Ep 308: What Questions Do You Have About PCOS? Answering listener questions from real patients about PCOS

 Fertility Docs Uncensored is hosted by Dr. Carrie Bedient from the Fertility Center of Las Vegas, Dr. Susan Hudson from Texas Fertility Center, and Dr. Abby Eblen from Nashville Fertility Center.  This episode answers key patient questions about polycystic ovary syndrome (PCOS) and fertility. We answer:

· How is PCOS diagnosed? Using the Rotterdam criteria: irregular cycles, more than 12 microfollicles per ovary, or elevated male hormones. Two of three confirm the diagnosis.

· Does stopping birth control pills help fertility? No. PCOS cycles return to baseline because the hormonal system does not reset.

· Why don’t patients with PCOS ovulate regularly? The brain does not release enough FSH to trigger ovulation.

· What fertility treatments work? Oral ovulation-induction medications succeed in about 80% of patients.

· Do patients with PCOS have ovarian cysts? No. Small follicles are normal; true cysts are a different condition.

· Does weight affect PCOS? Yes. Weight gain or loss can influence hormone balance and ovulation.

We also clarify why the name “polycystic ovary syndrome” is misleading. Patients with PCOS do not have true ovarian cysts. Instead, they have many small follicles, each containing an immature egg, which are a normal part of ovarian anatomy. True ovarian cysts, such as desmoids or endometriomas, represent entirely different medical conditions and are not part of PCOS. This episode provides clear, evidence-based guidance on PCOS diagnosis, myths, and effective fertility treatment.

Transcript

Susan Hudson (00:01)

You're listening to the Fertility Docs Uncensored podcast, featuring insight on all things fertility from some of the top rated doctors around America. Whether you're struggling to conceive or just planning for your future family, we're here to guide you every step of the way.

Abby Eblen MD (00:22)

Hi everyone, we're back with another episode of Fertility Docs Uncensored. I'm one of your hosts, Dr. Abby Eblen from Nashville Fertility, and today I'm joined by my electrifying and enjoyable co-host, Dr. Susan Hudson from Texas Fertility Center.

Susan Hudson MD (00:37)

Hello everyone.

Abby Eblen MD (00:38)

And the lovely Dr. Carrie Bedient from the Fertility Center of Las Vegas who's back and tan from her trip to Tahiti.

Carrie Bedient MD (00:45)

Let's pump the brakes on that just a little bit back and not absolutely roasted is probably the more appropriate phrasing for that.

Abby Eblen MD (00:46)

Yeah.

Susan Hudson MD (00:55)

Carrie, do you actually tan at all?

Carrie Bedient MD (00:57)

I can, when I was a kid, because I grew up in Arizona, I was always a very lovely shade of tan. Something happened when I hit 18 and went to college and double majored in two hard sciences and was in St. Louis and never saw the sun again and it has become really considerably a lot harder to tan since then and I think my skin was just like, we're committing to be a professional nerd now, yeah you don't need to look good. It's better than it could be.

Abby Eblen MD (01:28)

So while you were tanning or laying out in sun in Tahiti, we were back planning our New Year's resolution. Just curious, do you have a New Year's resolution that you worked on while you were in Tahiti?

Carrie Bedient MD (01:40)

I divide resolutions into three categories, personal, professional, and family. Wait, I missed that. What was that?

Abby Eblen MD (01:42)

You are a nerd.

No, I'm sorry. Did I say that out loud? I'm sorry.

Susan Hudson MD (01:47)

She said you are a nerd, which, you know, I think we are all nerds, but Carrie gets the nerdiest award.

Abby Eblen MD (01:54)

She gets the crown for the nerdiest, but we're all nerds. We're all nerds.

Carrie Bedient MD (01:56)

I will 100 % accept that and embrace it. I'm good with that. Yeah. Personal, professional, and family. Personal, I need to move my body more and I need to eat probably two or three less desserts per week, I think is probably reasonable and not an insane goal. If I can just not have something sweet every day, I will take it because I have a huge sweet tooth and just move my body intentionally more than just running around clinic, two to three times a week.

It doesn't need to be wild and crazy, but two or three times a week, at least 20 minutes time, go for that. And then for family, making sure that I am giving them the best of me and not the rest of me.

