Pregnancy is a complicated process that depends upon many factors, all of which need to be optimal. Some of the factors that are important for the process depend on the production of healthy sperm, healthy eggs ; patent (open) fallopian tubes that allow the sperm to reach the egg; the sperm’s ability to fertilize the egg when they meet; the ability of the fertilized egg (embryo) to become implanted in the woman’s uterus; and sufficient embryo quality.
Finally, for the pregnancy to continue to full term the embryo must be healthy and the woman’s hormonal and uterine environment should be adequate for its development. When just one of these factors is impaired, infertility can result.
Infertility is defined as the inability to conceive after one year of unprotected intercourse. This definition is reduced to six months for:
Infertility is often a couple’s problem, and is commonly due to some contribution from both the male and female partners. On an average, about one-third of infertility cases are caused by problems with the woman’s reproductive system. Another third can be traced to factors in the man. Of the remaining cases, combinations of male and female factors are at play. Interestingly, about 20 percent of infertility cases don’t have a known cause despite all investigations. This is termed unexplained infertility.
A man is most likely infertile due to low sperm count, poor sperm motility, abnormally shaped sperm or some combination of all three. Most cases of low sperm counts are “idiopathic” or unexplained. Some cases are associated with a swollen varicose vein in the scrotum, called a varicocele. Varicocele is the most common reversible cause of male infertility and can be corrected by minor outpatient surgery. Lifestyle can influence the number and quality of a man’s sperm. Tobacco, alcohol and drugs can temporarily reduce sperm quality. Environmental toxins, including pesticides and lead, may cause some cases of infertility in men. In rare cases, infertility in men may be caused by genetic diseases. Short term illnesses, significant stressful periods, and some medications may temporarily affect sperm counts.
Female infertility may be divided into several categories: Ovulatory problems; Cervical factors; Pelvic and tubal factors; and Uterine factors.
The most common cause is an ovulation disorder. Failed ovulation / anovulation occur most commonly in Polycystic ovary syndrome (PCOS). It can also occur secondary to malfunction of the hypothalamus and pituitary gland which are organs in the brain that are responsible for sending signals and secreting hormones that are responsible for initiating egg maturation in the ovaries, scarred ovaries and premature menopause. Ovulation can be seriously affected by abnormalities of the thyroid gland, overproduction of prolactin (a hormone leading to breast milk production), excessive male hormone (androgens) and physical stress, psychological stress and extreme lifestyle changes. Often, combinations of these problems exist.
Cervical infertility involves inability of the sperm to pass into the uterine cavity due to damage to the cervix. This can occur because of inadequate or hostile cervical mucus, infections of the cervix with common sexually transmitted diseases such as chlamydia, gonorrhea, or trichomonas and immune attack of sperm or “sperm allergy”
Pelvic causes of infertility include any disruption of the normal pelvic anatomy by scar tissue or “adhesions” as in pelvic inflammatory disease, endometriosis, blocked, scarred, or distorted fallopian tubes and benign tumors (fibroids) of the uterus.
Uterine causes of infertility include a thin or abnormal uterine lining and anatomic uterine problems such as polyps, uterine fibroids and abnormal shape of the uterus, septum or “dividing wall” within the uterus.
Approximately 10 – 30% of all couples undergoing infertility treatment are diagnosed with “unexplained infertility.” This simply means that the commonly performed tests available to fertility specialists to diagnose the cause of infertility are all normal and do not define the reason for infertility. These difficult to diagnose causes are subtle and include difficulty in picking up the egg by fallopian tube, failure of implantation of the embryo into the uterus and failure of the sperm to fertilize the egg even when in contact. The prognosis for conceiving for couples that are diagnosed with unexplained infertility is usually good. Couples who are diagnosed with unexplained infertility are encouraged to seek treatment. These couples usually respond well to an appropriate treatment regimen. Success rates for couples with unexplained infertility working with fertility medication and intrauterine inseminations (IUI) are between 15 – 20%. Success rates are even higher with assisted reproductive technology such as in vitro fertilization (IVF). The success of all treatments is age dependent with reduced success rates in older patients.
As a woman ages, the many biological changes taking place in her body that are responsible for the decrease in her ability to become pregnant and carry a pregnancy to term. There is a direct association between advancing female age and infertility. From age 30 to 35, the chances of becoming pregnant gradually decline and after age 40 there is a sharp decline. The probability of having a baby decreases 3-5% per year after age 30 and even faster after age 40. There are numerous reasons for this decline in fertility including diminished egg quality, decline in the number of eggs produced, and irregularity of ovulation, decreased production of estrogen and progesterone by the ovaries and resistance of the eggs to fertilization. The following general data is reflective of the effects of age on pregnancy rates: 86% of women in the 20-24 year age group, 78% in the 25-29 year age group, 63% in the 30-34 year age group and 52% in the 35-39 year age group, conceive within 12 months.
