PCOS & IVF- Your Questions Answered [Podcast]
“It’s helpful for people to come in and make sure they understand what’s going on, rather than making assumptions or going off of what their friend told them or what they read online. There’s a lot of misinformation out there, unfortunately.”
– Dr. Rashmi Kudesia
Fertility drives many women to their PCOS diagnosis. Then questions swirl about the challenges of becoming pregnant, maintaining a healthy pregnancy and ensuring a healthy baby after delivery. Will lifestyle changes help? Is IVF the answer? In this podcast, I spoke with Dr. Rashmi Kudesia, a Reproductive Endocrinologist and Infertility Specialist at Houston IVF in Houston, Texas. She is an award winning, practicing fertility doctor, and she answers some of your most burning questions. Most importantly, she explains what you can do to increase your chances of welcoming a healthy baby. Listen in as we discuss:
- Who is a good PCOS candidate for IVF?
- What advice does she give overweight or underweight patients?
- Are there risks of ovarian hyperstimulation for a woman with PCOS?
- Do women with PCOS have an advantage as they age?
- Should we worry about elevated risks during pregnancy?
- What can you do to boost your health and fertility?
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A full transcript follows.
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.
Full Transcript:
| Amy: | Hello and welcome to another addition of the PCOS Diva Podcast. I am welcoming back Dr. Rashmi Kudesia. She is a reproductive endocrinologist and infertility specialist who leads RMA of New York’s Brooklyn office. Dr. Kudesia specializes in treating couples who are trying to build their families. Welcome back to the PCOS Diva Podcast.
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| Dr. Kudesia: | Thank you so much, Amy. My pleasure.
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| Amy: | Thank you for your wonderful articles on PCOSdiva.com. Listeners, if you have not checked out Dr. Kudesia’s expert opinion on various new research studies, please do that. She also has a, we recorded a really great podcast about PCOS and menopause, so you don’t want to miss out on that either.
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| Today, we’re going to be talking about PCOS and IVF. I want to start with the question about, is there a certain PCOS phenotype, or who is a good PCOS candidate for IVF?
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| Dr. Kudesia: | That’s a great question. I think in general, any patient or any couple that’s trying to get pregnant, when they come in, we talk through all the different options. It is a difficult question to address of how do we move down the spectrum, and when do we talk about IVF. There’s probably a couple different categories of reasons why we might move down that path.
For sure, one is age. Really, once we’re looking at the female partner being forty and above, sometimes even younger than that depending on how they ovarian reserve testing turns out, but we certainly want to at least think about IVF for a couple reasons.
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| One is that even though someone might have good ovarian reserve numbers, that’s a quantitative assessment. We’ll talk about this a little more as we move forward. It doesn’t mitigate the age-related risk of there being chromosomal issues with the eggs, which is just something that happens as we get older. In that instance, we’re really, in looking at the ratio from number of eggs that are out there to the number of healthy embryos they might make. That number really starts to go up as we get older. For someone that is forty plus, we might be thinking, “Okay, if we go through IVF and can get a good number of eggs, we’ll hopefully find that healthy egg that will give a good embryo, that will give a healthy pregnancy.”
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| On top of that, with IVF now, we have the ability to do what we call PGS, or preimplantation genetic screening. What that is, is that on the fifth day of embryonic development, we can actually take a biopsy of the outer portion of the embryo that would eventually become the placenta, and send that off for chromosomal testing. Particularly as the age-related risk of chromosomal abnormalities go up, using PGS technology with IVF helps us to avoid abnormal pregnancies that are going to result in a miscarriage or an unhealthy pregnancy, and get us to a healthy pregnancy a little bit faster.
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| That’s one main category where we might get to IVF somewhat sooner. The other main category, and this is age independent, but is women that seem to either have too much of a response to other medications, whether they’re oral medications or they have such a high ovarian reserve that with injectable medication, we think it would be really unsafe to try to combine that with timed intercourse or intrauterine inseminations. They get stuck in the balance where maybe they’re not responding well to oral medications, but if we try to use injectables, we put them at a very high risk of multiples. Sometimes it actually kind of counter-intuitively turns out that going from oral medication straight to IVF might make the most sense for some patients that have a relatively healthy ovarian reserve. Those are the two main reasons that I would say are particularly applicable to women with PCOS.
