Day 3 :
- Prevention and Management of PCOS
Alternative PCOS Treatment
Endometriosis
Chair
Felice L Gersh
Integrative Medical Group of Irvine, USA
Co-Chair
Kirsten Karchmer
American Board of Oriental Reproductive Medicine, USA
Session Introduction
Rashmi Kudesia
Icahn School of Medicine at Mount Sinai, USA
Title: Prevention and management of PCOS
Biography:
Rashmi Kudesia completed her undergraduate degree at Brown University and received her MD from the Duke University School of Medicine. She completed her residency at New York Hospital-Weill Cornell and and her fellowship training at Montefiore Medical Center-Albert Einstein College of Medicine, along with a Master of Science in Clinical Research Methods. She is an Assistant Professor of Reproductive Endocrinology & Infertility at Icahn School of Medicine at Mount Sinai/Reproductive Medicine Associates of New York. She has presented and published clinical research, review articles and book chapters focused on PCOS, and enjoys the clinical care of PCOS patients.
Abstract:
Polycystic ovary syndrome (PCOS) can manifest in different forms – with phenotypes ranging from lean women who have irregular menses and polycystic ovaries to overweight women with insulin resistance, hyperandrogenism and high risks for worsening metabolic disease over the lifetime. Despite the different presentations, women who raise the clinical suspicion of PCOS require detailed and thoughtful evaluation to (1) confirm the condition, particularly in adolescents in whom diagnosis can be particularly challenging, (2) evaluate for specific phenotype and co-morbidities with ongoing screening intervals reflective of their individualized disease risks, and (3) counsel women regarding their lifelong reproductive and metabolic risks. Prior evidence has suggested that provider specialty and training influences how many of these goals are actually met, and thus more training and emphasis is required for both women with PCOS and their healthcare providers. The proposed talk could be tailored to cover the individual topics within this session, including managing PCOS in primary care settings, in adolescents, and/or over the long term. Detailed review of the evidence and available guidelines regarding risks, screening and treatments would be featured alongside tips to address common barriers to provision of complete care, such as provider discomfort with lifestyle counseling. An emphasis will be placed on prevention of co-morbidity development, particularly among young girls and adolescents, in whom the ongoing childhood obesity crisis raises concerns for increasing rates of PCOS.
Felice L Gersh
Integrative Medical Group of Irvine, USA
Title: The care and feeding of the microbiome: A new approach to lowering the inflammation of PCOS
Biography:
Felice L Gersh works in integrative and holistic medicine, creating new paradigms in women's healthcare. Searching for better, safer and more natural ways to achieve optimal health, she trained at the University Of Arizona School Of Medicine, completing the Fellowship in Integrative Medicine in 2012. She is a renowned national speaker on topics of women's health, with a special passion for educating all on the complexities of PCOS. She has received numerous awards, including being named Physician of Excellence in Orange County 11 years in a row, a Super Doctor of Southern California, a Top Doc, was recognized for her excellence as an attending surgeon at USC Keck School of Medicine by the OB/GYN Department, and was elected into the prestigious medical honor society, Alpha Omega Alpha. She is the Medical Director at Integrative Medical Group of Irvine, where she leads her team of dedicated holistic practitioners.
Abstract:
It has become increasingly apparent that the microbiota residing within our gastrointestinal tract plays a critically key role in a great variety of essential bodily functions. In fact, the microbiome is as essential to our health as are our other organs. More DNA exists within us which derives from the trillions of bacteria comprising our microbiome than from our personal genetic DNA. Sadly, the standard Western diet, comprised of large quantities of processed foods, which are nutrient deficient, chemically laden, antibiotic containing, and devoid of sufficient quantities of both soluble and insoluble fiber, kills rather than supports a healthy microbiome. Women with PCOS frequently experience gastrointestinal problems, have irritable bowel syndrome, and develop chronic low grade systemic inflammation as a consequence of the unhealthy state of their gut microbiome. This lecture will provide a comprehensive presentation of the best diet to support a healthy microbiome, thereby facilitating the myriad essential functions of the microbiota, supporting a healthy diversity of microbes, along with boosting the colony sizes, while promoting the growth and survival of the right balance of bacteria to keep the body functioning optimally.
