Articles of Interest


PCOS - what is it? How does it impact fertility? Why was I diagnosed so late in life? What would a PCOS diagnosis mean for fertility treatment?

PCOS was first described in the 1930’s, which is why this name is so confusing for us today. The physicians who were describing PCOS were looking under the microscope at ovaries from women with a clustering of symptoms of obesity, very few menstrual cycles, and hair growing where they did not want it. These physicians had no understanding about the hormones that were causing these changes in the ovaries and they mistakenly thought it was the ovaries that were abnormal.

PCOS is an abbreviation for poly-cystic ovarian syndrome. There are, however, no true “cysts” in the ovaries at all. The many small areas in the ovaries that we see on ultrasound are not cysts but “follicles”. Follicles are the areas in the ovaries where there are eggs. Women with PCOS recruit many small follicles containing eggs to start growing and then they get stuck before they mature and can release an egg. This is called anovulation. In most women, the reason that these follicles stop growing is due to the presence in the ovary of too much androgen hormone. In most women, the abnormal production of androgens is caused by increased amounts of insulin, a condition known as insulin resistance. Insulin resistance leads to many things women commonly experience in addition to the anovulation and missed periods. Insulin resistance can lead to obesity. When you have insulin resistance, your body’s metabolism is always in storage mode, making it easy to gain weight but very hard to lose weight! Insulin resistance is the most commonly inherited hormonal abnormality. Many women with insulin resistance have family members with weight problems and some with diabetes. The insulin resistance gene is turned on or off depending on many factors some of which are our determined by our lifestyle. Many women are diagnosed with PCOS later in life when they are less physically active and may have gained weight. More sustained physical activity will turn the gene off. The amount of processed sugar in our diet can turn the insulin resistance gene on or off. As we eat more processed sugar, our insulin levels increase.

Women with PCOS do not ovulate monthly making it much harder to get pregnant. Fertility treatments for PCOS will focus on getting the women to ovulate each month. The best way to bring about ovulation will vary from woman to woman and may change throughout the course of a women’s treatment.

For all women with PCOS it is very important to have a healthy lifestyle. This lifestyle should include 30 to 45 minutes of sustained exercise that elevates your heart rate daily. It should also include a well balanced diet full of unprocessed foods like lean meats, dairy, nuts, fruits and vegetables.

Lynda Wolf, M.D.

Varicocele: Surgical Repair vs. ICSI

Varicocele is an abnormal swelling of veins in the scrotum that drain the venous blood away from the testicle. It may result in painful sensation or heaviness, and may even lead to diminished reproductive capacity or infertility in men.

A large number of small veins from the back of the testis form a network of blood vessels known as pampiniform plexus. The individual veins of this network normally range in diameter from 0.5-1.5 mm. An increase of more than 2.0mm in diameter is considered clinically significant and warrants doctor’s attention. The function of this venous network is twofold: First, it helps in return of blood from the testis and the scrotum to the heart to ensure constant circulation, and second, it helps to keep the testis at a slightly lower temperature (34°C) as compared to the rest of the body (37°C) since sperm production in the testis occurs at 34°C.

Under normal circumstances, the upward flow of blood from the testis towards the heart is ensured by the presence of small one-way valves in the veins of the pampiniform plexus. These valves prevent backflow of blood into the testicular veins. Any defects in these valves can cause dilatation of the veins, leading to the formation of a varicocele. This causes blood to pool around the testicle interfering with temperature regulation. Retention of blood in these veins can increase the local temperature. An increase in the scrotal or testicular temperature can interfere with the process of sperm production including a decrease in sperm numbers, decrease in sperm motility and defects in the shape of the sperm (sperm morphology). These defects singly or in combination may interfere with normal fertilization of woman’s eggs and prevent conception resulting in infertility.

Although varicocele can occur in pediatric patients, young adults between 15-25 years of age are at greater risk. Varicocele occurs most commonly on the left side, and may or may not cause any significant symptoms. These symptoms may include swelling and discomfort.

Whereas the prevalence of a varicocele in the general male population is about 15%, it is more common among infertile men (35% to 40%). Varicocele is not always associated with infertility; however when varicocele is suspected to be a cause of infertility surgical correction of the condition is the most commonly used approach. The objective of surgical repair is to prevent the backward flow of blood to the testis. When successful the repair can reverse at least some of the adverse effects on sperm production; however this may take up to 18 months.

The effectiveness of surgical correction of varicocele on male fertility is not always guaranteed especially with respect to sperm morphology. In addition, the advantages of surgical repair must be weighed against the complications associated with the procedure. These complications include failure of semen profile to return to normal, prolonged recovery time, and the recurrence of varicocele. Severe cases of uncorrected varicocele may result in permanent damage to sperm production ability of the testis.

The advent of assisted reproductive technologies, especially IVF with intracytoplasmic sperm injection (ICSI), have added alternative, and often more effective, tools in the treatment of infertility in these males. This is especially relevant when the sperm production in a male is compromised to begin with, or when the sperm production is not likely to return to optimal levels for normal conception after surgical repair.

The ICSI procedure involves insertion of a single sperm directly into the cytoplasm of an egg using a fine needle under a high resolution microscope. Thousands of pregnancies worldwide have been reported using this technique. The ICSI procedure can help achieve conception even when the sperm morphology is compromised.

Tariq Shah, PhD, HCLD, ELD
Reproductive Medicine Associates of Michigan

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