present in PCOS patients, and whether they’re thin or not, of course obesity has to be overweight, but whether they are thin or not, they’re going to have those things. So, I address all of those medical problems before we just jump into a pregnancy. So, we do a two-hour-

Amy:                                     Which, I just want to interject, it’s so important, in order to have a healthy pregnancy you need to have a certain level of health yourself. That makes perfect sense.

Dr. Trolice:                          180 percent agree with that. So, we do a two hour blood sugar test. We check their blood pressure. We can check their cholesterol, and of course heir body mass index. An unhealthy patient will have an unhealthy pregnancy risk, and risks the baby. Obesity, unfortunately, risks many more complications during the pregnancy, high blood pressure, diabetes, even some birth defects and stillbirth, god forbid. It’s a hard thing, I completely get it, and when patients come in who are overweight, and have waited so long to try to get pregnant, If you talk about weight loss for them, they look at it as a punishment instead of a prescription. It’s a prescription, because even 5 to 10% of weight loss can improve ovulation function, and 30 to 50% increasing infertility. So it’s an area that will help them with their goal.

But it’s very hard, because people have eating issues for many different reasons. Unhealthy relationships with food, whether it’s a comfort, or whether it’s a stress reliever, or what have you. When you talk about nutrition, I think psychology should be part of any weight loss program for people, because of reestablishing a healthy relationship with food.

Amy:                                     Yeah. That’s one of the reasons the first chapter of my book is about thinking like a PCOS Diva, because that mindset piece is so important to managing your health and your weight.

Dr. Trolice:                          Yeah, so I think that … When a patient comes to see me with PCOS, as a reproductive endocrinologist, I take care of PCOS alone, but I am mostly seeing, of course, patients trying to conceive. Some of them are very proactive, very intelligent, and will come several years in advance, know they have PCOS, not ready for baby, but want to optimize their health before baby. That’s the dream, to do everything you can to make things better. And so, we go through the metabolic issues, and then going on the birth control pill.

The birth control pill has a way to help PCOS by reducing the amount of circulating male hormone, improving the hair growth issue. It will protect the lining of the uterus from risks of uterine cancer. Patients who have PCOS have higher risks of pre-uterine cancer and uterine cancer. Because once again, hose in a pool. The hose is estrogen, and if you’re not ovulating, all you’ve got is estrogen. Progesterone from ovulation protects the lining, and stops the pool from rising. So, if your lining is just getting estrogen, you’re going to increase the risk of hyperplasia, pre-cancer, and even cancer.

So, the birth control pill protects the lining. The other things that we do for the birth control pill, improving hair growth, and it also will help patients with ovulation after coming off it. I have so many patients, Amy, who come to me for a second baby. PCOS. First baby was conceived right after solving the birth control pill. They were on it for like five or 10 years. As soon as they come off it, they have some residual hormonal effect that seems to help with ovulation. We don’t understand that. But they don’t go back on the birth control pill after they deliver. They may breast feed, and then wait a year or two, and they’re back to irregular cycles and have to undergo ovulation induction to restore ovulation, and to see if we can try to get them pregnant with that.

So, those are the issues. So, do you want to try to conceive, or do you want to basically address the medical complications? So, we talked about those medical complications, the pre-diabetes, elevated blood pressure, elevated cholesterol, weight gain, hair growth, pre-uterine cancer and uterine cancer, and depression and anxiety. It’s so important to validate these patients with their medical and emotional devastation, with PCOS. They are so overwhelmed. So, the PCOS consultations that we have, we spend a good amount of time educating about what they have. They didn’t do anything about it.

And you know, going back to the weight again, you know you could have two women, one with PCOS, another woman without, they eat the same thing, the PCOS gains five pounds, the other woman doesn’t. So, the PCOS patient gains weight rapidly, and much more difficult to lose, but not impossible. It does take significant commitment, significant investment, but it is obviously much healthier in the long run. Because the overweight PCOS patient has much more risk than an overweight patient that ovulates. They have more risks of these metabolic problems, the pre-diabetes, elevated blood pressure, cholesterol, even the pre-uterine cancer. So not ovulating.

Even thin patient has risk factors that an overweight patient who ovulates has. I know that sounds confusing, so let me share with you. If you look at the spectrum of women, if a woman is thin who’s ovulatory, she has the lowest risk factors for disease, that we were talking about. If a woman is overweight and ovulatory, she has similar risk to a woman who’s thin with PCOS. So just having PCOS puts them at high risk. And then of course the most risk is the overweight PCOS woman. So, those are the areas that we address: do you want to get pregnant, or do you want to optimize your health? We do that on everybody of course, but some of them are maybe sometimes a year or two before they want to try to conceive.

