Get Pregnant With IVF: What PCOS Women Need To Know

Felice Gersh, MD

Welcome to the PCOS SOS summit. I’m your host, and actively skewering with me for this episode is my friend and very esteemed professor of medicine, Dr. Mark Trolice. He is the founder and director of the IVF Center in Orlando, Florida. Welcome, Mark. I’m so thrilled to have you join me. I can’t wait to hear all you have to say for this episode because, as we all know, PCOS is the number one cause of female infertility. And so many of them do have to resort to advanced reproductive technology, which you excel at. Tell us about yourself and how you became involved in this field. And then we’re going to do a deep dive into the reproductive issues and how every woman with PCOS can optimize her chances of having a successful pregnancy and, of course, conceive when she wishes. Give us an idea of how you got into this field.

Mark Trolice, MD, MBA, FACOG, FACS, FACE

Thanks. It’s wonderful to be with you and to see you again. It’s been too long. Thank you so much for the honor of the invitation. PCOS, as you eloquently described, is a devastating problem for women. And I was attracted to that probably 15 to 20 years ago when I saw the impact that this has. They suffer from a feeling of being out of control. Their friends are having regular periods. They have irregularities in general. And then there are the weight challenges and the metabolic problems. And of course, near and dear to my heart is the infertility aspect. And we see more than ten new patients a week with PCOS. As I developed this field research, I started writing more about it and met with the wonderful PCOS challenge people, Sasha Ottey, and William Patterson. And that’s how you and I got together by getting to know each other at these conferences. And it’s a niche. It’s a family of people who are dedicated to helping PCOS women. And when you go to these conferences that involve patients, it touches your heart because they tell you firsthand their story. And then you get involved in the energy and excess PCOS society, and you develop and continue to learn about PCOS. Much is written about that because we don’t know much about it. PCOS is probably not the right title for the syndrome because the ovary, which is the victim, is not the cause of this issue. But we can talk about the metabolic disturbances of PCOS, and I love the field. I love learning more and more about it, and I wish we could do more for patients, but it’s a challenging disease. And it is a disease.

Felice Gersh, MD

Well, it certainly is. And it is like an epidemic now. It is growing by leaps and bounds. And maybe you could tell our audience, like, what’s going on in women, as a general rule, who have PCOS that prevents them from easily getting pregnant? Why are they not eating what’s going on in them?

Mark Trolice, MD, MBA, FACOG, FACS, FACE

Perfect question. From eight to 13%, it’s estimated that women have PCOS. But I’ve seen studies of these that show up to 20%. Think about one in five women with PCOS. It’s not clear how it starts. It’s probably in utero when, when the woman was a baby inside mom and a fetus inside mom, some exposure to either androgen, which are the male hormones, or amh anti-malarial hormone seems to be the predisposing factor. Now there is the blocker hypothesis of stress on the fetus inside the mom, and that can cause some metabolic changes thereafter. As far as why women don’t ovulate, it’s a disconnect. The major access, as the health care providers that are viewing us, is the hypothalamic pituitary ovarian axis. And that all needs to be synchronized to be able to have a menstrual cycle. The menstrual cycle is a measure of a woman’s reproductive health. And when that’s a disturbance, something’s wrong that needs to be looked at further. With PCOS, the pituitary and the ovary are not communicating. There is a hypersensitivity to LH, which is from the pituitary to the ovary, so LH, combined with insulin, stimulates the ovary to produce a little bit too much male hormone. And that male hormone works in the microenvironment around the old way to block ovulation. Typically, when the patient is listening, the ovary is stimulated by the pituitary with these hormones. FSH agent LH is obviously in the top center; the hypothalamus is producing what’s called GnRH, and there is that hypersensitivity of LH to GnRH that is then increased, and the increase of LH causes the increase of male hormone. Interestingly, women trying to conceive with PCOS and infertility patients who are using an over-the-counter ovulation predictor kit are testing their urine for when they’re going to ovulate, and when they’re going to ovulate, there is a surge in the pituitary LH. 

