I don’t consider myself an advocate for infertility per se. More of a silent contender for those whose stories read a lot like my own. I’m not storming the hill like other amazing women but I am storming the gates of heaven begging God {much like I did for myself} to have mercy on women who are simply longing for what He creates – life.

I navigated through my journey of infertility with my faith as my guide. And now, I help lead this community of women, hoping to encourage those who are in the waiting, those who are just setting out on their path or those who have traveled so long they’ve lost sight of the destination. One of my greatest life passions is to share my story so that others know they are not alone and so that those who can, will make provisions for the millions of women who struggle to conceive.

I truly believe that if we are open, we can grow through whatever we go through. But the truth is, the journey to “the other side” is often long and always hard. Knowing your body doesn’t do what it’s supposed to do – can’t create or hold or grow life as it was meant to  – is one of the most confusing, maddening, heart-breaking realizations. It’s just plan unfair.

We will never fully overcome the injustice of infertility because it will never go away. But together, we can rise up as a community of family fighters that will not rest until others begin to understand what it’s like to feel broken and incomplete. We must not rest until we find a way to communicate our stories in ways that others understand – enough to do something about it.

This is why, although I’m “on the other side” of infertility, I will reach back across the fence and grasp the hands of my sisters – to steady them, comfort them and fight with them – until they can join me in seeing their dream come true.

No matter what the other side looks like for you, you WILL be better for having crossed over. . .for having endured years of hoping, waiting, and fighting for your family. And when you find yourself standing within the fulfillment of your deepest longing, I pray you’ll also reach back for those who need you to continue to fight.

Infertility has given me strength.

Infertility has given me gratitude.

Infertility has given me compassion.

Infertility has given me perspective.

I am a better woman for having endured and overcome my battle of infertility. I fought for my family and I pray strength and grace and provision for others in the midst of their battle.

Will you join me in the movement to bring awareness to those fighting for family?

{Photo Credit}

Friends, it’s infertility awareness week. I have been reflecting my journey and praying for those that find themselves longing for a child. Will you join us in praying and believing for LIFE to come to the over 10% of women who are struggling to conceive? Please share this message with others in your sphere and let’s storm the gates of heaven with prayers of healing and miracle life.

If you are struggling to conceive, please get in touch with us so we can be praying for you specifically.

He sees and he hears your cry. Trust him as you journey. Your story is being written and it’s not finished yet.

{Photo Credit}

Statistically more babies are born in October than any other month of the year. Actually the entire fall is crazy busy throughout the maternity ward. That means a lot of you are likely considering getting pregnant right now. The internet is chock full of ‘hints’ on improving fertility, but it is loaded with an equal amount of anxiety-provoking misinformation as well.  So what really works and what’s merely an old wives tale? Here’s what the most recent studies say:

1. Have sex

Have sex everyday or every other day for 5 days before and 5 days after ovulation.  Ovulation usually occurs  2 weeks before your period starts. Do not have sex more than once a day {Ain’t Nobody got time for that!} as that can lead to diluted semen.

Things that do not effect chances of conception:

• Female orgasm
• Sexual position
• Female position after sex

NO, it will not help if you stand on your head afterward. Neither is there a top secret magic sexual position that improves your chances of getting pregnant.

What may effect conception: lubrication. The best lubricants for fertility are canola oil, mineral oil or Pre-Seed.

2. Don’t smoke

Smoking is the culprit for up to 13% of all cases of infertility. Either partner’s smoking can effect their ability to conceive. The effects of smoking on your reproductive system can take up to a year to be reversed. There are so many reasons to quit smoking, but here is another excellent one: it can help make you more fertile.

3. Maintain a healthy weight

A BMI between 17-27 is ideal for conception. Recent studies report >60% of the US population are overweight. In some instances, being overweight can lead to higher insulin level, which can inhibit ovulation. This is a condition know as PCOS. (I did an entire series on it in the fall). In other instances, overweight women will have regular cycles (meaning they are ovulating) but still be subfertile. The good news is that even a modest weight loss of 10% of body weight can improve fertility.

Being too thin can also lead to subfertility. Your body senses that you don’t have enough reserves to handle the added nutritional demands of a pregnancy, so your brain tells your ovaries to shut down, causing your periods and ovulation to cease. This is often seen in cases of eating disorders.