Kirsten Karchmer
American Board of Oriental Reproductive Medicine, USA
Title: Using technology to deploy multivariate approaches to improving PCOS
Biography:
Kirsten Karchmer is a board certified Reproductive Acupuncturist and former President of the American Board of Oriental Reproductive Medicine. She is the founder of The Texas Center for Reproductive Acupuncture, one of the largest fertility wellness clinics in the US. For the last 15 years, she has been pioneering proprietary infertility assessment and treatment protocols that maximize the natural fertility of her patients and while improving their overall health. In 2013, she founded conceivable, translating her successful clinical programs into a technology enabled program that provides affordable and impactful reproductive solutions to women nationwide. She lectures internationally on the future of integrative medicine, and using technology to better serve patients, providers, and healthcare systems.
Abstract:
PCOS is a complicated, chronic endocrine disorder that accounts for roughly â…“ of infertility cases among women in the US. Common interventions such as metformin, temporary blood sugar management and inducing ovulation (to promote pregnancy) fail to address the chronic underlying metabolic issues which impact progesterone and severely impact miscarriage and live birth rates. The temporary management of PCOS distinctly as a disorder of ovulation eliminates the opportunity to examine and address long term health impacts such as heart disease and diabetes that significantly undermine the individual's overall health and dramatically contribute to future healthcare costs. Complex, multisystem disorders like PCOS require new medical paradigms that can employ multivariate interventions designed to identify and address a wide range of underlying factors. These interventions extend beyond treating inconvenient symptoms, such as anovulation, and fundamentally change patient health and future health care outcomes. As the stewards of our patient’s health, we should leave them fundamentally better than we found them. This plenary session will detail novel diagnostic models that can expand a physician's ability to address the underlying issues related to PCOS and infertility, discusses a multivariate intervention strategy that can easily be employed in any office, and reviews the relevant supporting literature.
Kelton Tremellen
Flinders University, Australia
Title: Can gut bacteria alter gonadal function? An overview of the DOGMA theory of PCOS
Biography:
Kelton Tremellen is a Gynaecologist and board certified sub-specialist in reproductive endocrinology and infertility. He has a PhD in the field of reproductive immunology from the University of Adelaide and is currently Professor of Reproductive Medicine at Flinders University and Clinical Director at a private fertility unit (Repromed). His research interests include how nutrition and the immune system influence reproductive function. He has published more than 50 journal articles, book chapter and a book (Nutrition, Fertility and Human Reproductive Function, CRC press). He is on the Editorial Board of the journal ‘Human Reproduction’.
Abstract:
Polycystic Ovarian Syndrome (PCOS) is the commonest endocrinopathy seen in reproductive age women, presenting with a myriad of features including reproductive dysfunction (anovulation, infertility, endometrial pathology and increased risk of miscarriage and preterm delivery), hyper-androgenism (acne, hirsutism), diabetes, cardiovascular disease and psychological impairment (depression, anxiety). From a biochemical perspective PCOS is characterised by a chronic state of inflammation, which is now recognised as a potential trigger for insulin resistance and possibly many other features of the disorder. Therefore, the key to effective long term management of PCOS is to identify and treat the cause of chronic inflammation underlying the creation of a PCOS state. Recently we proposed that the passage of gut bacterial endotoxin into the circulation may be responsible for triggering chronic inflammation and PCOS- the Dysbiosis of Gut Microbiota (DOGMA) theory. Women with PCOS have a significantly greater incidence of obesity and irritable bowel syndrome (IBS), both linked with an increase in intestinal wall permeability allowing translocation of gut bacteria into the systemic circulation. The resulting endotoxin exposure (metabolic endotoxaemia) triggers a chronic low grade inflammatory state, which in turn impairs insulin sensitivity, with a compensatory hyper-insulinaemia increasing free androgen levels, while also impairing ovulation. The presence of gram negative bacteria endotoxin in the circulation has been shown to impair lipid profiles and has been linked with poor mental health. Therefore, we contend that the effective long term treatment of PCOS may be best directed at reducing metabolic endotoxaemia, rather than directly treating individual pathologies such as anovulation.