Well, in PCOS, that LH is a little bit higher, so they get false positive levels of elevations in LS that they think they’re operating, but they’re not. The lack of ovulation has reverberating effects like increasing estrogen—not increasing it, but too much exposure to estrogen without the protection of an ovulating hormone called progesterone. With too much estrogen, the lining of the uterus gets built up. It’s not that the estrogen levels are high because they are continually bombarding the lining of the uterus, which they’re supposed to do, but a normal cycling woman should be getting progesterone every month while preparing for pregnancy. And if you’re not pregnant, those hormones go down, and you have a period. Well, I tell my patients, think about when you put a hose in a pool and forget to turn the hose off; the pool overflows. The bleeding from PCOS is overflow bleeding from estrogen, and estrogen unopposed without progesterone increases pre-cancer risk. These patients with too much estrogen and not enough progesterone have a 2.7 times higher risk of endometrial cancer, which is the lining of the uterus. These patients are at risk of reproductive problems. Remember, I talked earlier about a little bit of too much male hormone? Well, that causes the hair growth. And cosmetically disturbing and psychologically disturbing in the male pattern areas. They could have hair loss; they could have an upper lip, chin sideburns, a neck, a chest around the breast, a lower belly, a lower back, and an upper inner thigh. These are coarse hairs—not the normal soft hairs called Bella’s hairs—but these are terminal hairs. And what women have to realize is that you’re not growing new hair; the elevated male hormone, testosterone, is getting converted in the body with an enzyme called 5-alpha reductase to dihydrotestosterone, or DHT. So DHT stimulates the hair follicle in the dermal papilla to turn dark. They’re not growing new hair. Everybody is born with the same number of hair follicles. But in the male pattern areas, this DHT turns that hair dark; once it gets dark for these, it doesn’t go back. The only way to get rid of that is through electrolysis or a laser. But I encourage women not to go to these centers to get these hairs removed unless they stop that conversion. And the way you stop the conversion is with birth control pills or 5-alpha reductase inhibitors like finasteride. We have a lot of work to do. We have to stop the conversion, and then you can go get the electrolysis or razor. Otherwise, you’ll be in and out of the office all the time getting the hair removed because you’re not stopping the conversion. 

So that’s the reproductive issues now, but the metabolic issues—well, there is a syndrome called the metabolic syndrome. And PCOS women are at a two to four times higher risk of having that problem. What’s the metabolic syndrome? What’s the collection of five diseases that hang around together? And if you have three out of the five, you have metabolic syndrome. What is it? Abnormally low HDL cholesterol, which is the good cholesterol, which is less than 50. Elevated triglycerides—more than 150, elevated blood pressure—but above 100 over 80 is considered prehypertensive, 130 over 85 or so if you get into it. Then you also have diabetes and elevated blood sugar, as well as a waist circumference of more than 35 inches for women. Three out of those five are going to get metabolic syndrome. They also have sleep apnea issues, particularly those who are overweight. They have anxiety and depression—something about being overweight. It is a misconception that for PCOS women, you have to be overweight to have PCOS when the obesity of PCOS matches the general population of obesity. It’s not higher. About half of the patients with PCOS are overweight, and the other half are thin. It is important to know that patients with PCOS have a lower risk. A lower chance of losing weight, in other words, is more challenging. That means they can’t, but it is just more difficult to do that, presumably because of the metabolic disturbances. But they can, and they must do, because being overweight not only worsens all these metabolic issues but also challenges fertility more. That’s a lot of stuff on PCOS.

Felice Gersh, MD

It is. And you have to look at the total status, the health status, the metabolic and emotional state—every single aspect of a woman when she comes in to see you—which is so important because it sounds like you can’t just see a woman who says, I’ve been trying to get pregnant for two years. I have periods where no one knows who they are, like you said; this doesn’t mean they have ovulated. It’s just dysfunctional uterine bleeding because they have unopposed estrogen, and it just gets too thick in the lining. It just falls out. We don’t even know what that bleeding is. But they bleed every few months. It’s irregular. They can’t get pregnant. They show up in your office, and they’re sitting in front of you, and then you find out all these things: they have metabolic syndrome, they have all the androgen excess symptoms, and so on. Where do you start? You have this woman who will now say she’s 30, and she can’t get pregnant. Where do you start with a woman like that? I bet this is not uncommon for you to see just that type of patient.