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| Amy: | With your clients, do you, if they are outside of that age range and they’re a younger PCOS patient who’s struggling to get pregnant on her own, do you advise on some Clomid or letrozole cycles with IUI before you try IVF? I know that was something that, listeners are probably familiar with my infertility journey. I had a lot of trouble getting pregnant with my second child, and had to go through five or six Clomid cycles before I got pregnant, and then I would’ve been eligible to start the IVF process. I’m sure everybody has their own unique situation, but what is, is there a standard protocol?
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| Dr. Kudesia: | Sure. That’s a great question. Typically when I do the new consultation, we sit down and I talk someone through. I say, “Here is the spectrum of fertility treatments. In one bucket,” as I like to say, “are some of the less invasive, easier to do, and cheaper things.” These would be talking about using oral medications like Clomid or letrozole, and combining them with either timed intercourse or intrauterine insemination or IUI. Typically for women who have PCOS, letrozole has been demonstrated in the past few years to be a better medication, so I usually would start with that unless someone has side effects from the letrozole or something like that. Generally speaking, we start with letrozole, and probably again, usually IUI, but maybe timed intercourse, depending on the inclinations of the couple.
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| If it’s a younger patient I’ll say, “Look. We can try this. We’ll try two to three times, and after two to three cycles, we should regroup to see where we are.” We want to make sure at that time that we’re responding appropriately, that we feel the cycles have been at least going well, then revisit the issue and say, “Is this where we want to be or do we want to talk about moving to the next step of treatment?” It may very well be that after two to three cycles, we say, “Maybe you wanted to try another two times and then talk about doing IVF.” There’s no need to move very quickly down the spectrum. I want patients to feel comfortable helping to guide that decision. It becomes a balance of how their insurance coverage is and how comfortable they are with the process of IVF, etc. There’s a lot of individual factors that come in, but usually I tell people every two to three cycles of timed intercourse or IUI we should stop and regroup and say, “Does this plan still make sense for us, or should we talk about doing something else?”
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| The other thing that’s important to keep in mind is that it’s not like your period comes and you can decide all of the sudden that you want to start IVF. There’s a lot of logistical stuff that we usually have to do to get squared away. A lot of times I have patients that say “I’m going to try another two cycles of IUI, but I wanted to get talking about IVF, meet your IVF coordinator, and get the ball rolling.” Sometimes they get pregnant before we even get to that, and sometimes we do get to the IVF. There’s no harm in getting information in terms of understanding what your insurance coverage is, what the prices might be, etc. Being prepared and informed. That’s what I encourage people to do, is to have the information, but we don’t have to rush down that road unless there’s other reasons that seem to make sense.
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| Amy: | I get a lot of women that participate in my Jumpstart program, which, it’s an online program to help you adopt healthy lifestyle habits in terms of diet and exercise and stress reduction. These women are candidates for IVF, and it is a huge financial commitment for a lot of couples. They want to get in the healthiest place they can before they start the process, and want to lose weight. I wanted to ask you about the weight question. A lot of women with PCOS struggle with their weight. Is that something that you advise your patients, that do have some weight to lose, that they try to lose the weight before they start the IVF process.
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| Dr. Kudesia: | Sure. I think that being healthy, achieving a healthy lifestyle, and managing metabolic health are probably the most important things about having PCOS, honestly, in the long run. Sometimes we get blindsided by that because obviously when we’re trying to get pregnant, that becomes the primary focus and we forget about all these other things, or don’t have time to manage everything at the same time, and that’s totally understandable. The difficult thing is that IVF is not a cure-all solution, unfortunately. Even though rates are pretty good nowadays, there’s still, even in our best prognosis, for example when we do that PGS genetic screening of embryos, and we put back in our lab one healthy embryo, our pregnancy rate is about sixty-five percent. Which is great, that’s an awesome rate to be able to give to someone, but that means thirty-five percent of people aren’t successful, and we don’t always have a good reason for why.
