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Managing PCOS {The Experts Weigh In}

On this IG Live, Aimee Raupp MsLAc and Dr. Zaher Merhi discussed managing PCOS from the eastern and western medicine perspectives.

#pcos #ttcwithpcos #fertilitydetective #theeggqualitydiet #thefertilityexpert #yesyoucangetpregnant

See the full transcript below.

Hi. Coming to you live. It is that time where I am going live with Dr. Merhi of the Rejuvenating Fertility Center. We get to do these lives pretty much on a monthly basis depending on our schedule. We have laid out a bunch of topics for the upcoming lives. We’re super excited. Tonight, we’re going to talk about managing PCOS, which is a super duper common condition that affects 20 to 30% of women who are trying to conceive. Research also shows us that it is an inflammatory condition, but it also autoimmune characteristics. Yeah. I’m going to get into it with Dr. Merhi. I’m really excited to come to you guys and share both an Eastern medicine philosophy and a Western medicine philosophy so that you can vast manage PCOS if you are dealing with that.

Let me see where he is and make sure I have my time right. Do I have my time right? I think it’s 5:00. I hope it’s 5:00. Let’s see what my schedule says. Yeah. 5:00 PM. Where is my Dr. Merhi? If you guys don’t do know about Dr. Merhi, let’s see. He is a reproductive endocrinologist. He has several fertility clinics throughout the tri-state area. He has New York City, Long Island and up here where I live in Westport, Connecticut. He is really into all things reproductive medicine. He does IVF and IUI, and all that, but he does things to help also rejuvenate the ovaries. Ovarian rejuvenation is definitely an expertise of his. Things like PRP… Oh, my God. My book just fell off the shelf. Isn’t that funny? Platelet-rich plasma, ozone sauna. Really, really cool. Mini IVF, natural IVF. He’s an amazing doctor who really does think outside of the box on many of the cases. I’m honored to work with him. He loves acupuncture. I actually have an acupuncture practice in his clinic up here in Westport, Connecticut.

Let’s see. My team, do you see him on anywhere? I don’t see him on. He must be running late. I want to read to you about PCOS from my book Yes, You Can Get Pregnant while we wait for him to come on. I was a little prepared that maybe he’ll be running late because he’s in the clinic today and usually gets slammed, and runs behind schedule. As I was saying, PCOS affects 20 to 30% of women with fertility issues. Typically, it’s a hormonal issue with too much testosterone and estrogen. Then, also a metabolic aspect to it, right? There’s typically insulin. There can be insulin resistance, but there is also mainly abnormal blood sugar. The abnormal blood sugar then triggers more of the hormonal imbalance and you get into this cyclical pattern of anovulation, which basically means you’re not ovulating or you’re not ovulating on a regular basis. A lot of the girls I’ll see in my clinic have 100-day cycles or they ovulate on cycle day 40 or 50.

What acupuncture’s really good at is inducing ovulation, getting it to happen sooner and quicker, managing the cysts that are often on the ovaries. But not every woman with PCOS has cysts on their ovaries, which is also another fascinating thing. You can have five different patients with the PCOS diagnosis and they will all present differently. What I talked about in Yes, You Can Get Pregnant, which is still not as talked about, which I think is something that I’m always very intrigued by, is there is some controversy as to whether or not PCOS is actually an autoimmune condition. However, recent research published in 2007 stated a high concentration of anti-ovarian antibodies suggests that immune reaction is associated with PCOS. Basically, women are making antibodies to their own ovaries, which are causing this inflammatory reaction. They see in PCOS patients a high concentration of anti-sperm antibodies, which is also suggestive that autoimmunity and PCOS go together. Or at the very least, that there is this inflammatory reaction that’s causing an immune reaction.

I see Rejuvenating Fertility Center just joined. Is Dr. Merhi on yet? No. I don’t see that. Once he comes on, then we will get this party started. Oh, okay. He’s asking to join. I’m going to pick up the book that just fell behind me because I like it up there in that shelf. Let’s do it. He’s here. Now we’ll get really into it. I was just teasing you guys.

Hi!

Hi! How are you?

Good. Thank you.

Good. You’re home? You made it home?

Just made it home. Yes.

Okay. Busy day? How you feeling?

