Hi everyone and welcome to part three of our video series on polycystic ovarian syndrome. Today, we’re going to be covering your fertility options for polycystic ovarian syndrome so stay tuned. I know a lot of you have been waiting quite eagerly for this video. Sorry it took so long to make. We are back up and functional, fully operational at CAPE Fertility seeing all of our patients. So, things are getting a bit more crazy on this end, so bear with me this will be up on YouTube shortly.

So, let’s start off just by recapping. What is the major issue with trying to fall pregnant when you have polycystic ovarian syndrome. Well the biggest stumbling block is always going to be ovulating. So, if you’re not growing those little egg follicles and growing those eggs to ovulate every month, not having that regular period, you might struggle to fall pregnant because obviously you need to ovulate an egg to fall pregnant. Just bear in mind that just because you have polycystic ovarian syndrome does not mean that there can’t be other issues that we need to deal with as well. We still need to check your husband’s sperm, your partner’s sperm. We might still run into problems with tubes, things like endometriosis. So, it doesn’t mean that if you take treatment for polycystic ovarian syndrome to help you ovulate that you will definitely fall pregnant. We have to rule out all other contributing factors.

So, let’s start off by looking at what our treatment options are to help you ovulate. We’ve got some tablets that we can take, and we’re going to run through Letrozole, which has commonly known as Femara. We will also run through Clomid or Fertomid, which is medically known as Clomiphene citrate. We will run through where Metformin might fit into this. Some of the injections, that we might use alone or in combination with the tablets. And then obviously the remaining options would be IVF and egg donation. Let’s start off by running through your tablet options.
So, before we get kickstarted with the Femara discussion, just bear in mind that we don’t write a prescription for six months and say off you go, this is how you take it, come back. If you’re not pregnant. A lot of GPs might do this, some gynecologists might do this, but this is not safe. And the reason being the tablets that we are giving you are trying to tell your body to grow versatile eggs or follicles. Sometimes it works and sometimes by a certain amount of time into your cycle, you would have grown a nice big follicle with a nice egg inside, ready to ovulate. Sometimes it might take longer, sometimes you might not respond to that dose of medication and sometimes you might over respond. What I don’t want you to do is go home and ovulate six eggs and become the next mom with six babies or the next octo-mom. That’s definitely what we’re trying to avoid, so it is dangerous to just take a prescription and blindly take that for the next six months. You should be monitored in the cycle to see, first of all, that your response is adequate. And secondly, that the response is safe. It doesn’t make sense to keep it doing the same thing every month, if you’re not getting a good response out of the medication. Or if you’re getting an excessive response and putting yourself at risk of having multiple pregnancies.
And please note that I say multiple pregnancy, not twins, because if you’re going to ovulate four or five, six, seven eggs, you’re putting yourself at risk of having four or five, six, seven babies, which might sound like a novelty, have a big family, one go. But it’s a very high-risk pregnancy with a very high risk of miscarriage and having preterm babies. So, our aim is always to get you to ovulate one follicle, we will accept two, we will accept three, but no more than that.

So, let’s start off with our chat about Femara. So, it’s a drug called Letrozole, you almost commonly be prescribed Femara, which is the trade name. This is a tablet that we will usually start on day three of your cycle, you will take it for five days. It might come as a single tablet dose, or a double tablet dose. Some centers might even give you three tablets a day. So, it doesn’t matter when your period ends while you’re taking the tablets, it only matters that you start on day three. There is a window in which you can take the tablets. You can’t take them beyond day five, but we advise day three for maximum benefit. So, you would take those tablets for five days, what we would then do is arrange an ultrasound usually on about day 11 of your cycle.
So, if you count 11 days from when the period started, the idea then is to do an ultrasound, see how many follicles they are. Because remember, we don’t want more than three and ideally, we just really want one. We want to measure the size of that follicle, remember the follicle is a little egg factory, and we’re going to measuring the fluid around that egg because we can’t see an egg on ultrasound, just the fluid. We get an idea of the size of that little follicle if it’s the right size, we can actually then give you a medication to trigger you to ovulate. And you will know exactly when you are ovulating and have intercourse.