4. Exercise in moderation

For women with a BMI of >25, exercise was found to cause a slight improvement in fertility. However women with a BMI of <25, who exercised vigorously > 4 hours a week were found to have a slightly decreased fertility.

Much like being too thin can shut down ovulation, extreme athletes like marathon runners and dancers can go through times of no cycles (no ovulation) when training intensely.

A man’s level of exercise has not been shown to effect fertility, with the one exception.  Men who bicycle > 5 hours a week were found to have lower sperm counts.

5. Healthy diet

Is there a magic food that will make you pregnant? No. However there have been several large studies looking at the diets of women with a history of infertility who become pregnant.

The dietary recommendations based on this study:

• Get the majority of your protein from plants
• Eat high fat dairy food
• Take a multivitamin with iron
• Eat complex carbohydrates

Another smaller study has supported the Mediterranean Diet to improve fertility.

Celiac Disease (gluten sensitivity), if undiagnosed or untreated, can lead to infertility. The treatment for gluten sensitivity is to follow a gluten  free diet.

6. Limit caffeine

It is recommended to limit caffeine to less than 300 mg a day. Here’s a helpful chart to know how much Starbucks you can drink.

7. Alcohol in moderation

While a little wine might be helpful in conception (wink-wink); excess intake may inhibit fertility. Studies show that consuming >14 alcoholic drinks a week has an adverse effect on fertility in both women and men. Consuming 3-13 drinks per week had a a slight negative effect on the woman’s fertility in some studies; but none on the man’s. Three or fewer drinks a week had no effect on fertility. There is no safe amount of alcohol in pregnancy, so once the stick turns pink, then you should abstain completely.

8. Know when to see a physician

Most couples will conceive within 6 months of trying, with 85% becoming pregnant within one year. If you are less than 35 and have regular menstrual cycles (every 21-35 days), it is recommended to see a doctor if you haven’t conceived after one year of trying. If you are over 35, it’s recommended to see a doctor after 6 months of trying.  If you do not have regular cycles or if you experience severe pain with your period or intercourse, you should see a doctor right away.

There is not a magic formula for conceiving. No magic food or sexual position that guarantees quicker results. What does work best is being healthy and regular sexual activity.

Hopefully your journey to pregnancy will be a smooth. Check out this previous post on recommendations for the first trimester once you do conceive.

In the meantime, enjoy the process!

What is the craziest home remedy or fertility “cure” you have heard?

{Photo Credit}

Patient #1 - “Lucy” is a new patient who recently got married and relocated to my city. She is coming to see me to discuss fertility. Her inability to conceive despite 3 months of trying has left her feeling frustrated. She breaks down into tears during the visit, “It’s not fair. ALL my friends are pregnant, when is it going to happen for me?”

Patient #2 - “Diane” is a long term patient, seeing me for her yearly well woman check. Reviewing the chart before walking into the room, I notice that for the last 4 years she had told me that she was considering trying to conceive. When I brought this up to the patient, she stated that she wanted to have children, but it never seemed like the perfect time. She wanted to wait one more year to get a few more things in order financially.

“Lucy” is 19 and “Diane” is 38. My examples might appear extreme, but I see these scenarios on a weekly basis.

Determining when to have your first child is a personal decision based on a multitude of factors. There is rarely a ‘perfect time’ to have a baby, but there are areas of your life that are helpful to have in order before you embark on the adventure of parenthood. Children are a beautiful gift, no matter when they come, but I am often asked what is the optimal time to have a baby. With half of all pregnancies being unplanned, some couples do not have the privilege of getting their ducks in order first, but for those who get a chance to plan accordingly, here are some issues to consider.

Age

Tick. Tick. Tick. Many of us have heard the all too real alarm of our biological clock blaring. One of the biggest concerns of most women is age. While age is an important factor when considering fertility it should not be taken as the only indication to have a baby.

Women are most fertile between the ages of 20-24. Fertility then begins to decline at age 30 and then more sharply at 37. Miscarriage rates begin to increase after age 35, reaching upwards of 5o% after age 40. I don’t put those numbers out there to strike fear in your heart, but to give you a realistic picture of human fertility. Yes, in an ideal world it would be best to complete your family before the age of 30, but I have many patients with healthy pregnancies in their 30′s and 40′s. It is by all means possible to have babies in your 40′s, but statistically the chances of conception do decrease with age.

The risk of having a baby with Down’s syndrome and other genetic abnormalities increases with maternal age as well.