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| What ultimately is going to come out the more research we do in this field is that your metabolic health and having extra weight, or being severely underweight, for that matter, but either way, is sending your body not the greatest messages, and can certainly be having local effects in terms of the lining of the uterus, the inflammation, and other factors that are associated with being overweight. I can feel fairly certain that that is not a good environment in terms of the endometrium, or the lining of the uterus. Ideally, yes, we would want people to be in their healthy weight prior to getting pregnant, but as you suggested, particularly as we get older, I’m not going to tell my forty-year old patient that she needs to spend six months trying to lose weight when I know that that six months could have an important effect on her fertility.
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| It really is a balance. I do see a lot of young women, especially in their twenties, who are severely overweight or obese. I always check their hemoglobin, A1C, screen them for diabetes. A lot of them already have pre-diabetes. These are women in their late twenties, looking to conceive, and are severely overweight, and are pre-diabetic and didn’t even know it, because nobody tested them because otherwise you would think they’re young and why would they have pre-diabetes, but they do. Those are really the patients who I feel like it’s really important to take that time to lose the weight first. To me it’s a clear-cut answer. If the body mass index is more than forty and we’re in a morbid obesity range, it’s just not a good idea to be pregnant. The obstetric outcomes are not going to be great, either.
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| In terms of me giving somebody medication to help them get pregnant, I want them to have not only get pregnant and leave my office, but to have a healthy baby. That’s part of that counseling. For people that are really overweight, and have a little bit of time to spare, they may even be candidates for bariatric surgery. That’s a referral I do make sometimes as well, because again, I’m looking at these young women, I don’t want them to be thirty-five and now have frank diabetes and have a lot of other health conditions. That’s one area where it’s pretty clear-cut.
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| On the other side of things, where we’re kind of racing the clock as well, there are some other options. Particularly if someone is doing IVF, we do have the ability to say, “Even though we know being overweight may have some impact on the ovarian stimulation itself, another big area of where it matters is the implantation and the pregnancy outcomes.” We do have the ability to say, “Let’s go through the ovarian stimulation, get these embryos, freeze them, and then maybe you can spend six months losing weight and getting healthier before we do the embryo transfer.” That’s another approach that is a little bit of a compromise, that might make the most sense in terms of helping someone achieve a healthy pregnancy.
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| Amy: | You had mentioned the sixty-five percent success rate. Is that for the general population, or is that your PCOS population in your practice?
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| Dr. Kudesia: | That’s the overall population.
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| Amy: | Do you have any idea what the success rate is for women with PCOS, trying IVF?
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| Dr. Kudesia: | In general, there is some thought that when we look at the different reasons someone might be going through IVF treatment, there is some thought that PCOS women may have lower IVF success rates. The difficult thing is that that’s tangled up with a lot of other reasons. There’s two main aspects to IVF, in simple terms. One is, how did the ovarian stimulation process go, and how many eggs do we get? The second part is when we have those embryos, what is the implantation rate? What is the change of the embryo taking and turning into a healthy pregnancy?
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| In general, women with PCOS have good ovarian reserve, so we tend to get a good number of eggs, but there can be other risks that come along with that in terms of having an over-response to medication. There is some particular things that we worry about with PCOS women during the ovarian stimulation phase, but usually we get a reasonable number of eggs relative to anyone’s age. Usually the reserve is a little bit higher, and that’s a good thing. The second aspect, which I think is a little more unclear, is what are the impacts on implantation? Again, some of this may be due to the PCOS itself, and some of it may be due to patients being overweight or obese.
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| Like I said before, some of the inflammatory factors that get released by extra fat tissue may have an impact on implantation. I don’t think there’s a really great understanding yet, unfortunately, in the literature, of how much of all of these different outcomes is specific to having PCOS versus if there’s a weight issue, versus a combination of the two. I wish I had a better answer for you, because I’m also very interested to know what the deal is there. Unfortunately we don’t have strict numbers to say “This is the different contributions of all of these different diagnoses.”
