Ronald F. Feinberg, MD, PhD

[[{"type":"media","view_mode":"media_crop","fid":"28595","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_4684356248471","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"2916","media_crop_rotate":"0","media_crop_scale_h":"251","media_crop_scale_w":"180","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"line-height: 1.538em; float: right;","title":"","typeof":"foaf:Image"}}]]Reproductive endocrinologists should be contemplative when offering and performing elective egg freezing, a medical procedure using clinical and lab techniques similar to in-vitro fertilization (IVF). While many women believe they will have greater control over their future reproductive options through elective egg freezing, some aspects of these technologies could impact their decisions and overall expectations.

Our Hippocratic Oath states to first, do no harm (

). As a corollary to our oath-and as ethical physicians-we must accurately inform our patients about the potential risks and benefits of all care we provide. Here are some things to consider:

1. Egg Freezing Isn't Insurance for Future Fertility

Insurance means you are guaranteed to receive a financial payout or service to compensate you for a loss if a bad event occurs. Although egg freezing is no longer considered experimental by the American Society for Reproductive Medicine, egg freezing as it exists today does not protect women from infertility nor does it guarantee them a pregnancy in the future.

2. Success Rates With Freeze-Thaw Techniques Vary Significantly

Many IVF clinics have little or no experience with thawing eggs or, for that matter, proving that their freeze-thaw techniques can produce healthy embryos and babies in a statistically valid fashion. In other words, most IVF clinics do not currently have sufficient data to show a consistent track record of generating pregnancies from eggs they've both frozen and thawed.

3. Egg Freezing Success Rates Between Clinics Are Difficult to Verify

There is no current central registry or authority where IVF clinics can submit egg freeze and thaw results, or sites where patients can independently verify this data. Between 5% and 10% of women have eggs that don't survive well with current freeze and thaw technologies. The ability to compare individual freeze and thaw data from IVF clinics to national and international averages would be an invaluable tool for these clinics and their patients.

4. Statistics Play an Important Role in an Individual Patient’s Success

Before pursuing egg freezing, it is vital to understand what statistical chances one egg or group of eggs has in leading to a pregnancy in the future. For women in their 20s with a good ovarian reserve, five to eight unfertilized frozen eggs could potentially yield an 80% to 90% cumulative chance of achieving a pregnancy. This information comes from frozen donor egg data, where young egg donors are carefully selected for their presumed high fertility potential.

However, for older women-many of whom are contemplating egg freezing-the statistical outcome is often not as reassuring. How many eggs are actually needed to provide a reasonable chance of future pregnancy for a 35-year-old woman is hard to know with currently available data. Based on IVF statistics, the need could be as high as 20 to 30 eggs, or even higher.

Finally, regardless of a woman’s age, a high percentage of eggs obtained from ovarian stimulation are abnormal. With this information, it’s difficult to predict what insurance or reassurance egg freezing provides.

5. Consider Embryo Freezing Before Egg Freezing

IVF clinics are increasingly perfecting techniques to culture fertilized eggs in the blastocyst stage, which can allow reproductive endocrinologists to use diagnostic tools such as pre-implantation genetic screening (PGS) for chromosome abnormalities and time-lapse analysis of embryo growth. Individual blastocysts cryopreserved by vitrification and warmed properly for embryo transfer lead to healthy pregnancies 55% to 65% of the time if the embryo has a normal chromosome count.

As women get older, the quantity of normal blastocysts produced after each IVF cycle drops dramatically, explaining why the egg to baby ratio goes up with age. For women who are interested in future pregnancy, embryo creation and cryopreservation is a more proven option, as it gives direct and immediate information about future pregnancy potential.

However, by creating embryos with a male partner, women share ownership of their embryos with that partner unless they use an anonymous sperm donor. Some women may, therefore, choose to electively freeze both embryos and unfertilized eggs to help preserve future fertility.

6. Egg Retrieval Has Risks and Unintended Consequences

For some women, egg retrieval can commonly cause mild internal bleeding and the potential for scar tissue formation around the ovaries and fallopian tubes. Egg donors are routinely told this could interfere with future natural conception by preventing an otherwise normal egg from entering the fallopian tube after ovulation.

For IVF patients who have already committed to bypassing their tubes via IVF, the concern about tubal scarring is not as high. But for women looking to electively freeze their eggs, the process could worsen their future chances of conceiving naturally.

7. Predicting Current or Future Fertility Is Difficult

Numerous factors or diseases can impact male and female fertility, but predicting any particular woman's current or future fertility is a challenge. Many fertility problems for women are "hidden," particularly in common issues like tubal disease or endometriosis. Ovarian aging can be partially assessed, but it is not known to what degree current ovarian reserve testing predicts future fertility.