Pregnancy occurring at a later age is associated with increased chances of miscarriage and chromosomal abnormalities, resulting in birth defects such as Down’s syndrome. A woman in her 20’s has only a 12-15% chance of having a miscarriage each time she becomes pregnant, while there is a 40% risk of miscarriage for a woman in her 40’s. Also, assisted reproductive technologies, including in vitro fertilization and intracytoplasmic sperm injection become less successful as age increases.
Most, men retain the ability to produce viable sperm until late in life although there can be a decline in the volume and “quality” of the ejaculate. However, the semen analysis is a mandatory infertility test and must be performed early in the evaluation of the couple. Latest statistics indicate that male factor infertility is a component in approximately 47% of couples.
A medical evaluation may determine the reasons for a couple’s infertility. Usually this process begins with physical examination and medical and sexual histories of both partners. If there is no obvious problem, like improperly timed intercourse or absence of ovulation, specific tests may be recommended.
For a man, testing usually begins with tests of his semen (semen analysis) to look at the number, shape, and movement of his sperm. Sometimes other kinds of tests, such as hormone tests, are done.
For a woman, the first step in testing is to find out if she is ovulating each month. There are several ways to do this. For example, she can keep track of changes in her morning body temperature and in the texture of her cervical mucus. Another tool is a home ovulation test kit, which can be bought at drug or grocery stores. Checks of ovulation can also be done in the doctor’s office, using blood tests for hormone levels or ultrasound tests of the ovaries. If tests indicate that there is no problem with ovulation, more tests will need to be done. Depending on a couple’s individual circumstances, these include an x-ray of the fallopian tubes and uterus to see if the lumen of the tubes and uterine cavity are open (patent). Sometimes, a laparoscopy which is performed as an outpatient procedure may be necessary to look for endometriosis or scar tissue. All of these tests can usually be accomplished within 1-2 months.
The good news is that 85-90% of couples in the reproductive age group can be treated with conventional medical therapies such as medication or surgery. The treatment of infertility depends on its cause. Based on the test results, different treatments can be suggested. Fertility drugs may be used for women with ovulation problems. If needed, surgery can be done to repair damage to a woman’s ovaries, fallopian tubes, or uterus. Sometimes a man has an infertility problem that can be corrected by surgery. When these initial therapies fail, advanced reproductive techniques (ART) come into play. It is important to appreciate those complex treatments such as, in vitro fertilization (test tube babies) and similar treatments account for less than 3% of infertility services.
It is recommended that you seek evaluation after twelve months of unsuccessful attempts to get pregnant. If you are older than 35 years, you should see a reproductive endocrinologist (fertility expert) after six months. Women greater than 40 years should begin evaluation immediately.
Yes, patients have the option of surgically reuniting the fallopian tubes through a process called microscopic tubal reanastomosis. This can commonly be done as an outpatient procedure with good results. Dr. Pinto is proud to offer this treatment. Depending on other infertility factors, couples are able to conceive in a short interval of time. An alternative to this procedure would be in vitro fertilization (IVF), where the eggs are fertilized outside the body. The resulting embryo is then placed into the uterine cavity for implantation, thereby by-passing the blocked fallopian tubes. The best way to move forward would require a consultation with the physician and to consider all other fertility factors.
Laparoscopy is a minimally invasive surgical procedure that allows for a complete examination and evaluation of a woman’s pelvic and abdominal structures. It is performed as an outpatient surgical procedure and is particularly helpful in diagnosing and effectively treating endometriosis or pelvic adhesions (scar tissue). Both of these conditions can cause pelvic pain and/or infertility. In individuals with either of these conditions, a laparoscopy can dramatically improve the chances of conception.
It all depends on your insurance plan. Most insurance plans cover office visits and diagnostic tests. Treatment, on the other hand, may not be covered unless you have specific fertility coverage. You are encouraged to call our office to discuss any insurance questions or concerns.