In terms of I tend to leave it all on the field at clinic and am able to spend a lot of time and have a lot of patience and be really thoughtful and all of that. And somehow when 9 p.m., 8 to 9 p.m. hits in my house, I am no longer a nice human being. And so trying to actively focus on between 5 and 9 p.m. being the best of me and not just giving my family the rest of me. And then professionally, I really want to keep increasing our success rates. They're amazing right now, but we think that we can at least try and hit the high 80s, low 90s percentage wise. ⁓

It involves just being uber meticulous all the time. And that is hard to do in the real world. We'll see. That's talking about being meticulous among a group of people who are already insanely meticulous. REIs and their clinics, as a whole, we are compulsive people who have control issues and high standards and across the field, that is pretty universal. We'll see how it goes. What are your guys's resolutions or vague inklings of resolutions at this point?

Susan Hudson MD (03:54)

Generally not a New Year's resolution type person, but I have to say the things that I would like to do this year, I like the get moving more. And I, this year's a big birthday. And so I'm kind of motivated on that. And so getting moving more, I'm not I'm not a go to the gym type of person. And so I have to get moving where I am type of thing. And so working on that and just getting outside more. And I really want to declutter this year, I have to say. But one, there were a lot of things that were positives out of COVID. Obviously, there were lots of bad things. But one of our one of our positive for COVID is the fact that we even have this podcast. Exactly. Exactly.

Abby Eblen MD (04:31)

Yeah, we're definitely positive. We started the podcast. Yeah, we learned about Zoom.

Susan Hudson MD (04:41)

But I was amazing at decluttering at that point in my life. And I think it's because we did unintentionally have more free time because we weren't busy doing other things. I need to get into that. When I go to declutter, I literally start along a wall in a room.

And I have to work my way along the wall and I make myself go in a circle around the room. It works very well. I also set myself timers. That's how I do it, but I need to get back into it because there's things I want to fix up and do, but I'm like, there's too much stuff here. I think of in my kitchen, like I have my kitchen towels. I have a basket for them, but they're overflowing in the basket.

And so the basket is a good idea for the handful of them, but I'm like, I need more than that towels. have plenty of drawers, not all of them are full and a lot of them just needs to be cleared out. And it's just being intentional.

Abby Eblen MD (05:39)

Susan, one thing I do want to point out between now and 2020 was don't forget, you got that little degree, that little MBA degree, you kind of worked on that. Somehow that, sometimes I can take up a little extra time. You probably didn't have as much time to declutter over the last few years. give yourself a break.

Carrie Bedient MD (05:54)

We know that that didn't take you too much time.

Abby Eblen MD (05:56)

Yeah, piece of cake, MBA, no big deal. I'm not a New Year's resolution person either. I try to be intentional, like day to day, but the one thing I will say, if I had to pick something, I'm listening to this book called Outlive, and listening, not reading it. It's a great book, and it sounds like it's for old people, but it's really for everybody because it talks about so many cool things and...talks about how to keep yourself healthy and a lot of that starts when you're really young. You've to plant the seeds and talks a lot about metabolic syndrome, which we're going to touch on probably a little bit with PCOS that people that are younger that have PCOS may have more issues later on. But in this book, he even teaches you how to breathe correctly, how to walk correctly, how to do things for stability because a lot of people injure themselves, even young people injure themselves. And ultimately, then stop exercising and then they get heavy and then just things just kind of build. I'm gonna try to be more intentional about the type of exercise I do and how I do it and just try and be more healthy and spend more time doing that. And then I think also with family too, I think it's really important to be intentional about your family. And I think I've done that pretty well through the years, but I just think it's important to be able to give good time to your family as well. Like you said, Carrie, not just be the part that they get after work.

Carrie Bedient MD (07:13)

Yeah. Excellent.

Susan Hudson (07:20)

A new year is here and if IVF is on your mind, this is your moment to get clear and move forward. At Fertility Docs Uncensored, we've spent years answering real fertility questions and helping patients take control of their IVF journey. And now we've put everything we've learned into one straightforward, empowering resource, the IVF down the entire IVF process, step by step, in plain language so you understand what's happening and what comes next. No confusion, no guessing, just clear information and real support. Whether you're just starting to explore IVF or already in treatment, the IVF Blueprint helps you feel informed, confident, and ready to take the next book with a special conversation from us at the end wherever books are sold or at fertilitydocsandcensored.com. This is the year you stop waiting and start moving forward. The IVF Blueprint is here to help.

Abby Eblen MD (08:24)

All right, so today we are going to do a PCOS question episode and hopefully Susan has some good questions pulled up. We're going to talk about it.

Susan Hudson MD (08:33)

Our question for today. My husband and I are starting to try for a family in the next 6 to 12 months. I am 22 years old and currently have a BMI of 35 and trying to lose weight. I've had a Mirena IUD in for the last two years. I started birth control at 15 due to Accutane and never stopped until getting my IUD. From 10 to 15 years old, I had inconsistent cycles ranging from 35 to 100 days while having a BMI of 24 to 28.