Here’s the numbers:
At the age of 20 your risk of having a baby with Down’s syndrome is 1 in 2000
At the age of 35 your risk of having a baby with Down’s syndrome is 1 in 250
At the age of 40 your risk of having a baby with Down’s syndrome is 1 in 69
At the age of 45 your risk of having a baby with Down’s syndrome is 1 in 19

Let’s look at the numbers another way. What’s your chances of having a baby that DOESN’T have Down’s syndrome?
At the age of 20 i’ts 99.995%.
At the age of 35 it’s 99.6%.
At the age of 40 it’s 98.6%.
At the age of 45 it’s 94.8%.

 Health

It’s is best to conceive when you are at a healthy weight. Ideally a BMI between 17-27 is associated with the best chance of conceiving and having a healthy pregnancy.

All chronic medical conditions should be stable for 6 months before getting pregnant. Talk to your doctor if you have diabetes, high blood pressure, lupus, hypothyroid or other chronic diseases to make sure you are stable on medication that is safe in pregnancy for 6 months before conceiving.

Marriage

“Taking care of a colicky baby has really enriched our marriage!” said NO COUPLE EVER.

As I see women in my office for their annual checkups, I have noted several times over the years where a patient comes in to discuss getting pregnant in one visit, then sadly the next year she is divorced.

Having a baby is one of the most amazing experiences of your life. It is also very hard and stressful. A baby should never be looked at as a way to save or improve an already rocky relationship. It is going to test your relationship, so you want to make sure that you are starting in a solid place.

A lot of marriage experts recommend being married between 3-5 years before adding kids to the mix. Take the time to invest in each other and build a stable marriage before kids.

Ideally you want to limit the number of major life events that occur around the same year as having a baby such as moving, changing jobs or getting married. All of these add additional stress to your life and relationship.

Finances/Career

I recently prescribed a medication to help a patient conceive. She called the office later stating it was too expensive and requested samples. The medication was $25.

If $25 is straining your budget, you probably can’t afford a baby right now.

You do not have to be rich to have a baby, but you do need to have financial stability. A steady income and health insurance are a must, while 3 -6 months of savings in the bank, a budget, and plan for childcare would be ideal.

God’s Timing

You and your spouse should be in full agreement on your decision to start your family. As you prayerfully consider the timing, you should each feel a sense of peace about the journey. There are always moments in your parenting journey where you say to yourself, ‘What was I thinking?’ If you know from the start that you are following God’s timing for your life, then you will have an added level of reassurance on the long days of two year old tantrums.

In today’s society, there are not many couples who are going to be financially stable and married for 3 years by age 25 in order to be done with their families by age 30. These are all recommendations to help provide guidance, not rigid rules. There must be a balance between my examples of Lucy and Diane. You can’t wait until everything is perfect or it might not happen, and you can’t live in fear of getting too old and rush into kids before you are truly ready either.

Despite the best of our own planning, God has a way of putting our family together just the way it was meant to be, in His perfect timing.

 What do you think is the most important factor in starting a family?

For many of  you, its been years since you thought about the physiology of the birds and the bees. Before we launch into the discussions on how NOT to get pregnant, we are going to go back to basics to review the biology of reproduction.   

The first day of your period is also the first day of your menstrual cycle (day 1).  Spotting doesn’t count, we are looking for the first day of red bleeding. [And if we had any male readers, they just surfed onward.] The menstrual period occurs approximately 2 weeks after ovulation. If no embryo has implanted into the lining of the uterus, the brain immediately realizes you aren’t pregnant and begins sending signals to the ovary to try again this month. An egg is recruited within the ovary and begins to grow with the help of rising estrogen levels. Thus begins a complex fluctuation of hormones that cause the many changes in your body, helping it prepare for pregnancy. It is these hormonal shifts that help the brain trigger the ovary to ovulate each month.

For women with a 28 day menstrual cycle, ovulation occurs on approximately day 14. Ovulation is the act of the egg escaping from the ovary. After breaking through the ovarian surface, it will either sit on the outside of the ovary or fall into the abdomen. The fallopian tubes have finger like projections on their tips that literally pick up the egg and begin to shuffle it toward the inner uterus (endometrium). A small cyst forms on the ovary (the corpus luteum) where the egg escaped. This cyst begins producing high levels of progesterone that will help a pregnancy grow if implantation occurs.