Bob Tygenhof
Integrative Medical Group of Irvine, USA
Title: Exercise and PCOS: Filling in the lifestyle treatment blanks
Biography:
Bob Tygenhof is the Director of the Center for Active Lifestyle Medicine at Integrative Medical Group of Irvine. In that capacity he has designed and implemented a number of programs that utilize various lifestyle treatment modalities to reduce inflammation, oxidative stress and hormonal imbalances. He ties together detox, nutrition and fitness programs with other prescribed PCOS treatments to achieve optimal results. He is a Graduate of Princeton University and received his MA degree from the University of Southern California. He completed a Fitness Specialist certificate program and is an American College of Sports Medicine-certified Personal Trainer.
Abstract:
Exercise is an extraordinarily effective way to reduce systemic inflammation and lower oxidative stress, and should be an integral part of every PCOS treatment program. It also plays a powerful role in balancing hormones and increasing HGH expression. By attending this informative session, you’ll learn how and when to write a fitness prescription, and how to make exercise a part of your PCOS treatment plan. You will also find out how exercise and fitness complement other lifestyle aspects of an integrative treatment program and get answers to some of your patients’ most pressing concerns. 1) Learn how to begin a fitness program for de-conditioned PCOS patients and how to advance fitness over time. 2) Find out which types of exercise are most suited to dealing with PCOS symptoms – aerobic or resistance training. 3) How often should one train and at what intensity? 4) What’s the latest data on high intensity interval training – is compliance better or worse than it is for long, slow exercise and is the benefits worth the extra effort and risk? 5) How does exercise impact the elevated chronic disease risks faced by PCOS patients?
Nora Shilo
Yinstill Reproductive Wellness, Canada
Title: Alternative treatment options for PCOS patients looking to conceive
Biography:
Nora Shilo currently practices at Yinstill Reproductive Wellness in Vancouver. Her practice is primarily focused on fertility, reproductive wellness and women’s health. She has a strong passion for fertility and loves working with couples and women who are looking to optimize their health prior to conception. She also regularly performs on-site acupuncture treatments for embryo transfer day at 3 of Vancouver’s largest IVF clinics, including the Pacific Centre for Reproductive Medicine. She is a graduate of the Canadian College of Naturopathic Medicine and also has a BSc in Psychology from York University in Toronto.
Abstract:
PCOS is a disease that affects millions of women around the world. It is extremely common in North America and is also one of the most common causes of female infertility. Conventional treatment options for PCOS patients normally include oral contraceptives, spironolactone, or metformin for blood sugar regulation. It is important for us to realize that there are several dietary, lifestyle and alternative interventions that help to improve patients’ overall wellness and make this disease much more manageable. I am going to focus on a number of alternative treatments that have some good evidence backing their safety and efficacy in the complimentary treatment of PCOS. These include botanical medicine, acupuncture, dietary interventions and lifestyle interventions. I will also touch on the importance of stress management in PCOS patients and how we can naturally optimize the physiological environment of a woman with PCOS who is trying to conceive, as well as improve her chances of successful conception, a healthy pregnancy and a healthy baby.
Donna R Chizen
University of Saskatchewan, Canada
Title: A practical approach to the clinical management of polycystic ovary syndrome (PCOS)
Biography:
Donna R Chizen completed her BSc (Genetics) in Guelph Ontario, MD at McMaster Medical School in Hamilton, Ontario, FRCSC in Obstetrics & Gynecology at the University of Saskatchewan, Saskatoon, Saskatchewan, and Reproductive Endocrinology and Infertility (REI) founder status was granted in 2012. She has an academic, clinical practice and research program at the Department of Obstetrics, Gynecology and Reproductive Sciences, Royal University Hospital, College of Medicine, University of Saskatchewan, Saskatchewan. She is the Andrology Laboratory Director and Postgraduate Faculty Representative for REI. She has published more than 23 papers in peer reviewed journals.