On birth control, I had very light periods lasting two to four days, even when taking three month cycle pills. I had not any periods or spotting since getting my IUD. Should I remove my IUD to let my cycle regulate prior to trying to conceive? I'm worried about fertility issues due to my history of irregular cycles. I love the podcast and look forward to it every week. TIA. Thank you so much for listening.

Carrie Bedient MD (09:23)

Yay!

Abby Eblen MD (09:24)

Unfortunately, probably your cycle's not gonna regulate. In fact, it sounds like you might have gained a little bit of weight and even as little as 10 pounds can make a difference. But if you're somebody that's never had a regular cycle, and I think that's what you were saying, it's not gonna regulate. I tell my patients, it's like if you have seeds planted in the soil but they never get watered, they're not gonna grow and develop. If you have eggs in your ovaries, Essentially with PCOS, your brain is just not talking to your ovary. And so it's not sending the signal, not sending the water and the sunshine to make the seeds grow. Typically with medication, we can do that pretty easily for most people. About 80 % of people will produce an egg or ovulate on fertility medications. If you just take your Mirena IUD out, probably what'll happen is you won't have a period for a few months. Once your lining builds up, then you'll start having a period, but it'll  still be irregular because unless your brain is sending the right signal, sending the hormone FSH to your ovary to make your eggs grow, then ultimately you're going to have an irregular period because with ovulation, it produces the correct hormones so that basically two weeks later, if you ovulate and you're not pregnant, you're going to automatically have a period on your own. And unfortunately, that's probably just not going to happen for you. You're going to need some medical help for that.

Carrie Bedient MD (10:37)

A plus on the things that you were doing right. And that means taking the birth control pill while you were not wanting to be pregnant and when you were having those really irregular periods. Because what that did is that prevented your lining from building up and developing cancers or precancerous cells. So A plus on that. A plus on switching to the Mirena when you were at that phase in your life because that is also protective in addition to being really convenient and reversible much more quickly. Birth control pills and a Mirena will not negatively impact your ability to have a kid one day. Birth control pills can take a little bit longer to get out of your system. You should be totally regular within about six months of being off birth control pills. The Mirena you can regulate within a month or two. It's very, very quick. So A plus for doing all those things right when you were at a point where you did not want to conceive. One other thing to think about is as you're getting ready to get pregnant, because you said in the next couple months or so, focus on exercising, eating well, and weight loss. Now, weight loss is not the be all end all of everything, but it has a cascade effect. It may not be the reason you're not getting pregnant, particularly if you have a history of irregular periods, but it's also not helping you. And it's one of the few things we have somewhat more control over. Getting a handle on nutrition, exercise, and BMI will be helpful in the interim because just like a 10 pound weight gain can make a negative difference, a 10 pound weight loss can make a positive difference. Set yourself up for success, and if you can start focusing on that now, when you're not actively trying to get pregnant, it may take a little of the pressure off when you are trying to get pregnant.

Susan Hudson MD (12:17)

A couple of other things to think about, this is the time to start prenatal vitamins. We want to build up those folic acid levels before you conceive. A lot of people are like, oh, I'll start them when I'm actually trying. Now is the time to start them. I would also recommend taking some extra vitamin D, usually 2,000 IU's a day.

Most people in general are deficient in vitamin D. PCOS women tend to have a higher likelihood of being vitamin D deficient and it can impact pregnancy outcomes for you. And another supplement we tend to like in people with PCOS is Ovasitol which is a combination of inositols in a specific 40 to 1 ratio that has evidence that either it can help you become ovulatory or when you're taking fertility medications you will be more sensitive to those medications and more likely to ovulate at lower dosages. Now I would generally recommend you talk to either your local OBGYN or your reproductive endocrinologist.

Talk to them about pulling the IUD when you're ready and initially starting off with some medication like letrozole or clomid depending on what your particular physician wants. Letrozole is what is currently recommended for people with PCOS as the first line treatment because we don't want you going on and being anovulatory and getting frustrated. We know you have a problem. That's okay. All right.

PCOS is the way you are wired. It is how you are built. I always say it's kind of like me having red hair. I can dye it, I can curl it, I can do all kinds of things to it, but being a redhead is part of who I am. Having PCOS is part of who you are. And that's okay. We just have to manage it depending on what your goals are at the time. So previously your goals have been to stay healthy,

Abby Eblen MD (14:03)

But it's still gonna be red.