IVF is an advanced reproductive technique, usually undertaken when other simpler fertility therapies have been unsuccessful or are not possible. It has become the treatment of choice for patients with irreparably damaged fallopian tubes, profoundly low sperm counts, advanced endometriosis or failure to conceive after adequate attempts of intrauterine insemination. IVF is a complex, multi step process, which involves incubating eggs with sperm, resulting in the creation of embryos in the laboratory. The embryos are then transferred into the uterine cavity for potential implantation. IVF treatment enables many patients to achieve their dream of parenthood. Anticipated pregnancy rates for many patients depending on each individual situation, may exceed 50 percent.
IVF and other assisted reproductive technologies provide many couples with the opportunity to get pregnant that otherwise wouldn’t be able to have children on their own. During your consultation with Dr. Pinto, the discussion will focus on each patient’s unique circumstances and he will give you a realistic expectation as to your individual chance for success.
Once the decision is made to proceed with IVF, several test results on both partners are usually required to be reviewed prior to the initiation of the IVF cycle. These include tests such as hormonal profile, ovarian reserve screening, semen analysis, tests for infectious screening (HIV, Hepatitis B, Syphilis etc…), genetic testing when indicated and uterine cavity assessment. If you have been referred by your obstetrician, and some of these tests have already been performed in the recent past, you may not need to repeat them. Dr. Pinto will ask for your prior test results to be reviewed.
When all of the tests are reviewed, the IVF treatment cycle begins. Each patient’s treatment plan is unique. Dr. Pinto will discuss your specific treatment plan in detail, so that you will know what to expect every step of the way. He will always be available to answer all of your questions. This is a general outline of steps followed in an IVF treatment cycle plan. The patient is placed on oral contraceptives (birth control pills) for approximately 14-35 days followed by Lupron for approximately 12-14 days. These drugs prepare the body for the ovarian stimulation that will follow. A baseline ultrasound is performed at this time. Ovarian stimulation with fertility medications is begun and continues for approximately 10-12 days. Close monitoring with blood tests and ultrasound examination occurs during this time. Based on the test results, a trigger shot of hCG is given at the appropriate time, and is followed 34-36 hours later by egg retrieval. Progesterone supplementation is also usually started around this time. Fertilization of retrieved eggs with the sperm sample then occurs in the laboratory under the supervision and monitoring of an embryologist. Embryo transfer occurs 3-5 days after the egg retrieval. A pregnancy test is performed approximately 14 days later, followed by subsequent ultrasounds to detect a fetal heart beat.
The duration of a treatment cycle from the start of the birth control pills to the time of embryo transfer is approximately 6 weeks.
On the day of egg retrieval, the male partner is asked to provide a sperm sample. The quality of this sample is dependent upon what happened in the male’s body 3 months ago. This is because sperm development takes 3 months. Patients are encouraged to follow the guidelines listed below to help ensure that the semen sample is of the best possible quality.
We usually have a previously collected frozen semen sample as a backup for use on the day of egg retrieval. This will be used in the event that the fresh sample is of poor quality.
This will be discussed with you at the time of consent signing. We usually follow the recommendations of The Society for Reproductive Medicine guidelines:
These numbers may vary depending on individual diagnosis and centeral circumstance.
Alcohol should be avoided during infertility treatment and pregnancy.
Some medications may interfere with the fertility medications prescribed, some are not safe to use before an operation or medical procedure, and others might interfere with ovulation or pregnancy implantation. A prenatal or multivitamin will be prescribed. Please inform Dr. Pinto, if you are taking any prescribed or over the counter medication.
Stop smoking before ovulation induction begins. It is best to discontinue tobacco at least 2 months prior to an IVF cycle. Tobacco has been demonstrated to be toxic to the oocyte (egg). Numerous studies have also demonstrated that smoking during pregnancy results in reduced birth weight and fetal compromise.
Heavy exercise such as aerobics, jogging, weight lifting etc. is prohibited during ovarian stimulation and until the pregnancy test results are known.
A pregnancy test is performed 14 days after the Embryo Transfer. If pregnant, the patient is asked to return to the office for repeat blood work and ultrasounds to ensure an ongoing successful pregnancy. After a fetal heartbeat has been confirmed, patients are referred to their referring obstetrician for the remainder of the pregnancy. If patients do not have an obstetrician, Dr. Pinto will be happy to refer you to one. It is not necessary to follow-up with a high risk obstetrician, unless your obstetrician deems it necessary. A high risk obstetrician is only needed when there are complications that put the mother or baby at increased risk, or in the case of multiple births. Other than a higher incidence of multiple births, IVF does not increase the risk to the fetus.
