S9 EP 03_Fertility Treatments: Audio automatically transcribed by Sonix

S9 EP 03_Fertility Treatments: this mp3 audio file was automatically transcribed by Sonix with the best speech-to-text algorithms. This transcript may contain errors.

Intro/Outro:
Hi, I'm Kristyn Hodgdon, an IVF mom, proud women's health advocate, and co-founder of Rescripted. Welcome to From First Period to Last Period, a science-backed health and wellness podcast dedicated to shining a light on all of the women's health topics that have long been considered taboo. From UTIs to Endometriosis, we're amplifying women's needs and voices because we know there's so much more to the female experience than what happens at the doctor's office. With From First Period to Last Period, we're doing the legwork on your whole body so you can be the expert in you. Now, let's dive in.

Kristyn Hodgdon:
Hi everyone, and welcome back to From First Period to Last Period. I'm your host, Kristyn Hodgdon, and I'm so excited to be here today with Dr. S. Kemi Nurudeen. Hi, Dr. Nurudeen!

S. Kemi Nurudeen:
Hi, everybody!

Kristyn Hodgdon:
Hi, how are you?

S. Kemi Nurudeen:
I am doing well today. It's been a very busy day, but I'm doing great.

Kristyn Hodgdon:
I was just telling Dr. Nurudeen off recording that I think all fertility doctors are superstars because I know how busy they are. So I appreciate it.

S. Kemi Nurudeen:
We love our job. So we're very fortunate. Like we're very motivated. So that energy just comes from your patience.

Kristyn Hodgdon:
Oh yeah, you're literally helping people build their families. I love it. For those of you who don't know her, Dr. S. Kemi Nurudeen is a double-board-certified reproductive endocrinologist and infertility specialist at Aspire HFI in Houston, Texas. I'm so thrilled to be diving into this topic with you today. It's something close to my heart. I have PCOS, and I've been through many rounds of IUI and rounds of IVF. So today we're going to be diving into really just what to expect when you're about to embark on fertility treatments with PCOS, what sort of steps are the trajectory? I know that when I first started, I was 28 and had no idea what to expect. None of my friends were trying to conceive. I just had come off the birth control pill, didn't get my period back, and got sent right to a fertility specialist, so there was no trying in between. It was like I skipped that step, which, in one way, I'm grateful for because I didn't waste that time. But on the other hand, I felt every step of the way. It was like, hindsight's 2020, and I didn't get pregnant with IUIs, even though my doctor thought I would. And then IVF took a little longer than I thought, like, everything just was always a learning experience. Excited for those who are listening to get that foresight that I didn't have. First and foremost, can you briefly recap what PCOS is and how it can impact fertility?

S. Kemi Nurudeen:
Yeah, definitely. So PCOS, polycystic ovarian syndrome, is a multifactorial disorder. The main conclusion when we think about how it affects fertility is ovulation. Patients usually present with irregular cycles or infrequent cycles. Typically, a woman should have a menstrual cycle every month until they conceive. PCOS patients can go stretches of months without a period, and that's usually a big, basically a reflection of not ovulating. If you're not ovulating, there's no egg to be fertilized, which leads to pregnancy, so infertility is a result of that. Patients will have the other two factors: elevated testosterone or androgens. Then, on ultrasound, you'll see the polycystic ovaries. But the biggest thing is an ovulation. Typically, when a couple is trying every month, and they have that 15% to 20% chance of pregnancy when there's an egg waiting every month with PCOS patients, that opportunity is not there. So you really don't want to wait. You have a patient who's not having cycles. You diagnose her with PCOS. You should send her directly to a subspecialist or ob-gyn who can start treatment options.

Kristyn Hodgdon:
And some ob-gyn do prescribe Letrozole and Clomid and stuff like that, correct?

S. Kemi Nurudeen:
Yeah. So a lot of OBs are very comfortable with giving you Letrozole and Clomid as option medications, and we'll give you instructions on time intercourse. We'll talk to you about checking your ovulation at home with a urine test. Some OBs, with whom we have a lot of relationships, will say whatever you're comfortable with, some will start a process, some of them will send them directly to us. And we'll have that conversation of success rates with the different levels of treatment.

Kristyn Hodgdon:
Yeah, so that's a great question that I love to ask you because this was a conversation that my original fertility doctor did not have with me, and I wish she had, which is like when you first enter a fertility clinic for that first consultation with PCOS, what should you be thinking about as far as how many children you want to have and how can that influence that option that you decide to pursue?