Furthermore, a woman may have perfectly intact fertility but ultimately attempt pregnancy in the future with a man who has poor sperm numbers or quality. IVF could then become necessary for male infertility factors, which might be preferably performed with fresh eggs.

8. The Ideal Age for Egg Freezing Is Unknown

While fertility and egg freezing conversations commonly center around ages like 30, 35, and 40 years, the optimal age to freeze eggs is really not known. Ovarian reserve testing could potentially help provide information about the number of eggs obtained during an ovarian stimulation cycle. This information could then impact the dose of medications prescribed and broach discussions about egg freezing sooner rather than later if the results are less than optimal. However, it is not truly known whether ovarian reserve testing should be utilized in this manner.

9. The Costs of Egg Freezing Are High-and Climb Higher Over Time

Egg freezing requires a significant monetary commitment for medical care to create the eggs, medications to stimulate the ovaries, and laboratory costs to freeze the eggs. In addition, there are ongoing fees to store the eggs properly in a secure and monitored liquid nitrogen freezer.

There are also substantial fees to consider if the eggs are actually thawed and fertilized. Depending on the patient’s needs, it may more cost-effective to save these funds for a future IVF cycle.

Although egg freezing can and should be part of family building discussions, there is no current scientific evidence that elective egg freezing will enhance fertility for most women as they get older.

As an extreme example, one could argue a woman who freezes her eggs at age 25 to use at age 45 will most likely add to her future fertility options. However, for a woman at age 35 who uses her frozen eggs at age 39, the chances of success are less clear when compared with attempting conception on her own, or even pursuing IVF with her fresh eggs.

Currently, I recommend that all gynecologists and reproductive specialists keep a close watch on IVF and egg freeze technologies, which are destined to improve over time. All reproductive health care providers, including OB/GYNs, should openly discuss fertility and family building goals with their patients. In addition, women and men who strongly desire children should start setting funds aside now for some financial insurance just in case fertility challenges arise for them in the future.

Articles

Don't overpromise when it comes to elective egg freezing. It doesn't protect against infertility nor does it guarantee a future pregnancy.

Elective Egg Freezing: 10 Thoughts From an REI

Many women present with significant ovulation problems that may indicate an underlying issue with their metabolism and nutrition. The common symptoms that may indicate polycystic ovarian syndrome (PCOS) include very irregular or absent periods (100%), large and cystic ovaries (95%), obesity (75%), problems with excessive body hair growth and/or acne (70%), cholesterol and/or triglyceride abnormalities (70%), and a strong family history of diabetes, hypertension, heart diseases, obesity, and irregular periods (100%).

It has been demonstrated that PCOS is due to an underlying metabolic problem known as insulin resistance. When the body's muscle and fat tissues become resistant to insulin action, the pancreas produces increasing amounts of insulin, leading to very high insulin levels. The high insulin levels tend to produce food cravings, particularly in the form of carbohydrates, making the cycle continue. High insulin levels make weight loss virtually impossible, and tend to promote weight gain. High insulin levels also drive the ovary to produce high amounts of male hormone (androgens), and cause follicles to literally die before they release mature eggs. As such, multiple cysts form in the ovaries, and no healthy eggs are released. Thus, infertility and a lack of ovulation are the hallmarks of PCOS.

 take the issue of PCOS extremely seriously, with clinical research efforts targeted towards the insulin resistance issue. It is possible to provide a detailed evaluation and treatment regimen for women with PCOS, and the prognosis for achieving a healthy pregnancy and a healthier lifestyle is good.

Many women present with significant ovulation problems that may indicate an underlying issue with their metabolism and nutrition.

Reproductive Associates of Delaware Fact Sheet What is polycystic ovarian syndrome (PCOS)?

Much has changed in the fertility world since 1935, when two Chicago gynecologists - Dr. 

 Irving Stein and Dr. Michael Leventhal - first described an unusual cluster of symptoms in seven of their patients1,2.  To the doctors, it seemed more than coincidental that these women manifested absent menstrual periods, hirsutism (excess hair growth on the face, chest, abdomen, and thighs), and enlarged ovaries.  As astute surgeons of that era, Drs. Stein and Leventhal performed abdominal surgery on these women.   Fortunately, no cancer cells were found but under the microscope, portions of the enlarged ovaries contained multiple simple cysts.  One unexpected benefit of surgery was the resumption of menstrual cycles, and even some pregnancies!