Amy:                                     So, then what happens, they’ve got their health on track, but they’re ready to conceive, but they’re not ovulating. So, what’s the protocol?

Dr. Trolice:                          Right, so now we get into, how do we get them to ovulate. Weight loss, if they’re overweight, can help improve that. The best tool that we have right now to help them to ovulate is letrozole, which is sort of, most people know clomiphene citrate. It’s sort of clomiphene’s cousin, I call it. Letrozole works by blocking the conversion of testosterone to estrogen in the body. Particularly the fat cells. And what that does is, it makes the brain see, “Where’s all the estrogen, we need more estrogen.” So, the brain sends more signals to the ovary to get you to ovulate, and help restore ovulation function.

Amy:                                     So, I just want to clarify, in your practice you’re using letrozole as kind of first-line therapy over Clomid?

Dr. Trolice:                          Oh, yes. We’ve known that actually for several years, and recently the American College of OBGYN has come out to endorse that as well. They wrote a study-

Amy:                                     And that’s really important for those listening, because I can’t tell you how many women I hear from that, their doctors, they give them the prescription for Clomid, and there’s new science and research that’s coming out, as Dr. Trolice said, and letrozole is really preferred by reproductive endocrinologists, like himself.

Dr. Trolice:                          Yeah, for all women. But in all fairness, the study by Dr. Legro in Pennsylvania, in 2014, in the New England Journal of Medicine, looked at letrozole and clomiphene in PCOS women. And over five months of being on this medication, for all women, all weight, body mass index, letrozole was higher. But when they broke it down, the women who had a body mass index less than 30, it was pretty similar. Letrozole and clomiphene worked fairly well, and similar. About 30% or so, live birth rate, cumulatively after five months. When women started increasing their body mass index, that’s when letrozole stood out. Now, it’s important to know that, the higher their body mass index, the lower the pregnancy rate. So, women with a BMI less than 30, they had about a 35% live birth rate on letrozole. BMI above 30, less than 40, they’re down to 25%. Above 39, you’re down to 20%. So, weight is a big issue with PCOS.

So, I give them letrozole, but I also give them metformin. We screen their blood sugar pre-diabetes. If they don’t have pre-diabetes, metformin alone, in terms of reducing insulin resistance, has been shown to improve ovulation function. The live birth rate is still questionable on metformin, but that in addition to letrozole, I feel, may be of some value. But it is controversial as to what the live birth rate is, and are we really getting a benefit of take-home baby on metformin. So, the first line is that.

If patients don’t ovulate, or they’re still not getting pregnant, they then go to level two. Level two is either injectable fertility medication to get you to ovulate, and this is what the brain normally sends to the ovary when we give injectable meds, or laparoscopy ovarian drilling. So, I’m the only one in the region that’s doing ovarian drilling. I like that better than injectable medication, because if you have insurance it’s covered. You don’t have the risks of multiple births with the injectable medication, or the expense, or the multiple visits to the doctor for monitoring. Ovarian drilling, in our program we see somewhere around two thirds of patients ovulating, on average six to eight weeks after the surgery, it’s a laparoscopy, and about 50% or so of them are having a live birth. And I have patients, Amy, who have had multiple children, they get pregnant, they have babies, and they keep ovulating, and they have multiple children as a result of the ovarian drilling.

Amy:                                     I have to tell you that my mother has PCOS, I inherited it from her, and back in 1970 she had an ovarian wedge recession, which is what they kind of did back then, and then she was able to have me and my sister. And I don’t think a lot of people are talking about ovarian drilling. You’re actually one of the only doctors I’ve interviewed that has mentioned it. And you’ve mentioned the pros, are there any cons? Scar tissue development, what would the risk factor be?

Dr. Trolice:                          I’ve been doing ovarian drilling throughout my career, over 20 years. And I’m disappointed that my colleagues don’t talk more about that with patients, because really, the alternative is IVF. And unless it’s a mandated state for insurance coverage, IVF is costly without a guarantee. So, if a patient has insurance, they have the right to know that that’s an option. Even if they choose not to. A patient who has options is much more empowered and psychologically healthy than being told, “All you can do is IVF.” That really corners them, and disempowers them if you will, and making it more stressful.