So, let me just briefly run through how Femara works. So, here’s a very simplified introduction to how Femara works and that does help for you to understand how it works. So, you are really making those testosterones, so there’s androgens, as we discussed in our previous videos, that gets converted to estrogen usually. So now what’s going to happen with Femara is it’s going to block the little enzyme that tells it to do this. So no longer will you be converting your testosterone to estrogen. So, what happens your brain then registers, hold on. I’m not making enough estrogen something must be wrong and responds by pumping out this hormone called FSH, FSH stands for follicle stimulating hormone. So, it’s going to then tell that the ovary with those little egg factory follicles to grow. So, it will then influence that ovary to grow some more follicles. And that’s the stimulus that those little, egg factories that’s follicles need to start growing and to become a nice big follicle with a healthy egg inside, ready to ovulate.

So just a reminder, remember, this is what’s happening in a follicle in the ovary. So here sits your little follicle, there’s your little egg, and all this blue stuff around here is the fluid and that’s where we are measuring on ultrasound. So, when we do an ultrasound and we see one of these things there, that’s a big follicle and then we’ll measure it, we’re measuring the size of it. So, this is a picture from an IVF cycle, so we’re definitely not wanting to see so many of these big follicles, remember we would like one, maybe two, maximum three. So, we would measure this on ultrasound and when that measures the right size, we would be ready to trigger you for ovulation.

Okay, so let’s recap. So, you’ve been given your five days of your Femara medication started on day three. So, you’ll take it every day until day seven. You’ll come in for your ultrasound on day 11 and what happens if we do an ultrasound and there isn’t a big follicle there? Well, that’s easy, we’ll just tell you to come back a few days later, sometimes it might take a little bit longer. If there’s still no follicle the next ultrasound, then we might start adding in a few injections just to try and boost the process or offer you to sit out the cycle and restart the next cycle with injections.

So, once we’ve seen that nice, big follicle and everything is ready, we will give you a trigger injection. And we will tell you when to have intercourse. Now, what that trigger injection does is it starts maturing that egg and getting it ready to ovulate. That process takes between 34 and 38 hours, so we usually say 36 to hit that in the middle. So, we will give you a time when we estimate you will be ovulating and tell you then that time at home to have intercourse, which is usually 36 hours after your injection. If you want to do an insemination, we can also plan an insemination around these times, that’s really not a problem.

So why don’t we start off talking about Femara. Well there’s a lot of evidence now that this is the best option for patients with polycystic ovarian syndrome who are more likely to ovulate on Femara versus other drugs. The other thing we really like about Femara is you’re more likely to ovulate one egg; so, grow one follicle versus multiple follicles. Remember, we’re trying to get you pregnant with a healthy pregnancy. We’re not trying to make you a twin or a triplet mom, so ideally, we would just like you to ovulate one egg.

Moving on the next option might be Clomid, Fertomid or as we call it clomiphene citrate. So, this medication works a little bit differently from Femara, I will run through that whole process with you shortly, but in terms of how you take it, it’s very similar. Starts on day three, take it for five days, we set up the ultrasounds exactly the same as if we were doing a cycle with Femara. We plan ovulation the same and we can tell you then when to have timed intercourse. It’s run through hard works.

Let’s start with a super simplified explanation of how clomiphene citrate or Clomid works. So, believe it or not, that’s meant to be your brain, it pumps out a hormone called FSH, follicle stimulating hormone, we know this. Acts on the ovary and these little follicles egg factories will start producing estrogen as little eggs grow. So, I’ve made estrogen a little triangle over here, estrogen then feeds back to the brain. Here’s a little receptor, it measures the amount of estrogen and it tells the brain, okay, we’ve got enough estrogen, you can slow down on making the FSH. So, what do we do? We block these receptors here, so the brain is not sure how much estrogen you’re getting the brain then sends out a signal to say, let’s make more FSH, more follicle stimulating hormone, stimulate more follicles so we can get one of these guys to grow nicely. And this is usually the drug that we reduce for patients who are struggling to fall pregnant and not with polycystic ovarian syndrome, because it tends to make a few more follicles grow.