Gynecology textbooks have classically viewed Stein-Leventhal syndrome, (also called polycystic ovary syndrome, or PCOS), as a curiosity, with no apparent cause or cure.  What is most interesting,  however,   is  how  common  this problem has become, and how dramatic an impact it has created for women's health and reproductive function.  Even more significantly, we now know that it is shortsighted for healthcare providers to view Stein-Leventhal/PCOS as simply an ovarian disease or disorder.

The evidence has become clearer to many endocrinologists that fertility and ovarian function are profoundly impacted by metabolism, nutrition, activity, and stress.  While the ovaries are genetically programmed to house and protect thousands of healthy eggs, many other organs in a woman's body are responsible for initiating, and potentially interfering with, regular ovulation.  Organs and tissues such as the brain, pituitary, liver, pancreas, muscle, adipose, and adrenal glands are part of an interconnected fertility hormone system we call the glandular internet.  For women, these seemingly diverse parts of the body can have dramatic effects upon ovarian function and regular, healthy ovulation.

Ovulation disruption (or anovulation) has become the #1 worldwide cause of infertility3.  For the majority of women who manifest ovulation disruption, an understanding of the other aspects of Syndrome O - Ovarian confusion and Overnourishment - may help explain the roots of their fertility problem.  Ovarian confusion implies that improper production of key hormones - androgens ('male' hormones) and estrogens ('female' hormones) - disrupts many of the tiny follicles, or egg incubators within the ovaries.  Polycystic or 'poly-follicle' ovaries can result even when small imbalances in ovarian androgens occur.  Depending on other metabolic factors, many women have accompanying undesired problems associated with slight androgen excess - acne and/or hair growth on the face, chest, abdomen, and thighs4.

Why are the ovaries confused?  For years, gynecologists and endocrinologists have pondered this question.  However, as far back as the days of Drs. Stein and Leventhal, some astute physicians hypothesized that metabolism hormones such as insulin could be involved.  In more recent years, both clinical and basic researchers have unequivocally established the link between ovarian function, ovulation, and the insulin family of hormones.  Along this line of thinking, it has also become clearer that metabolic states associated with insulin overproduction have a direct impact on female fertility3,4.

Overnourishment is the simplest and most direct way to explain how 20th century societal changes have driven the rising current epidemic of insulin overproduction states - obesity, type II diabetes, and insulin resistance.  In the 1970s, Dr. Gerald Reaven described the widespread heart, vascular, and general health detriments of insulin overproduction, calling the problem Syndrome X.  As a keynote speaker at the recent 2001 PCOS Association Conference, Dr. Reaven, an emeritus Stanford University professor, spoke about insulin overproduction in women.  However, recent books about Syndrome X don't truly delve into female reproductive and fertility concerns5.  For this reason, Dr. Feinberg conceived of Syndrome O as a tool for teaching his patients about the modern phenomena linking insulin, metabolism, and fertility.

Eighty to ninety percent of women with Syndrome O are above their ideal body weight when they first seek fertility care.  Most women with Syndrome O take in more calories than their bodies require (our definition of overnourishment), and very few have a regular exercise routine.  Excessive carbohydrate intake, along with foods containing partially hydrogenated oils (i.e. trans fats) probably exacerbate insulin overproduction6.  Other aggravating factors appear to be modern 20th/21st century societal conveniences - motorized transportation, telecommunications, and computerization (including the Internet) - most of which necessitate inactivity for long periods of time7.  In 1935, Drs Stein and Leventhal described merely seven cases of their new Syndrome, identified after many years in medical practice.  In 2001, the Polycystic Ovary Syndrome Association (

) estimates that a staggering 5 to 10 million women in the United States are now affected.

Most readers of AIA newsletters, and this article in particular, have likely been prescribed one or more medications to promote ovulation.  Clomiphene citrate, an oral compound, has been the mainstay of ovulation induction therapy for many years8.  It works by tricking the brain and pituitary gland into producing higher levels of follicle stimulating hormone (FSH), thus promoting follicle growth.  Both gynecologists and fertility specialists prescribe clomiphene, but there are many different nuances to cycle monitoring which can help achieve a pregnancy.  It is beyond the scope of this article to review all the "tricks of the trade" associated with clomiphene usage.  However, combining clomiphene with hCG injection, and/or intrauterine inseminations may improve the cycle outcome.  With repeated ovulatory cycles not resulting in conception, a close assessment of other potential problems (i.e. fallopian tube disease, pelvic adhesions, male factors, and female metabolic factors) is strongly suggested.  Gonadotropin injections are commonly prescribed when clomiphene has failed to induce ovulation.  Conservative "step-up" gonadotropin protocols should be utilized (only by experienced fertility specialists), to minimize the risks of multiple pregnancy and ovarian hyperstimulation syndrome3.