Abstract:
As health care providers we need to make use of opportunities to engage women with PCOS to be involved in the management of their health. There is a tendency to address each presenting symptom as they turn up and miss opportunities to motivate healthy lifestyle practices that will improve symptoms and prevent future problems and disease. How and when can we motivate change? Teaching about the pathophysiology of PCOS will provide women with a global understanding about why symptoms such as weight gain, irregular bleeding and anovulation occur. The pathophysiology becomes more meaningful when personalmetabolic test results are translated to provide reasons to make changes. Theunique and ideal times to motivate women to be involved with the management of their health and the future wellbeing of their families occurs first at the time of diagnosisand again when problems need to be addressed. PCOS is often poorly understood by patients. Women believe that they have pathological ovarian cysts. The relationship between hyperinsulinemia and hirsutism, anovulation, diabetes and cancer is not appreciated. It is important to educate women to understand how lifestyle changes may offset hyperinsulinemia. Evidence based management of PCOS will be reviewed. Clinical cases will illustratetimes when women have common, significant presenting complaints. Practical management strategies will be offered that can help to motivate healthy changes & improve the pathogenesis of women’s journeys with PCOS.
Biography:
Amal A L Mulla has completed her Masters in Infertility in 2004, from Ain Shams University, Cairo and had 2 memberships from Royal college of Obstetrics & Gynecology in United Kingdom in 2009 and Royal College of Physician in Ireland in 2009. She is a Consultant in Obstetrics, Gynecology and infertility in Dubai Health Authority. She is a Member in Endometriosis Leak in UAE and member in Embryology club. She has published many papers in reputed journals. aaalmulla@dha.gov.ae
Abstract:
Polycystic ovary syndrome (PCOS) is a condition with a range of reproductive and metabolic features that affect 4-18% of reproductive age group, and subsequently affect the quality of life. Underproduction of estrogen and over production of androgen (testosterone, dehydro epiandrsterone and androstendione) by the ovaries can result in a number of additional clinical features, including tiny cysts on the surface of the ovaries and hair and skin symptoms. Women with PCOS and related disorders comprise a large proportion of women undergoing induction of ovulation for infertility therapy. The major reproductive adversity facing these patients is their elevated risk of endometrial cancer. Unopposed estrogen exposure probably contributes to this risk. Women with PCOS who become pregnant are at higher risk than those without PCOS of developing gestational diabetes or suffering a first – trimester spontaneous abortion.
Jae Yen Song
The Catholic University of Korea,South Korea
Title: Copy number variation in pelvic endometriosis
Biography:
Dr Jae Yen Song has completed his PhD at the age of 32 years from The Catholic university of Korea. She is the assistant professor of he Catholic university of Korea. She is committee member of many Korean associations and societies. She has published more than 35 papers in reputed journals and has been serving as an editorial board member of repute. She recieved Best oral presentation award of the Korean Society of Menopause, Best poster presentation award of Korean Association of Obstetrics & Gynecology Shan S. Ratnam – Young Gynaecologist Award et al, and research funds.
Abstract:
Samples consisting of 673 controls and 65 patients with Stage Ⅲ,Ⅳ endometriosis were used. The average age of subjects was 41.2 ± 11.6 in controls, 35.2 ± 8.0 in patients with Stage Ⅲ endometriosis and 34.5 ± 8.3 in patients with Stage Ⅳ. In CNVR of 1q21.3, there was no coding gene and the frequency of copy number loss CNVs was significantly lower in endometriosis patients compared to controls (p<0.028). In CNVR of 1p13.3, GSTM1 gene was positioned and the frequency of copy number gain CNVs was significantly higher in endometriosis patients than controls (p<0.038). It was found through Genomic qPCR that 1q21.3 CNVs had a significant difference in an independent replication set as well. While 20 out of 42 controls had deletion with the intensity ratio of 0.5 or less, only 9 out of 37 patients showed deletion (p=0.032). The average signal intensity ratio of controls was also lower than that of cases (0.6 versus 0.8). When it comes to CNVR 1p13.3, the average signal intensity ratio of patients was higher than that of controls (3.7 versus 3.0) and the frequency of copy number gains (intensity ratio ≥ 2) was higher in patient group (19 out of 37) than control group (16 out of 42). However, there was no statistical significance (p=0.235). This study identified two CNVRs for endometriosis. 1q21.3 and 1p13.3 could be a potential target for screening and diagnosis of pelvic endometriosis.
