PCOS

Should we try Femara first?

letrozole-femara-fertility

For years clomiphene has been the main medication that fertility doctors and obgyns use to help women with polycystic ovarian syndrome and irregular cycles to get pregnant

That may be starting to change. In fertility practices such as ours, we have switched to a different drug, letrozole, also known by the brand name, Femara.

What is Letrozole?

Letrozole is a medication that blocks an enzyme in the body that converts testosterone into estrogen. It causes the estrogen levels to drop which lead to the pituitary gland to produce more of a hormone called FSH. FSH (follicle stimulating hormone) is the hormone the causes the eggs to start growing. By doing this, letrozole stimulates ovulation The most common use for letrozole is to help women with breast cancer reduce their risk of recurrence.

Why would you want to use letrozole instead of clomid?

Stimulation with letrozole results in fewer eggs than clomiphene, resulting in fewer multiple births. It is also less likely to cause the side effects of hot flashes and mood swings that are common with clomid.

So, what do the experts say about Femara?

The American College of Obstetrics and Gynecologists has endorsed letrozole as first line treatment for women with PCOS and infertility.

 

The mediterranean diet and fertility

Mediterranean diet and fertility: Princeton IVF blog
paleo-diet-fertility.jpg

As a fertility specialist, one of the most common questions I get is about diet, what can changes can I make in my diet to help me get pregnant?

For some patients, particularly those with PCOS that answer is relatively simple. It well know that a diet high in protein and low in carbohydrates helps women with polycystic ovaries to conceive. 

For other women with infertility, the answer is less clear.

A recent study from Greece, looked at women who self-reported at following a "mediterranean diet." Women on a Mediterranean diet had a higher pregnancy rate that those who did not.

Does this prove that a diet in low in animal fats and high in vegetables and fruit can help you get pregnant? No, but it does suggest a health diet low in carbs and red meats may help your chances of having a baby.

Delaying the diagnosis of PCOS

PCOS may take years to diagnose: Princeton IVF blog
PCOS-delayed-diagnosis.jpg

How long to does it take to be diagnosed polycystic ovarian syndrome?

Apparently a lot longer than you might expect...

A recent study from University of Pennsylvania suggests that women with Polycystic Ovarian Syndrome may not receive the proper diagnosis for years.

Women across the US and Europe were surveyed and this is what the researchers found:

  • in 1/3 of women, it took at least 2 years to make the diagnosis
  • almost of half of women had visited at least 3 health care providers before the diagnosis was made
  • 84 % of women did not believe they received enough information about PCOS at the time of their diagnosis

As a Reproductive Endocrinologist, this is both surprising and not expected.

In our practice, as in most fertility and gynecology practices, PCOS is one of the most common disorders that we see. It is the most common hormonal disorder in women of reproductive age and the ovulation problems associated with PCOS are the most common cause for infertility in women. So, as specialists, we are attuned to look for polycystic ovary, and are more likely to find it in its more subtle forms. We are also committed to educate our patients about their condition, what causes it, how it is treated and what other health implications it might have.

It is also very common for us to see women who were never told by their doctor that they might have PCOS, and only came to see us because they cannot conceive. Still others, looked up their symptoms online, realized they had PCOS and referred themselves.

Sometimes seeing a specialist can help.

Most of the time your OBGYN, midwife or even primary care physician can manage the symptoms of PCOS. If your symptoms are under control and have a good understanding of your condition, there is no reason to seek out help. If your symptoms not controlled, you are having trouble getting pregnant or you don't feel you have an adequate understanding of PCOS, seeing a sub specialist in Reproductive Medicine may be a good idea. 

 

 

Red wine, Resveratrol and PCOS

Could a chemical in red wine help you if you have PCOS: Princeton IVF blog

Could one of the compounds found in red wine help women with PCOS?

red-wine-resveratrol-pcos.jpg

Yes, it actually might help women with polycystic ovarian syndrome.

What is resveratrol?

Reservatrol belongs to a group of chemicals call polyphenols which are commonly thought to act as antioxidants. It is found in the skin of grapes, as well is in peanuts and some berries. Most resveratrol supplements sold in the US, actually come from a plant grown in Asia, rather than from grapes. It has been used as a supplement to help inflammation and diabetes.

Why might resveratrol be helpful for with PCOS?

Polycystic ovarian syndrome is the most common hormone disorder in women of reproductive age, and a common cause for infertility. The symptoms of PCOS are largely related to irregular cycles and excess levels of male-like hormones, but the underlying cause is related to how the body handles sugars. Most women with PCOS have a condition called insulin resistance as the reason for their disorder, and diabetes drugs such as Metformin are commonly used as treatment.  Since resveratol can help women with diabetes, it is possible that it may help women with PCOS as well.

A new study suggests resveratrol may be helpful.

Researchers at University of California- San Diego took women with confirmed PCOS and gave them resveratol supplements to see what would happen. They found that these patient's levels of male hormone including testosterone dropped significantly, suggesting that resveratrol may be doing this by reducing insulin resistance. The researchers did not look at whether their cycles became more irregular or more fertility.