S. Kemi Nurudeen:
It does. A big part of my conversation is what you're saying exactly as a woman. I think that, too, like planning ahead. When we think about treatment options, I have also to tell my patients, let's not just think about baby one. Let's think about baby two. Let's think about baby three and how old will be on those pages. So when we think about treatment options, ovulation induction, Letrozole, and Clomid with insemination typically is what we start. We have to think about the success rate not being quite as high. It'll bring you maybe to 10% to 15%, a little bit closer to the population who we're trying every month with a natural ovulation, but then you have to think about treatment options like IVF, which are much higher. 60% to 70% live birth, and you're freezing for the future to have more children. If a patient's presenting in her early 30s and she's thinking I want at least three kids, maybe four, IVF has a higher success rate away and has long-term benefits. So I'm thinking by the time you have baby number three in your mid-30s or late 30s, your egg count and egg quality are going to be very different. The success rates are going to be lower at that age if you're pursuing something like IUI, and if you have the option of freezing embryos when you are in your early 30s, your success rate will be higher. So, planning ahead is super important to me because, as a woman, I think that is too. That's how I advise my family and my friends. It's not just about that first pregnancy. I always have faith that patients are going to be able to go beyond that if they want a bigger family.

Kristyn Hodgdon:
Yeah, that's why I say I wish that my doctor had that conversation with me because I went through actually the most difficult emotional part of my journey before my twins were that IUI portion, and because I wasn't asked how many kids I wanted to have, I knew I wanted three kids. By the time it got to IVF, I was like jumping at the opportunity. By the time I was educated enough, I knew that would give me not only the best possible chance for a live birth but also the ability to freeze embryos. Yeah, I think that's so important to note.

S. Kemi Nurudeen:
We're always open to IUI, but I always tell patients it can be exhausting when you get that result back because the majority of patients don't get pregnant, so it's a marathon. So you have to keep them motivated and know there is an option that has a much higher success rate. We will not keep you here forever if you want to start here.

Kristyn Hodgdon:
If someone with PCOS is gearing up for IVF, what are some things that they can do to improve their chances, like lifestyle changes, diet, and exercise supplements?

S. Kemi Nurudeen:
We do think lifestyle modification is paramount when it comes to PCOS patients and their care. Healthy lifestyle, healthy eating, and diet because there are risk factors for metabolic disorders, cardiovascular disease, and diabetes. All of these things impact not only getting pregnant but also your pregnancy itself. So we will talk about lifestyle factors. Weight loss through exercise and diet is important. The excess weight can not only have psychological implications but also have physical implications for your future pregnancy or even how you respond to your IVF medications, or even the quality of your embryos and implantation and risk of miscarriage. Healthy diet. There are a lot of diets out there that are available. I just tell patients to think about diets that are sustainable for them. Something you can stick with that will basically meet your nutritional needs, but I tell them, you don't need to go extreme if you think you're at risk for diabetes. Of course, they're going to be those diets that are better for you. I think consistency is important.

Kristyn Hodgdon:
Yeah, absolutely. And then, what are some other tests that you suggest running right off the bat before pursuing treatments for women with PCOS? I think of thyroid conditions because I have PCOS, and I had hypothyroid. Now I have Hashimoto's or hypothyroidism tipped me off to Hashimoto's, but I know they can be linked.

S. Kemi Nurudeen:
Yes, definitely. PCOS has its presentation. It is one of the most common reproductive disorders for women. In addition, hypothyroidism is also a very common endocrine disorder for women. They are not exactly the same, as far as the factors that lead to them, we think they could be genetically very similar to how they come to affect women. Sometimes, thyroid disorders like hypothyroidism are present, like PCOS. So when you're doing the PCOS evaluation, you are actually doing a thyroid evaluation, you're checking the CHAs, the free T4, and thyroid antibodies because you will see a higher risk for thyroid antibodies and Hashimoto's thyroiditis in women with PCOS. We are seeing those links. Poorly controlled thyroid disease can make PCOS worse for some patients. It has its own independent risk factors for ovulation thyroid disease. These can put you at risk for miscarriage independently, but we are seeing that connection, so what you said exactly. Thyroid testing is very important, and a well-controlled thyroid is important. We will also look at your prolactin. We look at other hormones that are present with PCOS and other rare hormones that can sometimes present other diseases like congenital adrenal hyperplasia, which is more risky and rare, but it can also present like PCOS. So there's a panel of hormones that your doctor will do to make sure. Is it PCOS alone? Is it something else that's presenting, like PCOS in addition to your PCOS diagnosis?