Mark Trolice, MD, MBA, FACOG, FACS, FACE

For women with PCOS, the bleeding is chaotic. They could bleed every few months, once or twice a year, never, or every day. They present with hemorrhage and anemia, sometimes life-threatening, and talking about the metabolic issue at the recent Endocrine Society meeting, it showed that the risk of cardiovascular disease, cancer, and diabetes is almost 50% in PCOS women. Let’s talk about: first of all, how do you make the diagnosis? The most common one was the consensus conference in Rotterdam in 2003. Two out of three of these issues make the diagnosis. some measure of ovulation dysfunction, what’s considered normal measure intervals? Well, between 21 and 35 days apart. But even if they’re within 21 to 35 days, if they’re 22, then 34, then 23, that’s irregular. Typically, regular cycles are what’s called a normal irregularity. It’s also important to realize that 20% of women who have regular menstrual intervals may not be ovulating with PCOS. So just because your periods are regular doesn’t mean you’re ovulating. I had a patient or a doctor’s wife who’d had regular cycles, and we tested. I said you had PCOS. She was not ovulating, and we did ovarian drilling, which is a surgery to try to induce ovulation with electrocautery. And she started ovulating after that. We are doing a study shortly on the vaginal approach to ovarian drilling through a company called Mahle. For those of you interested, reach out to us at ivfcenter.com, and we’ll give you more information about that. two out of three criteria: ovulation dysfunction. Second, some measures of elevated male hormone causes hyperandrogenemia. 

Either their testosterone is elevated, or sometimes DHEA, which is a weaker male hormone from the adrenal gland, or they have hair growth. The hair growth needs to be clinically significant. And that we use is a score called Ferriman-Gallway. For the providers that are watching, a score of eight or more would be clinically significant excess terminal hair called hirsutism: For testosterone, we usually get a ton of testosterone because free testosterone is a difficult assay; you need liquid chromatography, which isn’t often available in laboratories, so you can get a free antigen index. That’s where you have your total testosterone divided by sex hormone-binding globulin, and it’s in the units of nanomoles per liter. A little bit more difficult to calculate, but needless to say, that’s another way to do that. The third is the ultrasound appearance of the ovary. Here’s where it gets a little bit funny or fuzzy. Rotterdam in 2003 said there were more than 12 little, tiny cysts called prehensile follicles. The intrafollicles are rather two to nine. Mm. If you had 12 or more in one ovary, that would be considered PCOS. Now the antigen excess society, PCOS, is saying more than 25, and a more recent endocrine meeting was saying more than 20. I’m using more than 20 now in one ovary, but what is consistent with all those different societies is the ovarian volume being ten centimeters cubed or more. Ten centimeters cubed or more would be a polycystic ovary. When a patient comes to see me, it’s for infertility, but it’s also something that they would be dealing with; say, my hormones are out of whack. The way that we address this is that we look at the metabolic problems and the menstrual interval. If they are anemic from abnormal bleeding, we need to address that. And the best way to do that is to take the birth control pill. The birth control pill that regulates the hormones may make it easier for them to ovulate after being on the birth control pill, but it can also help restore hormonal balance. The estrogen the birth control pill and the progesterone inhibit LH to some degree, so reducing male hormone protects the lining of the uterus, and estrogen will also help increase sex hormone-binding globulin and lower the amount of free circulating male hormone. Birth control is good if hair growth is an issue. We talked about the anti-male hormones of spironolactone and finasteride, but I also get that, particularly in overweight PCOS patients, we check their blood sugar and look at that metabolic syndrome. We look at the lipid profile for HDL cholesterol and triglycerides. We do a two-hour glucose tolerance test for diabetes or pre-diabetes. Look at their blood pressure and lifestyle management for elevated body mass index; the Mediterranean diet is a very effective health diet. 

