Getting Pregnant with PCOS
*This blog post is just an excerpt of the podcast interview , if you wish to listen to the full episode , tune in here!”
Everthing about getting Pregnant with PCOS
PCOS is one of the most common causes of female infertility and as per a recent study, 70% of those with PCOS could struggle with anovulatory infertility. Now having said that, PCO doesn't mean that one cannot get pregnant at all, but one would need a little bit more support and monitoring. This blog is a podcast interview with Dr Nina Mansukhani where we talk everything about getting pregnant with PCOS!! Dr Nina is an obstetrician and gynaecologist based out of Pune, India with over 25 years of experience and she is passionate about ethical medical practice and natural delivery practices. Besides infertility, she also has a keen interest in Menopause, Female Endocrinology and High Risk pregnancy. Our community loves Dr Nina as she takes a very holistic approach and treats her patients with kindness. Let's get into the conversation of understanding PCOS and its impact on pregnancy.
Nidhi : Can you share some light on what are the challenges one could face in terms of getting pregnant when they have PCOS?
Dr Nina: Yes, so like you rightly said, 70% of PCOS women are actually an ovulatory, that is they don't actually ovulate during the cycle and the periods are haywire. Now, this could be most of the time it's a delayed period. Sometimes it could be an earlier period, which is like a breakthrough bleeding that happens. So a lot of them actually don't ovulate. Like we all know, ovulation and regular cycles are very important for getting pregnant because that's how you time your fertile period. And that's also the time where you can time your intercourse in order to achieve a pregnancy. People with PCOS, some women may have erratic periods and an ovulatory. And so therefore it gets challenging to then get pregnant because you don't know whether you're really ovulating and what is your fertile period. So it becomes very difficult to time your intercourse in that case. So I think that's the biggest challenge. The second challenge would be when even if you're taking treatment and you're seeking treatment from someone, actual response to that treatment may not be as you wish it to be.
And that's very, very frustrating and distressing for many women because it takes several months for them to achieve a pregnancy which a non-PCOS woman may achieve maybe in a cycle or two. Once they do get pregnant, are there any risks for people who have PCOS and they are pregnant while they are carrying their baby? Care before they are trying to get pregnant? A lot of these issues could be avoided. And just talking about the stats, almost 70% of people with PCOS remain undiagnosed. And a lot of them get to know about PCOS when they are trying to get pregnant, which means that women are, you know, they do not go for their checkups, annual checkups maybe, or just the healthcare system as such, may not force us or just make us go to our doctors timely. And what we hear now is preventative care is so important as soon as you are getting your periods as an adolescent as well. I feel that going to a gynaecologist for your yearly checkup is so important. And the reason why I'm talking is again, that the infertility issue is highlighted or PCOS issue is highlighted when you're trying to get pregnant after you get married.
Nidhi : Dr. Nina, I would like you to highlight the importance of certain lab tests or certain checkups that one could start doing with the help of their gynaecologist way before, just for their reproductive health, before they're trying to get pregnant. And of course, we'll talk about what are the things that you could do while you're pregnant. So could you share the insights around that?
Dr Nina: So here is where I'd like to highlight the importance of something called as a preconception health check. Like you said, it's really pertinent. And, you know, the surprising thing is that even women who are trying to conceive and couples try for a long time, and despite having regular periods, 30% of them actually don't ovulate. And this gets highlighted once they actually seek help from a gynecologist or a fertility expert. So here is where the importance of a preconception health check does come in. And here one would run a couple of tests, specifically the hormone test that you asked me. I would definitely do a thyroid check. I would do a prolactin hormone check. And based on the age of the patient concerned, I would definitely run tests to check her ovarian reserve, because that gives us very important timelines where we can work on. And one would get the couple then to maybe expedite their treatment in terms of fertility. And if, of course, like AMH, so anti-mullerian hormone. And I would also definitely run an ultrasound, which would tell me what her antral follicle count is. One has to remember that these tests of ovarian reserve that we are running also decide the mode of treatment, the timelines of treatment, and it helps in giving correct diagnosis and guidelines to the couple in question.
