PCOS (Polycystic Ovarian Syndrome)
by Jen

What PCOS Means and Its Impact on Fertility

PCOS stands for Polycystic Ovarian Syndrome. It is also known as PCOD (Polycystic Ovarian Disease) and Stein-Leventhal Syndrome.

The name of the condition is a bit of a misnomer because PCOS is a broad diagnosis for a host of problems, which may or may not actually involve cysts. PCOS is the most common endocrine disorder and affects as many as 1 in 10 women. The cause of PCOS is unknown. There is no cure for it and there are a host of symptoms.PCOS is treatable through diet, exercise and medication, most often a combination of the three.

“In 2003 a consensus workshop sponsored by ESHRE/ASRM in Rotterdam indicated PCOS to be present if 2 out of 3 criteria are met: (1) oligoovulation and/or anovulation, (2) excess androgen activity, (3) polycystic ovaries (by gynecologic ultrasound), and other causes of PCOS are excluded” (from Wikipedia).

The most common manifestation is anovulation (no ovulation) or oligoovulation (infrequent or irregular ovulation).Women with PCOS often establish normal cycle routines only with chemical induction.

Other symptoms include dark hair growth on the face and body, excessive weight and weight gain, especially around the midsection, acne, oily skin and hair, thinning hair, and in some cases, more serious health risks such as high blood pressure and high cholesterol.

PCOS is often accompanied by insulin resistance, and for unknown reasons, can eventually lead to Type II diabetes.

Because of the frequently associated ovulation problems, PCOS is one of the most common causes of infertility in women because the patient does not have the advantage of time, predictability or statistics. Fortunately, if the symptoms of an individual’s case are treatable, often this resolves the fertility issues.

Medication, diet and exercise can all assist the body in ovulating and with a combination of the three, PCOS women are frequently able to achieve pregnancy. It should be noted that PCOS women do have an increased risk of miscarriage and as such, your doctor will likely keep you on Metformin through your first trimester of pregnancy.

It is important to note that because of its increased risk factors for more serious health problems, PCOS should be diagnosed and treated regardless of whether or not a woman is trying to achieve pregnancy.

Diagnostic Process

While PCOS is often an umbrella diagnosis for a host of manifestations, it does require specific tests for diagnosis. Your doctor will conduct a full medical history (including menstrual history) and physical, as well as a complete blood panel to check various hormone, glucose and insulin levels. Your physician may also order a pelvic ultrasound to check for cysts on the ovaries, especially if you have been experiencing abdominal pain.Cysts may eventually disappear on their own or may be treated with hormones and medication, and in other cases, may require surgical removal. Provided that the cyst is relatively small in size and not tangled in anything, this surgery can usually be done laparascopically, resulting in little discomfort or recovery time for the patient. In the case of women who do experience a semi-regular cycle, your doctor may ask you to chart your cycle before and after diagnosis to search for detectable ovulation signs.

Your doctor will likely complete a metabolic panel on you once a year after diagnosis, to ensure that your glucose and insulin levels are normal and kidneys are unaffected. This is done through a simple blood draw and lab analysis.

Treatment Options

While PCOS has no cure, it is a very manageable condition.The effects of PCOS are often worsened by excessive weight or weight gain. Though the hormonal abnormalities of PCOS make weight loss more difficult, losing weight statistically shows overwhelming improvement in PCOS symptoms, including ovulation related symptoms.

Your doctor may recommend a diet that is high in fiber, protein and fruits and vegetables and low in carbohydrates and sugars, especially if your PCOS is accompanied by insulin resistance. Tailoring your dietary habits may help with weight loss, insulin levels, and gastro-intestinal response to medications.

Through the combination of diet and exercise, PCOS women can often reduce their symptoms to a point of not needing medical regulation.

Regular cycles (and at least 4 a year) are essential for total wellness and long term health maintenance. There are two primary courses of medication to assist in producing regular cycles.If a woman is trying to avoid pregnancy, a doctor may prescribe hormonal birth control.

If a woman is seeking pregnancy, her doctor will often prescribe Glucophage/Metformin to help induce ovulation. Often Glucophage/Metformin is introduced at a small dose, and increased if the body is unresponsive. If Metformin is not enough to induce ovulation, a doctor may pair it with Clomid or Femara. Metformin often produces unfavorable gastro intestinal reactions but is often managed by switching to an extended release version, and/or changing dietary habits. Often the body adapts gradually, resulting in less complications. Some patients (this author included) experienced relief or reduction from GI problems by taking over the counter acidophilus tablets (available at any health food store) along with the Metformin.