Kristyn Hodgdon:
Yeah. And does that include testing for insulin resistance?

S. Kemi Nurudeen:
Exactly, so that's a good point. So, I talked a lot about hormone disorders, but there are some endocrine disorders that do get tested. We do a hemoglobin A-1c to see if you're at risk for diabetes. Because we do see that high risk with our PCOS patients, so you'll see that for patients. So checking that is important, as well. PCOS patients are going to be at risk for gestational diabetes during pregnancy. So getting control of that before is important as well.

Kristyn Hodgdon:
That's really good to know. And diabetes in general in the future?

S. Kemi Nurudeen:
Yeah. It's in the future, with or without pregnancy.

Kristyn Hodgdon:
So, you talked a little about IUI success rates. But what about when there's a male factor involved? We've been on this awareness campaign, especially this month for Infertility Awareness Month. Just talk about how the male factor is a big part of the equation.

S. Kemi Nurudeen:
You can see up to 35% to 40% of factors involve male etiology for fertility and infertility. A woman is going through her evaluation, and she assumes that because she's not ovulating, she's the main source of the issue. Checking male factors is very important because we are seeing those parameters and the semen analysis that could be affecting their outcomes. When we see abnormal semen analysis, we recommend IUI and IVF, depending on how severe it is, for some men may have a medical history that would affect their fertility. They may be on drugs that affect their fertility. I have a lot of men who are taking testosterone replacement therapy. Sometimes it's being given in a way that the doctor is not thinking about this guy wanting to conceive and have a baby. We have drugs that affect their fertility. We have environmental factors and medical conditions depending on how serious the male factor is. A lot of the time, we are doing at least IUI as a recommendation, and IVF honestly overcomes most male factors.

Kristyn Hodgdon:
Okay, awesome. That's really good to know. And then, how do you personalize IVF treatment protocols for patients with PCOS? Considering that not every PCOS patient is the same, it's such a spectrum, and then also with the risk of OHSS, and you can go into that a little bit, too, just to let everyone know what that is.

S. Kemi Nurudeen:
Yes, that's a great point. With PCOS patients, there tends to be a higher ovarian reserve. So egg count or AMH levels are elevated. AMH is a hormone that comes from the follicles that sit in your ovary. The more eggs you have, the higher the AMH. PCOS patients tend to have a high AMH. AMH is a predictor of how you'll respond to the IVF medication. So, we see a high AMH, it tells us, okay, this woman's going to get a lot of eggs, and with a lot of eggs comes something called ovarian hyperstimulation syndrome. With this condition, women who have a big response to IVF medications have a lot of follicles and tend to have increased bloating. They may notice more nausea, some of the effects of their hormones being high, the estrogen being high, nausea sometimes vomiting. These cases of ovarian hyperstimulation are rare these days, especially hospitalization, for it is rare because we have ways to mitigate it and keep it from being very serious. These days, when patients have hyper stem, they're mostly complaining of bloating but we're not seeing as many admissions for the bloating where we have actually to take fluid off the tummy, what's called paracentesis, where we actually take the fluid out. Those cases are rare. It's there's a risk of blood clotting when that happens, but this is what we call severe OHSS. This is rare to see given the things that we have available with IVF treatment to tailor to avoid these. So it starts with even your dose. In your protocol, we tend to give the same hormones your brain needs to talk to your ovary. We give you gonadotropins to stimulate. We use a protocol called antagonist. We like the antagonist protocol because it allows for something called a Lupron trigger. Lupron trigger is a way of basically helping you release the eggs for the egg retrieval, but not continuing the symptoms of OHSS longer and having it last long past the two-week mark, as HCG may do for some patients. So, we have different types of triggers. The triggers we offer for PCOS patients with the big response can actually help decrease the OHSS symptoms. There are other medications we use, like Dostinex and even Seretide after retrieval, that can also help as well depending on the patient's ovarian reserve. We started off on a lower dose. Sometimes, depending on the patient's BMI, we may have to think about the fact that they may absorb the drugs a little bit differently. So, those are ways we can tailor the IVF process. But the key is avoiding ovarian hyperstimulation and planning for a frozen embryo cycle because, with a fresh cycle, some patients who are dealing with the OHSS symptoms, pregnancy, and the HCG from pregnancy can make OHSS continue in your body and make the symptoms last longer and make it more severe. So we typically recommend patients freeze their embryos and do their transfer the next month as a frozen transfer to avoid that risk as well.