The miscarriage rate following IVF is the same as in a pregnancy conceived naturally. It is about the same for pregnancy after IVF as the general population. Many times, older women undergo IVF and their miscarriage rates are naturally higher. Since pregnancy testing is done two weeks after embryo transfer, we often know about spontaneous miscarriages in the very early stages of pregnancy. These miscarriages would probably go unnoticed in the general population.
The egg donation process is usually considered for women with advanced maternal age over 42 years, in patients with poor ovarian reserve, premature ovarian failure, prior surgical removal of the ovaries and Turner syndrome. Usually this is an anonymous process where the eggs are removed from the donor, fertilization is allowed to occur in the laboratory using the husband’s sperm and the resulting embryos are then transferred into the recipient’s uterine cavity for implantation to occur. Success rates are extremely high with this process.
CDC’s ninth annual ART report summarizes national trends and provides information on success rates for 399 fertility centers around the country. Overall, 28 percent of ART procedures resulted in the birth of a baby for women who used their own fresh eggs.
The 2003 report offers more evidence that a woman’s age is one of the most important factors in determining whether she will have a live birth by using her own eggs. Women in their 20s and early 30s had relatively high rates of success for pregnancies, live births, and single live births. But success rates declined steadily once a woman reached her mid-30s."
Overall, 37 percent of the fresh non-donor procedures started in 2003 among women younger than 35 resulted in live births. This percentage of live births decreased to 30 percent among women aged 35-37, 20 percent among women aged 38-40, 11 percent among women aged 41-42 and 4 percent among women older than 42.
Women 42 or older are more likely to have a successful ART procedure if they use donor eggs. Egg donors are typically in their 20s or 30s. The average live birth rate for women who used ART with donor eggs is 50 percent, and is independent of age.
When low sperm counts or poor sperm motility (movement) is the cause of infertility, a procedure called ICSI (Intracytoplasmic Sperm Injection – pronounced ICK-SEE) can help. In these situations, the sperm require extra help to fertilize the oocyte (egg). After egg retrieval, the embryologist performs this micromanipulation procedure in the laboratory by capturing an individual sperm and injecting it into the mature egg by means of a small pipette. This process is repeated for each individual egg. For some couples, ICSI has overcome severe male infertility when only a few sperm were available for fertilization.
A Reproductive Endocrinologist / Infertility Specialist is a physician who has received two to three years subspecialty fellowship training after the completion of an obstetric and gynecology residency program. A fellowship in Reproductive Endocrinology provides focused training in all aspects of infertility as well as laparoscopy and microsurgery, endocrinology, menopausal problems, and endometriosis problems.
We are dedicated to helping couples with fertility problems achieve their dream of parenthood. Our practice also specializes in the evaluation and treatment of endometriosis, polycystic ovarian syndrome (PCOS), recurrent pregnancy loss, and laser laparoscopic gynecologic surgery. We offer a variety of diagnostic tests and treatment procedures including the following:
As a center dedicated to helping patients with infertility, we work closely with your primary care physician and obstetrician. With your permission, we will send a complete report to your physician detailing the types of tests and procedures performed here. When patients become pregnant, we refer them back to their obstetrician or family practice physician for ongoing prenatal care. Our practice does not provide general obstetrical care. If you do not have an obstetrician, we will be happy to refer you to one.
We have six offices in Dallas, Grapevine, McKinney, Tyler, Flower Mound and Rockwall. Patients can choose to see Dr. Pinto or at any of these three convenient locations. Contact Us
To make an appointment, please call the main office at 214-827-8777. We are available to see patients Monday through Friday from 9 am – 5 pm by appointment only. Weekend appointments are scheduled for specific treatments and time sensitive tests. We also remain flexible to accommodate patients who require appointments outside of the regular office hours.
We understand the anxiety associated with meeting a new physician in a new practice. We are here to alleviate your fears and support you during this process. If you are unable to follow any of the instructions detailed below, we will assist you with this process at the time of your visit. Your comfort is our priority and we encourage you to call us if you have any questions prior to your appointment.
Plan at least one hour for your first visit. Your first visit is usually a consultation with Dr. Pinto. You are encouraged to have your partner participate in the discussion. We will discuss your medical history, any prior tests and treatments and your diagnosis. If appropriate, future treatment options will be discussed. He will answer any questions you may have. If indicated, a physical exam and / or an ultrasound may be performed at this visit.