Not only is the Metformin and/or Clomid route helpful for stimulating cycles as beneficial in their own right, this also often leads to increased fertility as patients begin to ovulate regularly.

If inducing ovulation is not enough to help you achieve pregnancy, there may be other factors at play, such as suppressed egg release (eggs are produced but not released in to the system so your body thinks it is cycling regularly but eggs never actually drop), blockage from cysts and/pr scar tissue and other various problems.In some cases, injection FSH and LH drugs are introduced along with the Metformin and Clomid.

If fertility problems persist despite improvements in PCOS conditions, your doctor may order additional pelvic ultrasounds to check for new cysts, and/or a Hysterosalpingogram to investigate for additional complications related to other conditions.

PCOS is a fairly common disorder and can often be diagnosed and managed in its beginning stages by an OB/GYN. However, if normal course of treatment does not help, seek out the care of a Reproductive Endocrinologist.

Personal Experience

My PCOS came as a surprise because I’d always had regular (though long) cycles. We discovered that my cysts result from suppressed egg release so each month the follicle dies and attaches itself to the previous month’s follicle. The suppressed release explained why I still had regular cycles. I did produce eggs regularly and my body knew that (hence its response and my cycle)—the eggs just never successfully dropped down. I had a 4cm ovarian cyst removed 2 years ago, detected after increasing, regular pain on my lower right abdomen and confirmation through a pelvic ultrasound.I initially responded very poorly to the Metformin (frequent trips to the bathroom, especially following any meal) to the point where I stopped taking it. I have begun a new diet and exercise routine and have found that even with moderate weight loss and the new programs, I can tolerate the medication much better and need a much lower dose to produce the same results. We have not successfully conceived due to other fertility problems, but we have seen sign
ificant improvement in my PCOS symptoms, and in my insulin levels, with the combined treatment approach.

In the early stage of my diagnosis I did a lot of reading and research and found the following websites to be invaluable:

SoulCysters Website: http://www.soulcysters.com
SoulCysters Message Board: http://www.soulcysters.net
PCOS Association: http://www.pcosupport.org/
US Department of Health & Human Services PCOS Site: http://www.womenshealth.gov/publications/our-publications/fact-sheet/polycystic-ovary-syndrome.cfm

Additional Information:
“I am currently on Actos which did more that the Met in helping with the symptoms.”–Tammy

Finishing up a chapter and I need feedback/comments. We’ve been compiling a list of the usual suspects—comments and questions presented by the non-infertiles to the SQs and SPJs of this world. We drew these either from our own personal experience or your comments thus far on the blog. We’ll be posting a list of quotes that we’re using in the chapter when the chapter is complete.

The chapter is presented like this: the statement or question leads the section; we state what is probably the intended meaning (or why the non-infertile thinks this is a good thing to say); we state how the SQ or SPJ takes these comments/questions; and whenever possible, we give a better way to say the same thing (or warn them repeatedly to stay away from trying to say certain things in any manner).

The list of questions/comments follows below. Obviously, there are many variations that fall into each category—we’ve just listed the umbrella phrase. Please let us know if we’ve left off an important topic that we need to cover. Also, write in with any stories concerning these questions/comments. We’re trying to give many personal examples. As always, your name will be changed for the book.

Thanks, SQs and SPJs. What would I do without you?

The List

1. When are you going to have a baby?
2. Just stop thinking about it (or trying so hard) and it will happen.
3. Just relax (or you just need to take a vacation) and it will happen.
4. Unsolicited advice (have sex more/less often, lose weight, different positions, etc).
5. This is G-d’s (or nature’s) way of saying that you’re not fit for parenthood.
6. Are you sure you want to do this? Fertility treatments are dangerous!
7. You can always adopt (and the ever popular—if you adopt, you’ll get pregnant)
8. I know exactly how you feel… statements.
9. You’re so lucky that you’re not pregnant (that you don’t have kids) because… statements.

Also covered in this section is when infertile couples are not invited to children’s birthday parties.

I don’t drink very often, but I still feel the need to complain about the fact that I don’t drink during the two-week-wait. Because until it’s for something, it’s all for nothing! You skip the free French Martini at the open bar because you’re secretly hoping that you’re with child, and then AF shows up and you kick yourself because free alcohol doesn’t grow on trees!