Susan Hudson MD (14:20)

and not get pregnant, which as Carrie mentioned, you've done very well with the birth control pills and the IUD. But now that you're wanting to focus on pregnancy, you need a little help going in that direction. And that's okay. You just need to pick up the phone and call.

Carrie Bedient MD (14:34)

What's next?

Susan Hudson MD (14:34)

All right, our next one is, hi, I love the podcast. Thank you for listening. I am preparing for my first round of IVF. I am 35, partner is 34. I have classic lean PCOS. I have irregular cycles, high follicle count, and signs of excess androgens with a BMI of 21. We can see.

Carrie Bedient MD (14:54)

A plus for knowing her Rotterdam criteria for diagnostic purposes.

Abby Eblen MD (14:57)

Yeah!

Susan Hudson MD (14:58)

Carrie, do you want to before I read the rest of this you want to share what Rotterdam criteria is?

Carrie Bedient MD (15:02)

It's exactly what she said. You need two out of three, either irregular cycles, a very high follicle count, or signs of hyperandrogenism, which is high male hormone levels. You can get that either by blood work or you can get it by symptoms, because some people have totally normal levels, but they will have hair growth or acne where they really don't want it. A +, she's got her diagnosis nailed and...as a reproductive endocrinologist, I very much appreciate that precision, A+.

Susan Hudson MD (15:31)

We conceive my son via letrozole. He was born with a serious non inherited genetic condition caused by a de novo mutation on my copy of his gene. Prior to my son, I have had two seven week miscarriages. We had a recurrent loss panel with no findings. I suspect that egg quality is a concern. Is there anything I can do to support that as I prepare for IVF?

We will be doing all available genetic testing. I'm also concerned about OHSS with my high follicle count and AMH of 20.1.

Abby Eblen MD (16:02)

How old is she?

Susan Hudson MD (16:04)

She's 35.

Carrie Bedient MD (16:07)

I would just like to comment this has been the week of really high AMHs. She's got 20, I had another patient with 25 and a different patient with 27 all this week.

Susan Hudson MD (16:16)

That's unusual.

Carrie Bedient MD (16:16)

Tis. Sorry Abby, I interrupted you.

Abby Eblen MD (16:18)

That's okay.

I think the question about egg quality is a universal one, whether you have PCOS or otherwise. We get that question quite often. And unfortunately, age is the most important factor. And the fact that you're 35 years old is a good thing because that means that you're probably at the best place that you can be in terms of egg quality. As you get older, 36, 37, we start to see a decrease in the number of genetically normal embryos.

There's certainly some supplements out there and this goes really for anyone that wants to help their ovarian reserve. Some of the things that we think might help, there's not a lot of human data. Probably coenzyme Q10 is a supplement that has the best data. It basically helps cell division because it enhances or powers the mitochondria, which is the powerhouse of the cell. There's a couple of other ones. There's NAD, and essentially it also works in the mitochondria but just in a different location. It helps the mitochondria, the powerhouse of the cell.

Antioxidants can be beneficial as well. Nobody really knows which ones are the best and which ones help the most. But Susan mentioned previously vitamin D is one of those. Vitamin C is one of those. I think anytime you are trying to improve the mitochondrial function and just overall the cell division, it's probably a good idea to start those two months in advance if you can. And again, this goes for whether you have PCOS or whether you don't. We just talked in the last question about myoinositol, and that can be helpful for some women as well. Hard to know if it impacts egg quality or not, but that may be one particularly that you may be interested in as well.

Susan Hudson MD (17:47)

To the question about OHSS, I think this is a great topic for anybody who has PCOS because anyone with PCOS is at an increased risk of ovarian hyperstimulation syndrome or OHSS. And this is a condition where usually during IVF, occasionally can happen during ovulation induction with inseminations, but usually during IVF, you recruit lots of follicles.

Those follicles have little cells within them called granulosa cells. Those granulosa cells as the follicles get bigger proliferate and produce estrogen. Estrogen increases the production of something called VEGF which can essentially make your blood vessels leaky making fluid that is normally inside your vessels go to places outside your vessels, like in your abdomen, in your lungs, different things like this. Now, all people for the most part with IVF are going to have at least mild hyper stimulation because that's our goal. We want to stimulate you a lot to create lots of follicles, but we want to do that balancing the chances of you getting sick because not only do we want to have great pregnancy rates, we want to be safe about it.

A lot of people, including us nowadays, use a special type of medicine for our trigger shot called leuprolide or Lupron. And that medicine essentially triggers your brain to create a LH surge within your own body. And then it shuts down things relatively quickly.

By using that instead of the traditional HCG trigger, we definitely decrease the chances of you feeling bad and getting significantly ill.

