Wednesday, December 17, 2014

How PCOD can fool the gynecologist

I often see patients who have PCOD who have not been diagnosed properly. Typically, the textbook describes PCOD patients as being obese; hirsute; and having irregular cycles. However, not every patient with PCOD has all these classical symptoms. Many patients with PCOD are lean; and have regular cycles, which means many gynecologists and GPs don’t even think of the diagnosis when they see them. We all know that the eye only sees what the mind knows.

These patients then end up getting poor medical care, as a result of which their chances of getting pregnant go down considerably .

Thus, these patients are often mis-labelled as having unexplained infertility, which is a convenient waste paper basket diagnosis to lump all patients who don’t fit any other convenient diagnostic bucket. These patients are then often advised to do IVF. However, when the doctor starts the superovulation with the standard dose of FSH injections , the patient grows too many follicles. The doctor then gets flustered,  because this is not something which he anticipated ; and because doctors are so scared of the complication of ovarian hyperstimulation , they cut down the dose of HMG. They end up “coasting”  these patients, and the trouble with this is that these patients end up getting poor quality eggs because of the lack of appropriate FSH stimulation.

Because the eggs are of poor quality, the number and quality of embryos also drops considerably. Even though these patients grow lots of follicles , and the doctor is able to collect lots of eggs , the doctor then blames “poor egg quality” as the reason for the unexplained infertility, and advises the patient she needs to do donor egg IVF ! Remember that patients with poor ovarian reserve who have poor quality eggs will usually grow only a few follicles – quantity and quality usually go hand in hand.

This is why it’s so important for patients to become well-informed, so that they can discuss the possibility of their having occult PCOD with the doctor when they find they are growing lots of follicles during superovulation.

It’s easy to confirm the right diagnosis once the doctor thinks of the possibility. The tests requires are quite simple – an AMH blood test ( the AMH level is elevated in these women); and an increased antral follicle count.

Once the right diagnosis has been made , the chances of getting pregnant are very high, because these patients have high ovarian reserve, and can grow lots of good-quality eggs and make high quality embryos when they are superovulated properly.

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