Stirrup Queens need special drinks during their two-week-wait as well as any night that they need to give themselves an injection (real alcohol can be consumed on any evenings when you get a…don’t say it…BFN). Drinks that they can pour into a martini glass and feel shmancy.

I am currently drinking one of these drinks as I write, so in addition to making you send me your comments, blog addresses, write-ups for Operation Heads Up and every other little thing I demand from all other SQs and SPJs, I am now asking you to add your best 2ww drinks.

The Whoa-Nelly (tweaked from the Jen’s Delish of Northampton’s Haymarket Café)

1 cup decaf iced coffee (that’s the only drawback to this drink—you need to have the coffee cold so make it the night before)
1 cup milk
a few squirts of chocolate syrup
a few glugs of hazelnut syrup

Shake together and pour into chilled martini glass. Drink while staring longingly at that unopened box of pee sticks. Continue drinking while not testing.

International Adoption: China
(written on December 21, 2006)

Why Choose China?

(Note: this article addresses adoption of children without special needs. The process is somewhat different for parents adopting children with special needs.)

Some of the most common reasons parents choose to adopt from the People’s Republic of China (PRC) are

• • Ethics. The PRC’s program is well-established, complies with the Hague Convention, and has comparably fewer incidents of corruption.

• • Community. Because the PRC’s program is well-established, there is a correspondingly well-established network of parents who have adopted from the PRC.

• • Familiarity. Some people are drawn to the PRC’s program because they have a friend or family member who has had a positive experience with Chinese adoption.

• • Gender preference. Most of the children adopted from the PRC are girls, and there is an overall preference for adopting girls, especially intercountry adoption.

• • Certainty. Once parents obtain adoption approvals from their agency and home country’s government, adoption from the PRC is generally a matter of “when” not “if.”

• • Confidentiality. The PRC’s program is more “closed” than other countries, meaning that currently there is little or no possibility of contact with birth parents.

• • Economics. The fees for the PRC’s program are among the lowest of intercountry adoption programs, and parents are only required to travel once.

• • Health. The health report that accompanies the child’s referral is reportedly reliable, and evidence of in-utero exposure to drugs or alcohol is rare.

• • Humanitarianism. Some people choose the PRC because they have seen or read something that has led them to believe that there are children who would otherwise grow up in orphanages if not adopted by people outside the PRC.

• Culture. Some people choose the PRC because they are of Chinese (or other Asian) descent, or because they have an affinity for Chinese culture or people.

For a series of first-hand accounts by bloggers about why they adopted from the PRC, from the PRC, click here.

What to Expect

Outline of process

Adopting a child from the PRC who has not been identified as having special needs follows a straightforward and predictable process. Parents who qualify to adopt from the PRC first select an agency. Then, the parents obtain the necessary government permits and complete any paperwork required by the agency — for example, a home study, background checks, personal statements, and adoption coursework. This part of the process usually take a minimum of 3 months, but can take a year or more.

Once the parents complete their pre-adoption requirements, their paperwork — known as a “dossier” — is transmitted to the China Center for Adoption Affairs (CCAA). The date that the dossier is sent to the CCAA is called DTC (dossier to China).

The CCAA conducts an initial review of the dossier and then logs it into their system. The date that the dossier is logged in at CCAA is called LID (log in date). In general, the LID is about 2-4 weeks after DTC.

The CCAA processes the applications in LID order. Each dossier is matched with an available child, and the CCAA sends out batches of referrals to the agencies every 25-35 days. Usually referrals consist of photo(s) and a health report, and parents have the option to accept or reject the referral. Parents who accept their referral can expect to receive their travel authorization from the PRC 3-5 weeks later, and will travel 4-8 weeks after that.

Parents are given full custody of their children within the first few days after arrival and remain in the PRC for a total of about two weeks to complete official adoption paperwork. During this time, parents bond with their children and do a little sightseeing. Depending on where the parents live, there may be additional official paperwork necessary to complete the adoption upon returning home.

The CCAA requires families to file post-placement reports after the adoption is complete. These reports are due at 6 months and 12 months after adoption. In addition, if the child remains a PRC citizen, parents must file post-placement reports every 6 months.

Time frames

Time frames from DTC to travel have been increasing steadily since 2005. For example, families with LIDs in mid-August 2005 did not travel until December 2006 (approximately 16 months from DTC to travel) — about double the time frame from what it was for families with LIDs in late 2004/early 2005 (approximately 8 months from DTC to travel). See this post for a discussion about the current slow-down in referrals and application trends.