With clinical studies demonstrating the impressive impact of insulin-lowering agents upon ovarian function and ovulation, Reproductive Associates of Delaware was one of the first fertility centers in the U.S. to prescribe troglitazone (Rezulin, Parke-Davis) to women with clomiphene-resistance and a strong desire to avoid gonadotropin injections.  The initial results were impressive.  Troglitazone, with or without clomiphene, restored ovulation in 13 of 14 women, and 10 successful pregnancies resulted within 4 months of therapy.  Troglitazone is no longer on the market, due to very rare but lethal liver abnormalities.  Two chemically-related medications, rosiglitazone (Avandia, GlaxoSmithKline) and pioglitazone (Actos, Takeda and Lilly) are FDA-approved for type II diabetes, but have not been tested for Syndrome O-related anovulation.  Another insulin-lowering agent, metformin (Glucophage, Bristol-Myers Squibb), is now widely prescribed for both type II diabetes and insulin resistance, although it is only FDA-approved for  type II diabetes.

As a short term adjunct to help promote ovulation induction, published studies incorporating metformin are very encouraging9,10.  For long term usage related to insulin resistance and Syndrome O, the potential benefits and risks are not clearly established.  Furthermore, the impact of consistent and diligent insulin-lowering lifestyle strategies appears quite favorable in halting the progression of Syndrome O 11.

There is no magic cure or miracle pill for Syndrome O.  Each woman’s treatment plan will vary with her symptoms and specific concerns – metabolic, cosmetic and/or reproductive.  Therefore, it is essential to seek medical care from a physician who understands the whole-body complexities of Syndrome O, and who is willing to individualize care and treatment options.  Finding a physician who is both knowledgeable and interested in providing quality Syndrome O care can be challenging, but rewarding.  Fortunately, in today’s environment of accessible support networks and increased awareness, the likelihood of finding top-flight Syndrome O fertility care is better than ever.

Here are some tips for organizing your approach to Syndrome O fertility care:

Develop and prioritize a personal Syndrome O symptom     inventory

Determine what types of specialists you may need

Seek referrals for care from reliable sources -     primary care health providers, trustworthy websites, community physician     directories, other Syndrome O patients

Fellowship trained Board-certified and Board-eligible     reproductive endocrinologists tend to be the most updated about fertility     care as it relates to insulin overproduction.

Stay positive and do your part to optimize your health

We believe that while many physicians do offer high quality options and services to women with Syndrome O, your success with fertility treatment will greatly depend on YOU!  In Part II of this article, we will delve into more details regarding insulin-ovary-fertility connections, and how specific insulin-busting strategies can be incorporated into your life.  We will also explain the dramatic impacts of nutrition and exercise upon Syndrome O symptoms, and encourage you to find your own personal approaches.

There is no one diet, no one exercise plan, and no one book or article that holds all the answers.  Finding what works for you may take some trial and error.  Educate yourself, don’t be afraid to experiment and, most importantly, keep a positive attitude!

Coming in Part II of Getting Pregnant When Syndrome O Gets In The Way:

Calming the Insulin Storm. . .  For Your Fertility's Sake  
Get Real. . .  And Get Strategic!  
Networks of Support

-Dr. Feinberg is a Board-certified reproductive endocrinologist, and the IVF Medical Director for Reproductive Associates of Delaware, located in Newark, DE on the campus of Christiana Care Health System.  He is also an Associate Professor (adjunct) in the Department of Obstetrics and Gynecology at Yale University School of Medicine.  Dr. Feinberg is currently writing a book entitled "Giving Your Fertility A Fighting Chance When Syndrome O Challenges You", to be published and released by Penguin Putnam in 2003.

, Inc., a non-profit 501c corporation committed to Education, Motivation, and Stimulation for women with Syndrome O and 'polycystic' ovaries.  She is a recognized national leader in the PCOS advocacy and support movement, serving as the Mid-Atlantic United States and International Chapter Development Coordinator for the PCOS Association.  She has been responsible for initiating 14 PCOSupport Chapters in 7 states.  She was recently appointed by the AIA to assist with PCOS Division Development.  Ms. Childers works as the Regional Coordinator of Child and Family Case Management for the Smoky Mountain Center, a mental health agency serving the area west of Asheville, NC. 