Kristyn Hodgdon:
I remember being so disappointed that I couldn't do my transfer right away, but good to know this right off the bat from this podcast. Yeah, there are no long-term implications once you're done with your family-building journey. Like PCOS, it's just managing symptoms on a day-to-day.

S. Kemi Nurudeen:
It can, but there are going to be some health risks you should keep in mind. I will talk about the reproductive risks, but also cardiovascular. You have to stay on top of the diet and lifestyle changes because there are always going to be those risks for cardiovascular disease, and diabetes outside of pregnancy, patients need to keep in mind their cholesterol is going to be at risk as well. So, those lifestyle factors still play a role. And with PCOS, the regular cycles and ovulation are important to not ignore either. You should be shedding every month. Typically with PCOS patients who don't have regular periods, the lining never gets the chance to shed regularly and can grow and grow. And that can lead to something called endometrial hyperplasia. Endometrial hyperplasia can be managed by putting patients on birth control pills or progesterone-only pills. So basically, keep their cycles regular or keep their lining thin or exposed to progesterone. When there's constant estrogen and growth, there's a risk for endometrial hyperplasia, which can lead to endometrial cancer. There are some long-term risks that patients should keep in mind after having their baby. They have to think about their health. They also need to think about their uterus as well.

Kristyn Hodgdon:
Yeah, absolutely. The cardiovascular and the diabetes. It's definitely scary to think about. So, do you recommend birth control if you're not currently in treatment?

S. Kemi Nurudeen:
That's an option for patients. It really depends because the birth control pill can have a lot of effects. It can help with that excess growth from the endometrial lining. We can actually help with some of the effects of the excess testosterone. So, some women will have acne and hirsutism. And the birth control pill can help with that. I think it has there are a lot of therapies that are available, but you have to look at your patients. Sometimes, they want to be able to just trigger a cycle every few months. So they'll do progesterone only a few days of the month, or they'll do the pill because it's easy to keep track of, or they'll do a Marina IUD and just place that in the uterus to help keep the progesterone exposure to the lining as well. And there'll be some other hormone drugs you can consider that may target some of the androgen effects of PCOS. So there are many options. I think you have to look at your patient's PCOS diagnosis, what bothers them the most, and what symptoms they're dealing with outside of pregnancy that you want to manage.

Kristyn Hodgdon:
Yeah. And then what about during pregnancy? I know there may be a heightened risk of miscarriage, but what are some of the risks to be aware of?

S. Kemi Nurudeen:
Yeah, and that's a definite topic we should bring up. PCOS patients have an independent risk for miscarriage outside of just sometimes obesity puts you at risk. But just having PCOS, regardless of your BMI, puts you at, they say, a 20 to 40% chance of miscarriage. Women can also be at risk for preterm delivery. Patients can be at risk for cesarean delivery. We just have to keep in mind that some of these are, obviously, your doctor going to be managing you the whole time, but these are potential risks. We've already talked about gestational diabetes. With gestational diabetes comes big babies. And for some patients that means sometimes a C-section. At the same time, there could be hypertensive disorders. So, some patients may be dealing with blood pressure issues during pregnancy. Or, then with that, they can also have something called IUGR sugar intrauterine growth restriction of the baby. There are some obstetrical outcomes that can come with PCOS patients. Your OB will be quite aware and be in tune with keeping you on top of that during your first, second, and third trimesters.

Kristyn Hodgdon:
Okay, and going back to the risk of miscarriage, why is it so high in women with PCOS?

S. Kemi Nurudeen:
We really don't know. It could be multifactorial. It could be. They say it's independent of obesity. But we do know obesity plays a big role in miscarriage in women. So, with PCOS patients, it could be for some patients the endocrine factor that we just can't pinpoint, but it may have something to do with some of the insulin resistance and maybe how the endometrium functions during patients during pregnancy. We do know it's there. There are a lot of factors that are probably playing a role in it.

Kristyn Hodgdon:
Okay, on a positive note, many women with PCOS go on to have healthy pregnancies. Correct?

S. Kemi Nurudeen:
You need many women do.

Kristyn Hodgdon:
Yeah, yeah. To that point, I know so many women who might be embarking on fertility treatments with PCOS, might be feeling overwhelmed, and it's such an emotional journey. What is the silver lining as a PCOS patient about VF outcomes?