It is not clear how much longer the time frames will continue to increase, but the CCAA hopes that the upcoming revisions to its adoption criteria will eventually help reduce the time frames to 8-9 months from DTC to travel. To estimate referral time frames, based on current data, see the calculator at this website.

General qualifications

The CCAA’s requirements for adopting from the PRC are posted here. If you are a United States citizen, the State Department information on adopting from the PRC is here.

People of Chinese descent may be eligible to have their dossiers processed on an expedited schedule.

The CCAA is updating its policies and will soon announce revised criteria for eligibility to adopt from the PRC. These criteria have already been unofficially released to adoption agencies, and are expected to be applicable to dossiers sent to the CCAA after May 1, 2007. Some agencies already have the expected changes posted on their websites, but contact your agency for specifics.

COMMON ISSUES SPECIFIC TO CHINA

Eligibility under revised criteria

Parents who do not expect to be able to meet the revised eligibility criteria should get started as soon as possible to complete the necessary paperwork, including the home study and any government permits before early April 2007 (assuming it takes about a month between DTC and LID). In the US, obtaining advanced processing approval from the United States Citizenship and Immigration Service (USCIS) can take a month or more after the application is complete. In addition, all documents must be translated and authenticated before a dossier can be sent to the PRC. Expect additional time for completing these steps as it’s likely that there will be a large number of parents trying to get their paperwork in before the revisions take effect.

Expiring paperwork

One consequence of the increased time frames is that some adoption paperwork may need to be updated or renewed while waiting for referral. For example, the I-171H issued by the USCIS is only valid for 18 months, and FBI fingerprinting is valid for less than that. Also, most home studies are only valid for one year before they need to be updated. Parents who are currently preparing their dossiers should expect that their paperwork will expire and factor this cost into their adoption budget.

Personal Tips

Stay informed</em >

If your adoption or home study agency has a email newsletter, subscribe to it to keep abreast of changes in the PRC’s program. Many people also monitor this website and its forums for updates and speculation on referral trends.

Get support

You can connect with other parents adopting from the PRC online. There are yahoogroups, such as the very large Adoptive Parents China (APC) yahoogroup, as well as yahoogroups for individual DTC months and agencies. Also, the link to the “Why China” series of posts is a good starting point for connecting with the active community of Chinese adoptive parent bloggers.

You can also visit Families with Children from China to see if there is an FWCC group in your area where you can meet parents and prospective parents who have adopted from the PRC.

Become prepared

Adopting a post-institutionalized child can be challenging. Transracial and/or transcultural adoption can be challenging. This website is an excellent resource for information on attachment and identity to use as a starting point for parents and their families. There are links to websites with further information, as well as book recommendations.

Diagnosis: Unexplained Infertility
by Jackie

What Unexplained Infertility Means and its Impact on Fertility

Unexplained infertility is a diagnosis given after all other possibilities have been excluded. That is to say, after going through the diagnostic process (see below) there is no explanation for the infertility. The male partner has a normal semen analysis. The female partner ovulates and her hormone levels are all within normal limits. In addition, her uterus is free of anatomical abnormalities and the Fallopian tubes are open or patent. In addition to these physical findings, neither the couple’s nor their families’ medical histories indicate any reason why the couple should be infertile. Couples with unexplained infertility have substantially reduced cycle fecundity rates, 1-4% compared to 20-25% for normal couples. Pregnancy rates decrease with increasing maternal age and duration of infertility. Estimates place unexplained infertility at 10-20% prevalence among infertile couples.

Diagnostic Process

Male partner: medical history, family medical history, semen analysis.

Female partner: medical history, family medical history, physical examination, hormone tests (such as Day 3 FSH, estrogen, progesterone, prolactin, thyroid hormone, androgens), demonstration of ovulation (mid-luteal progesterone), hysterosalpingogram (HSG, to determine whether the tubes are patent). Other tests may be performed if indicated by the history. This may include laparoscopy to determine whether endometriosis or adhesions are present. The post-coital test to determine sperm viability in cervical fluid may also be performed although it has been determined that this test has poor predictive value for conception rates.

After the test results come back and no detectable reason for infertility is identified, the unexplained infertility diagnosis is given. This does NOT mean that there isn’t a reason for the infertility. It means that the science and the diagnostic tests are not advanced enough to detect the cause of infertility. Egg quality, fertilization, and implantation factors are difficult to test and may be the underlying problems.