Carrie Bedient MD (19:36)

And it's very interesting for patients who have OHSS or who have symptoms that are pretty close to it. Like Susan said, everybody is going to have some version of it going through IVF controlled ovarian hyperstimulation is very intentional in IVF. That's the goal. But it is always very interesting to me is who gets those symptoms that are very notable for them and who doesn't because it doesn't necessarily line up with the number of eggs you have or the level of your estrogen.

We will sometimes have people who have really very very high levels who are just bouncing right through hopefully not literally because we don't want their ovaries to twist and torse but they're just bouncing right through and they're totally fine and then other people who have relatively lower numbers who are really feeling it and so it's not a reason for anxiety just because you have high numbers it's worth knowing and paying attention to but don't don't give yourself the anxiety until you know it's worth it.

Susan Hudson MD (20:29)

Every adventure begins with a dream, and for many, that dream is growing a family. At IVF Florida, we understand the road to parenthood can take unexpected turns. Our team is here to guide you with expert care and advanced fertility treatments designed to support you at every milestone. With convenient locations across Jacksonville and South Florida and flexible monthly payment plans, IVF Florida makes it easier to move forward with confidence.

Visit ivfflorida.com to schedule your consultation because every great adventure deserves a trusted guide. Start yours with IVF Florida.

Abby Eblen MD (21:08)

Well, to add on when you said talked about multiple eggs, just from the standpoint of stimulation, you probably will have a higher number of eggs than the average person, most likely, but just be prepared that your body only makes a certain amount of eggs really well. I think most of us feel like they're a sweet spot. Sometimes I'll have patients go, have you ever had anybody that had this many eggs or that many eggs? And the answer is yes. 60s, 70s, sometimes 80s, I think.

But we don't really want that because your body can only make a certain number of eggs really well. I feel like the sweet spot is 20 to 25 eggs. If you get much more than that, the quality goes down. And sometimes people are really surprised because they may get 35 eggs and then they only end up with three or four normal embryos. They're like, what happened here? And it's just because your body just can't make those eggs very well. So just be prepared that even if you get a bunch of eggs, you might do great. You might have a lot that are good and genetically normal, but you may be just like everybody else, you may only have two or three that really amount to be good embryos.

Susan Hudson MD (22:07)

Okay, our next one. 34 years old, G0, PCOS, BMI 24, husband's sperm is normal, never have had regular periods. Six failed IUIs, they had an insurance requirement with letrozole and Ovidrel. One chemical pregnancy after IUI number four. First egg retrieval, nine follicles, six embryos, three PGT-A normal, grades 4AB, 4A-A-4AA.

Am I crazy for wanting to do another egg retrieval? Feeling like three is not enough given the chances of implantation failure. Worried about having a successful pregnancy in the next year or two and running out of embryos when trying for second baby in late thirties when I may not have as much success as I did with this egg retrieval. Feeling selfish for wanting more than one child and worrying about three healthy high grade embryos not being enough.

Carrie Bedient MD (22:58)

You are very normal in that concern. And I would say that pretty much everybody who goes through IVF is always worried even when they get the embryos that it won't be enough for whatever their family goal is. I think that you can do this a couple of different ways. And some of this is gonna be based on what is your financial slash insurance situation? What is your ultimate goal of family size? Sounds like you want two kids. But what we oftentimes find is that people, they say we want two, but there's a range.

Abby Eblen MD (23:00)

Yes, absolutely.

Carrie Bedient MD (23:26)

It's one to two or it's two to three and where you fall in that will probably impact what you do. If you're in the one to two where you're a little bit more okay with maybe just having one rather than having three if you don't hit the two number, you may decide I'm not gonna do another retrieval I'm just gonna go ahead and transfer what I have. If you're in the two to three group and particularly if your insurance is a little bit more user-friendly to it, yes go ahead and get another round so you've got additional embryos to choose from.

What may impact this particularly for you is if you do have insurance coverage, they may have rules that you have to transfer before you can do another retrieval. And so that may impact what you do as well. And your embryos do sound like they're great quality. You have a young age. Like this is highly likely to be successful. The other way that you can think about this is if you say, okay, let's transfer one. And if it works, fantastic, we keep going. If you transfer one and it doesn't work, now you have two embryos left and a desire for two children. That may be a point where you say it's a little bit more critical of, all right, maybe we get some more embryos because there's a reasonable likelihood in any given time that any one embryo won't implant, just in the same way that there's a high likelihood in any given time that one embryo will implant. If you are a glass half full or half empty person, that's going to shape this as well.

Abby Eblen MD (24:47)

Well said.