And besides this, then one would look at her medications. So for instance, start preconception folic acid, which is really important in terms of preventing spinal cord and neural disorders in the baby, in terms of preventing miscarriages, which is already like we discussed, slightly higher in women who are getting pregnant with PCOS. And most importantly for a woman who gets diagnosed with PCOS, like we said, it's sometimes a clinical diagnosis, sometimes it's an ultrasound diagnosis. and sometimes it's a biochemical diagnosis. So you need at least two factors to actually zone in on the diagnosis. And once you have got it, then it also would help in encouraging her to go ahead with the weight loss, which would then work wonders for her. So even a 5 to 10% of weight loss preconception would actually increase the chances of her having a spontaneous pregnancy, and she may not even have to seek fertility treatments then. And secondly, then if she is not responding to natural ovulation cycles and monitoring of her own cycle, then maybe she would need treatment with fertility drugs, like for instance tablets, or we could use injections and monitor the sonographies to see how the follicle development is happening. Very important thing is the psychological aspect, because women who get diagnosed with PCOS sometimes get very frightened just looking at the report and they feel it's a disease. This is one thing I really want to highlight. PCOS is not a disease. It is a collection of symptoms that you may be having and that comes into a syndrome where it predisposes you to not ovulate. So one doesn't need to get worried and think it's a disease. That's the first thing, because the stress itself is so, so it's such a deterrent for getting her pregnant. She starts believing that something is wrong with her and psychologically gets very distressed.
Likewise, when they are pregnant, they have to take a little bit of extra care. Like we said earlier, it's a high risk pregnancy. So definitely frequent checkups with the doctor, taking important medications to help in maybe placentation, prevention of miscarriage, regular ultrasounds to diagnose, look for predictive markers for hypertension, do a serial blood test, maybe add bookings or booking blood tests to determine whether she's actually diabetic or because already insulin resistance is prevalent. And then once you get pregnant, you get predisposed to gestational diabetes. So a booking blood test called as glucose tolerance test, the entire three are one, and then repeat this again at 24 to 28 weeks to pick up the gestational diabetes, proper multidisciplinary care with the help of a nutritionist, maybe a trainer to look at your exercise. Monitor the adequate weight gain. So according to the BMI, the woman would actually need to gain a certain amount of weight. For instance, any normal woman without a PCOS, I would say that she could gain at least 12 to 13 kgs in pregnancy. But somebody starting pregnancy per se at a higher BMI, I would restrict the weight gain then to maybe 7 to 10 kgs. So monitor the weight gain, monitor the diet in terms of macros and micros, everything that she's getting for the baby at the same time restrict the weight gain very very important to achieve decent results and outcomes for the pregnancy and Monitor blood pressure at every visit monitor weight at every visit You know at the outset give her a non-judgmental advice. I think this is where we have to really Be tread on you know to enter hook and not get them to believe that something is really wrong with them because if at the outset if you tell them you're a higher weight and you have a chance of having this, this, they get very frightened. So I think that is also very important.
Nidhi: Dr. Nina, what has been your experience with people who are lean and they may not have a very high BMI? So in that case, is there anything special that you would advise them?
Dr Nina: You know, this is a real challenging part because it is, I always say this, it is easier to treat a high BMI PCOS girl as compared to lean PCOS because lean PCOS, even if you ask them, it's firstly losing weight is a big, it looks, it looks very strange because they don't look overweight, but they have a higher visceral fat, which is the body fat as compared to their body weight would still be higher. So it's very difficult to get them to say lose weight. They look at you and they say, hey, I'm already okay. So to encourage them to lose weight, which I usually don't, I just tell them start exercising. Because the beauty of exercise is even if you do 150 minutes a week, and you do aerobic exercise most of the time and include weight training maybe twice a week And even if you don't lose weight, but you're still exercising, even that reduces your insulin resistance. Like we said, almost 70 to 75 percent of lean PCOS are also insulin resistant. And more so in certain ethnic populations, like Asians, for instance, have a higher instance of insulin resistance. So still reiterating the importance of exercise in such women is very, very important. The second challenge with lean PCOS is their response. They tend to be a little higher androgenic, and then their response to treatment then reduces, because it's not as effective as one would get probably with somebody who is less androgenic. So that's what I have seen in my practice. The lean PCOS tend to have more of an androgenic component of the male hormone or the testosterone, it's slightly higher and that becomes a little challenging because then you have to increase the doses. And here is where the real challenge lies because such women, when you increase the doses, they either get no response or they get a massive response called as ovarian hyperstimulation syndrome. So one has to tread very, very carefully when we are treating them with the hormone tablets and injections.
Nidhi : Very interesting. And lean PCOS, as always, I would say, a very under-researched and underspoken. Because I am a lean PCOS case, although I haven't conceived yet and not planned too anytime soon. But just managing PCOS in general has been a lot of learnings, which I had to learn myself, because there is very less information out there. And you rightly pointed out that we may look thin, but there is a lot of visceral fat component. Fat to muscle ratio is what you have to look at. And working with somebody who is a professional trainer who understands PCOS and a nutritionist can really help. I would always recommend anybody who's trying to work on their health, work in a holistic way with a nutritionist, a fitness trainer. I would like to go into the topic of understanding ovulation a bit and what is available in the market right now for people to maybe test their ovulation. I wanted to speak about this because I see a lot of women using these ovulation strips which may not work for PCOS because a lot of people with PCOS already have high LH levels and they don't sort of, they won't see that peak when they tested on the urine strips. So what are the things people could do to understand their ovulation patterns?