In order to maximize the benefit of your first meeting, you are encouraged to address few important issues prior to your appointment. Please bring copies of all medical records relating to infertility, on yourself and your partner. If you fill out the "Request for Medical records" form (downloaded from this website) and send it to your physician before your appointment, we will have your past records in our office for review at the time of your appointment. It is also advisable to download the required forms and complete all paperwork prior to your appointment. Alternatively, you have the option of doing this at the office. We do ask that you arrive 15 minutes early for your first appointment to give you time to complete the necessary forms. We make every effort to remain on schedule and to not keep you waiting. In order to do so, we kindly ask the same consideration from you.
Dr. Pinto will be personally involved in your treatment every step of the way from the initial consultation, through the monitoring to the final ultrasound confirming a pregnancy. You can be confident that you will receive the best possible, personalized and individualized care with a commitment to detail.
After evaluating your medical history and reviewing test results, Dr. Pinto will perform a physical examination including a pelvic exam. Initial tests to determine hormone levels and ovulatory function will be done before making a diagnosis. After the diagnosis, we will discuss options for increasing your chances of a pregnancy including ovulation-inducing medications, assisted reproductive technologies (IVF and ICSI) or if appropriate, the use of an egg donor when other therapies fail.
Since each patient’s needs are unique, he will formulate a fertility plan that is right for you with an emphasis on patient education and a focus on patient safety.
Payment is expected at the time of service. ReproMed Fertility Center participates in a variety of health insurance plans. If you have questions regarding our insurance participation, please contact our office. We encourage you to contact your insurance carrier to determine your insurance coverage prior to visiting our office. We will help you navigate the insurance maze. We will provide you with specific codes so that you can request a written explanation of specific benefits. If necessary, we will also attempt to contact your insurance carrier to confirm your benefits prior to your visit, although this does not guarantee payment by the insurance carrier for services provided.
Endometriosis is a benign (non-cancerous) condition in which the lining of the uterus (called the endometrium) migrates / grows outside the uterus and is present in places where it is not normally found.
Endometriosis is usually confined to the pelvis. Common sites of involvement are the ovaries, space behind the uterus (cul-de-sac, rectum, uterosacral ligaments) and urinary bladder. Although most common in the pelvis, endometriosis has been documented in nearly every location of the body, including such remote and unusual sites as the brain, sciatic nerve, lungs and even skin.
The endometriotic implants outside the uterus continue to break down and bleed periodically; the result is internal bleeding, degeneration of blood and tissue shed from the growths, inflammation of the surrounding areas, and formation of painful adhesions and scar tissue. These endometrial lesions can block the fallopian tubes or impair ovulatory function.
According to the American College of Obstetricians and Gynecologists (ACOG), endometriosis is a common condition affecting 10 to 15 percent of reproductive-age women. Endometriosis occurs in about 30 percent of all infertility cases.
There are several theories, none of which have been proven. However, research has shown that many women with endometriosis appear to have a defect in their immune system. Other causative factors may be: Retrograde menstruation or the spillage of menstrual blood into the pelvis through open fallopian tubes; Transplantation theory or the movement of endometrial cells throughout the pelvis (and even outside of the pelvis) through blood and lymphatic systems; and Coelomic metaplasia or the ability of certain cells to change into endometrial cells. Heredity is also said to be a factor in endometriosis. Some believe that endometriosis may actually be caused by "a combination of several factors.
The symptoms of endometriosis may be highly variable from one patient to another. The centeral presentation and symptoms of the disease are frequently related to the anatomical site of the disease. The most common symptom is pelvic pain, which can be spontaneous non-cyclic pain, painful menstrual periods, pain with intercourse or chronic pelvic pain. Other symptoms include abnormal uterine bleeding, spotting prior to periods, severe cramping, infertility, diarrhea and painful bowel movements especially during menstruation, abdominal tenderness, painful or burning urination, urinary frequency, retention, or urgency.
The magnitude of the symptoms may not correlate with the extent of the disease. Symptoms may be completely disabling or mild. Sometimes the condition is present and causes few to no symptoms or a patient with severe disease may have very little pain. However, the likelihood of infertility does increase as the severity of the disease increases. Endometriosis rarely causes symptoms following natural or surgical menopause.
Scarring of the peritoneum around endometriosis is a typical and very common finding. This occurs because of periodic bleeding from the endometriotic spots and collection of the blood in these areas. Since there is no escape for this blood, it will start irritating the adjacent peritoneal surface, causing inflammation and eventually, scarring. The adhesions are most common in the immobile pelvic structures, and are most commonly found in the pelvic sidewalls, behind the uterus, between the sigmoid bowel or colon, and on the posterior aspect of the uterus and cervix.