American Infertility Association Newsletter

1.   Speert, H (1980), Obstetrics and Gynecology in America: A History.  Baltimore: Waverly Press, 1980.

2.   Stein IF and Leventhal ML (1935).  Amenorrhea associated with bilateral polycystic ovaries.   Am. J. Obstet. Gynecol. 29: 181-91.

3.   Yen SSC, Jaffe RB, Barbieri RL (1999).  Reproductive Endocrinology: Physiology, Pathophysiology, and Clinical Management.  Philadelphia: WB Saunders Company, 4th Edition.

4.   Thatcher SS (2000).  PCOS: The Hidden Epidemic.  Indianapolis: Perspectives Press.

5.   Reaven, G, Strom TK, Fox B (2000).  Syndrome X: Overcoming the Silent Killer That Can Give You a Heart Attack.  New York: Simon and Schuster.

6.   Schlosser E (2001). Fast Food Nation: The Dark Side of the All-American Meal. Boston: Houghton Mifflin Company.

7.   Shimer P (1996).  Too Busy to Exercise.  New York: Barnes and Noble Books.

8.   Greenblatt RB, Barfield WE, Jungck EC, Ray AW (1961).  Induction of ovulation with MRL-41. Journal of the American Medical Association 178: 101-106.

9.   Nestler JE, Jakubowicz DJ, Evans WS, Pasquali R (1998).  Effects of metformin on spontaneous and clomiphene-induced ovulation in the polycystic ovary syndrome. N Engl J Med 338: 1876-80.

10. Vandermolen DT, Ratts VS, Evans WS, Stovall DW, Kauma SW, Nestler JE (2001).  Metformin increases the ovulatory rate and pregnancy rate from clomiphene citrate in patients with polycystic ovary syndrome who are resistant to clomiphene citrate alone.  Fertil Steril 75: 310-15. 

11.  Huber-Buchholz MM, Carey DG, Norman RJ (1999).  Restoration of reproductive potential by lifestyle modification in obese polycystic ovary syndrome: role of insulin sensitivity and luteinizing hormone.  J Clin Endocrinol Metab 84: 1470-74.

To the doctors, it seemed more than coincidental that these women manifested absent menstrual periods, hirsutism (excess hair growth on the face, chest, abdomen, and thighs), and enlarged ovaries.

Getting Pregnant When Syndrome O Is Getting In Your Way

Washington,       D.C. (AP), September, 2051. U.S. Surgeon General Michaela Smith       announced today that a major health and reproductive problem afflicting       millions of women for over a century has effectively been eradicated.       Known by various names - Stein-Leventhal disease, polycystic ovary       syndrome, and Syndrome O - this scourge had become the #1 cause of       female infertility and other gynecologic problems earlier in this century.       "Towards the end of the 20th Century it was recognized that fertility       and metabolic function were closely intertwined," noted Dr. Smith,       "And that eradication of Syndrome O necessitated a full scale assault       on the environmental insults of that era - dietary habits, processed       foods, sedentary modes of transportation, and electronic communications       and conveniences."

The       Surgeon General noted that when she started medical school in September,       2001, the curriculum was only partially geared towards teaching about       metabolism and disease. "I think American society really       started attending to its health at the beginning of this Century, as       events in the world prompted much more introspection and motivation,"       said Dr. Smith. "Out of necessity, democratic societies very       quickly adopted lifestyle habits of earlier times that were viewed as       quaint and out-of-date. For example, millions of people started       walking or bicycling to work, school, and stores to save precious oil and       natural gas. Countless others created community fruit and vegetable       gardens, even in metropolitan areas, as ways to assure that food sources       were fresh and plentiful. We garnered renewed respect for our       natural resources, and family activities were more focused on living and       learning from the land. It was an amazing transformation to witness,       but it probably saved countless millions from premature death and       disease."

Syndrome       O has emerged as a major women's health and fertility issue. From a       historical perspective, as described in Part I, the roots of Syndrome O       date back to the rare polycystic ovarian disorder first described by Drs.       Stein and Leventhal in 19351,2. In 2001, Syndrome O - defined as       the triad of Ovulation disruption, Ovarian confusion, and Overnourishment       - has become a leading scourge of reproductive health for millions of       women in the U.S. and around the world. In Part I we described the       link between Syndrome O and the insulin overproduction health problems       caused by Syndrome X. Based on this knowledge about insulin, we also       summarized medical strategies for overcoming ovulation disruption and       ovarian confusion.

Syndrome       O, believed to affect 5 to 10 million women, impacts directly upon       reproductive function, body image, and current and future health.

