“When we do an ultrasound of a woman’s ovaries and a string of 10 or more pearl-like cysts are visible just below the perimeter lining of either or both ovaries, then we need to start investigating for Polycystic Ovary Syndrome or PCOS,” says reproductive specialist Dr Stephan Volschenk, who has treated a significant number of women with PCOS who could not fall pregnant.
The string of 10 or more cysts, each measuring less than 10mm in diameter, is often a clear indication of PCOS, he explains from his consulting rooms in the Vitalab Centre for Assisted Conception in Sandton. He stresses “10 or more” because less than 10 is regarded as normal.
“About 20 percent of women have polycystic ovaries with up to 10 of the same pearl-like cysts, but this isn’t cause for alarm, provided their ovaries function normally and they do not have PCOS. It is only when the numbers exceed 10 that PCOS becomes a possiblilty.”
How does PCOS prevent conception? Volschenk says sufferers never know if and when they ovulate; some of the eggs produced are of inferior quality; and, due to the hormonal imbalance, the lining of the uterus is not always receptive to the embryo.
PCOS affects an estimated 10-12 percent of women and is one of the leading causes of infertility, as Eve Godden, 31, a teacher in Johannesburg, discovered. Her case is typical of women with PCOS.
“My menstrual cycle was normal from the age of 13, but from about age 18 this changed and I would cycle once a year or less. It didn’t worry me for a couple of years. In fact, it was quite nice to be young and free and not to have a monthly cycle,” Godden recalls.
A regular cycle is “clockwork 28 days,” Volschenk says. “In some women it ranges between 27 and 29 days but when it goes past 35 days, this indicates a possible problem.” Godden was not at all concerned about her cycle until her early twenties when she decided to see a doctor. “She told me it might be PCOS but not to worry about it until I was ready to have children. She put me on the contraceptive pill and my cycle normalised,” she explains.
“In my mid-twenties I decided to get a second opinion from a gynaecologist, which I did. He said I had a ‘small hormonal problem’ but that there was nothing to worry about. He advised me to stay on the pill and to lose a bit of weight – I was about 15kg overweight at the time. He was so blasé about it all that I believed there was nothing to worry about.”
The “small hormonal problem” to which he referred was above average hair growth on her arms and legs. This did not overly concern Godden because most of the women in her family have a similar type of hair growth.
“Hair growth on the body in places associated with masculinity, such as on the upper lip, below the belly button, on the face, between the breasts or, as in Eve’s case, a heavier-than-usual growth on her arms and legs, is a common PCOS symptom,” Volschenk explains. This and baldness in women indicates an excess of male hormone activity, notably testosterone, which some women have from an early age and others suddenly develop.
An excess of male hormone activity, together with the presence of the “string of pearls”, acne and weight problems are four key PCOS symptoms. Women who have three of the four may diagnose positive for PCOS.
“It’s diagnosis by exclusion,” Volschenk continues. “We first make sure the patient is not showing positive for three specific disorders with similar symptoms, namely Congenital Adrenal Hyperplasia, Cushings Syndrome (a disorder of the adrenal glands) and androgen-secreting tumours.
“Once these have been excluded (through blood tests and a clinical examination), we can start narrowing down the diagnosis to PCOS.”
Godden was 29 years old when she got married and wanted to start a family. “I knew it was going to be a bit of a challenge when I came off the contraceptive pill but my gynae gave me Clomid to stimulate ovulation and advised me to give it three months.”
Three months later she still had not cycled and decided to seek a third opinion. “I searched the internet for a fertility specialist and found Dr Volschenk. My husband and I went to see him and we both underwent various tests to identify the cause of the fertility problem. Within a week, Dr Volschenk diagnosed me with PCOS.
“Obviously it is not lucky to find out that you have PCOS and you feel hard done by and angry that you have it – the typical ‘Why me?’ response – but if he had not diagnosed it I would still be trying unsuccessfully to have children today.”
“We do not know exactly what causes PCOS,” Volschenk says. “We think there’s a genetic aspect to it and that environmental conditions can play a role – including what your mother ate or drank when she was pregnant with you, and whether she was overweight.
“What we do know is that women who are overweight and who have PCOS and cannot fall pregnant, significantly increase their chances of conceiving if they lose weight.”
Which is what Eve did. She lost 15kg in as many months by exercising three times a week at the gym and by committing to a low-fat, no refined-sugar lifestyle eating plan, put together for her by a dietician who specialises in PCOS, recommended by Volschenk.
“No more doughnuts for me – which I love,” Godden smiles. “The dietician worked out an eating and exercise plan for me. The eating plan is all about good, healthy eating, low-GI porridge (such as oats r All Bran), lots of vegetables and lean meat or fish. Snacks include a piece of fruit, a slice of low-GI bread or a small carton of yoghurt. Most of us know what healthy eating is all about; few of us practise it, but I had no choice.”
Volschenk also put Godden on an insulin sensitising drug called Metformin, and her cycle returned after a couple of months. “One of the underlying symptoms of PCOS is insulin resistance, which reduces the body’s ability to metabolise glucose which has an adverse effect on ovary function.
“If you don’t address this, apart from the pregnancy aspect, it can lead to diabetes,” explains Godden who says the past two years have proved a journey of discovery of her body.
“I took my body and how it works for granted until I was diagnosed with PCOS. From then on I had to start understanding my body to help heal it because the possibility of being infertile and of getting diabetes really scared me,” she says.
Volschenk emphasises that it is extremely important for women with PCOS to control their weight or to lose weight if they are overweight and then keep it down. “Women who are overweight have a higher tendency to develop glucose intolerance when they conceive,” he says.
Once Godden had lost the weight, she and her husband returned to Volschenk who started her In Vitro Fertilisation (IVF) treatment. “It’s R40 000 to R50 000 for a twoweek process and my husband and I had long discussions about whether I should have it. He has been really wonderful through all this, and he has kept positive whereas I have been through negative phases where I wondered if I would ever fall pregnant. We decided we would like a child and we would try to have one, knowing it might fail.”
Godden explains that eggs were harvested from her after two weeks and then combined with her husband’s sperm in the fertility laboratory to fertilise them. Fertilised eggs were then returned to her womb after about three days and two weeks later she was confirmed pregnant.
“I was really fortunate. Things can go wrong every step of the journey and it was a really tense time,” she recalls. “Dr Volschenk was wonderful. He was really there for us, he took the time to explain everything and support us through the whole process. He was visibly happy for us when I fell pregnant.”
At the age of 31 Godden is now four months’ pregnant.
“This morning I was lying in the bath and the baby kicked for the first time – I could see literally saw him or her kick – and it suddenly became real for me that I am pregnant. I’m really starting to get excited now and wondering whether we will have a boy or a girl. I am so grateful to be pregnant after all we’ve been through.”
Volschenk says that women with PCOS who want to fall pregnant need “perseverance, patience and not to lose hope”. The PCOS group of women is one of the most difficult categories where pregnancy is concerned. “However there is good news. With treatment and following our lifestyle and weight control plan, most fall pregnant within nine to 12 months no matter how bad their PCOS might be.”