Fertilization occurs within the fallopian tube and the fertilized embryo then begins to develop and works it way toward the uterus. ~30% of fertilized embryos dissolve spontaneously before implantation. Four to six days later the embryo completes its journey and implants into the the lining of the uterus. Another ~30% of embryos will dissolve after implantation, before a period is missed. Another ~10% will be lost as first trimester miscarriages. For every 100 fertilized embryos that form, only 30 will result in a healthy birth.¹

Based on the fact that 60% of fertilized embryo dissolve spontaneously before the first period is missed, it is my opinion that life begins some point after implantation. It is difficult for me to fathom that God would place a soul in each fertilized embryo and then immediately take 60% of them to heaven. The scripture “God knit me together in my mother’s womb” is often used to support the belief that life begins at conception, but the ‘womb’ is the uterus. By the time the embryo reaches the uterus 30% of the embryos have dissolved with another 30% following soon.

The sperm are deposited in the vagina and then must travel through the cervix and uterus to reach the fallopian tube. A few of the strongest swimmers make it all the way to the egg. Only one can break through and fertilize. The sperm take appropriately 72 hours to travel through the uterus to get to the fallopian tube. The average sperm will travel 8 inches to reach its prize egg, this is why women can get pregnant without having actual vaginal penetration. Even sperm released near the vaginal opening can swim into the uterus.

Each month a normal fertile couple has a 20-30% chance of conceiving. If implantation does occur, the progesterone levels begin to increase and HCG increases. The HCG hormone is what makes the pregnancy test positive.

If pregnancy does not occur, then a period will start 2 weeks after ovulation. To determine when you are ovulating, you can count backwards 2 weeks from the period, and then use those numbers to predict when you will ovulate the next month. For example: with a 32 day cycle, you should ovulate on day 18.

To get pregnant, have sex at least every other day for 5 days before ovulation and 5 days after. Do not have sex more than once a day. [And if any men were still reading, now they really just stormed off.]

This week as we discuss contraception, we will see that there are 3 basic ways to prevent pregnancy: preventing ovulation, killing sperm and blocking the sperm from getting to the egg.

1 Sperff et al, Clinical Gynecology Endocrinology and Infertility (Philadelphia: Lippincott Williams & Wilkins: 2005), 245-246.

{Fertilization and Implantation Photo Credit: © 2010 Wolters Kluwer Health |Lippincott Williams and Wilkins. Used by permission.}

It’s fall and somehow the leaves that abandon their source to make way for new life once winter rest has passed gives me hope. I see evidence of this cycle of life all around. What looks as though it’s been lost is giving way to something new.

But we must wait. Wait until the time has come for the newness to flourish in sun and rain.

I notice the color of loss is vibrant yet deceiving. So full yet so empty. Sad but hopeful.

I allow myself to feel every emotion that waves through me as I process this process. But I am determined to land on hope.

There is a sweetness in the sorrow as it draws us closer to our Maker and His divine purposes. As He comforts our pain and silences our questions with His love.

There are many different colors and shapes to our grief and they mirror the variation I see through the seasons.  There is no good or bad. Our variety reveals who we are.

We beg the Maker to remove loss and replace it with abundance because we are desperate for joy. . .we are desperate for peace.

But there is peace in the process. . .that passes understanding.

My dear friend, I grieve with you in your process. I weep as you weep and I question as you question but I pray you find hope. I implore you to find the beauty that is hidden within the buds of growth and life as you journey through the seasons.

He will not leave you barren. He will not leave you bare.

“May the God of Hope fill you with all joy and peace in believing.” Romans 15:13

This post was written in honor of Pregnancy and Infant Loss Awareness Day. I am part of this community having experienced 3 miscarriages and 1 ectopic pregnancy. Today I stand with the brave women who have endured loss and I remember the life we once carried in our wombs. I also stand in hope that the desires of their hearts will be fulfilled in His perfect timing. He is faithful.

A while back I did a post on my life with PCOS. I was in the middle of trying to conceive our second child and we’d had several set backs. That post was honest and a bit sad but hopeful. A few months later I conceived miraculously and that sweet boy is now 15 months old.

I have my babies but I still have PCOS. And although I’m not facing the challenge of fertility any longer, I daily face the challenges of living with this condition. I shared in that post that I felt like my body was broken – that it didn’t do what it was supposed to do (easily produce babies). We got it to do that but there are so many other things it’s not doing well. And I’m left with the choice to live with a broken body or to fight for wholeness, even if it might take a bit more work than I’d like.