Susan Hudson MD (24:48)

Exactly. I think that the biggest thing is knowing what your insurance coverage is, because even the most generous insurance coverages out there for the most part, if you have three chromosomally normal embryos probably won't pay for you to do another cycle at this point in time. Now that doesn't mean you can't pay for it yourself, but I'm getting the idea that you have insurance coverage at this point in time.

But I also think that realize with any chromosomally normal embryo granted this success rate can vary from clinic to clinic, but it's generally going to have somewhere between a 50 to 70 % chance of you being successful. Out of three embryos, statistically, you had a pretty decent chance of getting one and maybe two children. I think transferring one embryo, if you get pregnant, great. Then you have two more for baby number two. If you don't get pregnant, then you start weighing your pros and cons on whether or not we want to do another egg retrieval and the cost associated with that.

Abby Eblen MD (25:46)

And the one other thing I would say too is, usually we're more concerned about you not having enough embryos. So I, if it were me personally, I definitely would err on the side of, if I wanted two to three, maybe do it another cycle like Carrie was talking about, but also think about what if, what if you end up with another three genetically normal embryos and now you have six, are you going to use all those? Say you get pregnant, baby one, two, boom, boom, and you're like, I think we're done. What if you have leftover embryos? What are you going to do with those? And for some people, the decision is not difficult. Some people would choose to discard them or donate them or whatever. But if that's something, psychologically or religiously that that could be an issue for you, I would also think about it from that aspect as well.

Susan Hudson MD (26:27)

Very good. All right, our next one. I am 31 and stopped the pill about a year ago after 11 years. I had an ovulatory cycle in November of 2024, but then experienced 40 plus days anovulatory cycles. In June, my OB-GYN lab showed FSH4, LH6.4, AMH15.4 leading to a PCOS diagnosis due to my AMH levels anovulatory history and a 2021 hemorrhagic cyst rupture. We're going to come back to that.

She referred me to a fertility specialist. Since then I've taken an inositol blend Reducing my cycles from 40 plus days to 31 days. I've had a day six Dpo progesterone of 9.5 and three months of positive OPKs. We've been trying to conceive for nearly a year But only two or three real attempts since I've started ovulating again. I'm torn between continuing to try naturally or moving to a fertility clinic. Is it too soon to see an REI?

Abby Eblen MD (27:27)

No, that's a simple answer. No, it's not too soon. You've been trying for a while and you've had some success in terms of your cycles getting better and closer together. It does sound like you've ovulated, but it doesn't really sound like you've done a whole lot in the way of true treatment. Now's the time to think about at least doing something like oral ovulation induction with letrozole, which is the typical one that we use, and or Clomid, and maybe even IUI or intrauterine insemination. And that's where even if your partner's sperm count is very good, The American Society for Reproductive Medicine recommends doing both of those together rather than either one of them separately just because you have a better outcome. And the outcome's still only about 10 % or so per month. But if you've tried for a year and you've truly had some ovulatory cycles in there, and we generally say if you're younger, you need 12 ovulatory cycles. If you're older, over 35, maybe six ovulatory cycles. But if you've had those chances to get pregnant and you have not, then unfortunately you have the diagnosis of an infertility.

And at that point, we would recommend treatment with both, with oral ovulation induction and intrauterine insemination during the fertile window of your cycle.

Susan Hudson MD (28:29)

I'm going to get on one of my favorite soap boxes of all time. And what that is, is that PCOS or polycystic ovarian syndrome is a terribly named condition.

So first of all, from a fertility specialist standpoint, a cyst is something on your ovary that's greater than two centimeters at a time that we don't want it to be there. That actually has nothing to do with PCOS. PCOS should be poly follicular ovarian syndrome. A follicle is a fluid filled sac that contains your eggs. People with PCOS have lots and lots of follicles for the most part, not actual cysts. You're not sitting there with 15 greater than two centimeter cysts on your ovaries. That's what you look like at the end of IVF, not when you're sitting here coming in for your new patient consultation.

This thing where people think that if they've had a cyst, which you have had a real cyst by our definition, this hemorrhagic cyst, that cyst actually has nothing to do with your PCOS. And in general, a true hemorrhagic cyst usually is the result of that you probably ovulated randomly. Great. At some point in time, when ovulation happens, that follicle undergoes a conformational change and becomes what we call a corpus luteum. That corpus luteum has lots of vessels and sometimes a vessel can break and you can have bleeding into that corpus luteum. Because it's an enclosed space, the bleeding stops just like if you cut yourself, you put pressure on it. It's a different way of creating pressure.