Xia Hexia
Obstetrics and Gynecology Hospital of Fudan University, China
Title: Preconception sex-hormone binding globulin (SHBG) as a valuable predictor for gestational diabetes mellitus in infertile Chinese women with polycystic ovary syndrome
Biography:
Xia Hexia has completed her MD from Fudan University. She is pursuing her Doctoral studies in Fudan University and also working as a Doctor in charge of Ob & Gyn Hospital of Fudan University. She has published more than 7 Chinese papers and 1 English paper in reputed journals. xhx0101@hotmail.com
Abstract:
We aim to elucidate whether preconception SHBG levels are predictive of GDM in women with PCOS. A prospective cohort study was conducted between January 2010 and December 2013 in Ob & Gyn Hospital of Fudan University. A total of 94 infertile Chinese women treated with ovulation induction were recruited and then prospectively followed up until 6 weeks after delivery. Serum SHBG levels before conception was measured. Diagnosis of GDM was based on a 2-hour, 75 g oral glucose tolerance test (OGTT) performed between 24 and 28 weeks of gestation. We examined the incidence of GDM and plotted a receiver operating characteristic (ROC) curve to assess discrimination. We found that 31(32.98%) were diagnosed with GDM in the 94 pregnant PCOS women. The SHBG levels in women with GDM were (41.5±37.5) nmol/L, significantly lower than (123.7±95.7) nmol/L in those without GDM (P=0.000, and P= 0.041, even after BMI was adjusted). And the area of insulin under the curve (IAUC) in GDM group was (389.6±153.7) mIU/ml, significantly higher than (252.4±93.3) mIU/ml in the non-GDM group (P=0.000, and P= 0.003, even when BMI was adjusted). The area of SHBG and IAUC under the ROC was 80.8% (95% confidence interval [CI] 0.692- 0.925, P=0.000) and 0.786 (95% CI 0.656- 0.916, P=0.001). The optimal cut-off value for detecting GDM was a SHBG ≤37.26 nmol/l and an AIUC≥313.42 mIU/ml. SHBG associated with IAUC predicted the risk of GDM with a sensitivity and specificity of 77.8% and 77.5%. We concluded that SHBG levels before conception might be a valuable predictor of GDM in pregnant women with PCOS.
Biography:
Dr. Anita Mani is a renowned infertility specialist in south India with 15 years experience in ART (Assisted Reproductive Technology). She completed MRCOG from Royal College of Obstetrician and gynecologist, London and worked in UK for 5 years. She believes in scientific and ethical practice and is currently the director of Gift Gyno IVF Centre, Cochin and Bangalore. Apart from advanced laparoscopic surgeries, she is also an expert in various ART techniques including IVF, IUI, ICSI, donor egg / sperm and surrogacy. Her proficiency is in genetic abnormalities and high-risk pregnancies.
Abstract:
PCOS is a chronic condition, affecting 3 to 20 % population, of which 70 % remains undiagnosed. Reproductive symptoms of PCOS are anovulation, sub fertility and hyperandrogenism. Metabolic disorders include glucose intolerance, type 2 Diabetes and CVD. Depression and anxiety are found in some patients. Life style changes including diet, exercise and weight loss should precede any pharmacological intervention. Even a 5% loss of body weight will reduce insulin resistance and circulating androgens, resulting in spontaneous ovulation and relief of symptoms. Behavior change techniques should target optimal weight. Protocols should be provided to clinicians, to assess CVD risks considering obesity, physical inactivity, smoking, dyslipidemia, hypertension, glucose intolerance and type II diabetes/family history. Clinicians should also look for sleep apnea symptoms. Pharmacological indications includes, gestogens to induce periods in severe oligomenorrhea patients to reduce risk of endometrial hyperplasia /cancer. Insulin-sensitizing agents does not seem to have long-term benefits. Weight reduction drugs reduce hyperandrogenaemia in selected patients. Laparoscopic ovarian drilling will induce ovulation in 60% of the subjects for 20 years. When weight loss strategies fail, morbidly obese women can benefit from bariatric surgery. Psychological issues like depression and anxiety must be screened assessed and referred to professionals. Creating public health awareness on healthy eating and the necessity of regular exercise and including them in school curriculum is needed. A multidisciplinary approach involving a trained team of physicians, dieticians, exercise specialists and counselors is needed in long-term management of PCOS.