So, should I start drinking red wine if I have PCOS and want to get pregnant?

Not a great idea, at least when you are or might be pregnant. It is possible (but still unproven at this time) that resveratrol may help promote fertility in women with PCOS. On the other hand, it is well known that alcohol, including red wine, when consumed by pregnant women can increase the risk of serious birth defects. It may be reasonable to have red wine before conception, but no OBGYN or  Fertility Specialist would recommend you drink once you might be pregnant.

The inventor of clomid and his legacy

The legacy of the inventor of clomiphene, Frank Palopali
Frank Palopali invented the fertility drug Clomid.

The story behind the first fertility drug, Clomid.

As the year draws to a close, the newspapers, TV stations and other media outlets will share stories about individuals whom we lost in the past year. We will hear stories about great artists, musicians, athletes, politicians and others, about how they lived their lives and how their life's work impacted our own lives. It is likely these accolades will miss out on someone whose impact on world of reproductive medicine and generations of couples suffering from infertility. That man was Frank Palopoli.

Who was Frank Palopali? 

Frank Palopali was a research chemist at the Merrell Dow Company. He was the leader of the team that developed clomiphene (Clomid) one of the most commonly used fertility drugs in the world. His work in the laboratory started back in the 1950's and first clinical trials of clomiphene were published in 1961. In 1967, Clomid was approved by the Food and Drug Administration and it became available to the public.

So, why was Clomid such a big deal? 

In this age of high tech, highly effective fertility treatments, IVF with genetic testing and the like, it is somewhat difficult to understand why an  inexpensive pill you pick up at Walmart for less than $10 might be such a big thing, but it was a huge breakthrough. If you look back to the world of women's reproductive health care 50 years ago, most fertility treatments were relatively ineffective and more often than not involved major surgery. For instance, the treatment of polycystic ovarian syndrome (PCOS) at the time involved in operation called the ovarian wedge resection. The gynecologic surgeon would make it open incision in the abdomen (similar to a cesarean section) and remove a wedge-shaped portion of the ovary, and then stitch the remaining ovary back together before closing the abdominal incision. Like other major surgeries, recovery from this operation could take weeks or months, but the benefit, if any, was very short term, just a few months afterwards. Additionally, eggs were inevitably lost in the process and scar tissue could develop on the surface of the ovaries, both of which could harm a woman's future fertility.

With the invention of clomiphene it was now possible to treat PCOS with just a pill. It completely revolutionized the treatment of infertility caused by problems of ovulation, and ovulation problems such as irregular cycles are among the most common causes of infertility in women. No longer would costly and invasive procedures be required, at least for most women with PCOS. While future inventions such as injectable fertility drugs, alternative methods of ovulation induction and IVF would bring success to many more people, it all started with the development of Clomid.

Over past nearly half a century since this time, millions upon millions of women all over the world have been able to have children and grow their families because of this invention. The number of couples helped by clomiphene actually dwarfs the number of those helped by IVF.

How does Clomiphene work?

Clomiphene is an anti-estrogen. It is part of a class of drugs called SERMs (selective estrogen receptor modulators) which include tamoxifen (Nolvadex) and reloxifene (Evista), drugs which are used to breast cancer and menopausal symptoms. Clomid works by blocking estrogen, the main female hormone. By blocking estrogen from working at the brain and pituitary gland (the master gland at the base of the brain), it tricks the body into sensing that there is no at there is no estrogen around. As a result, the hormones (FSH and LH) that stimulate the ovary, start to rise. This rise in hormones then kickstarts the process of the egg starting to grow and begins the path towards ovulation.

What are clomiphene's side effects?

It is easier to understand the side effects of clomiphene when you understand how it works. Because Clomid is anti-estrogen, it can cause hot flashes, headaches, breast discomfort and other symptoms that we normally associate with menopause. Because it stimulates the follicles (the cysts which contain the eggs) to grow, it can cause discomfort in the abdomen and increases the risk of multiple births. There are also concerns about whether clomiphene increases the risk of ovarian cancer, though most of the studies suggest it safe that when use for a brief period time. This is another reason to seek out the care of a fertility specialist early in the course of your treatment.

What is clomiphene used for?

The original and most common use for clomiphene is to help women who don't ovulate regularly, to produce and release eggs, become pregnant or hold on to a pregnancy. Clomiphene is also that used to help women produce multiple eggs to help improve the chances for success with insemination (IUI) and IVF. Clomiphene has also been used in men to assist in their fertility. This medication is intended to be used under the guidance of us physician experienced in their use.

How much is the price of clomiphene?

Like any other medication, the cost of clomiphene varies from pharmacy to pharmacy. Generic clomiphene in the typical starting dosing (50 mg) frequently sells for less than $10 at large retailers such as Walmart or Target. In the US, this medication always requires a prescription.

How many days after Clomid do you ovulate?