Now that can cause pain and that's probably why you got diagnosed with that. But that hemorrhagic corpus luteum has nothing to do with fertility. It has nothing to do with PCOS. It has everything to do with that you have ovaries and you probably ovulated at some point. If you have an endometrioma, which is a different type of blood collection in your ovaries, that's a whole different fertility diagnosis. But unrelated to PCOS.

Abby Eblen MD (30:47)

And that type of cyst will go away because it is part of your normal body function. Whereas there's other types of bad cysts. Things like endometriomas, those are collections of fluid in the ovary. They don't go away. Dermoids, they don't go away. And there's other types of cysts that don't go away. If month after month after month you come in and the doctor says, you have this three centimeter cyst on your ovary, then whatever that is, is not going away. It's probably not normal body development and ovulation.

But what Susan's saying is that hemorrhagic cysts, we all get those when we ovulate. It's just typically they're not real big. They don't cause pain. You don't go to the doctor for them. You don't even know you have them. Your ovary releases the egg. There's a little bleeding inside and the cyst is small enough that it just goes away without any symptoms.

Carrie Bedient MD (31:28)

We'll make the other plug for getting evaluated by a fertility doc in that even when there is a really obvious reason for why someone is not getting pregnant, in this case not ovulating, likely PCOS, there can be other reasons at the same time. Even when we have somebody who comes to us and says, I have periods every 62 and a half days, I don't ovulate, my LH kits are never positive, I never have regular cycles, blah, blah, blah, blah. Even when there is a slam dunk PCOS diagnosis, we still check all the other things. Because just because we know that you have PCOS doesn't mean you can't have endometriosis or block tubes or your partner doesn't have sperm or any number of other things. Just because you know about one issue doesn't mean there's not another one coexisting. The better part of 40, 50 % of fertility patients have more than one thing going on. And so we want to know what it is so that whatever fertility treatment you find most appropriate, we're taking into consideration all the information.

Susan Hudson MD (32:24)

Another thing just based on what Carrie just said, I want to go off on for another moment is ovulation predictor kits in women with PCOS. Generally it's, it's in general a bad idea. The reason is, is because you may have an LH level that is not detectable because you're not ovulating, but you may actually have an LH level that is detectable because you have PCOS and a lot of people with PCOS have naturally high LH levels. They don't have the same normal baseline that other women may have. It doesn't mean they can't have an LH spike, but those ovulation predictor kits are, they're not regulated for people with PCOS.

If you're getting frustrated with those sticks, throw them in the trash and come see one of us.

Abby Eblen MD (33:17)

Don't use them. Yeah, you may never have to use one of those again if you come see us.

Susan Hudson MD (33:23)

Exactly. All right,

Hi docs, I'm 29 with a diagnosis of PCOS anovulation trying to conceive for three years. During IUI baseline, first ultrasound showed a right ovarian cyst. Letrozole, 7.5 milligrams for five days, no follicle growth, just the cyst. Switched to Clomid two days later, 50 milligrams for five days, the cyst grew. Now scheduled for second cyst aspiration, the last one was probably about six months ago, had hysteroscopy with 1.4. 10 years of  birth control.

I'm getting absolutely discouraged. How can I improve this or my next IUI? I listen religiously. Thank you for listening. I take supplements, ovasitol powder, please send help.

Abby Eblen MD (34:08)

I think there's some times that Clomid and letrozole are great for PCOS patients. I think there's other times where you just got to go, this ain't working. We got to do something different. Back several years ago, before 2020, we used to be more inclined to give you the hormone you don't have. PCOS patients make FSH, the hormone that normally stimulates the egg, but they just don't make it in high enough quantities, or you don't make it in high enough quantities for it to grow and to develop.

Essentially, oftentimes then we would give women just like you, FSH in injections, small quantities, and then still do intrauterine insemination with partner sperm. And that way we could control the growth of your eggs and your follicles. We'd monitor you frequently, look with ultrasound. That way, particularly the half-life with clomid can sometimes really make cysts continue to grow over time because it hangs out in your system for a long time.

But typically with PCOS your cycle is not used to listening to your brain and your ovary doesn't work well with your brain sometimes. By controlling it with FSH that can be really effective. The challenge there was in patients just like you who were young, otherwise healthy, might grow two, three, four eggs. And if we do IUI, it wasn't uncommon sometimes for people to end up with twins or triplets or quadruplets. So we don't want that.