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| In general, I would say that compared to, oftentimes we compare to women, for example that have tubal disease. That just means that their tubes are blocked so they need IVF for that reason, but they don’t have any other fertility diagnosis. I would say relative to that, it does appear that women who have PCOS have a slightly lower success rate with IVF. Again, unclear exactly why, but that being said, in any given couple, we can look at their individual factors and say, “Okay this is a reasonable success rate for you based on your specific ovarian reserve, your specific age, and any other coexisting diagnoses,” including their weight.
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| Amy: | You had mentioned about the risks of ovarian hyperstimulation. Maybe you could just go into a little bit more detail so listeners can get a better feel for what that risk really is?
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| Dr. Kudesia: | Sure. That’s an important thing to keep in mind. What that means, what we call ovarian hyperstimulation, essentially means that as all of those eggs are growing, they’re basically growing in fluid-filled sacks that we call follicles. As they’re growing, they’re making estrogen. Particularly for a young woman with PCOS that has lots and lots of follicles, that “polycystic” part of PCOS; if somebody has a baseline follicle count of twenty follicles on each egg, if all forty of those, god forbid, tried to grow into maturity, they would be making a ton of estrogen. If that level gets too high, then we end up in this severe hyperstimulation syndrome range.
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| What the message is that that high estrogen sends to your body end up resulting in is basically that our blood vessels become very leaky. The water content that is normally in your bloodstream starts to spill out into your abdomen, you get really distended, feel very bloated. At the same time, your bloodstream is getting very concentrated. Your urine output goes down, your blood is very thick, it has a propensity toward clotting, it can lead to a blood clot, which can be serious. There’s a lot of different factors that go into, or a lot of things that can happen, if you have severe hyperstimulation. We definitely try to avoid that.
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| The ways to avoid that, essentially, and this is how I would explain it to my patients as well, is one, we try to stimulate you as safely as possible. I always say “We want to get as many eggs as we can, safely.” Again, if somebody has forty potential eggs, I don’t want to get forty eggs. It’s very unlikely to get forty mature eggs with a healthy or safe estrogen level. We try to be realistic in terms of what we’re doing, in terms of our stimulation- the doses, etc. Then the other thing that we have is there are certain protocols that can use different medications for the ovulation trigger, that also decrease the chances of hyperstimulation developing. Those are two of the important things that should be taken into account for anybody who has a really robust ovarian reserve, is the dose, or how the dose of the medications effect your chances of your estrogen levels being too high, and then what kind of trigger medication is ordered.
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| A Lupron trigger is the medication that we typically use that prevents severe OHSS, or really mitigates that risk. The other thing that goes along with all of that that’s important to remember is that there is kind of an emerging story in our field that though the high estrogen levels that we make during ovarian stimulation are a good sign in terms of the health of the ovary and the eggs, that high circulating estrogen level may not be so great for the endometrium, or the lining of the uterus. It may be that, particularly in women that have PCOS with a really high reserve and they make a ton of eggs, and their estrogen level goes very high, oftentimes we’ll plan to do the egg retrieval, have the embryos and freeze them, and do a subsequent embryo transfer, with a frozen cycle, where the estrogen levels will be more physiologic.
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| We presume that the implantation rate will be better because it’s a little bit healthier for the lining. That’s a common approach we also take to mitigate the risks of hyperstimulation. If somebody has high estrogen levels and then they get pregnant, that will propagate the condition to continue and get even worse. That’s another consideration people should realize, that if they have a very robust response, it’s best for them to freeze all the embryos and then do a frozen transfer later.
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| Amy: | Is that called IVM? That process that you just described? There’s this article that I often see it gets circled around in the PCOS communities about this new, the title of the article is “New Fertility Procedure Helps PCOS Patients get Pregnant without Hormone Injections.” They talk about IVM.