       As       we have witnessed this year, our environment and world can undergo rapid       upheavals and changes that require the adaptation of our attitudes,       intellect, and inner resolve. Using some old-fashioned American       ingenuity, now is the time for women and men to live up to the predictions       and hopes of a futuristic, but optimistic September, 2051 press release.       

Calming       the Insulin Storm. . . For Your Fertility's Sake

Insulin       is an incredible hormone. It keeps us alive by continuously and       efficiently shuttling sugar fuel into every cell within our bodies.       But too much insulin is harmful, particularly to women. Excessive       insulin, or hyperinsulinemia, causes women’s bodies to convert excess       sugar fuel into fat and, in short order, a vicious cycle of       ever-increasing insulin production commences. Hyperinsulinemia is       the body's way, or more specifically the pancreas' way, of compensating       for a deep-seated systemic process known as insulin resistance.

Insulin       resistance is caused by a dysfunction or uncoupling of one or more enzymes       responsible for insulin's action within cells. One reasonable theory       for the widespread initiation of insulin resistance in our society       suggests that chemically-modified lipids found in many foods, (i.e.       partially hydrogenated oils known as trans fats), make their way into the       lipid bilayers of cell membranes. When these foreign lipids perturb       the outer cell membrane, insulin can't bind to its cell membrane receptor       effectively3,4. This is analogous to an airplane trying to land on a       crooked runway. The result is ineffective insulin action for       shuttling glucose fuel into cells, and a compensatory hyperinsulinemia.       Many other studies have demonstrated defects of insulin-induced enzyme       cascades and glucose transport in tissues from women with ovulation       disruption and ovarian confusion5,6. The search for a genetic basis       for Syndrome O has yielded information about regions of genes that some       affected women may have in common, but a specific gene defect per se has       not been found7. Worldwide and diverse ethnic representation, along       with apparently normal fertility in parents and grandparents of Syndrome O       women, argues against a specific gene abnormality.

In       a woman’s reproductive system, the insulin family of hormones is       absolutely required for many organ functions that are uniquely female -       the nourishing and maturing of eggs, the preparation of the womb for       conception, and the maintenance of a healthy pregnancy. With       Syndrome O, improper levels of insulin hormones exert a harmful effect on       the female system - the ovaries become confused, egg release (ovulation)       is disrupted, and fertility and pregnancy are hampered. Thousands of       scientific articles have been written about the normal and not-so-normal       impact of insulin and related hormones - insulin-like growth factors -       in female reproductive processes8.

Part       I of this article described some of the insulin-lowering medications which       have been used to combat hyperinsulinemia for women with ovulation       disruption and ovarian confusion. These medications allow the       ovaries to adjust to a more normal insulin environment, with reductions in       androgen production and improved chances for follicular development and       ovulation. We believe these medications provide a short-term       metabolic jumpstart, but are skeptical about their longer-term ability to       "cure" Syndrome O. Consequently, it is imperative that all       women affected by Syndrome O consider making a personal and long-term       commitment to lifestyle strategies designed to overcome hyperinsulinemia.       Such strategies have proven highly effective in minimizing the risk of       developing type II diabetes9, an insulin resistance epidemic currently       affecting 20 million American women and men.

"I feel overwhelmed, and I need to be pointed in the right direction,”       is the universal battle cry of Syndrome O women. Whether justified       or not, we all feel overwhelmed at different times and many of us become       inefficient, depressed, and withdrawn when faced with too many tasks and       responsibilities. Women with Syndrome O have additional tough       challenges of lifestyle, health, and fertility to think about. We       believe: “If it is important to you, you will accomplish it,"       and here are the first few steps to consider:

1) Don’t panic. Help for Syndrome O comes through       education, determination, meditation, and a strong internal desire for       self-improvement and enhanced well being.

2) Start thinking. Imagine the unhealthy, insulin-spiking       daily junk calories that will not be missed, better quality       insulin-moderating foods that can be eaten without guilt, and important       insulin-busting opportunities for activity and exercise.

3) Begin living. Dr. Feinberg first presented the       concept of the Syndrome O Survival (SOS) StrategiesTM to his PCOSupport       group in Delaware, followed by a plenary presentation to the international       PCOS Association annual conference in Philadelphia in June, 2001. We       believe that the SOS Strategies provide a blueprint for a lifelong       fighting chance to improve fertility and health.

The SOS Strategies invoke 3 very important principles - Organization,       Optimization, and Offering. Like the legs of a strong and stable       3-legged stool, we believe that each of these three Strategies are equally       important to women with Syndrome O, leading to enhanced healthfulness and       happiness in their lives. This 3-pronged strategic approach is       balanced, and encourages equal devotion to each Strategy.