Ovarian endometriosis probably starts as a surface lesion. The process becomes invasive and the endometriotic lesion internalizes into the ovarian tissue. Once the menstrual flow and debris collect at the site of endometriosis in the ovaries, endometrial cysts form that are filled with chocolate-colored liquid. These are commonly called chocolate cysts, or endometrioma. These are nothing more than cysts which represent debris from prolonged cyclic menstruation in an enclosed area. These cysts may sometimes attain impressive size, with some documented as large as a baseball or grapefruit that completely obliterate the normal ovary. However, usually there is a well-demarcated separation between the cyst wall and the normal adjacent ovarian tissue.
Endometriosis has been identified as a major cause of infertility. Endometriosis with scarring that distorts the anatomy of the pelvic organs may impair fertility. Endometriosis is the cause of infertility in approximately 35% of women with the disease. When there is no distortion of the pelvic organs or blockage of the fallopian tubes, endometriosis is less likely to impair fertility. Some women with endometriosis conceive without trouble.
With appropriate treatment pregnancy can certainly be achieved by a woman with endometriosis. Sometimes, surgery may improve the chance of pregnancy in women with endometriosis.
The gold standard to diagnose endometriosis is by laparoscopy, a surgical procedure in which a thin telescope is placed through the belly button into the abdomen to view the uterus, ovaries, and fallopian tubes directly. While a biopsy of the lesion does document the presence of endometrial tissue, the gross appearance of endometriosis and visual inspection of the pelvis is also considered adequate and accurate for diagnosis of endometriosis. Ultrasounds, MRIs, CT Scans and other diagnostic tests are not conclusive for the diagnosis of endometriosis.
Endometriosis is a progressive disease. While there is no known cure for endometriosis, medications and surgery can help delay the progression of the disease. In general, endometriosis is managed most effectively with a combination of properly performed surgery and the use of appropriate medical therapies.
Medications that are helpful in alleviating symptoms and controlling pain include gonadotropin-releasing hormone (GnRH) agonists including Lupron, Aromatase inhibitors such as Letrozole and birth control pills.
Surgical Management includes laparoscopic surgery to remove the lesions–laser laparoscopy can remove endometrial tissue and blockages from the body by excision, fulguration, cauterization, and ablation. Hysterectomy is also an option but will not eradicate the disease. Patients with infertility may benefit from in vitro fertilization.
After surgery, approximately 50% of patients experience major pain relief, a further 30% have adequate improvement and the final 20% are not improved. In 50% of patients, symptoms can recur with 6 months to a year.
Alternative medicine, acupuncture, herbal therapy, massage techniques, good nutrition, and adopting a generally healthy lifestyle may also contribute towards improving symptoms.
There is no current manner of preventing Endometriosis, and it is not a disease which is "contracted" or "caused" by anything the patient did – nor is it contagious. It is, however, suspected to be genetic.
Polycystic Ovarian Syndrome (PCOS) is a common endocrine (hormonal) disorder in women of reproductive age. This disorder is a "syndrome" which is defined as having a set of symptoms. PCOS is a collection of symptoms related to infrequent ovulation, characterized by irregular menstrual periods and evidence of excess androgens (male hormones), which can cause excessive facial hair growth, acne, and/or male-pattern baldness. Women with PCOS may or may not have many small cysts in their ovaries. PCOS is a health problem that affects a woman’s menstrual cycle, fertility, hormones, insulin production, heart, blood vessels, and appearance.
This syndrome was originally named Stein-Leventhal Syndrome in recognition of the two physicians who, in 1935, first described the condition. Other names for PCOS include hyperandrogenic chronic anovulation and functional ovarian hyperandrogenism.
An estimated five to 10 percent of women of childbearing age have PCOS. As many as 30% of women have at least some characteristics of the syndrome. It is a leading cause of infertility. In fact, PCOS causes 75 percent of all cases of anovulatory infertility.
The exact cause of PCOS is unknown. Women with PCOS frequently have a mother or sister with PCOS. Some studies are looking at the possibility of a genetic link to this disorder.
Researchers are also looking at the relationship between PCOS and the body’s ability to make insulin. Since some women with PCOS make too much insulin, it’s possible that the ovaries react by making too many male hormones, called androgens. This can lead to acne, excessive hair growth, weight gain, and ovulation problems.
Signs and symptoms of PCOS often begin around the time of puberty, but for others, symptoms do not develop until adulthood. Symptoms vary among women, but can include:
Any or all of these symptoms may be present, but some women have none of these symptoms and still can carry the diagnosis. These tend to be very lean, athletic women who may be even underweight and this may mask the PCO syndrome.