Ovarian drilling is a very, very simple procedure. Telescope through the belly button, under general anesthesia. I do one other little puncture site right in the public hair. It takes me less than a half hour. We just cauterize, put little needle cautery into the ovaries, looks like a golf ball. Patients are home a few hours later, back to work a few days later, and then we wait on average six to eight weeks for ovulation. Studies that did what we call second look laparoscopies, they looked back in a few weeks after the surgery, and there was more scarring around the ovary in patients who did drilling. It was not clinically significant. The patients still conceived the same rate whether they had scarring or not. So, do they get scarring after ovarian drilling? Looks like it. Is it clinically important? Doesn’t seem like it. So, I don’t think that’s a reason to withhold that.

So, what about the risk to the ovary? Well rarely, you can cauterize excessively and actually induce ovarian failure. So, we don’t cauterize near the blood supply going to the ovary. We cauterize the opposite side of that ovary. And I have not seen ovarian failure, but it’s been reported in the medical literature. Reported in the medical literature means that there are cases where it occurred. It doesn’t mean that it’s a high risk, and if you’re prudent when you do the surgery you shouldn’t have that risk. You are going to reduce the number of cysts. AMH levels will probably decline. But you’re able to potentially conceive naturally, at home, as long as sperm count is reasonable and you have at least tube open.

Amy:                                     That’s really interesting, and I’m so glad that you brought that up, because like you said, it’s another procedure that you can kind of ask about, and advocate. In your practice in Florida, do you have people that come to you from other states to have this done? Just curious.

Dr. Trolice:                          Sometimes, yeah. I tell them to avoid the expense and travel, to try to find somebody locally, but I’m honored to help them if they want to travel here. It’s a well described technique, so I don’t think I’m doing anything different than what is already known. I’m just passionate about giving patients fertility options that don’t train their bank account, and take advantage of the fact that they have insurance for that.

Amy:                                     Moving on I guess to IVF, is there anything, considerations that are special, as a woman with PCOS?

Dr. Trolice:                          Yes. Terrific question. IVF clearly is level three for the PCOS patient after trying oral medication, and then either injectable medicine or drilling, which is level two, and then level three is IVF. So, IVF is always an option. It is costly and involves daily injectable fertility medication. The PCOS patient typically makes a lot of eggs. So, whereas 10 to 15 eggs on average, you’ll see 20, 30 eggs retrieved with a PCOS patient. They, as a result, have risks of something called hyperstimulation syndrome. The PCOS patient has risks of producing so many follicles with eggs that they can increase the risk of getting sick. And after the egg retrieval, particularly because of the HCG trigger shot to mature the eggs, they can develop a situation of severe dehydration, fluid accumulation in the tummy, blood clot, and they could be hospitalized. Extraordinarily rare life threatening, and we have less than one patient a year who has this condition.

What we do now for the patient with PCOS who is a known risk for hyper-responder, based on their AMH level and their antral, the number of follicles they have? What do we do, we do a two-step. In other words, we will get the eggs out, but we trigger, not with HCG, we trigger with a GNRH agonist, which is the top, top brain center hormone. But this is chemically altered to be able to give in medical form, and it’s leuprolide acetate, and it’s been well described for years to reduce the risk of hyperstimulation syndrome. So, we trigger that, and then we just fertilized the eggs and freeze the embryos.

So, when you said are there any special considerations, here’s the thing. Over the years of IVF, Amy, in my career, fresh embryo transfer days after the egg retrieval was always king. That was the best method. And frozen embryo transfers were the consolation prize. Over the years, because of improvements in freezing, with the advanced technology of vitrification, we’re seeing equal success with fresh and frozen. Except in the hyper responder like the PCOS patient. They do better frozen embryo transfer than fresh. For two reasons: one, a fresh transfer can increase the risk of hyperstimulation, then being hospitalized and getting sick. But the second is, the high response that their ovaries have to the medication causes high levels of estrogen production from the ovaries, and the lining of the uterus, called the endometrium, just doesn’t like that. It is not as receptive. And a study in the New England Journal of Medicine showed this to be, what we had all experienced. Is that PCOS patients don’t do as well in a fresh transfer as they would in a frozen.

So PCOS patients, unless they also have ovarian aging, which can happen, PCOS patients are eventually going to have ovarian aging, like all women, but usually at a later age, however there are some patients who have some ovarian aging in PCOS. Those are patients you could do a fresh transfer on. But the hyper responding PCOS patient does better with freezing the embryos right after the egg retrieval, and then doing a frozen embryo replacement cycle. That’s the big difference with PCOS patients.