Busy. Very busy. Very well. Very well. Just lot of traffic. It’s been crazy.

I know. I notice it even just driving around town. There’s just so many people out. Everybody’s out and about.

Right. Right.

I didn’t love all the things of COVID, but I did love less traffic in COVID. I really liked that.

Yes. March of last year was the best traffic. It was 15 minutes from New Rochelle to Manhattan. Seriously-

That’s amazing.

… it was amazing.

That’s amazing.

It was amazing.

I was keeping them busy talking about what I talked about in Yes, You Can Get Pregnant, how I sum up PCOS and the common things. It’s impacting 20 to 30% of women with fertility challenges. It’s too much testosterone and estrogen coupled with a metabolic issue, whether or not there’s insulin resistance, right, depends on the case. In Yes, You Can Get Pregnant, I talked about that it’s still not super clear, at least it wasn’t in 2014 when I wrote this book, about whether or not it’s an autoimmune or just an inflammatory condition, but that it has some characteristics. In some of the cases, they’ll see anti-ovarian antibodies or anti-sperm antibodies with PCOS patients, too, which I find interesting if you will, to say the least. Maybe from your side, impacts treatment. From my side, not necessarily either, right? I’m still going to come after it to manage the immune system and manage inflammation, and that should help regulate things. Yeah. Tell us about how often you see PCOS and how it’s impacting your clients?

Yeah. Like you said, it’s extremely, extremely common. First of all, I want to start with the name, PCOS or polycystic ovary syndrome. There is misconception that a lot of patients think they have cysts on their ovaries. They’re not really cysts; they’re multiple follicles. That’s why, actually, the Endocrine Society wanted to change the name three years ago, but they never did for two reasons. One is a lot of patient think they have cyst, but they don’t. Two, the name PCOS does not reflect the metabolic, which is diabetes and all that stuff that’s associated with a PCOS. They didn’t come up with a name that everyone agreed on, apparently. That’s why the name remained the way it is, but it’s important to know that. That’s one.

Two, like you said, there are two things for PCOS: reproduction and metabolic. Very important for patients to be counseled this way. Because the metabolic part is women needs to know there’s couple of things that’s associated with PCOS. One, diabetes.

Diabetes. Yeah. Yeah.

Metformin is given commonly to patients with PCOS even if they’re not diabetic. It’s a medication for diabetes, but to prevent them from going into diabetes. One, it’s a nasty medication, but…

Yes. It’s not fun for the girls, but it does help.

Yeah. Yes. Absolutely. It does.

It can really have a positive impact on the insulin.

Absolutely.

Yeah.

I’m going to talk about this in a few seconds. Two, women with PCOS are associated with apnea, lot of sleep apnea. Very important to counsel them about that. Three, depression. More predisposed to depression. Four, endometrial cancer. The reason why endometrial cancer because there isn’t ovulating-

Because they’re not shedding the lining.

Exactly.

Yeah.

These are the four things that’s definitely we need to tell patients about women with PCOS. Let’s talk about the diabetes part. Fat cells are used for energy, right? That’s what it stored, it’s energy. The body of women with PCOS is made in a way… The body thinks there’s going to be starvation one day and everything you eat, seriously, is going to fat cells-

It just holds on to. Yeah.

… because the body’s afraid. “Okay. I’m going to use these fat cells one day for energy because there’s not got to be food anywhere.” Wrong. That’s what metformin does. It breaks this body.

This chain.

This chain to say, “Okay. Relax, body.” Metabolism is different, right? The metformin… Some study showed they make patients lose weight [inaudible 00:10:16], but it has important that it makes women-

Regulates the enzyme. Yeah. They do.

Exactly. Some women start to get regular period on metformin. We talked about the metabolic part. I’m going to repeat. In summary, it’s diabetes, sleep apnea, depression, and endometrial cancer. As far as endometrial cancer, women who don’t have period regularly has to have at least three periods per year. At least.

And need to fully shed. Yeah.