This a common question without a straight forward answer. Most women will ovulate around day 14 of the cycle, give or take a few days. Since clomiphene is usually taken day 3-7 or days 5-9, that means about 5-7 days after the last pill. However, some women will ovulate earlier, some later or not at all. At our center, we like to monitor everyone on clomiphene to make sure we get the timing right, and not delay pregnancy any longer than necessary.

Clomid success rate- how well does it work?

When used for to help infertile women with irregular or absent menstrual cycles, clomid enables about 80% of women to ovulate when used over a period of time. About half of these women will go on to conceive. This is actually quite good when you realize that natural conception in normal fertile women is only about 20-25%. The success rates when using clomiphene for other causes of infertility (unexplained, male infertility, endometriosis, etc.) is lower. 

Can clomiphene be used in men?

Clomid is sometimes used to treat male infertility, though it is considered an "off-label" use. Since its use and its effectiveness in men is somewhat more controversial than its use in women, it is best prescribed and managed by a urologist with special expertise in male fertility.

Dr Derman featured in Princeton Packet

Infertility causes and solutions in the Princeton Packet: Princeton IVF blog

YOUR HEALTH: Infertility: causes and solutions

By Stephanie Vaccaro

Dr. Derman talks about the causes and treatments for infertility

This article recently appeared in the Health Matters Column of the Princeton Packet...

   So You Want to Have a Baby?

   Infertility is defined as the inability to conceive after engaging in unprotected sex for one year, according to the Centers for Disease Control and Prevention.

   What causes fertility problems?

It can be a number of factors. Dr. Seth Derman of Princeton IVF and Delaware Valley OBGYN, said that approximately 40 percent of the fertility issues he sees are due to male problems, 40 percent are due to female problems, and 20 percent a combination of both partners.

   ”The exact cause of male infertility is a little harder to diagnose because it’s not well understood,” Dr. Derman said. “With female infertility, the most common cause is ovulation problems, which usually show up as irregular cycles. Polycystic ovarian syndrome is the most common of these.”

   Fertility problems can be caused by endometriosis. They also can be linked to damage to the fallopian tubes, which can be caused by previous sexually transmitted diseases. This is particularly a problem in women who have had prior Chlamydia infections.

   And sometimes infertility has no identifiable cause.

   What options exist for treatment?

   ”Well, it depends what’s wrong,” Dr. Derman said. “If there’s an ovulation problem, usually the treatment is fairly simple with fertility drugs. These are medications that induce ovulation, such as clomid or letrozole.”

   ”For tubal problems — the treatment is usually surgery or IVF (in vitro fertilization),” Dr. Derman said. “IVF is clearly the most effective treatment for these problems.”

   Oftentimes the most effective option involves treating the female partner. IVF allows for the sperm to be injected directly into the egg, and is the most effective treatment for male infertility. “The poorer the husband’s sperm the more likely the couple will need more invasive treatment such as IVF,” Dr. Derman said.

   A less invasive alternative to IVF is insemination, in which sperm is injected up into the uterus. In contrast, IVF involves fertilization of the egg outside of the body, and the transfer of that embryo into the woman’s womb. It is also much more effective than insemination. When patients have unexplained infertility, insemination is oftentimes done first, and if that doesn’t work then they may try IVF, Dr. Derman said.

   What are the odds of success?

Typical fertile couples have a 20 to 25 percent chance of getting pregnant each month. Infertile couples have a 3 percent chance when trying on their own. IVF increases the odds of having a child to twice what it would be in a fertile couple. Those numbers can vary based on age.

   IVF is very often successful in the first or second cycle, particularly in young women. If it isn’t successful, it’s not unusual for a couple to try three or four times, according to Dr. Derman.

   Who pays for IVF?

In New Jersey, the Family Building Act (August 2001) requires companies with more than 50 employees to cover fertility testing and treatment, including IVF. There are exceptions in the law, and since the passage of healthcare reform, those exceptions have gotten even larger.

   Some of the other treatments can be relatively inexpensive. “For instance, treatment using fertility pills and some monitoring is not terribly expensive,” Dr. Derman said.

   When should you go see a fertility doctor?

   ”Generally, over 35, we recommend coming after six months,” Dr. Derman said. “If they are under 35, one year is the right time.”

   What should you expect when you go see a fertility doctor? When patients go to see Dr. Derman for the first time, the first stage in the process is to try to understand why they are unable to conceive. After getting a detailed history, tests will be ordered, which include testing to make sure their eggs are not running out, to make sure their tubes are open, to make sure the ovulation process is going well and that the sperm is normal. After getting a clearer picture of what is going on, they can better determine the next steps.

   ”Not everybody with infertility needs IVF, even though it is the most effective treatment out there,” Dr. Derman said. “IVF is the last thing that we do, not the first thing.”

 

Welcome to our blog from Seth G Derman, MD

I welcome you to the Princeton Fertility Blog. I am a specialist in Reproductive Medicine and the Medical Director at Princeton IVF in Lawrenceville, NJ. I have been caring for couples with infertility and recurrent miscarriages, polycystic ovarian syndrome, endometriosis and other reproductive hormonal disorders for the past two decades.