But we follow the guidelines of the American Heart Association. You have to get out there. You’ve got to exercise right for everybody. But particularly the overweight PCOS patients, cardio for at least 30 minutes to get into the fat-burning zone five days a week. The target zone is at least five days a week. But what’s also important for PCOS patients is two days a week of strength training. Muscle strength training increases insulin sensitivity and can help those patients, particularly those with pre-diabetes and those also getting into diabetes. We work with patients to understand what their goal is. If pregnancy is not immediately desired and we do an awful lot of lifestyle management, we try to do that with everybody. But when patients come to a specialist like myself, they don’t want to spend a lot of time on lifestyle management. They want to get pregnant right away. PCOS patients have similar cumulative pregnancy rates as non-PCOS patients, but PCOS patient does have more challenges to get to that point.

Felice Gersh, MD

Yeah, I was going to ask you because they have so many metabolic issues, and then they show up, and maybe they’ve had no lifestyle education. They’re eating the standard American diet, they’re watching TV, and they’re barely moving. They’re achy every time they try to start doing exercise programs. and then they show up, and it’s like, I want a baby. I want to get pregnant right away. Do you say, Wait a minute, let’s take a couple of steps back? We need to prepare you. We need this pre-conceptual health to be worked on, and let’s do some lifestyle medicine for a few months. Or do you say, Well, okay, let’s just start ovulation-inducing drugs? Or, like, how do you handle those women who aren’t healthy but yet want to conceive?

Mark Trolice, MD, MBA, FACOG, FACS, FACE

Well, that’s a salient question. It’s a million-dollar question: What do we do with a patient who is desperate for a baby but has some red flags? Physicians are teachers. We want to provide them with informed consent. We let them know the risks. When the risks outweigh the benefits, we need to take time out. A new onset of diabetes, an increased risk of birth defects, a baby without control, blood sugar control—that would be a time out. That’s a hard stop. Hypertensive without control, with an increasing risk of pre-eclampsia in pregnancy, would be a hard stop. Body mass index, huge sensitivity issues of body shaming, and paces have a difficult time talking about that. We know that a high BMI increases the risk of pregnancy complications, miscarriage, diabetes in pregnancy, and birth defects. All we can do is counsel. The success rates in pregnancy are not as dramatic based on body weight, but the complications in pregnancy are the elevated body weight. We had them see a high-risk obstetrician to go into more detail. If they have difficulty with the delay of wanting to lose, we do talk about lifestyle management. We even talk about bariatric surgery to help them lose weight if they feel they have done everything. We do bring that up. Addressing the health problems of all of our patients is vital before pregnancy. Because what I say is out of the frying pan and into the fire. If you avoid the problems going into a pregnancy, well, then the pregnancy is just going to be worse. You’re dealing with a fetus that’s going to be a baby, and you want to do everything possible to reduce complications for that baby. It’s a lot of education if you don’t have the time to educate a PCOS patient about their problem. The more they know about their problem, the more compliant they will be. But if you don’t have that time, just refer right away. It’s not fair to the patient or you to give a capsule Reader’s Digest version if you will. It takes a lot of time for these patients to understand their problem, the why, and the significant impact on their reproductive health and babies.

Felice Gersh, MD

That sounds like great advice. And I’ve heard that even losing, say, 5% of your body weight can help you be more successful with ovulation induction and the medications that you give. This is not such a trendy thing now. Do you try to help women maybe for three months to try to get some weight down, like 5% to help, with a higher success rate, whether they do IVF or they’re using one of the ovulation induction protocols? And are you using the new, trendy medication, the GLP-1 agonist? Because I’m sure everyone wants to know, is this for me? Is this going to help me? Will this help me achieve a pregnancy more readily? What’s your experience, and what do you suggest?