Dr. Rupe has shared some amazing information and tips for those of us living with PCOS in her series this month. As my contribution in honor of PCOS Awareness Month, I wanted to share my point of view as a patient along with some encouragement for how we can get our bodies on track.

Like me, you may feel like you are broken because your body isn’t working properly. Much like those that live with diseases or disabilities, it can be discouraging and frustrating to feel less than whole. But I believe that He works all things together for our good (Romans 8:28) and therefore good can come out of a place of lack. I’ve spent the past year since my second (and last) child was born in denial about what it’s going to take to get my body to a good place. Worn out from life with a baby (and a preschooler), I didn’t want to face it. But the time has come and Dr. Rupe’s posts have been a great encouragement for me to get off my butt and fight for my health. In this post she said, “The metabolism of  PCOS is really just not fair. Your girlfriends can pig out on pizza on the weekend and still fit in their skinny jeans, meanwhile, you walk past a bag of Oreos and gain 5 pounds. Acceptance that this is how your metabolism works is a key first step. You must learn to treat yourself like a diabetic. A higher protein, lower carb diet is going to be your best bet.“

She’s right. It isn’t fair. I hate that I have to deal with this but sometimes life isn’t fair. I can think of a million worse, unfair things that people have to deal with. “Injustice” (that seems dramatic but stay with me here) should lead us to fight not cower in defeat. So friends, it’s time. It’s time to redirect all of my fighting energy that I once put into conceiving my children to taking care of myself and beating this thing called PCOS. I hope those of you that struggle with it will join me. If we have enough girls in our community, perhaps we can form an accountability group. I’ll admit, I’m scared to death to put this out there. I’m not the most disciplined person in the world and I often give up before I overcome. But I cannot look only to myself for strength to do this. I am trusting the Lord to provide everything I need because He desires that we are healthy and whole beings, at our best to do what He’s called us to do.

5 Ways to Beat PCOS (or any weight issue)

1. Find Your Motivation – For me, my motivation was once the desire to conceive. Now, it’s the desire to be healthy so I can keep up with my kids and be a good example for them. While I was pregnant with my 1st, I had gestational diabetes. I was put on a strict diet and ended up losing 20 lbs while pregnant. I’d never lost 20 lbs in my life. I was motivated by the desire to keep my baby safe and have a healthy delivery. But once I delivered, my motivation was no longer there and I blew it. Gained it all back. I failed to find the motivation to keep it off. Let’s find our motivation and keep it at the forefront of our life.

2. Find Your Support System - Whether it’s your husband, girlfriends, mom or a personal trainer – find someone (or a few people) to keep you accountable. Don’t neglect to vocalize your goals because you are afraid you might fail. Put it out there. No one is going to fault you for falling short. The important thing is that you try and work hard to meet your goals. Let’s put together a support system of people we trust that will cheer us along the way.

3. Find Your Strategy for Exercise – This week I started the couch to 5K program. I’ve been wanting to do this for a while. Now that I have both kids in mother’s day out, I have the time to spend on “training.” I chose this plan because it is simple, goal oriented and attainable. Perhaps you don’t have time without your child(ren) at all. Talk with your spouse or family members and find a way to fit in some workout time. Dr. Rupe said working out is not an option, it’s a command. We have to do it. I don’t enjoy working out which is why I never worked hard to find a strategy for doing so. But we have to get moving. Even if you just put on some music and dance around with your kids, you are doing more than you were before. Put on a workout DVD and let them play around you while you exercise. It may not be the ideal situation but at least you are starting somewhere. Let’s find a strategy for exercising regularly that is simple and attainable.

4. Find Your Plan for Healthy Eating – Dr. Rupe gave us some good tips in her post last week for eating with PCOS. I am determined to get back to the plan that I followed when I had gestational diabetes because it worked for me. Low and controlled carb intake is key for women with PCOS. Talk with your doctor or a local nutritionist about what plan would be best for you. But don’t over think it. Making small changes can also do a lot for your body. In addition to the low carb plan, some of the small changes I will be making are:

- Drinking more water (I’ve gotten in a bad habit of drinking more coffee than water)

- Eating a more well-rounded breakfast to start my day

- Eating out less (also a bad habit we’ve gotten into with busyness)

- Allowing myself small treats instead of the full size daily ones I have been eating (I adore chocolate)

I will be posting this list on my fridge as a reminder to myself that I must follow these guidelines. As I said in The Pregnancy Companion book, making healthy choices happens one choice at a time. Don’t think about the life change that has to happen overall at first. Let’s try to make the best choice, one choice at a time.