Amy:                                     Wow, that’s really fascinating. So, kind of wrapping this discussion of working with women with PCOS in your practice, and the different steps and stages of fertility treatment, is there anything else that you feel like we need to add before we take the podcast to a close?

Dr. Trolice:                          Sure. Absolutely, Amy. This is going out to the women, I’m a huge advocate like you. I was in DC advocating with PCOS Challenge in March, going to legislators to try to increase PCOS awareness and research. And then I was, in May, in Washington DC again for Resolve, the national fertility organization to advocate for insurance coverage for all infertility patients. If you, as a PCOS patient, do not feel that your healthcare provider is taking ownership in your problem, get someone else. You have been frustrated long enough, you have been overwhelmed long enough, and you need someone to be your advocate, to answer your questions, to provide you with options as opposed to only one way, to be cost-conscious, and to be your ally. To work with you along your journey. However long it takes to find the right doctor, I think you need to do that.

And how to find somebody with PCOS, well PCOS Challenge is probably one good resource. There’s also the Androgen Excess Society. Androgen is A-N-D-R-O-G-E-N, Excess Society. I’m a member of that. You want people who specialize in PCOS, and who don’t just say “Okay, let’s do IVF.” Yes, IVF is an option for any PCOS patient, or typically any PCOS patients provided that there’s no other contraindication, but it is not the only option, and it’s using a jackhammer for a thumbtack sometimes. So, in medicine we are ethically and morally responsible to treat with the most conservative measures, and then proceed to the most aggressive, and we work through that with all of our patients.

What I am, Amy, is … we talk together. It’s a dialogue. My responsibility is to educate, provide appropriate treatment options, talk about success rates, and then not to break the bank. And so, I always will advise my patients, and I tell them I’m the best GPS  system, like in a car. I give you the best guidance I can, but you’re behind the wheel, so you have to feel comfortable. And I’ll do whatever you feel comfortable as long as there’s no medical contraindication to that.

Amy:                                     That’s such great advice. I really think about it as a partnership. You both have to do your part in the relationship, and if you have a doctor that you feel is not … Then you’re totally entitled to find somebody else that is.

Dr. Trolice:                          Absolutely.

Amy:                                     So, we’re going to put in the show notes a link to your IVF center in Winter Park, but tell us more about … You have a book that’s coming out, and congratulations, it’s a huge undertaking to write a book. But tell us more about that.

Dr. Trolice:                          Thanks Amy, and I know what the accomplishments you have had in terms of having a book, and what work went into that, but also what satisfaction. And I’ve been working on my book for several years, and finally it is going to be released in October of 2019 this year by Harvard Common Press. It’s on Amazon actually now for pre-orders. It’s called The Fertility Doctor’s Guide to Infertility. I could not be happier. I’ll probably be having it at the PCOS Challenge weekend in September, September 20, 21, 22, for the patient advocacy symposium.

Amy:                                     For the symposium.

Dr. Trolice:                          Yeah, the symposium, it’s going to be fantastic. So that’s coming out in October. The other is my podcast, which we launched in January. I’m way behind you Amy, in terms of episodes, but we have experts from across the country that I interview in Reproductive Medicine, that we talk about every and all things infertility, to really give the patient the resources direct from the experts to dispel myths, and to give them an opportunity to hear it from the source so that they could get the information that they need, and not hear it from Dr. Google.

Amy:                                     Well you dispelled a lot of myths today, and there’s so many myths around PCOS and fertility, so I’m so glad that you have that podcast. Tell us the name of the podcast, and we’ll be sure to post a link in the show notes.

Dr. Trolice:                          Thank you so much Amy. The podcast is The Fertility Health Podcast, and it’s on iTunes and Amazon, and the book is The Fertility Doctor’s Guide to Overcoming Infertility: Discovering Your Reproductive Potential and maximizing Your Odds of Having a Baby. That’s Harvard Common Press, and October 2019.

Amy:                                     Excellent. Thank you, Dr. Trolice, for taking time out of your very busy schedule to talk to us and educate us, and I want to thank everyone for tuning into another episode of the PCOS Diva Podcast. I look forward to being with you again very soon. Bye-bye.

Dr. Trolice:                          My pleasure, Amy. Thank you for inviting me.

Amy:                                     Great. We’ll see you all soon. Bye-bye.

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