Right. We want to shed this lining by giving them progesterone because they have estrogen, but not progesterone. Progesterone comes after ovulation. If you’re not ovulating, no progesterone, that lining doesn’t shed. These are for [inaudible 00:10:57]. Now the reproductive part is also very common. The reproductive part, as you said, they don’t ovulate regularly. They do ovulate. They can get pregnant on their own. But if they don’t know when is the ovulation going to happen, it’s extremely hard to know when are they going to have sex. That’s why we give them medication to-

Induce.

Letrozole or Clomid. Letrozole seems to be better than Clomid for women with PCOS in order to induce their ovulation, in order for them to have timed intercourse, or whatever it is. These are, in general, the two main categories of PCOS, but extremely common. Fifty percent of my patients, they were told they have PCOS and they don’t, and vice versa. Why?

Why?

Because there is so many criteria to diagnose PCOS. If you’re in Europe, it’s different than here. We follow the Rotterdam criteria. There are three: there is Rotterdam criteria, which we follow in the United States; there is the Endocrine Society diagnosis; and Andogren Society diagnosis. Us, with Rotterdam criteria, there are three criteria. You need two out of three to have PCOS. Am I going into details? If I am, please stop me. No? Can you hear me?

Yeah. I just lost you for a second. Start. That’s great.

I said am I going into much details? If I’m going too much details, you can stop me.

No. I love it. I love it. I think it’s very educational.

Because I can talk about PCOS for two days.

Yeah. Well, tell us of Rotterdam criteria. Tell us this.

Two out of three criteria for you to have PCOS in the United States. One, skipping periods. Two is high testosterone in the blood or hirsutism. Hirsutism, be careful. Women from Middle East or-

Yeah. Are going to have it. Right.

… India have hair. That’s not hirsutism. That’s why we talk about hirsutism. But hair in the middle of the body. You know what I mean. Between here-

Yeah. Midline, I know, and definitely from the belly button below. You see that line of hair. Yeah.

… here. Right. Here, here, between the breasts and in the thighs, that’s abnormal. Either one of them is a criteria. Three, when you do an ultrasound and you see this [crosstalk 00:13:20] lot of follicles around. So you can have PCOS and have regular period. Remember, it’s one of the criteria.

Yes. One of the…

You can have hirsutism-

What about the FSH, LH ratio? That’s not in the Rotterdam?

That’s taken off. No. It’s not part anymore.

Oh.

Twenty five percent of women with PCOS do have regular periods. You don’t have to have a regular period. That’s why there’s a lot of confusion about diagnosis, but also it’s a spectrum, the PCOS. It could be mild; it could be severe. The severe form, someone is overweight with hair all over their face and they shave everyday. In the other spectrum, and there is lean PCOS, which are thin and all that stuff.

Yup. Which I see a lot of.

Right.

I feel like there’s a lot of lean PCOS. Yeah.

Right. These are the things that are related to about PCOS. You are going to talk? I don’t want to talk the whole night. I can talk for-

No. It’s okay. I was going to say let’s explain the difference why they’re not cysts and what they actually are on the ovaries. It’s basically immature follicles that have just not in the right condition to mature, right?

It’s called a pearl necklace imaging. I’m going to show it to you if that’s okay.

Yeah. I love it.

PCOS ultrasound. Here. I’ll show you the difference between a cyst and a PCOS ovary. Okay. Here. Hold on. You see, these are follicles. You see how they are?

All black?

Around, at the surface. Nothing in the middle. See how they are at the surface. It’s called a pearl necklace, actually. Some books they call it. Look at this. This is typical PCOS. You see how they are, the black circles. These are not cysts. If you google a cyst and ovary, and ultrasound, that’s a cyst. Look how big it is.

Yeah. That’s what I had. Yeah. That’s a cyst.

There’s a difference between this cyst and… Sorry. I keep getting text messages. I apologize. I’m using my laptop for text messages and [inaudible 00:15:42].

Smart. Smart.

That’s what-

What they are is follicles that have never just had the chance to mature, right?

They’re all fighting, but no one is winning the war to ovulate.

No one’s winning. I say that often, too. Even how the quality of those follicles or once they become eggs could be compromised in PCOS because they’re basically all fighting for the same nutrition. They have to divide it up amongst them.

Well, let’s talk about nutrition. First of all, the egg quality of woman with PCOS is… Usually they have a lot of eggs.

Right. But quality can be compromised.