S. Kemi Nurudeen:
And I'll be honest, when I think about all the challenges we face as fertility doctors, I think you meet all kinds of challenges. And when I see PCOS patients, I know these risks are here, but I feel less worried. And maybe the best way to say it is because the ovarian reserve tends to be higher. IVF outcomes yield better numbers. Most PCOS patients present younger just because they are dealing with it. They're trying to conceive and they're not having periods, and it's something they're dealing with their whole life. So you tend to see them a little bit younger when the egg quality is best. So personally, I find PCOS patients not as worrisome. I think for me it's okay, this is an option. I know what we can do for PCOS patients. I know these risks are here, miss care, all these things. But you're young, high egg count, to me, those are all positive things to help improve outcomes and give a good prognosis. So I get less worried actually.

Kristyn Hodgdon:
Okay, good.

S. Kemi Nurudeen:
All the other challenges we come across.

Kristyn Hodgdon:
That's very good to know. And just knowing that in your field, there's so much research going on at all times, is there any exciting research targeting fertility issues with an individual with PCOS?

S. Kemi Nurudeen:
I definitely feel there are some targeted drug therapies coming out, which is good. With PCOS, we have to divide and conquer. Sometimes, it's okay; you're trying to get pregnant, or you're not trying to get pregnant. And we're trying to decipher what we are going to do. Are we doing birth control? Are we doing ovulation induction? There are drugs out there that are even targeting things like insulin resistance. At the same time, to help lower testosterone levels, there are potential drugs that may have a combination.

Kristyn Hodgdon:
Not yet on the market or?

S. Kemi Nurudeen:
Not yet, not on, it's out there, drugs out there that are trying to lower some of the excess hormones that prevent women from getting pregnant, while at the same time trying to induce ovulation. So it's actually pretty insightful because some people may be dealing with the side effects of their PCOS and, at the same time, want to conceive. And there are drugs that are trying to basically, they're trying to do research on finding other ways, other receptors to target that affect PCOS patients and maybe try to help with symptoms and help with pregnancy at the same time. So I think it'll be really interesting to see what comes out. We're definitely more open to the spectrum of PCOS and the wide range of topics that you can target research-wise, metabolic, and hormonal. There are a lot of ways you can target it.

Kristyn Hodgdon:
Absolutely. In the six years since I got pregnant with my twins to now, I feel like just the field has come such a long way. PGT-A wasn't necessarily recommended to me six years ago, but now it's of course I have a history of miscarriage. It's just that technology is so amazing, and if there are ways to mitigate those risks.

S. Kemi Nurudeen:
And it's good because patients are aware, patients are more knowledgeable and aware of their options. It's a good conversation to have with your OB/GYN, your endocrinologist, and your reproductive endocrinologist because we want to have those conversations and be able to tailor them to the patient.

Kristyn Hodgdon:
Yeah. Do you find that a lot of patients come in with taking a million supplements? And what do you typically recommend as a fertility specialist?

S. Kemi Nurudeen:
Yeah, unfortunately, supplements aren't as well studied there for PCOS patients. Inositol has been studied to help with the metabolic aspect of PCOS, but as far as fertility, not quite yet, I honestly tell patients supplements are not a bad thing. Just don't overdo it. Of course, I'm a big fan of acupuncture. With PCOS, there can be some emotional disorders that go along with that. PCOS patients may be at risk for depression and anxiety. So I find that obviously, a mental health specialist can be helpful. But acupuncture, I think is also helpful, helps with stress, helps with the fertility side of things as well. But when it comes to supplements that we know, we try to keep it very basic because sometimes you can overdo it with your supplements and it may be unnecessary and it's not well studied.

Kristyn Hodgdon:
Yeah for sure. I'm a big proponent of acupuncture. I love it, it's awesome. Is there anything that we missed that you can think of?

S. Kemi Nurudeen:
I think the biggest thing is making sure PCOS patients don't get discouraged. I know I think in the moment, because patients are young, not having periods and wanting things to happen naturally. It's a multifactorial disease that affects a lot of women. It's very common, but to me, it can be overcome, and your doctor will help you with that. I think being open to the possibilities and knowing your doctor will take you on that journey to get you to your goal.

Kristyn Hodgdon:
Yeah, I love that advice ending on a positive note. Thank you so much Dr. Nurudeen. It was lovely and I think our listeners are going to learn so much. I appreciate your time.

S. Kemi Nurudeen:
I appreciate meeting you today too. I hope this was helpful.

Kristyn Hodgdon:
Absolutely. Talk to you soon.

Kristyn Hodgdon:
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