A normal menstrual cycle is dependent upon regular cyclic changes in the blood hormone levels of estrogen and progesterone. These hormones are produced in the ovaries. A woman’s ovaries have follicles, which are tiny sacs filled with liquid that hold the eggs. Each month about 20 eggs start to mature, but usually only one becomes dominant. The growing follicle produces the hormone estrogen. As the one egg grows, the follicle accumulates fluid in it. When that egg matures, the follicle breaks open to release the egg so it can travel through the fallopian tube for fertilization. When the single egg leaves the follicle, ovulation takes place. After ovulation occurs, the remainder of the ruptured follicle in the ovary produces progesterone. This is the process that occurs normally on a monthly basis in women with regular menstrual cycles.
In women with PCOS, the ovary doesn’t make all of the hormones it needs for any of the eggs to fully mature. They may start to grow and accumulate fluid. But no one egg becomes large enough. Instead, some may remain as cysts and continue to produce estrogen. Since no egg matures or is released, ovulation does not occur and the hormone progesterone is not made. Also, the cysts produce male hormones, which continue to prevent ovulation.
It is the abnormal hormone levels that lead to irregular periods in women with PCOS. As a result, the inside lining of the uterus – called the endometrium – is exposed to the hormone estrogen for great lengths of time without being exposed to the hormone progesterone. It is the cyclic rise and fall in both estrogen and progesterone that cause menstrual bleeding. In the case of PCOS, there can be prolonged lengths of time without the production of progesterone. During this time the endometrium is continuously exposed to estrogen. The result of this prolonged estrogen exposure is the buildup /growth of the endometrium. When the endometrium becomes too thick, heavy and irregular bleeding can occur. Also when the endometrium is exposed to estrogen for prolonged periods of time, cell changes can occur in which the cells of the endometrium become abnormal and, if not treated appropriately, can develop into cancer of the uterus. Progesterone prevents this build-up of the endometrium.
Although PCOS is primarily a problem of the ovaries, the condition alters hormone levels and affects tissues throughout the body.
Weight gain and obesity – PCOS is associated with gradual weight gain and obesity in about one-half of the women with this condition. Diet and exercise can help maintain a normal body weight. For some women with PCOS, the obesity develops at the time of puberty.
Insulin abnormalities and diabetes – PCOS is also associated with abnormal blood insulin levels, the hormone that regulates blood sugar levels. These abnormalities may include:
Insulin resistance and hyperinsulinemia can occur in both normal-weight and overweight women with PCOS. By age 40, up to 35 percent of obese women with PCOS develop impaired glucose tolerance, and up to 10 percent of obese women with PCOS develop type 2 diabetes. These rates are much higher than expected for normal women at this young age.
Impaired glucose tolerance and diabetes are usually detected by blood tests. Often a fasting blood test is sufficient, but sometimes a glucose tolerance test is needed. Weight loss, exercise, and drugs can help normalize blood sugar levels.
Heart disease and hypertension- The presence of both obesity and insulin resistance might increase a woman’s risk for coronary artery disease, which is the narrowing of the arteries that supply blood to the heart. Both weight loss and treatment of insulin abnormalities can decrease this risk.
Uterine cancer – Irregular menstrual periods and the absence of ovulation cause women to produce the hormone estrogen, but not the hormone progesterone. Without progesterone, which causes the endometrium to shed each month as a menstrual period, there is a hormonal imbalance. This promotes persistent growth of the endometrium (the lining of the uterus). Eventually, this can lead to endometrial hyperplasia or cancer. Treatment with oral contraceptives or intermittent progesterone-like drugs can promote normal menstrual bleeding and lessen overgrowth of the endometrium.
Sleep apnea – Sleep apnea has been reported to occur in up to 30 percent of women with PCOS. This is a disorder characterized by excessive snoring at night with brief spells where breathing stops (apnea). Patients with this problem experience fatigue and daytime sleepiness
Hirsutism – Hirsutism is the excess growth of coarse dark hair in a predominantly male pattern. Women affected by PCOS commonly experience hirsutism due to increased levels of the male hormones called androgens. The longer a woman with PCOS goes untreated the more severe her hirsutism will become.
Infertility- Lack of ovulation or infrequent ovulation results in difficulty in getting pregnant.
Most of these above mentioned effects can be anticipated and thus prevented or promptly treated before they pose significant health problems.