Technically, they should go into later menopause even though some studies have not shown that. Their AMH is very high. If you have AMH that’s above 4, suspect PCOS. If you don’t have an ultrasound, you can replace the AMH by the ultrasound if you don’t have it. The quality of eggs is lower than women who don’t have PCOS because we don’t understand what PCOS is and why it’s happening.

Right. The insulin issue. The metabolic issue really compromises mitochondrial function, which would compromise quality. Yeah.

Right. The most common reason for PCOS that scientists agree on is a defect in the insulin receptor that causes both diabetes and anovulation, but that’s not the only one.

Right.

Yes. They have a lot of eggs and they’re predisposed to ovarian hyperstimulation syndrome. You have to be very gentle when you do IVF. If you pump her with drugs, ovarian hyperstimulation syndrome, they collect fluid all over their body and all that stuff, but they get tons of eggs. A lot of those eggs are not good quality, but because they have a lot, it makes up for…

Yeah.

They tend to have good outcome.

Right.

Now as far as nutrition… We studied nutrition in the humans and animals, and PCOS, believe it or not. We had an animal model of PCOS.

Wow.

We give them androgen. But nutrition is extremely important. Studies on vitamin D are the most common.

Oh, my God. D is amazing. Yeah.

Vitamin D… When you replace women with PCOS who have low vitamin D, believe it or not, a lot of them start to have regular cycle and they have lower chance of having diabetes. Something about the vitamin D and PCOS-

Well, because it’s not a vitamin. It’s actually a hormone, right?

Correct.

It’s a precursor to everything that they do need. It probably helps regulate the testosterone, I would think. Yeah.

Right. They tend to have much lower vitamin D absorption in their system, but they need to be-

That’s like Chinese medicine, though. We often say it depends on the presentation. But generally speaking, when there’s this metabolic disorder, there’s usually a deep spleen deficiency, is what we say in Chinese medicine, which basically means they can’t absorb their nutrition properly. They all are inherently deficient in really important micronutrients like D and B12, and magnesium. For us, too, that’s how we come in. We really want to fix the digestion and the absorption, and that will actually oftentimes rectify the PCOS situation.

Right. You’re absolutely right and that’s very true. Regarding the diet, vitamin D, as far as…

What else did you in the study? I want to hear.

The quality of diet, Aimee, is very, very important.

I know.

Right? We studied something called advanced glycation end products, which basically when you make a burger or french fries, or anything that’s grilled [inaudible 00:19:30]

I lost you.

This stuff that we eat, the quality seems to affect very badly the quality of eggs in women with PCOS. Okay? The quality of diet-

It’s the glycation?

Correct. It becomes more significant in women with PCOS, the quality of diet compared to woman who don’t have PCOS. I can tell you. I’m sure that it’s something of the GI system of women with PCOS that’s contributing to this because something about the diet and PCOS is so intricate with each other. Right?

Yeah. Because it’s a sugar molecule, right? That’s what glycation [crosstalk 00:20:23]

That’s exactly true.

Excess glucose and skin fibers are formed, make collagen rigid, and lose its ability… Right. That’s for aging, but yeah. That’s the one thing I see clinically is they can have carbohydrates, which we know turn into sugar pretty quickly, but in the form of good quality carbohydrates from vegetables mainly. Maybe rice, but grains seem to really, really aggravate their condition; so the lower in the grains they do, the better. That protein is so important that they have to be eating protein almost like a Mediterranean salad. That’s what the research shows at least, but every few hours. If you maintain blood sugar, I think, then you prevent yourself going into… Maybe that’s the glycation process in a sense. You prevent that insulin shift, if you will, the blood sugar spikes, and that seems to even things out, right?

Well, absolutely. Like you said, that’s very, very true. Back with the diet, like you said, the quality and how to maintain and eat protein, and eat the healthy sugar, it’s more important in women with PCOS than anybody else.

Yeah. I find alcohol. It’s like a trigger for a lot of the PCOS girls where if-

Thank God I don’t have PCOS because I cannot stop alcohol.

But didn’t you see that I can get a girl to really to eat well-

You want to see my bar? Do you want to see my bar?

My God. You’re so funny.

This is one of them.

Well, your insulin can get affected. We’ve had this conversation actually.