Dr Nina: You know, you have to take into context that everything universally is not available world over for everyone. So I'd start with the clinical part of it, and then we'll go into the biochemical and the ultrasound bit. So when you're starting conception, we have to understand you have to understand very well what your cycle length is, and you have to figure out whether you're really ovulating. Now, if you're smart enough, you figure it out clinically that you are ovulating and you are getting a mid-cycle ovulation slippery mucus and you get a pain on one side or the other mid-cycle pain called as mittelschmerz. A lot of women when they are, you know, in their 20s, late 20s, 30s figure it out that they are ovulating and you can very accurately even say that you're ovulating from the right ovary in one cycle and maybe the left ovary in the other because that's how you get the pain. Now the most accurate clinical way is this. So cervical mucus, a lot of people do figure out themselves. The second thing is the basal body temperature. Again, not very accurate in picking it up. And many times when the temperature does rise, sorry, mid-cycle, ovulation has already taken place and you've lost the fertile period. The third thing you mentioned is the LH strips, the ovulation detection strips. Again, not very accurate for PCOS. And then you've got to use it for a long period of time, especially in women who have very erratic periods, 35, 38 day cycle. You probably just get a single line and you're not ovulating. The fourth thing that I'd like to highlight is the apps. They seem to be very popular worldwide and a lot of people use these apps. Now the app will only tell you that what your fertile period really is based on the cycle length. it is not going to really tell you whether you're ovulating or not. So that is the fallacy. You know, a lot of people say, oh, my app is telling me this. And this is my fertile period, but the app is not telling you whether you're really ovulating. So that is where it falters. And the most accurate method then becomes folliculometry or ultrasound monitoring of the follicle. And this may be done either in a natural cycle or it may be done when you've started certain medications.
Obviously, in PCOS, women who are not ovulating, you may need to start with fertility-inducing drugs. And when I say ovulation induction, we are talking about trying to develop one single follicle in that cycle, which eventually ruptures on a particular day and then you time your intercourse. And when you talk about ovulation stimulation, you are using more than a particular drug. You may be using a combination of tablets and injections called as gonadotrophins which work towards increasing your FSH hormone and then causing the eggs to release. And here you may get more than one egg, and this is called as controlled ovarian hyperstimulation. We are trying to get in more eggs in order to get a better chance of conceiving or in women who are slightly resistant. Now there are women who, like I said earlier, they respond very little or they respond very much. And that may predispose them to get something called as ovarian hyperstimulation syndrome. In such cases, one would consider, especially in those women who have a very high androgen level and very high AMH level
Nidhi: very, very helpful Dr. Neena. And I just want to also add that sometimes, you know, it gets very, very difficult to access a doctor, especially now that I'm also in the US, we have a lot of people who are not able to see their doctors as much as like to see them. And in that case, I think there are sort of unsponsored recommendations that I would plug in here. There's this technology by Inito and I can put it in the description if you like and they actually test the estrogen levels along with other hormones. And some of the community members have found it really helpful. And it's obviously an app based and from an affordability standpoint, you'll have to see if that works for you. Other similar technologies in different markets. like there is Miro and there is Clear Blue.
Dr Nina: Again, the efficacy is obviously depending on a lot of several factors and to get your doctor's support along with it is always very helpful. And that itself may induce spontaneous ovulation. So that's worth looking at when it's very difficult to get fertility-inducing drugs. So I think that's a huge thing, but you have to break your insulin resistance. I think that could be the first step before you even seek. fertility treatments.
Nidhi: Absolutely, and I was coming to that, that's our next segment where we talk about supplements and medications, and there are some which are available off-label, and there are some which is available on, you know, if you have to get a prescription. So I think Inositol is quite, it has received a lot of positive response from our community and from doctors, but some people also need combination of metformin. And what has been your experience, Dr. Nina?
To access the full episode tune in here where we talk about the below important aspects with respect to getting pregnant with PCOS
Supplements that can help improve conception chances
Managing Pregnancy with PCOS : considerations and challenges during pregnancy for individuals with PCOS, including potential complications.
Medical Monitoring and Support one may require while they are pregnant and have PCOS
Post-Pregnancy Challenges and Care that individuals with PCOS may face and the importance of postpartum care.
Long-Term Health Considerations: post-pregnancy, including the management of PCOS symptoms.
Patient Stories & Audience Q&A
To know more about ways to reverse your symptoms and manage your PCOS, keep reading and follow me on Instagram, YouTube and my new Podcast PCOS & “You”!
Be #strongerthanpcos !
Nidhi S.
PCOS Coach & Holistic Nutritionist