Mark Trolice, MD, MBA, FACOG, FACS, FACE

We encourage health before pregnancy. It’s not easy. By the time they get to see a report, the specialist has tried. They’ve probably gone through their primary care physician. Then they are with you, and then they get to see me. And if I say, well, if we lose a little bit of weight, that’s hard. They’ve gone through a lot already. I encourage the gatekeepers who are watching this interview. You all need to be the ones to address these on the first visit. Whether they’re trying to conceive or not, when they’re talking about trying to conceive, that needs to be reinforced by the time they come to see me, which is not the time to identify that this needs to be addressed. It’s very hard for them as far as the weight loss medication or the medications that are out there; we do not prescribe them, but we have had patients use them. It’s recommended to wait about six to eight weeks or so before trying to conceive and getting that medication to clear out of the system. Anything that’s going to work as long as there isn’t a risk to the patient that exceeds the benefit we encourage them to do. But the tried and true is moving by getting movement multiple times throughout the day. The tips for weight loss, small and frequent meals, or intermittent fasting are gaining tremendous benefits that we read about in the medical literature and their effectiveness. Not eating for two hours before you go to bed. No eating after dinner, walking, eating slowly, or so that your feedback from your stomach is due to the brain saying that you’re full faster than your eyes. And then, of course, the good things about a Mediterranean diet: nuts, legumes, berries, fruits, vegetables, olive oil solids, omega-3 fatty acids, all those kinds of things. It’s a commitment. If you think you can, you can. If you think you can’t, you won’t. And yet, I empathize with the struggle. It’s a real challenge for people. Weight is a big challenge for non-PCOS patients. It’s affected us all, and we just don’t have a great handle. You have to adjust to what the patient’s capabilities are. We could say, Okay, go to the gym five days a week. That may not do it for them, or they don’t want to go to the gym because they feel uncomfortable around others. Given that there are newbies, as it were, the physician needs to work with the patient to adjust it accordingly. Personalized. It’s not a cookie cutter; one size fits all.

Felice Gersh, MD

Well, I love that you take such a personalized, individualized approach to every patient because, yes, they all have their unique backgrounds, goals, and such. And in terms of that, now you’re going to move forward, full steam ahead, to get this woman pregnant. Maybe you could tell the audience a little bit about, well, what kind of drugs do you use to help them ovulate? Because this is a big barrier to successful conception if you’re not ovulating. What can you do as a specialist in this field to help them get a healthy egg out so it can become fertilized? And what if you use the specialized protocols to help them ovulate? Well, what is the success rate in general for PCOS women? And if it doesn’t work, what do you do next? How do you decide when and if they should try IVF? Maybe you can delve a little bit more into your specialty and how you handle these women who are actively trying to conceive.

Mark Trolice, MD, MBA, FACOG, FACS, FACE

Great question, Felice. Thank you. But ovulation is vital. The three most important factors in fertility are ovulation, sperm, and open fallopian tubes. With an ovulation function that affects 40% of infertility patients, clomiphene citrate has been tried and true for decades. It’s a selective estrogen receptor modulator. It internalizes estrogen receptors in the pituitary. But several years ago, the manager of medicine, Dr. Largo, at Penn State, showed that Letrozole was effective after five months of treatment. Letrozole, which is an aromatase inhibitor, sort of tricks the brain as well. But it blocks the conversion of androgens to estrogens, testosterone, estradiol, and androstenedione to estrone, and it increases stimulation in the ovary. Letrozole was superior to clomiphene citrate overall, but when they stratified it by body mass index, it was for women with a body mass index above 30. There was a difference. But we still give lectures to all the PCOS patients. Based on their successful ovulation, we’ll give them Letrozole for five days. Then we do ultrasound monitoring because of the false positives that they can get from the urine. If there is no response several weeks later, then we’ll check the progesterone level. If they haven’t ovulated, we just increase the dose. Then they don’t have to have a withdrawal bleed where they have a period and start all over again. That just delays things. When we reach the maximum dose of Letrozole, which is 7.5 milligrams, we’ll back off and add clomiphene citrate to that because it’s been shown that the combination is superior in patients with a body mass index above 30. The American Society of Medicine does feel metformin may be of help. Metformin is a diabetic medication. We give it to all of our patients with prediabetes. But for those without prediabetes and a BMI above 30, there may be a benefit. It is debatable whether there is any improvement in the live birth rate. With metformin alone, it hasn’t been shown, but it might help. In terms of ovulation function, it seems like there is some regulation of the menstrual cycle. The addition, if that’s not helpful, of injectable medication called gonadotropin and gonadotropin inside the FSH gene knowledge of the pituitary gland means that injectable form medicine is more costly, certainly more powerful, more successful in reducing ovulation, but also more likely to end up on Oprah with multiple births. We had to be very careful about monitoring patients for that. It does get more costly as well because there are more frequent ultrasounds, more blood work to monitor, and more costs. Also, the medications are more expensive. 