So why would we use something like Clomid or Fertomid versus Femara? Well, it’s been around a bit longer, so there’s a bit more history to it. And there were a few concerns right in the beginning about using Femara to make you ovulate, that there might be some abnormalities in the babies. That has now been proven to be incorrect and that’s no longer a concern, no longer a reason to not take Femara. Thousands and thousands of babies are born every single day because of Femara and they are nice and healthy. So please don’t worry when it comes to any Googling that you might do for concerns about taking Femara and abnormalities in the baby, we now know that’s not true.

So as far as taking the Clomid, as I’ve explained you take it exactly the same as the Femara. But Clomid does tend to make a few more follicles. So, your chances of having a multiple pregnancy are a little bit higher, so it is not more effective at making you ovulate than Femara is for polycystic ovarian syndrome, but it does come with that increased risk of a multiple pregnancy. It also tends to have a few more side effects and what women tend to complain of the most when it comes to the Clomid or Fertomid is hot flashes. You might get a bit of headache, you might get a little bit moody, but a lot of the time women complain of hot flashes. Versus the Femara where a lot of the times the main issues are just feeling maybe a little bit dizzy, but otherwise, very few side effects whatsoever.

So where does Metformin fit into all of this? So, Metformin as we’ve discussed in one of our previous videos helps to bring down your insulin levels. So, they’ve done some research on whether we can give them Metformin alone and there was a lot of excitement in the beginning about maybe just by giving Metformin we can make you ovulate. So, what we do know is when we compare Metformin versus nothing where placebo, that it is more effective of making you ovulate if you have polycystic ovarian syndrome. However, Clomid and Femara are always going to be a lot more effective. And the only time that we would consider using Metformin on its own is if you can’t actually access care to be monitored in the cycle, then potentially there’s a role for starting you on Metformin to see if you would ovulate, because it’s better than nothing.

But remember Femara and Fertomid or Clomid are always going to be better options. Another time we might add Metformin in is on top of your Clomid or your Fertomid. Some women might be a little bit resistant to the Clomid, so we start off on an easy dose. We increase the dose; we’re still not seeing your response. One thing we can consider doing is adding Metformin to this, because we think you might ovulate a little bit better if you’re not responding well to the Clomid/ the alternative is really putting you on Femara, which should have been the first line choice. And the other option might be adding in some injections. So, we think Metformin might help you ovulate a little bit better, whether that influences your pregnancy rates or not there’s a little less convincing, but it might make you ovulate or grow a nice follicle, a little bit more convincingly.

Maybe that’s a good place just for us to recap, but if you grow an egg and you ovulate that egg, that does not guarantee pregnancy. That should be the only barrier if we’re talking purely polycystic ovarian syndrome. But remember not every couple who ovulate on their own at home is pregnant the first month they try. So, while we expect good success rates, if the main issue is only just getting you to ovulate, it is not a guarantee. So please don’t confuse the term ovulation with successful pregnancy. And that’s why some of these drugs might be better at making you grow a follicle to ovulate, but that doesn’t transfer into a successful pregnancy. Remember, unfortunately a pregnancy doesn’t always mean healthy live birth. So, when you are looking at information above fertility things, remember egg number, ovulation, pregnancy rates, and then the take home baby rates are very different concepts.

So, let’s talk about the injection option. So, what we tend to do when we think we’re going to start off with injections, and that’s usually when we’ve struggled to get a good response out of the tablets. We start off at a very, very low dose. So, you would inject yourself every day and we would usually give you injections for a couple of days, probably a week before we start scanning. And you would have to do injections for a bit of a longer period then the tablets and you would probably need to come back for a few more scans. I want to show you what these injections typically look like. So, this is a typical injection, we would teach you how to set the dose and we use these usually in IVF, but these can be very helpful and have been around a very long time for helping you ovulate with polycystic ovaries.