5. Find Ways to Reward Yourself – I have a picture on my fridge of a shirt from my favorite store that I am going to buy myself when I lose 10 lbs. Not only will losing 10 lbs give me the reward of buying a cute shirt, I will look much better in said shirt after I’ve lost 10 lbs. So it’s a win, win! Find small ways to reward your progress. Give yourself something to look forward to for working hard and reaching your goals. Let’s find ways to tell ourselves “you deserve {insert awesome and motivating reward here} because you overcame the obstacle of PCOS!”

Friends, I am excited about this new season. I am fueled with a passion to beat this annoying, challenging and unfair condition. I want to thrive in my life as a woman, a wife, a mom. . .I don’t want to be bogged down by the unhealthy effects of PCOS.

Will you join with me?

{Photo used courtesy of Creative Commons}

Often one of the first things that women hear when they are given the diagnosis of PCOS is that they will be infertile or at least have a challenging time getting pregnant. Such news can be devastating. What I prefer to tell women is that we know there is a problem, BUT we also know how to treat it! Sometimes there is a journey to health and fertility, but not always. Many women with PCOS can have successful pregnancies with only simple interventions.

When couples go for infertility testing, about half the time all the tests come back with normal results. Patients often find this reassuring, but as their doctor if there is nothing wrong, I don’t have anything to fix. I love to see infertility patients with PCOS because at least I know what the issue is that I need to correct: they are not ovulating regularly due to insulin resistance.

Metformin

As I mentioned in my last post, diet and exercise are key to treating PCOS. Women with PCOS who loose just 10% of their body weight will often see a return to ovulation. Weight loss and Metformin will lead to ovulation 60% of the time. Metformin is safe to take at the time of conception. Continuing it during pregnancy has been the basis of debate and is provider dependent.

Pregnitude

Pregnitude is a dietary supplement recently available in the US that has been shown to help women improve their fertility, especially women with PCOS.  It contains folic acid and myo-inosol, which is derived from a B vitamin complex. Myo-inosol is a natural insulin sensitizer made by the human body. The product was the focus of an article in the August edition of The Female Patient that listed 2 small but significant scientific studies which found improved menstrual regularity and ovulation in those taking the supplement versus folic acid alone. 82% of women on the supplement ovulated within 3 months, while only 63% on folic acid alone ovulated. The supplement allowed women to ovulate much quicker as well,  24 days versus 40 days.  Women undergoing IVF who took the supplement had significantly more eggs retrieved (12) on the supplement than those on  placebo (8). The supplement is taken as a powder mixed in water twice a day and is available over the counter. The cost is ~$30 a month if ordered from their website or bought from Walgreens.

Almost daily, I get requests for a ‘more natural’ option for fertility and Pregnitude appears to be the perfect answer. It also appears ideal for women who don’t meet the definition of infertility (one year of trying without conceiving) but are frustrated that conception seems to be taking longer than they think it should.

Clomid

When diet, exercise and Metformin have not resulted in pregnancy, then it may be time to discuss Clomid.  Mention the words ‘fertility drugs’ and people see visions of women getting shots in the butt, seven babies and a reality show. Clomid is the mildest of the fertility medications. It has a risk of twins of 10% but triplets or higher is extremely rare. Clomid is taken for 5 days during the cycle and has an ovulation rate of 70%. Clomid is inexpensive at less than $50 a month. So if you can’t afford Clomid, you likely can’t afford a baby.

To monitor if Clomid is working, your doctor will either perform ultrasounds or check progesterone levels at different points of your cycle. Once you have found a dose of Clomid that produces ovulation, you will usually conceive within 3-6 months. If you haven’t conceived in 6 months, the likelihood that you will is extremely low, so additional therapies should be considered. This is the point where  I will refer my patients to a reproductive endocrinologist (infertility specialist).

Clomid is an estrogen receptor modulator. It acts to starve your body of estrogen for 5 days, tricking your ovaries into ovulating. A lot of women report significant hot flushes and mood swings during the 5 days they are on the medication. Like estrogen itself, it can increase your risk of blood clots, so it should not be taken if you have a history of DVT or stroke.

