Deborah Howell (Host): September marks Polycystic Ovary Syndrome, or PCOS Awareness Month; a time dedicated to shedding light on a condition that affects millions of women globally, yet remains often undiagnosed or misunderstood. Today, Dr. Jane Nani, Reproductive Endocrinologist and Medical Director of Third Party Reproduction at FCI, joins the podcast to unravel the mysteries behind PCOS, exploring its root causes and how it impacts fertility. This is the Time to Talk Fertility Podcast. I'm your host, Deborah Howell. Welcome, Dr. Nani.

Jane Nani, MD: Well, thank you for having me. And I'm pleased to be able to speak with you today about polycystic ovary syndrome and its relationship to fertility issues.

Host: And we are pleased to have you. So let's dive right in. What is PCOS?

Jane Nani, MD: Well, it stands for polycystic ovarian syndrome. It happens to be really the most common endocrinopathy in women of the reproductive age. So we do see quite a bit of it in our practice. And most commonly it's associated with women who are infertile because they do not have normal ovulatory cycles.

Host: Got it. And how common is it?

Jane Nani, MD: Oh, it's really up to about 20 percent of the reproductive age women, but worldwide, maybe it's lower. You know, we think about it in the United States, perhaps as women get heavier, they can even develop these kinds of symptoms. So maybe somewhere close to 10 percent worldwide.

Host: That's quite common. So what are the symptoms of PCOS?

Jane Nani, MD: It's really frequently associated, as I said, with irregular menses, so they don't ovulate spontaneously and therefore they don't get regular periods. It can also be associated with weight gain and obesity, and it can also be associated with unusual sort of male pattern hair growth. And not all women have all three of these things, but usually they have two out of three. Some women are more some inclined to complain about their periods being unusual, can't get pregnant. Some women are more bothered by too much male pattern hair growth and people are often bothered by their weight. So we see all of this in women.

Host: Sure. And it's never for underweight women. Is that correct or incorrect?

Jane Nani, MD: No, actually about a certain percentage of the PCOS women we refer to as lean or not obese. We still see patients that have this underlying cause of PCOS, but are not overweight. These are what we call the lean PCOS patients.

Host: Okay, Okay so it does span the spectrum.

How is PCOS diagnosed?

Jane Nani, MD: Well, it's usually diagnosed based on the history. So we say there are criteria for it and it comes down to the major studies and societies that have categorized it for us. So one of them was in 2003 called the Rotterdam Criteria. And we still use that quite a bit, but there was a more recent one called the Androgen Society.

All of them understand that you have to have some aspect of too much male hormone in the blood, and that's where we get these symptoms as well. So one of the major things we diagnose is too much androgen hormone. The other thing that is part of the diagnosis is a polycystic appearing ovary by ultrasound. And so we, this means that there's a lot of little cysts that we see on the ovaries. These are very, very commonly used to make the diagnosis.

Host: But it's not endometriosis.

Jane Nani, MD: No, not endometriosis, that's something different.

Host: How does PCOS affect fertility?

Jane Nani, MD: Well, primarily these women are non ovulatory, so they have a very hard time getting pregnant spontaneously. That's the major thing with polycystic ovaries. They don't, they fail to ovulate. We do think that there could be other things associated with PCOS as in any fertile couple, like for instance, it could be a male factor, but in general with the female, it's a lack of normal ovulatory cycling.

Deborah Howell (Host): And so I'm curious, how does PCOS impact the quality of a woman's eggs over time?

Jane Nani, MD: Well, just as all women experience some decrease in fertility with aging, this also happens in the women with polycystic ovary syndrome. However, they might be a bit more delayed than the average woman because they start out with a larger reserve. So this can be, in a way a benefit. We sometimes see that they have an increased number of eggs that still exist even as they get into their late 30s and early 40s.

So they may retain some of it, but still qualitatively, it's best even for polycystic ovarian ladies to get pregnant when they're less than 35 years old.

Host: Okay, got it. I'm very curious, I'm always looking for something helpful. Are there any emerging treatments for PCOS that show promise in improving fertility?

Jane Nani, MD: Interesting. We now have a lot of different medications and even, uh, surgeries that we can do to help women who are really, really heavy. And some of them are quite obese. And we know that even with weight loss, some of these will start to have normal ovatory cycles. So it's always a benefit, particularly if PCOS ladies are overweight or very, very overweight to do whatever they can to lose weight. And so sometimes, especially younger people, they may go through bariatric surgery to lose weight. And now we have these medicines that are called the semaglutides and they come in the form of Ozempic or Wegovy. And some women have had success with those just to lose weight. However, we don't want them to get pregnant while they're on the medicines.

Host: I see.

Jane Nani, MD: And certainly lifestyle modifications, diet and exercise, weight loss, all of that is a benefit in terms of their fertility for women with PCOS and obesity.

Host: Let's drill down a little bit on that. How do lifestyle changes specifically affect the reproductive aspects of PCOS?