So, we set a dose, which we will tell you what to do, and this will change throughout your cycle. We then teach you how to inject, as you can see a teensy tiny little needle, right there, really not painful at all to take. And you would inject yourself every day with these. So why don’t we start off the bat, every patient on these, because number one, these are more expensive than tablets, unfortunately. So, each one of these pens will be significantly more expensive and you would probably need more than one pen and hopefully not, but you would probably need more. Secondly, it’s a bit more labor intensive. You need to come in, but more frequently for ultrasounds, not just one or two scan or we need to track what’s happening with the ovaries.

The other risk is these injections are very effective. So, you might start growing more than one, two or three follicles. And what we don’t want to see as I’ve said is five or six follicles starting to grow because at that point you might say, well, let’s consider switching you over to IVF. If IVF isn’t an option we’re going to need to back out of that cycle. And we would advise you to not have intercourse because it is too dangerous. We know these are very effective, we know that these injections of the most effective option when it comes to pregnancy rates, but they also come with the much higher risk, three times higher risk of you having a multiple pregnancy. So, we don’t mess around with these lightly. And you should definitely not be taking these from anyone other than a fertility specialist who is monitoring your cycle.

So now we’ve recapped your tablets that you can take as well as your injections. The fact that we need to monitor your cycle, we need to see how many follicles there are. We need to time the point where we can trigger them to ovulate. Let me just add in a side note about that. We can’t just blindly trigger you to ovulate. And the reason being is sometimes that follicle might be a little bit too small and the egg inside will be immature. If we try and make you ovulate that either we might fail to make you ovulate the egg, or you might ovulate an immature egg. And an immature egg is not going to be fertilized, unfortunately and result in a successful pregnancy.

Remember just the same as other couples can do inseminations, patients with polycystic ovarian syndrome can do inseminations if they need to. If there’s a male factor, for example, with the sperm test, we can do that. If you’re require IVF, for example, if the tubes are blocked, we can do IVF. We just need to be very gentle with how we stimulate the ovaries, because sometimes your ovaries can go a little bit crazy and make too many follicles and put you at risk of hyperstimulation. But this is something that your doctor will take into consideration for you. Another thing they might discuss with you is if we are going to do an IVF cycle and you do respond by making a lot of eggs, so only 15. But typically, we see sort of more than 20, we might decide to stagger your cycle. So, retrieve the eggs, create the embryos, and only transfer embryos in the next cycle, that’s called the frozen transfer. So, there’s some data coming out that there might be better in patients who respond excessively. So that’s something you can chat to your doctor about.

I hope this has cleared up any questions that you might have about your fertility options if you have polycystic ovarian syndrome. We’ve now run through all of the drugs, what the procedure looks like, why you need to be monitored and some of the side effects that you can expect as well as what are your next steps if for example, one of the tablets is not working. Remember all of these drugs are very different to Provera, which just regulates the cycle. So, while we might bring on a period to start a treatment cycle with Provera, Provera itself, like progesterone tablet is just going to keep you having a regular cycle, not make you ovulate. If we’re winning with making you ovulate, you should have a regular cycle on the tablets anyway, so you won’t need to take both if you are ovulating successfully on medication.

Please remember that if you have any questions, you’re always able to reach out to us. We are available on our Facebook page as well as our Instagram page. And all of these videos are kept on our Instagram highlight reel as well as our YouTube channel. That’s all from us and our series of polycystic ovarian syndrome. If we didn’t cover something that you would like us to cover, please do let us know.

We will deal with all of these questions in a separate video, just to make sure that everyone is benefiting from the answers. Just bear in mind there is no such thing as a stupid question. So, something that’s not clear to you or the videos didn’t explain might be something that we forgot to add in. So please do send us your questions and we will make sure to answer all of them directly.