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| Dr. Kudesia: | IVM is another burgeoning technology, that I think the efficacy of that hasn’t been demonstrated yet. It’s stands for in vitro maturation. The idea with that is that we can take eggs that are not … Normally in IVF, we’re trying to grow eggs to a certain level of maturity before we do the retrieval. What IVM does is try to take immature eggs, retrieve them earlier, and then grow them in the lab. The idea of how that might be particularly applicable to PCOS women is that, again, when we have so many mature eggs or mature follicles, that’s where that estrogen level gets really high. The idea is that if you’re a women with PCOS and you have lots of follicles, and they haven’t quite reached maturity yet, but we can get those immature eggs and then grow them in the lab, and then fertilize them and move down the path, that that might be safer.
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| It’s great in theory. It makes sense logistically, but it hasn’t been reproduced in enough different labs that I would say it’s something that I would recommend someone to be asking their doctor about. I would still consider that to be experimental.
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| Amy: | Thank you for clarifying that.
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| Dr. Kudesia: | Of course.
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| Amy: | Let’s talk about egg quality. Is there a concern about egg quality in women with PCOS?
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| Dr. Kudesia: | Yeah. I would say there is. Because again, of what I was saying before, there seems to be somewhat lower rate in IVF success rates in women that have PCOS, relative to all of the other prognostic factors. Unfortunately, we don’t have any good tests for egg quality. There’s not a good way, sometimes it’s obvious when we do an egg retrieval and the embryologists are looking at the eggs, they may see certain factors that don’t look so great, or the egg doesn’t look so healthy. Aside from that, in general, there’s not a good test for egg quality. Really, all we can do is sort of go ahead, do the fertilization, and see how the embryo develops. Then sometimes, like I said, we get a really high number of eggs retrieved, but then for whatever reason, a poor number of healthy embryos that develop. We don’t have a good reason, necessarily, to explain why that should be.
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| Unfortunately at that point it’s retrospective, but at that point we would say, “There’s clearly an issue here,” and if there is a PCOS diagnosis, particularly if it was a stimulation that again, there was a very high estrogen level, or something that we wouldn’t consider to be optimal, we might think that that contribute to the poor development. It’s really hard to say. I wish we had better tests of quality.
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| The other thing I would say is that if we do IVF on someone that has PCOS that’s, let’s say forty-one. We get fifteen eggs. Again, I have to remind people that at that age, a lot of those eggs are going to be chromosomally abnormal. Even though we’re excited because we got so many, I would expect a relatively high attrition rate, because many of those eggs are going to be abnormal, and they’re not going to develop onto a healthy day five embryo. Again, I don’t have a way to test that or to prove that to someone, but I just know that statistically that a lot of them are going to be chromosomally abnormal. That’s another factor to keep in mind. Depending on our age, that even if we get a ton of eggs, we may still not end up with ton of embryos.
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| Amy: | What is that end age? There’s a lot of women that follow PCOS Diva, and I hear them saying, “I’m forty-four, I’m forty-three, forty-five, and I want to do an IVF cycle.” Is there sort of a point where it’s just not advisable? Age-wise?
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| Dr. Kudesia: | I hear you. That’s a difficult question. I would say that when I look at our statistics in our center, the pregnancy rate per cycle for women who are forty-three to forty-four is just under ten percent. It’s hard for me to tell someone off the bat that they shouldn’t try, but it really comes down to a numbers game. What I tell anybody in that age range is, like I said in this thing in the beginning; if we can get to where we have a healthy, chromosomally-normal embryo, then your pregnancy rate is very high, but there are a lot of hurdles that we have to clear to get to that point. We have to get a reasonable number of eggs, that then turn into a reasonable number of embryos, and if we’re doing genetic screening than we need some of those to come back normal.
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| For many women who are forty-three, forty-four, we just won’t clear all those hurdles. This is where having PCOS could potentially improve your chances, because we would think that hopefully we get more eggs to start off with, so that even though there’s going to be an attrition at each step, if we start out with a high enough number, perhaps we will get a healthy egg that turns into a healthy embryo.