I know. I know. I know. I’m terrible.

It’s another conversation for another day. But yeah, I’ve seen though. I think because it just causes such intense blood sugar spikes. If you are to have it, you need to have food in your stomach, the same thing. Coffee’s the same thing. Because of the blood sugar spikes, it does a number on PCOS patients where their symptoms will come back or they might get a delay in their ovulation, or not ovulate at all. But it’s the protein, keeping blood sugar consistent, and really watching the source of the carbohydrate seems to be critical to getting them balanced. Then obviously, layer in stress because we know stress impacts cortisol, which we know-

And lowering inflammation.

Yeah. We have to.

PCOS-

Is an inflammatory condition. Right. Yup.

You can google it. PCOS is a chronic low inflammatory process. It’s like endometriosis.

It is. Exactly.

They have inflammation. Same thing.

Same thing.

The good thing for PCOS, like I said, watching diet, getting metformin and exercising, and all that.

I have a question, though.

It’s easier said than done.

What about some of the research that shows the myo-inositol or the d-chiro having similar effects, if you will, in comparison to metformin? Do you ever recommend the two together or one in place of the other?

Yeah. I wouldn’t replace. I like myo-inositol. There is, like you said, a lot of studies. For some reason, the Endocrine Society… You know us, worse than people.

I know.

They didn’t really give a lot of focus on it for some reason. I don’t know if it’s an ignored thing, but I like it because there’s a lot of studies shown. Myo-inositol with vitamin D and metformin, why not? They don’t hurt. Why not? Now metformin-

And B12. Then, you put them and get them on a good magnesium, right? Those things seem to really help even out. Then, the metformin… I just got off a call-

Not everyone should be on metformin. I’m not saying everyone should; it’s case by case basis.

But it can really help.

Right.

At least short-term to regulate things while they’re working on their diet, while they’re working on their lifestyle. There’s also a high correlation, though, correct me if I’m wrong, but I think with-

You’re never wrong.

… autoimmune thyroid disease-

You’re never wrong, Aimee.

I’m never wrong. With Hashimoto’s, autoimmune thyroid disease and PCOS, there seems to be a high correlation between women with PCOS that have Hashimoto’s. Do you tend to see that clinically?

You know what? I’m not sure. You might be right, but remember Hashimoto’s is so common.

I know.

Okay? That if I had mention-

Most women with PCOS who have a thyroid condition, are we always checking their antibodies? Maybe not, right?

Exactly. I don’t know if it’s one to one, but I can tell you diabetes and Hashimoto, there is correlation. There is both antibodies especially diabetes type 1. With PCOS, a lot of them have Hashimoto’s, but it’s so common. Like I said, lot of people with antibodies, it’s every hard to know what-

Which came first.

… one person is causing it.

Yeah. Yeah. You see… Go ahead. Yeah.

Now as far as the fertility, it’s very important for women with PCOS… If I was woman with infertility, I’d rather have PCOS than anything else, just to let you know.

I always say it. It’s the easiest one to treat. I say the same thing. I’m like, “Listen. We just got to figure out when you’re ovulating and we can make this work.” You know what I mean?

Right.

Yeah. Then obviously, there’s other things going on.

With letrozole, Clomid and have sex. Might or might not work. Not work, do these three cycles, then move on to IUI. Three cycles. Doesn’t move on, then move on to IVF. But I’d rather have this than have blocked tubes or no… You know what I mean? I always reassure patients that hopefully they will have-

It’s treatable. It’s totally treatable.

Yeah.

A lot of times, too. I have girls that they get fixated on like, “Oh, I need to get a regular cycle. I need to get a 28-day cycle.” I always say the best I’ve ever done, I think, even naturally with really severe PCOS patients is ovulating on day 20 or so. You know what I mean? They still get pregnant. It’s not about achieving perfection or getting this 28-day cycle; it’s really just about we want consistent ovulation and we want progesterone in a healthy luteal phase.

Right. Right. Absolutely. Yeah. It’s really easy for them.

You’ll do it with… What did you say? Why letrozole versus Clomid?

We can take actually some questions if someone-

Go ahead.