Women with PCOS generally have irregular, infrequent, or even absent ovulation. Without ovulation there is no egg or ovum that is available for fertilization. Also, due to the abnormal hormone levels, the endometrium, or inside lining of the uterus, does not develop normally in women with PCOS. Therefore, even if a rare ovulation was to occur and the egg was fertilized, the endometrium may not be properly developed to allow for the attachment and growth of the embryo.
The good news is that this problem with ovulation can be fixed with medications. These include ovulation induction agents, insulin sensitizing drugs and Gonadotropins. It is important to know that these options work best for women who are not obese. Even a modest amount of weight loss may improve the effectiveness of the medications.
Medications called ovulation induction agents, such as clomiphene citrate stimulate the ovaries to release one or more eggs. Clomiphene citrate triggers ovulation in about 80 percent of women with PCOS, and about 50 percent of these women will actually become pregnant. In women taking clomiphene, ovulation can be confirmed by blood and urine tests or by measurement of body temperature. If the original dose of clomiphene does not trigger ovulation, a higher dose may help.
Several studies have shown that the insulin-sensitizing drug, metformin, increases the effectiveness of clomiphene in producing ovulation. However, it is unknown if this drug is safe during pregnancy, and is stopped once the woman is pregnant.
Gonadotropin therapy is the second line of medical treatment for PCOS-related infertility. Gonadotropins include Leutinizing hormone (LH) and Follicle Stimulating Hormone (FSH). FSH is used without LH for women with PCOS, and is given as a daily injection under the skin for 7 to 10 days. These drugs trigger ovulation in almost all women with PCOS and can lead to pregnancy in approximately 60 percent.
Surgery is an option in rare situations. In very rare cases, ovulation is not achieved with medications and ovarian surgery may be necessary to stimulate ovulation. This surgery is usually performed via the laparoscope.
If the above mentioned treatments are not successful in producing a normal pregnancy, then the use of the assisted reproductive technologies (ART), such as in vitro fertilization, can be attempted.
In conclusion, a diagnosis of PCOS suggests that you are likely to have some difficulty becoming pregnant. However, with help from your physician, pregnancy should be an option for almost everyone with PCOS.
There appears to be a higher rate of miscarriage, gestational diabetes, pregnancy-induced high blood pressure, and premature delivery in women with PCOS. Preliminary studies also suggest that metformin might reduce the risk of early pregnancy loss and the development of gestational diabetes mellitus (diabetes during pregnancy) in women with PCOS, while pregnant. Researchers are also looking at how the drug lowers male hormone levels and limits weight gain in women who are obese when they get pregnant. It is not yet known if Metformin usage is safe during pregnancy, since the drug crosses the placenta.
There is no single test to diagnose PCOS. A physician can often diagnose PCOS by obtaining a detailed medical and gynecological history and performing a physical exam. At the physical exam, evaluation of the areas of increased hair growth will be important. During a pelvic exam, the ovaries may be enlarged or swollen by the increased number of small cysts. Blood hormone levels such as testosterone levels are often measured to confirm the diagnosis. Additionally, glucose or sugar levels, as well as insulin blood hormone levels may be measured. A vaginal ultrasound may be performed to help distinguish PCOS from other disorders that cause multiple cysts in the ovaries. The ultrasound exam can also identify a thickened uterine lining. If menstrual periods have been irregular or absent, an endometrial biopsy may be necessary to rule out a pre-cancerous endometrial condition.
The current criteria for the diagnosis of PCOS include the following three items:
The combination of a detailed history, physical exam and blood testing is usually adequate to diagnose PCOS.
There is no cure for PCOS, but it is manageable with medications, diet, and exercise. Adequate treatment can help prevent serious long-term risk factors. The treatment is relatively simple and based upon the goals of the patient. Some patients may be concerned primarily with fertility, while others may be more concerned about menstrual cycle regulation, hirsutism or acne. Regardless of the primary goal, patients are advised to report all symptoms to their physician as specifically as possible.
Below are general descriptions of treatments used for PCOS:
No. PCOS is a condition that can be managed, but currently no cure exists. Treatment of the symptoms can help reduce risks of future health problems. Today, several drugs and lifestyle modifications can help control the signs and symptoms of PCOS. Medical and surgical treatment can also help women who want to become pregnant, but are having difficulty conceiving. Treatment is individualized and depends on each woman’s symptoms, reproductive goals, and presence of other medical conditions. In some women, symptoms of PCOS may be minor and simply annoying, and treatment may seem unnecessary. However, untreated PCOS may increase a woman’s risk of other health problems over time. Women with PCOS should take an active role in their medical care by learning as much as they can about the condition and by working with their physician to develop the best treatment plan.