Within The SOS Strategy of Organization, it is recommended to:

1) Organize Your Goals and Desires. What do       you want to achieve in life? What are your strengths? What are       your talents? How do you envision yourself and your family in one year?       In five years? In ten years? Is your career or profession a       priority? How does time for family and friends fit in? Is       having a child or more children a strong desire? Are good health and       quality of life important?

2) Organize Your Schedule and Time. Evaluate every       hour of your 168 hour week. How many hours at work? How many       hours with family? How many hours at rest? How many hours at       chores? How many hours outside the house? Could you organize       your time in such a manner that there is sufficient time to devote to the       other Syndrome O Survival Strategies?

3) Organize Your Approach to Health Evaluation and       Treatment. Make lists of the Syndrome O symptoms that bother you the       most. Seek help from the right health care providers. Read and       learn everything you can. Come to initial consultations armed with       questions. Be prepared to arrange your life schedule to accommodate       treatments.

The SOS Strategy of Optimization provides an uplifting, positive       opportunity to focus on insulin-busting techniques:

1) Optimize Your Life Activities. Be pro-active       towards the life goals you identified in The Strategy of Organization.       Are you happy at work? Can you optimize your attitude and activities       to bring more joy to the job? Are you content at home with yourself       and your loved ones? Can you optimize your home life to bring       greater joy to yourself and your family? Can you optimize your       relationships with other friends and family?

2) Optimize Your Nutrition. Make lists of the foods       you like and dislike, and create personalized lists of the foods that are       Syndrome O healthy. Plan ahead to eat healthful and balanced higher       protein, lower carbohydrate meals on a regular basis. Set a       reasonable initial goal for weight loss, such as the “anyone can lose       5%” plan. Follow the “calories in = calories out” rule.       Water is your friend, but only when sugar-free. Ask family and       friends to respect your Optimized Diet goals, and ask them to help you       with your new optimism and determination.

3) Optimize Your Fitness. With an organized and       prioritized 168 hour per week schedule, you should be able to identify 5       hours devoted only to physical activity. Make lists of the physical       activities you enjoy - walking, bicycling, swimming, dancing, gardening       - and do any of the activities on the list for at least 5 hours/week.       That will burn one full day's worth of food calories, shifting the       “calories in = calories out” equation in your favor.

The SOS stool will surely topple if attention is not paid to The SOS       Strategy of Offering:

1) Offer Your Attention to Loved Ones and to Yourself. Do       you spend enough quality time with family or friends? Could this       time be spent in a more physically active way? Could quality time be       spent in a more nutritionally healthful way? Do you spend enough       time attending to yourself? By offering more attention to your own       self-improvement, it will become natural to offer compassion to important       people in your life.

2) Offer Your Time Outside the Home. There is a       whole community filled with important needs outside of your home.       Could you offer any special service? Are you active in your house of       worship? Is there a particular charity for which you could       volunteer? Does your local school need tutors? Does the local       school board need committee members? Is there an upcoming political       campaign that interests you?

3) Offer Your Assistance to Others with Syndrome O. A       crucial aspect to successful SOS Strategies is to teach others about the       personal approaches that have been helpful to you. No one woman will       follow the same path to success with the SOS Strategies.

Networks       of Support - Steps to Awareness

Thousands of women are already working hard to improve their physical and       emotional wellbeing, with the knowledge that their fertility, pregnancy,       and health depend upon it. There is no doubt that many Syndrome O       symptoms can negatively affect self-esteem and body image, particularly       when loved ones are confused and are trying to help. As such, it has       become clear to those of us in the Syndrome O / PCOS movement that       specific Steps to Awareness are vital for Syndrome O women and their loved       ones.

Many women find that sharing their experiences with others facing similar       challenges is the best way to stay motivated and on track to success.       This development of relationships with others comes in many different       forms, and the level of involvement depends greatly on the comfort zone of       each individual. The pace of acquiring Syndrome O awareness is       unique to each woman, but for those who find appropriate networks of       support, we have witnessed amazing patterns of increased consciousness and       personal empowerment.

Within this framework it has been our experience that each woman       experiences five steps to Syndrome O awareness:

 -- Individual Sadness and       Frustration: This typically begins before a woman is diagnosed or       treated for Syndrome O. She realizes that her body is not       functioning properly and she experiences many emotions tied to infertility       and diminished self-esteem. She does not understand what is       happening to her and is seeking answers.