Treatment Options

Since there is no known abnormality to remedy in unexplained fertility, all treatments are considered “empiric”. In general, this means the therapies have been observed to be helpful in getting over the infertility, but how? Unknown. All options are possible here and really are only limited by your resources, beliefs and desires.

1. Expectant management: Also known as wait and see, or my favorite term: keep on having the sex. At the end of three years, the pregnancy rate for women with unexplained infertility is about 30-60% without intervention. But can you wait 3 years for a cumulative 30-60% chance of getting pregnant? This is not the same as cycle fecundity rate. In fact, if you have a 28 day cycle, in 3 years, you will have had 39 cycles. My extremely rough math places the cycle fecundity rate at about 0.75-1.5%.

2. Clomid: This drug is a selective estrogen receptor modulator. Basically, it acts on estrogen receptors in the pituitary gland to increase release of FSH and LH and thereby increasing the quality and possibly quantity of mature follicles released from the ovaries. Clomid alone for unexplained infertility increases cycle fecundity rates only a couple of percent over placebo, so from about 1-2% to up to a whopping 4-5%. There is no benefit of using clomid alone for more than 6 cycles with unexplained infertility.

3. Intrauterine Insemination (IUI): One factor that can be difficult to ascertain is hostility of the female environment toward the sperm. The aforementioned post-coital test was more routinely performed until it was determined that the test is not a great predictor of pregnancy rates. To get around any potential hostility, the sperm can be prepared from a semen sample and injected into the uterus bypassing the vagina and cervix altogether. IUI has been found to have a small benefit over timed intercourse in unexplained infertility (5% vs. 2% cycle fecundity rate).

Fallopian sperm perfusion (FSP) also circumvents the vagina and cervix as well as the uterine environment by placing the sperm directly into the Fallopian tube using a laparoscopic procedure. Studies are divided on whether pregnancy rates are improved with FSP compared to IUI in couples with unexplained infertility.

4. IUI following controlled ovarian hyperstimulation (COH): This normally combines Clomid with IUI, but gonadotropins can also be used. Cycle fecundity is improved when ovarian stimulation and IUI are combined over either treatment alone. The average increase in cycle fecundity with combined therapy is about 10%.

5. In Vitro Fertilization (IVF), Gamete Intra-Fallopian Transfer (GIFT), Zygote Intra-Fallopian Transfer (ZIFT): Assisted reproductive technologies offer the highest pregnancy rates among those with unexplained infertility. Most published studies indicate 25-50% pregnancy and live birth rates in those with unexplained infertility. These procedures are more costly and invasive that the other therapies and have somewhat higher incidences of multiple births.

A typical treatment trajectory goes from low cost, low tech for several cycles, advancing from Clomid alone to COH/IUI to IVF. Couples with more resources may opt for the higher cost, higher tech treatments immediately. Since the cause of the infertility is unknown, it is impossible to know how much intervention is necessary to get pregnant.

Personal Experience

My husband and I sought assistance after 18 months of unsuccessfully trying to conceive. Our medical histories are normal. I have extremely regular 28 day cycles (almost to the hour), I have never been pregnant, and I have never been diagnosed with endometriosis. For his part the semen analysis was normal. My day 3 hormone levels were spot on. My HSG showed open tubes with bilateral peritoneal spillage of dye. My mid-luteal progesterone was 9.6-definitely ovulating, but sort of mediocre. My RE’s office likes to see it closer to 15. Therefore, my first treatment was Prometrium, which elevated mid-luteal progesterone to about 25.

After 2 unsuccessful cycles, I have opted to try Clomid. In fact, I will take my first dose today. My clinic does not monitor ovulation by ultrasound so I will be peeing on sticks to determine the LH surge. The clinic will draw a mid-luteal progesterone which I expect will be higher than 9.6, but who knows. If Clomid doesn’t work, then we will move on to COH/IUI, and if that doesn’t work, then we will likely undergo IVF. We are definitely taking the low tech, low cost to progressively higher tech, higher cost route. All testing is covered by our insurance including a once-in-a-lifetime laparoscopy which I may elect to have performed sometime this year to definitively rule out any endometriosis.

I must admit that it’s quite frustrating, not knowing WHY. Any more frustrating than knowing why and not conceiving? That’s highly unlikely. And it doesn’t change the treatment options that much from some other “known” types of infertility.