If someone has PCOS, we can take some questions. I’m not sure if-

Yeah. We can do that. I want to hear, though, Clomid versus letrozole. Why? Why do you see such as side effects like the estrogen?

No. Actually, there is one big study published in New England Journal of Medicine by Legro. They randomized women with PCOS to letrozole and Clomid. Women who took letrozole have much higher significantly improved chance compared to Clomid. I think it was 24% versus 18%; it was statistically significant. Now no one knows why, but there could be that the letrozole is good for implantation in those women compared to Clomid. Remember, Clomid can cause thin lining in less than 10% of patients.

Oh. Right. Okay.

It could be. It could be that that’s what’s happening. That’s why. But since then, we started to use letrozole compared to Clomid. Now someone is asking about the AMH.

Yeah. Higher than 4. I see that. Right? Is that the one you saw?

Right.

Oh, yeah. The best supplements to take for, do you see that one, for PCOS? I think I always put my girls on a myo-inositol. I like Ovasitol. There’s a list on my website. Vitamin D, like you said, magnesium-

CoQ10. I like CoQ10 a lot, honestly.

CoQ10?

Yeah. You know why? Because it’s vitamins to the mitochondria.

Fish oil, the lowered inflammation.

It’s good for the mitochondria-

Exactly.

… and that’s what they use. It’s for everything, even for the heart, for the brain. These are the three things that I like.

Yeah. Then, to go after the inflammation like the fish oil, but remember, you cannot supplement a crappy diet. You still have to really focus on making sure your blood sugar is even all day long and you’re eating your protein, and you’re getting your carbs from vegetables. I would really reduce grains all together and make sure you’re getting protein in every two to three hours, and good quality protein, but yeah. Sometimes I go with NAC, too, because I like the N-acetylcysteine for-

Every Aimee I’ve known so far in healthcare, they like…

We love it, NAC? I know. Now it was on exfoliant, but we think it’s still good.

Something about Aimee and NAC.

It’s a great antioxidant, but so similar to CoQ10, if you will.

No, no, no. They are. Listen. The reality is they’re so many and we need to be also careful not to spend so much money on supplements.

That’s it.

They have to tell you also, “We will forget to take them.” That’s why you and I, we talked about having a pill that’s a magic pill with everything in it.

I know. We want to have a magic pill. I thought that we can do it.

Because who wants to take six pills everyday, seven pills. I hate it, but it helps. Yeah. Someone is asking about-

Yeah. The high AMH.

… the high AMH. Normal for age, but I’ve never been told that I have PCOS. Look. AMH above 4, like I mentioned earlier, can be one criteria, but there are two other criteria.

Not all of that. Correct.

It doesn’t mean someone who have AMH above 4 have PCOS directly, one. Two, the decision for IVF is never just based on AMH in my opinion. Okay? Because it tells you quantity; it doesn’t tell you quality. Like I said, age is the most important. If your AMH is low, what tells me is don’t waste time. Okay? Don’t go on vacation for six months; do it right now. But if you look at women with low AMH and women with high AMH, and I said this many times-

The outcomes are…

… AMH, they have same outcome, but this person has to do multiple cycles in order to reach the same outcome. That’s the only difference. Age-

Yeah. The outcomes are the same. In one year, the outcomes are the same regardless of AMH, right? In the same setting?

Exactly. That’s absolutely true.

Yeah. Which is good for the girls to hear that. The AMH also impacts how you’re going to do in a fertility cycle, right? It’s to keep that in mind, too. It doesn’t necessarily mean you’re not ovulating every month. You still have the eggs in there. Yeah.

Right. Right.

Okay. I see the next question. I have a consult with you next week. Can we check for PCOS? I was on metformin and I wasn’t. Yeah. I’m sure you guys will talk that through.

PCOS doesn’t go away. Okay? It’s very important. Like I said earlier, if someone is a little bit chubby or so, they lose weight. The period comes back to normal. They gain weight, it stops again.

Yeah. I always say, “You have PCOS tendencies. Right now, you’re managing that.” I had seen this in girls a lot because a lot of girls, they’re so well read now. They read the diets or the supplements. They’re doing all the things and they come in. I always say to them, “You’re managing your symptoms right now. If you were living a standard American life and following the standard American diet and not taking the best care of yourself, you probably wouldn’t be cycling.” It’s true. The tendency is always there. It’s just like the tendency towards the diabetes. You have to be very on top of it and very careful because you could slip right back there. It’s the same thing with any autoimmune condition, right? You can’t cure it, but you can heal from it. That’s a very distinct difference.

