Collab Founder and Mother of Three, Dr. Thalia Segal Overcame PCOS Fertility Challenges and So Can You

September is Polycystic Ovary Syndrome (PCOS) awareness month. Chances are you or someone you know has PCOS - which impacts 1 in 10 women –  and can lead to infertility and health consequences. What exactly is PCOS, how can you get a proper diagnosis if you think you have it, what is the treatment, and how will it impact your fertility?  In this post, in addition to sharing her empowering journey overcoming PCOS, Dr. Thalia Segal, the founder of the Walnut Creek Fertility Clinic and IVF lab Collab Fertility, will answer these questions and more.

‍As a medical student in my 20s, I struggled with irregular periods and acne. My aunt, Dr. Betty Nelly Szlachter, MD, a reproductive endocrinologist in New York City, accurately diagnosed me with PCOS. She told me that without treatment, I could have trouble conceiving someday. She also explained the metabolic life-long risks associated with PCOS, such a diabetes and cardiovascular disease. Because I was not trying to get pregnant at the time, she prescribed birth control pills for me, which stopped the irregular bleeding and improved my acne. This diagnosis was one of the key factors thatdrove me to specialize in reproductive endocrinology and infertility.

I knew that one day I watned to have kids, so I was determined to learn all I could about the fertility challenges associated with PCOS and how to overcome them. As I delved further into PCOS and other infertility issues, I felt compelled to help other women facing the same diagnosis. This passion led me to complete a Reproductive Endocrinology and Infertility (REI) Fellowship and earn dual board cerficiations in REI and Obstetrics and Gynecology.

PCOS can be a difficult diagnosis, but it is treatable. Below, I’ll provide key information about PCOS, along with answers to the most common questions I get about it. If you suspect you have PCOS, whether or not you are planning to become pregnant in the future, please don’t hesitate to schedule an appointment with us. We are here to support you.  

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What is PCOS?

Polycystic ovary syndrome (PCOS) is a common condition that affects up to 1 in 10 women. PCOS is a genetic, hormonal, metabolic, and reproductive disorder and one of the most common endocrine (hormone) disorders. If left untreated, in addition to infertility, PCOS can lead to lifelong complications including psychosocial disorders, type 2 diabetes, cardiovascular disease, and endometrial cancer. During pregnancy, women with PCOS have an increased risk of miscarriage and a higher risk of gestational diabetes and preeclampsia.

In women with PCOS, numerous tiny fluid-filled sacs, called cysts, develop along the periphery of the ovary. These cysts, known as follicles, hold immature eggs. Because of hormonal imbalances, the eggs fail to mature consistently, resulting in cycles where ovulation does not occur.

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What causes PCOS?

The exact cause of PCOS remains unclear, but it’s believed to result from multiple factors. There have been reports of several family members being affected, suggesting a possible genetic link. Insulin resistance may also contribute, as elevated insulin levels can lead the ovaries to produce higher amounts of androgens, which are male hormones. This imbalance can disrupt the hormonal feedback required for ovulation to occur. The surplus of androgens can manifest in symptoms such as acne, male-pattern hair loss, and increased hair growth in areas like the chest and chin.

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What are the symptoms of PCOS, and how is PCOS diagnosed?

You should see a doctor if you are experiencing any of the signs and symptoms listed below. And the sooner, the better.

Common signs and symptoms of PCOS include:

• Irregular menses: fewer than nine periods a year or cycles that are more than 35 days apart, random bleeding every two weeks, heavy bleeding for many days, or just a bleeding pattern that is all over the place.
• Acne
• Excess facial and body hair
• Male pattern hair loss
• Small cysts in ovaries
• Insulin resistance
• Weight gain
• Infertility

According to a set of guidelines called the Rotterdam criteria* for diagnosing PCOS, two out of the following three must be present for a PCOS diagnosis:

• Oligo-anovulation: An irregular menstrual cycle, such as having periods more than 35 days apart or fewer than nine menstrual periods per year
• Hyperandrogenism: Clinical or biochemical signs of androgen excess
• Polycystic ovaries: At least 12 follicles in a single ovary that are 2–9 mm in diameter or an ovarian volume greater than 10 cm³ in at least one ovary

It's very important to note that when diagnosing PCOS, your doctor should rule out other diagnoses that could cause hyperandrogenism or ovulatory dysfunction.

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I have PCOS. Does this mean I'm infertile?

Despite its challenges and prevalence, with proper diagnosis and treatment, many women with PCOS can successfully conceive and have healthy pregnancies and healthy lives. As a mother of three young boys who navigated my own journey through PCOS and fertility, I am a testament to this possibility.

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What is the best treatment for PCOS when you’re trying to conceive?