PCOS does not have to be synonymous with infertility. PCOS can present challenges for those wishing to conceive, but these challenges can often be overcome with minimal interventions. For more on the diagnosis of PCOS, see the first post in this series.

Sources for this series of posts include: Clinical Gynecologic Endocrinology and Infertility, Seventh Edition pages 465-498; Summary from Up to Date; ACOG technical bulletin #109, in addition to the article from The Female Patient that was linked to within the post.

 What fertility interventions have you taken in order to become pregnant with PCOS?

In my last post I tackled the complex diagnosis of PCOS, compacting a 60 page text book chapter into an 800 word blog post that, hopefully, the average woman could understand. Good thing our readers are above average, right? This post will discuss the common treatment strategies, and next time we will look at attempting pregnancy and addressing infertility.

The root cause of PCOS is insulin resistance. The best treatments are those that help your body process insulin better. Exercise, diet and the medication Metformin are key to accomplishing this goal.

Exercise

If you have PCOS, exercise is not a suggestion but a command. It is the single best thing you can do for your body. Exercise helps your body process insulin better, revs up your super sluggish metabolism and helps maintain your weight. Getting at least 30 minutes of aerobic exercise 5 times a week is a MINIMUM. Weight training is also key. Building muscle can help boost your metabolism. PCOS increases your risk of diabetes, but regular exercise reduces your risk by 50%.

If you have trouble finding the motivation to exercise, then find a buddy or accountability partner; join a class or consider personal training. If you live here in Franklin, I recommend Temple Fitness (not a paid advertisement, just my honest opinion) as several of my patients have had great results there, and this is where I go to get my butt in gear.

Diet

The metabolism of  PCOS is really just not fair. Your girlfriends can pig out on pizza on the weekend and still fit in their skinny jeans, meanwhile, you walk past a bag of Oreos and gain 5 pounds. Acceptance that this is how your metabolism works is a key first step. You must learn to treat yourself like a diabetic. A higher protein, lower carb diet is going to be your best bet.

The first step to losing weight is determining how many calories a day you need.  Dieticians recommend for PCOS patients to distribute these calories as : 40% carbohydrates/ 30% fat/ 30% protein.  The carbs should be complex, not simple.  Avoid eating carbs alone, instead pair them with a lean protein.  To track your daily intake, try an phone app like “My Fitness Pal“.  As you enter your food throughout the day, it gives you a pie chart graph of carbs, protein and fat so you can actually see how your percentages are tracking each day.  It also has a bar code reader so you can easily scan in your foods (on that rare occasion that you are eating packaged food).  If you are continuing to have difficulty determining what your diet should be, meet with a dietician.

Metformin

Metformin (Glucophage) is a diabetic medication that decreases the amount of sugar (glucose) excreted by the liver, which reduces the amount of insulin your body needs. While not a weight loss drug, it helps put PCOS women back on the level playing field with everyone else. When they are following a lower carb diet and exercising, it helps them lose and maintain their weight. In addition to weight loss effects, Metformin will help up to 60% of women return to regular periods and ovulation. It must be stressed the Metformin works well WITH diet and exercise, but cannot replace it.

Side effects of Metformin are mainly GI upset. When first starting the medication, you can have serious diarrhea. Usually, the symptoms will resolve within a couple of weeks. If the stomach discomforts last longer than that, notify you doctor.

Birth Control Pills

For those women not wishing to conceive, birth control pills are ideal to treat the symptoms of PCOS. They increase the protein in the blood that binds the male hormone, reducing acne and unwanted hair growth. They also induce monthly cycles, preventing the heavy, crampy, unruly periods that sometimes accompany PCOS.

It is important to have a period at least every 3 months to help prevent the build up of endometrial tissue and the possibility of endometrial cancer. If you don’t like taking birth control pills, then taking progesterone every 3 months to induce a period is also an option.

Healthy Weight Women with PCOS

For the 20% of women with PCOS who are not overweight, these same principles still apply. Change the composition of your diet to the recommended percentages, just set your overall calorie goal to maintain rather than to lose.  We do not have a great laboratory test for insulin resistance.  Only 50% of PCOS patients show elevated insulin levels.  Often patients with normal insulin levels will still respond to Metformin, so it continues to be recommended as the treatment of choice.

For those women attempting pregnancy, often instituting exercise, diet and Metformin will lead to ovulation and pregnancy.  My next post will consider what happens when this is not enough.