 – Group Sadness and Support:       At this juncture, a woman finds there are others with Syndrome O who are       dealing with similar frustrations. She feels motivated to share her       feelings and to both offer and receive comfort from others "in the       same boat".

 – Group Enlightenment: Through       education and sharing, the woman and her support group begin to find       answers to their Syndrome O challenges. There is a feeling of       encouragement and a desire to share this enlightenment with others.       The Polycystic Ovarian Syndrome Association (PCOSA), now boasting       thousands of members, was formed in exactly this manner. Since 1997       the PCOSA has developed a support group network with chapters meeting       across America and internationally (

, a very informative and       comprehensive physician-reviewed women's health informational Website.

 – Individual Motivation: After       gaining the knowledge that she can make a difference in her own health,       along with the positive support of others, the woman is now motivated to       make changes, utilizing the SOS Strategies. Neither she nor her       doctor has all the answers, but she is ready to try!

 –       Discipline for Change: With continued support and with personal       motivation, the woman explores her lifestyle options, finds what works for       her, and develops the discipline to permanently implement the new       practices into her life. She knows that each day is an opportunity       to make the right decisions for improved health!

Acknowledge       the ongoing Syndrome O challenges in your life. With       self-improvement and compassionate medical care underway, women with       Syndrome O should revel in every small victory they achieve. Through       empowerment with the SOS Strategies, health and attitude will improve,       weight will drop, energy levels will increase, and the ovaries and       reproductive system will be given a break from the bombardment of excess       insulin hormones. Dr. Feinberg witnesses this transformation       everyday in his clinical practice; Lesa Childers promotes this philosophy       in her support groups. We find that when the SOS strategies are       implemented, fertility treatments are more efficient, and pregnancies turn       out healthier. To this end, we thank the American Infertility       Association for the opportunity to share this information and philosophy.

-Dr. Feinberg is a Board-certified reproductive endocrinologist, and the IVF Medical Director for Reproductive Associates of Delaware, located in Newark, DE on the campus of Christiana Care Health System. He is an Associate Professor (adjunct) at Yale University School of Medicine in the Department of Obstetrics and Gynecology. He was the Conference Medical Chair for the 2001 PCOSA Conference, and Chairs the PCOS Pavilion of obgyn.net. Dr. Feinberg is currently writing a book entitled "Giving Your Fertility A Fighting Chance When Syndrome O Challenges You", to be published and released by Penguin Putnam in 2003.

, Inc., a non-profit 501c corporation committed to Education, Motivation, and Stimulation for women with Syndrome O and 'polycystic' ovaries.  She is a recognized national leader in the PCOS advocacy and support movement, serving as the Mid-Atlantic United States and International Chapter Development Coordinator for the PCOS Association. She has been responsible for initiating 14 PCOSupport Chapters in 7 states, and was a contributor to Dr. Sam Thatcher's best-selling book about PCOS10. She was recently appointed by the AIA to assist with PCOS Division Development. Ms Childers works as the Regional Coordinator of Child and Family Case Management for the Smoky Mountain Center, a mental health agency serving the area west of Asheville, NC.

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2. Stein IF and Leventhal ML (1935). Amenorrhea associated with bilateral polycystic ovaries. Am. J. Obstet. Gynecol. 29: 181-91.

3. Mann GV (1994). Metabolic consequences of dietary trans fatty acids. Lancet 343:1268-71.

4. Lovejoy JC (1999). Dietary fatty acids and insulin resistance. Curr Atheroscler Rep 1: 215-20.

5. Dunaif A, Xia J, Book CB, Schenker E, Tang Z (1995). Excessive insulin receptor serine phosphorylation in cultured fibroblasts and in skeletal muscle. A potential mechanism for insulin resistance in the polycystic ovary syndrome. J Clin Invest 96: 801-10.

6. Dunaif A, Wu X, Lee A, Diamanti-Kandarakis E (2001). Defects in insulin receptor signaling in vivo in the polycystic ovary syndrome (PCOS). Am J Physiol Endocrinol Metab 28: E392-9.

7. Venkatesan AM, Dunaif A, Corbould A (2001). Insulin resistance in polycystic ovary syndrome: progress and paradoxes. Recent Prog Horm Res 56: 295-308.

8. Yen SSC, Jaffe RB, Barbieri RL (1999). Reproductive Endocrinology: Physiology, Pathophysiology, and Clinical Management. Philadelphia: WB Saunders Company, 4th Edition.

U.S. Surgeon General Michaela Smith announced today that a major health and reproductive problem afflicting millions of women for over a century has effectively been eradicated.