Jane Nani, MD: Well exactly. We think that certainly when women get pregnant, we want that baby to be healthy. So it's always recommended that they get into a relatively normal body mass index. So we say that's less than 30 ideally. They don't all manage to get that, but not significantly higher than 30.

And the way to do that is by modifying diet and increasing physical activity, non smoking. We also think about this idea of some of the symptoms are due to what we think of as chronic inflammation in PCOS. And so those women can adopt what we think of as an anti-inflammatory diet. This is usually the diets that are rich in antioxidants. So that kind of thing is always recommended in women with PCOS.

Host: So that's about the lifestyle, and we appreciate your answer, but are there environmental factors that contribute in exacerbating or alleviating PCOS symptoms?

Jane Nani, MD: The major thing I think in the environment is just the exposure to let's say secondhand smoke, it depends on the lady's environment, but to avoid any, any of those outside, what we think of as inflammatory reactants that can exacerbate the symptoms of PCOS.

Host: And how does PCOS influence the success of assisted reproductive technologies like IUI and IVF?

Jane Nani, MD: Yeah, it's true. They start out with a lot of potential eggs there, so we often have trouble, we can have trouble with when we start to stimulate the ovaries that they are too robust in their stimulation. So, particularly with IUI, they are at risk of twinning as compared to the normal person when you do a stimulation.

So they can be at risk of a twin gestation as opposed to a singleton that is not normally in their background, for example. And when they do IVF, they can end up with a very robust number of eggs and sometimes they can get what we call hyperstimulation syndrome and the polycystic ovary patients are more at risk with that than the normal person would be.

Host: And how does PCOS affect the endometrial lining and its receptivity to embryo implantation?

Jane Nani, MD: So again, if they're not ovulating, we know the lining can get very, very thick and not be what we think of as receptive to implantation. In fact, sometimes we see that if there was a chronic months or years where they're not ovulating, they can get what we think of as unopposed estrogen influence at the uterine lining and run the risk of things such as hyperplasia that needs to be treated.

And certainly with a very, very thick lining, that's a negative in terms of embryo implantation.

Host: Okay. And this is getting into the weeds a little bit, but I'm curious, how do androgens in PCOS specifically impact ovarian function and ovulation?

Jane Nani, MD: Yeah. So the high androgens is one of the hallmarks in the diagnosis. So yeah, in particular, the high androgens can lead to what we think of as metabolic syndrome. And this has, not all the girls will have metabolic syndrome. This speaks to those who have what we think of as insulin resistance and things like that.

And that's particularly brought on by the high androgens. The high androgens also lead to what we said earlier, chronic anovulation, and they can have unusual hair growth. So it really does lead to a constellation of these symptoms, primarily due through these high androgens.

Host: Now you mentioned inflammation earlier. Can chronic inflammation associated with PCOS influence reproductive outcomes?

Jane Nani, MD: Yes, we think it's a negative in terms of reproductive potential. In fact, we do a lot of evaluation for women who are failing to get pregnant by looking at the inflammatory reactants that sometimes exist at the level of the uterine lining. So we do that and we tend to like to put them on, particularly with aging in particular, these women, with antioxidant therapy, things like coenzyme Q10, which is commonly available as a dietary supplement, things like that are an aid to kind of combat the chronic inflammation that we often see with PCOS.

Host: Okay. Final question for you, Doctor. How does PCOS affect menstrual cycle tracking and fertility awareness methods for conception?

Jane Nani, MD: It's very, very difficult because they don't always ovulate. And one of the things that we see often is they have, something called the high LH to FSH ratio. When they do these ovulation kits, they think they're surging all the time, you know, so, those are very hard to use those kits to track them. In general, because they're not ovulatory, they never see a peak they can see chronically never peaking, they tend not to peak. And so they get frustrated with that. They really do.

Host: Tricky business.

Jane Nani, MD: Yeah.

Host: Are there any words of hope you can share with anyone with PCOS who's struggling to conceive?

Jane Nani, MD: I would say that there are more therapies than there have ever been in terms of trying to combat the symptoms in particular. So more than ever before, our understanding has increased too. So I think we tend to direct it to more individual, to the person who's maybe not so much struggling with infertility, but maybe unusual hair growth or weight.

So there are a lot more, I think, potential therapies than we've ever had. So it's always the best interest of individuals who struggle with this to be seen and, see what kind of treatment seems best suited.

Host: Absolutely. Well, thank you so much, Dr. Nani, for the great information and for being with us today.

Jane Nani, MD: It's lovely to be with you and I appreciate the opportunity. Thank you.

Host: That was Dr. Jane Nani, a Reproductive Endocrinologist with FCI. To find out more about the services FCI provides for patients, call 877-324-4483 or visit fcionline.com to schedule a consultation. And if you enjoyed this podcast, you can find more like it in our podcast library, and be sure to give us a like and a follow if you do.

This has been the Time to Talk Fertility Podcast. I'm your host, Deborah Howell. Have yourself a great day.