In your situation now, what I would recommend if you had tried Clomid and tried Letrozole, they didn't work, you kept getting cysts. Usually at that point I say, we probably just need to do in vitro fertilization. And IVF is a lot safer for you because we can control the number of eggs that you grow. And more importantly, we aspirate all those eggs and we get to choose how many we want to transfer back in you. And that number now is one. If we have a genetically normal embryo, we only wanna transfer one at a time. It's a way to safely stimulate your ovaries and it's way to safely make sure that we do everything we can to transfer one embryo and make sure that you only have one baby at a time. That's what I would recommend at this point. I'd be interested to see what Susan and Carrie would recommend.

Susan Hudson MD (36:02)

When I have a situation like this, usually, and I can say this is definitely something that I have changed over my career. Earlier in my career, I did a lot of cyst aspirations. I don't do many of them anymore. And I have learned to medically treat these much more aggressively. If somebody comes in for a baseline ultrasound and they have a cyst, so as I mentioned, something probably around two centimeters or greater. And the first thing I'm going to do, and if it's not an endometrioma, it's a clear cyst, so the wall appears white and the inside looks black, then I'm often going to do an estrogen level at that point. If that estrogen level is high, then I will put somebody on birth control pills, sometimes a progesterone only pill called Aygestin, depends on the situation.

I will repeat the labs in usually a couple of weeks and when that estrogen level has fallen and I know that's no longer a functional follicle, that's when I'll redo the baseline ultrasound and usually move forward from there. If it is low, I talk to the patients and sometimes we just stimulate around it. I don't use Clomid.

Honestly, can't remember the last person I prescribed Clomid to. It has more side effects, higher risk of multiples, and less chance of pregnancy. It just doesn't make sense to me in most situations. And then I go forward with either Letrozole or Letrozole with a little bit of injectable gonadotropin, usually maybe a single 75 unit dose after I've finished the Letrozole for five days. And I tend to have very good chances of success. I just don't worry about those non-functional follicles as much as I did. Of course, we keep an eye on them. We don't want them getting super big or that type of thing. If those follicles were not there at your baseline when you established care and you had your full-gyne ultrasound or whatever, your clinic calls that full ultrasound that they do when they establish care with you and this has popped up and it is not a standing cyst. Most times it's not going to grow or it's just not going to be functional and it's a non-matter. Carrie?

Carrie Bedient MD (38:24)

One thing that popped into my head about this question is what else can I do? And starting to get more and more down about this. You mentioned your BMI was 34. That's something that may be helpful to try and get down. Sometimes the GLP-1 medication can be helpful. There's always nutrition and exercise, which if that works all the time, then we would all be out of a job, but it doesn't because PCOS is really kind of a pain in the ass about that.

But making sure that you're moving your body regularly. This actually has a couple of benefits. One is weight loss makes getting pregnant a little bit easier. Number two is that it will help your mood, which is invaluable and I would argue probably one of the most important things to get in all of this because especially with patients who have PCOS who are otherwise young and have a really good prognosis, there's a really high likelihood you're gonna get where you wanna be. But one of the biggest determinants of that is can you put your head down and keep going. Anything you can do to improve your mood, whether that is exercise, medication, therapy, regular bitch sessions with your girls, whatever it may be, do that.

Because if you can keep going, there's a very high likelihood that you're gonna get where you wanna be. And then of course the other benefit of that regular movement, even without weight loss, is that it better helps your insulin regulation within the body. That can help with ovulation. Even if you are not losing weight, that regular movement can help you to ovulate and help you get where you wanna be. We'd definitely put that on the list of things to do because clearly you don't have enough to do and think, about already and why not add one more thing? But that can potentially be helpful and on the mental health component of it, pay attention to that. That's important. It's important for you. It's important for your partner.

It's important for that future kiddo that you're gonna have and and pay attention to it. There's medications, there's therapy, there's groups, there's any number of things that can help you with that and it is well worth paying attention to because that is one of the biggest barriers to people having good success because that can get in the way and that can stop everything. Worth paying attention to it's important.

Abby Eblen MD (40:29)

All right, well good episode today. So to our audience, thanks for listening. Tune in next week for more. Also be sure to subscribe and leave us a review in Apple Podcast. We'd love to hear from you.

Carrie Bedient MD (40:40)

Visit fertilitydocsunsensored.com to submit questions and sign up for our email list. Pick up your copy of the IVF Blueprint today at Amazon, Barnes & Noble, your favorite bookstore. Check out our Instagram and TikTok for quick hits of fertility tips between our weekly episodes.

Susan Hudson MD (40:55)

As always, this podcast is intended for entertainment and is not a substitute for medical advice from your own physician. Subscribe, sign up for emails, and we'll talk to you soon. Bye.

Carrie Bedient MD (41:04)

Bye.