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| I would always encourage someone to come in for the consultation, to see where their ovarian reserve is, to see where their other fertility parameters are, and then make the decision about whether it makes sense or not. We’re not that scary. I always feel bad when people tell me they just put off coming to see a fertility doctor for four years because they didn’t want to come in. It’s always helpful to get empowered and to get the information, even for younger women, to come in and make sure they understand what’s going on with their fertility. You don’t want to all of a sudden wake up and be forty-five and say, “Oh no, I didn’t realize that now my chances are so low.” That makes us really sad when that happens. It’s helpful for people to come in and make sure they understand what’s going on, rather than making assumptions or going off of what their friend told them or what they read online. There’s a lot of misinformation out there, unfortunately.
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| Amy: | Can you talk a little bit about, once your PCOS patients are pregnant, are there any elevated risks during that pregnancy for the woman with PCOS?
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| Dr. Kudesia: | In general, the main thing I worry about is gestational diabetes, or diabetes in pregnancy. That is a slightly-elevated risk with PCOS. That is the first step, if somebody develops gestational diabetes is they are at risk for the baby gaining too much weight, or having issues with that. Generally speaking, what I would tell people is that, as we’re discharging them, I try to tell them to remember to tell their obstetrician that they have that diagnosis, and they might meet the criteria for an early screen for gestational diabetes, around twelve weeks or so. Usually the normal screen for someone that doesn’t have additional risk factors happens in the second trimester, around twenty-four weeks or so. Usually for the women with PCOS, I would test them early just to be sure they’re not developing any gestational diabetes. That’s really the main thing that I would worry about.
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| There’s definitely not a need based on PCOS diagnosis alone, to be seeing a high-risk obstetrician or anything like that. A general OBGYN would be able to take great care of you. The main thing is watching out for metabolic disease in pregnancy. Really, again, what’s really interesting about PCOS, I think, is there’s some sort of signals that are being sent in our body that we don’t a hundred percent understand yet, that can then be carried over to the fetus. If we have poor habits and we have PCOS, and we’re pregnant, essentially whatever our metabolic state is, that’s really creating the changes, this is what we call epigenetics.
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| It’s basically influencing on top of the genes that the baby’s already got, or the fetus has already got. There’s epigenetic, or above those, changes that are being influenced by the metabolism of the pregnant woman. If you’re eating really unhealthfully, or there’s high circulating levels of insulin, or there’s too much sugar, if these things are all off, these things are basically turning on and off signals in the developing fetus’s brain that will then govern how they will have their metabolism run for the rest of their lives.
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| It’s really important, because if you have a predisposition to be insulin-resistant, and you’ve got high circulating sugar levels, and that’s the environment in which your fetus is growing, it’s important to do as much as you can to be healthy during that time. The last thing you want is to then predispose your child to being obese and having all of these same issues, and the circle continuing. It’s not just that you’re eating for two, all that stuff is out the window. You have to be as on top of it as you can, obviously understanding, real life, that it’s not easy to do all these things perfectly, but to be cognizant of the fact that this isn’t just for that nine months, it’s really something that determines the lifelong health of your child.
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| Amy: | The elevated androgens, too, if we can lower those androgens as much as you can through diet and lifestyle, that can be a big help for your baby, as well.
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| Dr. Kudesia: | Totally.
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| Amy: | I asked some of the divas if they had questions for you. I was hoping you could field a few questions before we wrap up our podcast. Great. Our first question is from Lauren. She wants to know, is it worth it for PCOS women to even try IVF if all blood work and female and male testing is normal?
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| Dr. Kudesia: | I would say definitely. Out of all infertility cases, about a third of them end up being unexplained. If you have PCOS, or even if you didn’t, in all honesty, if we don’t find an obvious reason for why someone’s not conceiving, sometimes there are things that we don’t have a good test for that we’re able to circumvent with IVF. That’s a very individual question, but oftentimes I find that people get discouraged if they’re not successful after a couple cycles of Letrozole and IUI or something, and they think maybe they’re just not meant to be pregnant. I try to be very candid with my patients and say, “This is what the prognosis is,” etc.