If you know you have PCOS you should seek help immediately. Don’t wait 6 months trying as typically recommended for women who are attempting to conceive for the first time. At Collab, our fertility assessments include preconception blood tests, a semen analysis for the male partner, and an evaluation to ensure that your fallopian tubes are open. We will also check for PCOS and investigate other potential reasons for anovulation (or not ovulating). Once we rule out other issues and diagnose PCOS, the first line of treatment is a pill called letrozole (Femara). Letrozole lowers systemic estrogen levels, so your pituitary can start to produce follicle-stimulating hormone (FSH) and luteinizing hormone (LH). In turn, the ovaries are stimulated to grow a dominant follicle, which will ovulate.

It’s important to take a urine pregnancy test each month before you start a new round of letrozole because it’s safe to help you conceive, but it’s not safe if you’re already pregnant. We typically start at the lowest dose, one 2.5mg tablet started on cycle day 2 or 3 for five days. The next step is to track your ovulation with an ovulation predictor kit and have timed intercourse.

When I decided to have my first child, this treatment worked, and I got pregnant during the first month of taking letrozole. With my third child, I was older and I did experience a chemical pregnancy and it took 6 rounds of letrozole to finally achieve a healthy pregnancy. This highlights the decline in egg quality as we age, regardless of PCOS. I now have three healthy and lively little boys.

In summary, I tell my patients with PCOS who want to conceive that they can get pregnant at home with letrozole, ovulation kits, and timed intercourse!

“I just had a patient with PCOS who had been trying to get pregnant for a year when she finally decided to come and see me. I prescribed her letrozole and sent her home with an ovulation kit. We just did an ultrasound confirming she is pregnant. She and her partner are thrilled!”

That being said, here at Collab, we understand that everyone is unique. We will take our time to get to know you and understand your fertility status to create a personalized treatment plan that offers you the best chances of success.

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What lifestyle changes can help ease the symptoms of PCOS?

From doing comprehensive research on this topic, here are the top five lifestyle tips:

• Avoid processed and sugary foods
• Try to cook at home and eat real food
• Try to pick low glycemic index foods
• Start inositol vitamin supplements
• HITT type exercises are great for weight loss and strength training
  

Everyone trying to conceive should be on a prenatal vitamin with at least 1,000mcg of folic acid. This has been shown to improve egg quality as well as prevent neural tube defects in the developing baby.

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What is the treatment for PCOS when you’re not trying to get pregnant?

If you have PCOS and you're not trying to conceive and are not experiencing regular ovulation, it’s crucial to be on some form of combined hormonal treatment because your body isn't producing progesterone, and you could be at risk for uterine cancer.

Here’s why: In a typical menstrual cycle, estrogen levels rise during the first half, called the follicular phase. After ovulation, your body produces progesterone, which helps protect your uterus from cancer. Regular exposure to progesterone is essential. Without ovulation, you have no progesterone, leading to unopposed estrogen in the uterus, which can increase the risk of hyperplasia and endometrial cancer.

It’s very important to know that if you haven't had a regular cycle for over a year and you are overweight, you are at an even higher risk for endometrial cancer. So, it's really important to ask your doctor to do an endometrial biopsy to make sure that you don't have cancer or pre-cancer.

Also important: some women in their 40s with PCOS start to have regular periods as egg quantity declines. And just because you have PCOS doesn't mean you are infertile. If you don't want to get pregnant, you should be on some form of contraception.

After each pregnancy, I went back on birth control pills to prevent endometrial hyperplasia and uterine cancer. I encourage women to talk to their doctors about ongoing treatment.

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Final Thoughts from Dr. Segal

I’m grateful for the privilege I had in my 20s to have access to an exceptional doctor—my aunt—who was skilled in diagnosing and treating PCOS. Throughout my career as an OB-GYN and Fertility Specialist, I've seen how untreated PCOS can lead to infertility and other serious health problems and how frequently it is misdiagnosed. I’ve also had the honor of helping hundreds of women navigate a PCOS diagnosis and have healthy pregnancies. This experience drives my commitment to offering evidence-based fertility care through my East Bay clinic and IVF lab, Collab Fertility.

Do you think you may have PCOS? Want advice on your path to parenthood? Thinking about freezing your eggs or IVF? Struggling to get or stay pregnant? Just want to learn more about fertility treatments? Make an appointment today and visit us at our state-of-the-art fertility clinic and IVF lab. We believe that everyone has a right to evidence-based fertility care, and we are here to guide and support you in making the most informed decisions for your family-building journey while prioritizing your physical and emotional well-being. We welcome and celebrate all kinds of family structures.

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^{*The Rotterdam criteria were established in 2003 at a conference sponsored by the American Society for Reproductive Medicine and the European Society for Human Reproduction and Embryology.}