Right. Right. Someone is asking if the string of pearls always show up on ultrasound. If it shows up, one tech saw it, but no one has seen it since. Yes and no. It is, again, one of the criteria of the PCOS, remember? Pearl neck, high testosterone or hirsutism, and irregular periods. You don’t have to have it to have PCOS. You can have it in one ovary or both, but you don’t have to have it all the time. Does it come and goes? Sometimes you might see it, the PCO looking. Sometimes not, but also it depends on the location of the ovary. A lot of times, it’s hard to see it.

What else? I’m looking through the question.

I’ve got a nerdy question, too. Those follicles that we would see, the string of pearls, are those maturable? You know how when you manage PCOS if their AMH is super high, their AMH will come down? Girls tend to freak out about that, but it’s usually a good thing, not a bad thing. Would that string of pearls just go away? What would happen to those follicles, if you will?

First of all, what you said is good because actually there is lot of scientists looking at AMH to take it as a contraceptive because high AMH-

Right.

… stops ovulation.

Anovulatory. Fascinating!

If you take AMH, which is very expensive, you can stop ovulation if you don’t have PCOS.

What about girls that have low AMH and you give them AMH? Could you do that?

I don’t know if it’s going to do any difference to be honest with you.

Gotcha.

Because AMH is a reflection of…

It’s secreted by… Right.

It’s like a shadow of the person. If I bring shadow, it doesn’t mean it’s a person. But if you give it to them, it stops the ovulation. That’s why women with PCOS have high AMH. Lower it down, they’ll start to ovulate.

Right.

Yes. The answer is yes. They respond to medication. You can grow them immediately because they’re called antral follicles. You can see them.

Yeah. They’re still there.

Anything that you can see in ultrasound can respond to medication and can become mature, and you can [inaudible 00:34:20].

You’re not worried if they’ve been sitting there for months or something like that? It’s the same thing as they’re dormant, if you will. Yeah. They’re just dormant.

Does not matter. Does not matter. Does not matter.

Right. Yeah. Okay. That’s interesting. I wondered about that. Say a woman with PCOS ovulates on cycle day 40 in a normal cycle, you still think she could get pregnant with a healthy child? Because the maturation stage is still the same, it was dormant. It’s almost like you see a flat line in the beginning of their cycle. Nothing’s going on. Nothing’s going for 20 days. Then, they almost start to cycle, right?

When I used to do Ob, believe it or not, I delivered a lot of babies and C-section. I had lot of patients who had PCOS. They were like, “I don’t know I was going to get pregnant because I don’t get a period.” Boom, they get pregnant. They think it’s a boo boo. You don’t have to. You can just ovulate at any time. Even if you haven’t had a period in a year, you can ovulate and get pregnant.

They can get pregnant.

Because remember, women with PCOS tend to be young and tend to be, like I said-

Fertile.

Exactly. Fertile. Yeah.

Yeah. Yeah. Yeah. They’re fertile. They’re just not ovulating. Then, you see clinically and what you saw in the research, the best ways to manage it, if you will, you use the metformin if you need to for certain, but diet is super important. Then, vitamin D is your supplement of choice for sure when you’re looking at PCOS.

Yeah.

Then, what about you? Do you think about lifestyle factors like exercise, or sleep? Because the apnea must impact sleep cycles, I would think. If you get that under control, deeper sleep probably leads to better quality eggs, too, and better insulin.

Right. Oh, absolutely. It’s all linked together. The sleep apnea is related to the insulin resistance or pre-diabetes. If someone is a little overweight, it becomes a vicious cycle. They’re all related. You can have someone who is skinny. If they’re pre-diabetic, they could have sleep apnea just because the insulin resistance can cause this on their neck. Exactly. Metformin could potentially help by lowering this stuff. Of course, exercise and all that stuff should be done as well. Yeah.