Rather than that, I favor either ovarian drilling or IVF. Ovarian drilling has traditionally been called laparoscopy. It’s a one-day surgery where a woman is asleep in the operating room. We put a telescope through the belly button and fill her belly up with gas, and then, with a laparoscope and cautery, we drill holes in the ovary. Two-thirds of our patients, when we presented at the American Society of Medicine meeting, ovulated, and half of them got pregnant. About one-third of those who go for the surgery will have a baby. We had a patient who had five children with one ovarian drilling. She kept ovulating and having children. We’re doing that study with May Health that’ll be coming up soon, where we’re going to be doing it vaginally in the office under sedation, sort of like a negligible, to see if it gets the same effect. As I said, please contact us at ivfcenter.com for more information. IVF is certainly a successful option for PCOS patients. We could reduce it a little bit, but certainly not a lot. However, for a lot of IVF centers, including our office-based surgery now in Florida, where I am, the office-based surgery guidelines by the Florida Board of Medicine prohibit giving sedation to women with a body mass index above 40. We are limited in being able to offer IVF to patients until they have a weight loss with a body mass index below 40. But it’s a very effective option and one that we have used very often.

Felice Gersh, MD

Well, that’s encouraging because I had read that of all the different types of infertility patients that you deal with with IVF, women with PCOS have the lowest success rate. that’s encouraging. You’re doing well. You’re getting quite a lot of these women pregnant with IVF.

Mark Trolice, MD, MBA, FACOG, FACS, FACE

Yeah, sure. IVF, of all the things in our reproduction specialist’s armamentarium, IVF has the highest per-cycle pregnancy rate. The advantage for PCOS women is that they have a lot of eggs. The more eggs, the more embryos; the more embryos, the greater the opportunity, particularly for the younger patient, to have chromosomal normal embryo implantation. IVF is certainly an option, but it is costly, and we offer tremendous financing options, even in-house financing, hopefully, insurance will cover it as well if they don’t have the financial ability. It’s a dialog. It comes down to a dialog with the patient. Not every patient wants to do one type of treatment or another. They certainly want a baby. But for a variety of reasons, maybe IVF is not for them, or maybe ovulation induction is not for them. They did not want to go, and they did that with their OB urine, and they wanted to get more aggressive. We’re educators. A physician just needs to provide objective data, and realistic expectations, certainly empathize, understand the challenge and the devastation, and then give them the facts so that they can be informed and make a proactive decision. And patients need to be their advocates. They have to be in a center where they feel engaged, where they feel the team has accountability and ownership of their problem and is not just treated like a number.

Felice Gersh, MD

Well, that’s great. It is very optimistic that women, even those who have been struggling for years, still have hope that that’s great. And I have read that many women who have PCOS have systemic inflammation. Inflammation kind of rules their bodies, including their follicles. in surrounding their eggs. And perhaps there are some supplements out there. People are using myo-inositol, some with tiny bits of D-chiro-inositol, N-acetyl cysteine, and antioxidants. Do you see the role, if any, of using over-the-counter supplementation either before going into, like, trying more advanced reproductive technologies that you utilize or in conjunction with them?