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| There’s very few couples for which there’s just no point in trying. I almost never tell anyone that. It’s more a matter of saying, “This is your specific situation, this is the realistic success rate for you. Does it make sense for you based on that and based on your financial and insurance situation to try this?” For most couples the answer to that ends up being yes, but it’s something that is a very good question, but also a very specific question.
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| Amy: | Great. Now Courtney is asking, any suggestions for someone with low AMH to help boost the number of good eggs retrieved, and then she also wonders what you consider a good number of follicles and eggs retrieved. What would that number be?
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| Dr. Kudesia: | Also great questions. With AMH, that’s basically the anti-mullerian hormone, that’s the hormone that’s made by all the resting follicles inside the ovary. The higher it is, the more eggs there are. In general, relative to age-based standards, women with PCOS tend to have somewhat higher AMH levels. A lower AMH indicates that the ovarian reserve is lower than one might expect. The interpretation of that is very important. I wouldn’t look at the AMH of a forty-year old, and then compare it to the AMH of a twenty-five year old. There’s a very good study out there that had about seventeen thousand women, and gives us some idea of age-based medians of AMH levels.
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| I always look at that number and I’m not comparing it to someone of a different age. I’m saying if you come in the door and you’re thirty-eight, here is where I would expect your AMH to be, and if it’s significantly lower than that, then we’re talking about something called diminished ovarian reserve, where relative to your age, it looks like that number is a little bit lower than expected.
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| Unfortunately with ovarian reserve, and this is very frustrating for us, there’s not a good way to boost it. That decline that we have is basically because women are born with a certain number of eggs, and that number goes down with age, but that rate at which is goes down is different from woman to woman. We don’t have a good way either really of predicting for any given woman when her ovarian reserve will start to decline significantly, or unfortunately to do anything once we see that it’s getting lower, of boosting it back up.
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| The main thing I can say for people that have lower reserve is that you want to make sure that you’re watching through your cycle, make sure you’re taking your medications as directed, all of those good things, and trying to be as healthful as possible. Again, that’s another place where, the healthy lifestyle, though we haven’t been able to conclusively demonstrate it yet, but that could certainly, I truly believe, that that could make the difference in terms of the response that we see. That’s where trying to take your control back and say, “These are the things I can control, which is how I’m eating, how I’m managing my mental health,” those are the things that we can try to say we hope we assisted the best possible outcome.
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| Amy: | That’s really a great point. From someone who’s been through the fertility roller coaster, it can be so emotionally exhausting. It causes a lot of stress and anxiety, which is, I think women with PCOS are more susceptible. This is my opinion. The way we’re wired, I think we have more of a heightened sensitivity to stress. Certainly our cortisol levels are a little more out of whack.
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| Dr. Kudesia: | Yes!
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| Amy: | That all plays, that’s all part of this equation. When so many things can feel out of your hands, it’s so important to try to take control of something. You certainly can take control of your lifestyle and your diet, and what you’re eating. Also your attitude, trying to keep a positive frame of mind.
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| Dr. Kudesia: | Definitely.
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| Amy: | I was just going to say, you probably see this in your practice. Sometimes women that take a little break from fertility and relax, then end up magically getting pregnant, right?
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| Dr. Kudesia: | Yeah, that does happen. Sometimes we have people who went through IVF for their first pregnancy, and somehow after that their stress levels are improved or whatever the case may be, but end up with a spontaneous subsequent pregnancy. That’s always great to see.
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| I want to make sure I don’t forget the second half of that question, how many eggs we’re going for. That is another question that is very individual. Sure, I would love to be able to get into the double digits for any couple that comes through the door, but that’s not always a realistic goal. Usually what I tell people is that when you come in and we do your baseline ultrasound on day three of your cycle, or what would be the equivalent of a day three if you don’t have regular cycles yourself, we can look and see what we call the basal antral follicle count, or how many little follicles we see at that time. Out of that number, whatever it is, I hope to be able to get a majority of those to grow in synchrony when we do the stimulation cycle.