For those of you living with PCOS, which do you find more challenging: diet or exercise?  What strategies have you incorporated to help overcome your challenges?

I don’t fault patients for finding the diagnosis of PCOS perplexing. It took me nearly 4 years of medical school to fully grasp it.  September is PCOS Awareness Month and with 5 % of  reproductive age women affected, we plan to bring you several posts this month on this often confusing diagnosis.

Polycystic Ovarian Syndrome is a misnomer. It is not an ‘ovarian syndrome’ at all. The root cause of PCOS is a combined genetic and metabolic issue. Women with PCOS do not react normally to insulin. When sugars hit their blood stream, their body requires extra insulin to process the sugar. The higher levels of insulin have several effects in different areas of their body, including messing with their ovaries. The insulin molecule is very similar in shape to another molecule that has receptors on the ovary.  Insulin then falsely attaches to the ovary, causing it to release too much male hormone, leading to lovely features like acne, abnormal hair growth and even male pattern baldness in extreme cases. The extra male hormone gets converted to excess estrogen in the fat cells, which prevents ovulation. The excess insulin makes weight loss more difficult, which can lead to obesity.

Estrogen is the hormone responsible for creating the blood and nutrient rich lining of the uterus. A normal amount of estrogen makes a healthy lining for an embryo to implant. With PCOS, there is an elevated level of estrogen, creating excess tissue, leading to heavy, crampy periods. In extreme untreated cases, it can lead to precancer of the uterus.

It is much harder for women with PCOS to lose weight and keep it off, due to their body’s resistance to insulin. As they get heavier, the fat cells themselves secrete additional hormones that worsen the insulin resistance.  Essentially, the more weight a woman with PCOS gains, the harder it is to loose the weight. This helps explain why 80% of women with PCOS are obese.

Some of you extra smart ladies are already thinking, “Isn’t extra insulin just like diabetes?” Yes and no. PCOS is in many ways a pre-diabetic condition. However, there has to be a genetic predisposition to PCOS as well.  PCOS is caused by how a woman’s body reacts to the excess insulin. Not all diabetics have PCOS. Many diabetics will ovulate regularly and have no excess of male hormone, despite their elevated insulin. We also see that PCOS tends to run in the family.  In studies of identical twins, if one twin has it, there is a 70% chance the other twin will have it as well. This leads us to think that the abnormal insulin metabolism is caused by an inherited genetic defect…yet another thing that we get to blame our mothers for.

Despite the hormonal imbalances going on in the body with PCOS, the ovary tries its best to ovulate. Much like the “Little Engine That Could” the ovary desperately attempts to make its eggs grow each month, but rarely will it mange to get an egg mature enough to fully ovulate. This leads to a swollen ovary with multiple tiny cysts of immature eggs (follicles). The PCOS ovary stays enlarged and swollen, but the ‘cysts’ associated with PCOS are multiple tiny cysts; not the large painful kind that women often need to be surgically removed.

I often see women for second opinions for PCOS. One doctor told them they had it, then another said that they didn’t. They are frustrated and want answers. However, PCOS is a clinical diagnosis, making it subjective. When your throat hurts, you go to the doctor.  She thrusts a q-tip down your throat and runs a test. The test is straightforward: positive or negative. Alternately, PCOS  is based on a collection of findings that can be supported by blood work, but there isn’t a definitive test.

To further add to the confusion, there are currently 3 sets of diagnostic criteria for PCOS floating around. Also, in Europe physicians put a lot more emphasis on ultrasound finding, while in the US clinicians look more at symptoms.

The most common definition in the US is the NIH {National Institutes of Health} criteria:

1. Irregular periods

2. Evidence of elevated male hormone (either lab work or symptoms)

3. Exclusion of other causes of elevated male hormone.

The classic patient with PCOS is overweight, with most of their obesity in their abdomen. Weight loss is extremely challenging due to their body’s insulin resistance. Their cycles are sporadic, every 2 to 3 months. They struggle with fertility due to their ovary’s inability to ovulate despite its best efforts. They get the added bonus of often needing to wax their chin way more than their friends. PCOS is a challenging condition but the good news is, it’s manageable. In my next post I will look at the different ways to manage your symptoms and a new natural therapy to help fertility.

Have you been diagnosed with PCOS? What questions do you hope we’ll answer for you as we participate in PCOS Awareness Month?

{PCOS Image Source}