Mark Trolice, MD, MBA, FACOG, FACS, FACE

Excellent question again, Felice. Years ago, the medical endocrinologist at Brilliant Medical Technologies, John Nestler, discovered the metformin effect on PCOS patients. He realized that when he gave them metformin for prediabetes and diabetes, they were calling him with pregnancies. And so I called him to tell me about metformin and what we could do. He has published a lot on that, and he said there is no absolute perfect test for a measure of insulin resistance. I do the two-hour most tolerance test; the instant clamp test is much more involved and a little bit risky. He said all patients with PCOS have some measure of insulin resistance, and we don’t know how to define that. He was a big fan of the great article about D-chiro-inositol, a national substance, and that’s fine. I don’t think you need metformin and D-chiro-inositol. But we don’t give D-chiro-inositol to everybody, and avasitol and myo-inositol are all the same substance that’s included, so that’s fine over the counter. I can’t speak to the definitive impact of systemic inflammation if you will. That’s not my area. And I look at the end goal, and ovulation is ovulation. So if they’re coming with me for that purpose, then the goal is observation. And if we’re successful, I can’t say that information has any impact on pregnancy chances or embryo implantation. If that’s more of an effect on the metabolic syndrome, then I would leave that up to your specialty. Integrative medicines, talk more about patients for that.

Felice Gersh, MD

Great. And you also mentioned that sometimes you deal with egg freezing. Maybe you could address, for example, if you have a woman who has PCOS. Say she’s around 30, and she doesn’t have a partner, but she would love to have a baby someday. Do you recommend egg retrieval and egg freezing? At what point and what about that? In terms of women with PCOS, is there any specific data on the success rate in that group?

Mark Trolice, MD, MBA, FACOG, FACS, FACE

Yeah, I don’t. I don’t see any evidence that PCOS is any different from anybody else in terms of egg freezing, but egg freezing is still in its early stages. The American Society of Medicine changed the designation from experimental to standard in 2012, so it has dramatically increased the number of patients. Initially, we did it for cancer patients before they were undergoing toxic therapy, chemotherapy, or radiation. We get their eggs frozen because they could go into ovarian failure and never have the opportunity to have a child. The success rate of freezing is based on two factors: the number of mature eggs that we get and the age of the woman when she froze her eggs. I don’t think PCOS patients are much different. And in terms of what I recommend, it’s a personal decision. Every part of fertility is a physical, emotional, and financial investment. It is an insurance policy. But probably it is more of a psychological insurance policy to know that they have those eggs there. Because I tell them that, the caveats are that you may never use these eggs; you may get pregnant on your own with a partner. Or we use them, and you don’t get pregnant. You have to realize that it’s an investment, but it’s not a guarantee. You’re like an actual life insurance policy or something like that. But if a woman was the ideal age, according to a study on fertility, the cost-effective ideal age for egg freezing was around age 37. And why is that the case? Well, my theory is that below age 37, they’re probably going to get pregnant on their own. Above age 37, the success rates are going to be lower. That’s sort of the sweet spot. But the earlier you freeze your eggs, the more successful you’re going to be.

Felice Gersh, MD

Well, that’s great. I thought they were recommending it earlier, and that’s good to know. But just listening to everything you’ve said, it seems like if you’re a woman who plans to get pregnant, work with your primary care provider or find someone who will work with you to help you with lifestyle medicine to optimize your health so that you can optimize your ability to ovulate and so forth, and then conceive naturally, and then, if you’re not successful, find someone just like you or find you. Go to see you, and then get started on these more sophisticated approaches using letrozole, sometimes Clomid, and sometimes Metformin. Going into ovarian drilling and your study going through the vaginal approach seems so logical. It’s just like, you can go; you can access things right through there. I’ve done, I don’t know, thousands of hysterectomies vaginally. Why can’t you have a vaginal approach and make it simple for women? Your success rate is phenomenal. Yes, that’s so impressive. And then, if they have to go into IVF, you just go ahead and do it, and if that’s what you want, and you’ve individualized what you want, think through things like what you’re willing to do, what’s your budget, and how you pay for it. And finding the right team, like you, to help women be guided and also to do the job—the hard work to get them to become fertile when they were sub-fertile and achieve their goals to have that beautiful, healthy baby in their arms—it’s just that you must just have so much joy every day when women come back with their babies.