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| If somebody has a total of ten follicles at that time, I know I’m not going to get twenty eggs, but I’m hoping to get maybe seven or eight. I try to set conservative expectations. If we get more than that, awesome, but I think it’s important not to oversell what could happen. For somebody that has PCOS, if they have very active PCOS type ovaries and we see a total count of forty, again, I don’t want to get forty eggs, but I would feel confident that at that point we will be into the double digits, if we have an optimal stimulation.
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| It’s a very individual number, and then also like I was saying before, what that will turn into is also very dependent on your age. If I have ten eggs from a twenty-five year old, versus a thirty-five year old, versus a forty-five year old, those are all going to have differential ability to turn into a healthy embryo. It ends up being a pretty personal answer in terms of what seems realistic and what would be a good goal, but like I said before, the most we can get safely, is what we aim to do.
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| Amy: | This has been really fantastic- so much information packed into our thirty-minute time Frame. Anything else that you can think of that we didn’t cover that would be important for the PCOS woman to know about IVF?
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| Dr. Kudesia: | No, we sort of covered it. I feel very strongly that because our IVF success rates are increasing and increasing, a lot of times in busy clinical practice, as physicians we don’t get as much time as we would like to talk to people about their long-term health, and how they can improve their well-being to the best degree. As you were saying before, Amy, with PCOS, we know that there is a predisposition to anxiety and depression, and a diminished quality of life, whether it’s because of the symptoms of PCOS or because of something about the hormones, we don’t really know. There’s a lot of stuff going on.
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| Definitely want to make sure that if you feel like that question wasn’t answered about, or the topic wasn’t brought up about your lifestyle and what are the things that you can do on your end to improve your outcomes in terms of not only your fertility but a healthy pregnancy and long-term health, that’s part of what our training as reproductive endocrinologists is supposed to be about. You should be with someone that is interested in at least talking to you about that and making sure that you understand what it means to have PCOS, not just in terms of doing IVF or not, but what it means from a long-term hormonal standpoint for you. That message and that empowerment is really important. Making sure that you’re as healthy as you can be before you start treatment. We’ve double-checked that you’re A1C level is good, and your weight is as good as it can be at that time frame.
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| Just a summary of a lot of things we talked about, but finding the right match of someone that is going to take all those things into consideration. IVF is not supposed to be the cure-all for everything. Establishing those healthy lifestyle habits is the best way to get the best outcomes for everything, and start your family in the most healthful manner. That’s something I’m very passionate about.
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| Amy: | If somebody is in the New York, Brooklyn area, and wants to have a consultation about IVF, how can they reach out to you?
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| Dr. Kudesia: | Sure! If you just, probably the easiest way is if you just Google my name, or RMA of New York, our office website will come up. It has the phone number there. You can call any of the phone numbers there, just say that you’re interested in seeing Dr. Kudesia at the Brooklyn office, they’ll get you scheduled. We’re happy to do consultations. I love when PCOS pops up as the reason for a visit in my schedule, because it’s an important conversation to have. That’s the easiest way to get ahold of me. I’m very available. I also have some appointments that can be scheduled on zocdoc.com. I am here to help.
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| Amy: | Great, and we will definitely post all that information below the podcast, as well. I just wanted to let you know, Dr. Kudesia, that there’s a program that I’ve really enjoyed using myself. They have a PCOS version, but they also have an IVF version. The name of the company is called Circle and Bloom, and they put out these really great visualizations for women going through IVF, to maintain that positive space and to try to reduce the stress of the whole process through visualization and meditation. I wanted to make everybody aware of it. I’ve written about the program on my site, and I’ll post a link, as well. I’ve had several clients that have used it and felt like it decreased the emotional distress of waiting to find out whether the IVF cycle worked, and all of the waiting game. Just wanted you to know that that’s out there. You’ll have to check it out.
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| Dr. Kudesia: | That’s fantastic. I definitely will check it out. Thank you so much.
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| Amy: | Sure. Thank you again for coming on. It’s always a pleasure and I look forward to having you back on the podcast soon.
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| Dr. Kudesia: | Yes, which would be great.
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| Amy: | Great. Thank you everyone for listening, and I look forward to being with you again, soon. Bye bye.
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