Yeah. Yeah. That’s what I see clinically, too. It really is the diet, getting enough protein, watching where your carbohydrates are coming from. The white carbs, the breads, the pastas, no good for really anybody, but really for PCOS. The alcohol…

I have a patient. We wrote the paper actually. I know people think I’m obsessed with all things PRP. Yes, I am. She came. She does not want any medication. She hasn’t had a period in one year. Okay? I read the study that same week how an animal model, they gave them PRP, and they resumed ovarian function in PCOS animals. I said to her when I read the study, “I won’t charge you for the PRP. Would you like to do it because you’ll be the first patient?”

Wow.

Believe it or not, she ovulated back to back two cycles. Didn’t get pregnant. Someone passed away in her family or whatever. She lost to follow-up, basically, but she did. Yeah. I’ll show you. Here. This is Preliminary Finding of PRP-induced Ameliorative Effect on PCOS. That’s the first study that show-

Wow.

Yeah. Exactly. That’s done in animal models, but we did this in a human. We measured all the hormones. We measured progesterone. We measured AMH. We measured LH, FSH, androstenedione, 17-hydroxy… All that. We made a nice table. Send in our fellows in that section, did great job here and Dr. Marcos. Once it’s published, we will share it.

Wow.

Yes.

That’s amazing. The PRP induces ovulation, basically.

Yeah. But think about it, like you said, they’re lacking a lot of those growth factor.

That’s it.

A lot of things that’s missing by diet. You’re taking it from the blood and you’re putting it there. You’re just assisting it by putting this stuff inside their follicles. But also, the mechanical poking, in my opinion, also helps.

That’s why I think acupuncture because there are some great research on acupuncture induction in inducing ovulation in PCOS patients. I think it’s the same thing. We’re just aggravating the area. I’ll hook the needles up to electrical stimulation. You literally get them to jiggle, basically.

It works!

It works, or I’ll do cupping over the ovaries. It’s just pulling out. We say it’s stagnation. We call it like there’s poor blood flow to the ovaries. You know what I mean? They’re not functioning properly. If we just improved that… In some cases, it could be phlegm and damp, but really just depends on the presentation of the patient. But if we improve the blood flow and circulation to the ovaries, then they start doing their job in a sense.

Right. Right.

It’s fascinating. It’s the same thing. PRP gets in even deeper obviously.

Yes. All treatments… I didn’t do it. I did one in my training 20 years ago. It’s called ovarian drilling. They go laparoscopically. You make holes inside the ovary of women with PCOS and they resume ovulation. That’s well known. They use electricity. Babababap. They buzz it. They buzz and make a hole. Yeah. I think it’s a combination of both mechanical and the factors that we put there, but it seems to be interesting.

Yeah. That is really interesting. All right.

All right.

Any other questions?

Oh. We have more questions.

If not, we’re going to let you guys go. Let’s see. My blood sugar spikes after two hours of meal even though I’m taking digestive enzymes to control blood sugar. What else should I do to control sugar spikes? You’d have to eat enough protein. I think that’s the biggest thing that I’ve seen clinically. You got to watch your carbs. Not keto, by any means, but what I have in the equality diet. The 45% fat, 30% protein, 25% carbohydrates from good-quality carbohydrates, not starchy carbohydrates, but the protein is so key.

I just had a call earlier with a girl who’s using a continuous glucose monitor just out of curiosity. On my diet, her sugars are great. But she notices that some days if she skips breakfast, but even if she puts collagen peptides in her tea… She’s having some protein, but it’s not really food. Her sugars will not stay stable throughout the day. She has to actually eat like a real deal breakfast and then her sugar stays stable throughout the day. I would just continue to play around. I would aim for probably 20 grams of protein per meal if you’re having three meals a day. Then, some snacks, too, but that should help even you, anyway.

Well, speaking of carbohydrates-

Yeah. Go.

… I’m going to have them now.

Go. Go. Go. Okay. Thank you for this conversation. Always great. Then, we have more in stored for you guys. We’re going to keep doing this regularly, but you go relax. Happy Wednesday.

Bye.

Good seeing you this morning.

Thank you so much, Aimee.

Okay. Bye.

Let’s keep doing this. Let’s keep doing this.

I love you. I’ll talk to you later. Okay. Bye.

Okay. Bye.

End transcript.

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