Mark Trolice, MD, MBA, FACOG, FACS, FACE

Well, yes. Somebody asked me, What’s the most rewarding part of my field? And I said, when I’m out of the office meeting a patient coming up to me and showing me her six-year-old, or they’re in high school, or the multiple children of the family, that gives you chills because you knew them as a little embryo. And to see that is remarkable. I’ll never forget the time that I was outside of a hospital and a patient came running to me to say that the child was her daughter. And it was remarkable. The daughter ran to me and hugged me, and the woman started crying, she said, “She’s never done that to anybody, and I’ve never told her about you.” It was just that I got chills just thinking about it.

Felice Gersh, MD

Saying the same, getting chills just picturing this beautiful, like, reunion, from the embryo to that little adorable child.

Mark Trolice, MD, MBA, FACOG, FACS, FACE

I’m a big advocate of health. I’ve been on a Mediterranean diet for years. Whether you’re PCOS or not busy, as a result, I know pre-conception health and general health are vital, so we all do three things. I tell my patients that we all do three things without thought. We don’t think about the weather or the time of the year; we all eat and sleep. And unless we hit the lottery, we all work. If you make four, if you make health number four without any option, you will be healthy. But if you say, “Well, the holidays and I put on a lot of weight or I was on vacation, oh my gosh, it was December.” Now that you’re not going to remain healthy, health has to be a part of your life. It’s not an option if you want to remain healthy. It’s not a hobby. Well, I do it sometimes; other times, it has to be a part of your life. And if that’s the case, you will be healthy. Once again, whether you think you can or whether you think you can’t, you’re right. And I encourage everybody to embrace health because it gives you tremendous energy and reduces your risk of a difficult life when you’re older. And one last thing Felice, if I could say to the patients trying to conceive, I wrote in my book, and I want you all to realize that my book is the Fertility Doctor’s Guide to Overcoming Infertility on Amazon and other places. And I wanted to share that. My wife and I went through ten years of infertility, and I understand the suffocating burden of that life. We adopted our five children, and I’m very blessed. But I want you all to think about this. You are not defined by your ability to procreate; your value in life is not based on your fertility. Your value is based on your contributions to the world, making it a better place, and to others, not something that you have no control over. Fertility is not a skill that you can acquire, brag about, or accomplish because of its nature. if you can look at it that way, and my prayers are for all those struggling to build a family.

Felice Gersh, MD

That is so beautiful, and you have created a beautiful family. My goodness. Five adopted children. How wonderful, and what a journey you had! And you go through this journey over and over again with your patients. And I just cannot let you sign off without telling people again. How can they find you? Because I’m sure many say, My goodness, I want an endocrine reproductive specialist just like him, or how about him? How can they find you?

Mark Trolice, MD, MBA, FACOG, FACS, FACE

Well, that’s very kind of Felice that I’m right back at you in terms of mutual admiration. I am in Orlando, Florida. We have two offices and the easiest ways TheIVFcenter.com I’m also on social media of course. Dr. Mark Trolice, So we are just committed to providing optimal reproductive healthcare in a compassionate setting. I have a wonderful staff. They have all faced fertility in some manner, either themselves or they’ve been an egg donor or gestational carrier or a family member. And that’s what’s important to me.  When you build a team, I can sort of train people to do a lot of things, but you can train somebody’s heart, you can train their compassion, their empathy, their emotional intelligence to engage with others. So that’s whatI’ve been proud of most about this center.So thank you Felice

Felice Gersh, MD

Thank you for joining me and for your big heart. Thank you. And to everyone out there, you know, define yourself by what you do and go and, you know, take charge of what you can control and, you know, have a wonderful life. So this is beautiful. Thank you again.