Trying to Conceive with PCOS

PCOS symptoms can make it difficult to get pregnant. Learn how PCOS impacts fertility and treatment options for trying to conceive with PCOS. 

By OBGYN and fertility expert Dr. Kenosha Gleaton

Trying to conceive (TTC) already comes with its own set of challenges without adding Polycystic ovary syndrome (PCOS) or other conditions into the mix. If you’ve been diagnosed with PCOS or if you suspect you have it, it’s important you know your treatment options for getting pregnant. Here’s your overview of TTC with PCOS. 

PCOS 101

PCOS is a common disorder of the endocrine system that impacts up to 15% of women of reproductive age [1]. Those diagnosed with PCOS must experience at least two of the three diagnostic criteria, including increased male hormones, irregular menstrual cycles, and polycystic ovaries (ovaries with many small, fluid-filled sacs). Living with PCOS can also cause symptoms such as obesity, infertility, excessive hair growth on the face, chest, and abdomen, and skin conditions [2]. PCOS can make it difficult to get pregnant and may increase the risk of pregnancy complications, diabetes, cardiovascular disease, sleep apnea, and depression [2-3]. 

Is it possible to get pregnant with PCOS?

After reading an overview of PCOS, it may sound like conceiving is out of the question. While it’s true that PCOS is one of the leading causes of infertility in women, it is a treatable condition that leaves you with multiple options when TTC [1]. The first step to getting pregnant is successful ovulation, which unfortunately does not regularly occur for many women with PCOS. This doesn’t mean that pregnancy is impossible, but first you need to understand the basics behind ovulation and the menstrual cycle.

Menstrual cycle, hormones, and ovulation

There are four phases of the menstrual cycles that are marked by hormone levels increasing and decreasing. The menstrual cycle begins on day one of your period and lasts until the beginning of your next period. About halfway through your cycle is when ovulation occurs. You may recall that ovulation is the release of a mature egg from the ovary, which travels into the fallopian tube and toward the uterus, waiting to be fertilized by sperm [4]. The hormone responsible for ovulation is known as luteinizing hormone (LH), which can be detected in the urine using ovulation tests. Ovulation tests can help you determine if and when you’re releasing a mature egg, and if you test regularly, you can get a better idea of how consistently you are ovulating. Sometimes ovulation doesn’t occur (this is known as anovulation), which is a fairly common occurrence if it’s only happening every once in a while [5]. Those with PCOS may experience anovulatory cycles regularly, which can make it much more difficult to time sexual intercourse in order to get pregnant. It’s also likely that you’re not ovulating regularly or at all if you have irregular menstrual periods. 

Read a more detailed guide on the phases of the menstrual cycle. 

Why does PCOS cause irregular ovulation?

So why exactly does PCOS cause anovulatory cycles? We don’t know exactly why PCOS happens in the first place, but we do know that the increase in male hormones and cystic ovaries are likely to blame for irregular periods or anovulation [2]. 

Increasing fertility with PCOS

So what are your options for getting pregnant with PCOS? There are many ways to manage PCOS and treat infertility that may be right for you depending on your specific symptoms. If you’re just looking to manage PCOS symptoms overall, check out on our previous guide called How to Manage PCOS Symptoms. If you’re specifically looking to conceive with PCOS, you’ve come to the right place. Let’s take a look at your fertility support options. 

General recommendations

It’s recommended that anyone trying to conceive should begin taking a comprehensive prenatal vitamin every day [17]. Additionally, the general recommendation for most overweight females with PCOS hoping to conceive is to lose weight. Research shows that even minor weight loss can improve PCOS symptoms, may improve conceiving, and may help decrease the risk of pregnancy complications [2]. Along with your prenatal vitamin, it may be beneficial to take a supplement such as inositol, which has been linked to improved in vitro fertilization (IVF) outcomes for women with PCOS, improved egg quality, and ovulation support [6-8]. 

As a reminder, you should always speak to your healthcare provider before the use of any supplements or medications. 

Prescription medications and injections

If you’ve just started TTC, it can be really daunting to hear the words fertility treatment. While surgeries and treatments can be very effective, they may not be the best option for you when starting out. There are minimally invasive treatments and medications with a slightly lower price tag that you may want to explore first. 

Ovulation induction agents

We know that successful ovulation is the first step to getting pregnant, and that PCOS can often lead to anovulatory cycles or irregular periods. Luckily there are oral medications you can take that may help induce ovulation. Two widely used ovulation induction drugs are clomiphene citrate and letrozole; the latter being chosen for use by clinicians in many PCOS patients even though "ovulation induction" is not technically the on-label use for the medication. These medications are typically taken once a day for about five days starting midway through menstruation and encourage the production of follicle stimulating hormone (FSH), which helps ovarian follicles produce a mature egg [15]. There are some additional medications that may be used if someone has irregular periods and is trying to conceive with ovulation induction. After induction drugs are taken, you can begin testing for ovulation in order to appropriately time intercourse or a procedure such as intrauterine insemination (IUI)! 

Ovulation induction is a great option for many people trying to conceive with PCOS as it’s minimally invasive and more affordable than most other fertility treatments. Cost varies depending on insurance, prescription costs, any required lab tests, consult fees, and more, but you’re likely to spend less than a thousand dollars for one cycle of ovulation induction, compared to IVF which ranges from $15,000 to $30,000 [9]. If you have PCOS and experience irregular periods, ovulation induction may be a good fit for you.

Injection drugs

Oral tablets sometimes fail to stimulate ovulation, and if that’s the case, injection medications such as gonadotropins may be used instead. Gonadotropins are already released by the brain regularly, but when given in higher doses, they encourage the body to grow more than one egg in one cycle [15]. In some cases, additional injections can be given to help trigger ovulation. Injection drugs are typically more expensive than oral induction agents, but are usually still more affordable than procedures such as IUI and IVF. 

Surgeries, inseminations, and procedures

Other options for conceiving with PCOS include procedures that actually retrieve eggs and/or sperm from the body in hopes of increasing fertilization and conception rates or surgical procedures to improve ovulation rates. 

IUI and IVF 

In vitro fertilization (IVF) and intrauterine insemination (IUI) are two assisted reproductive techniques that may be used for people unable to conceive through heterosexual sex. IUI is a procedure in which washed semen (selecting healthy sperm from a semen sample) is placed into the uterus using a catheter. IUI is often performed with ovulation induction agents to help stimulate ovulation and increase the chances of fertilization [16]. Of course, the price of medications, doctor’s visits, labs, and insemination can all vary, but it’s estimated that one cycle of IUI can range from $460 to $3,000 [10]. 

IVF is a more involved and pricey procedure that requires egg retrieval. Injectable fertility drugs are given to stimulate the ovaries and produce multiple eggs. These eggs are then retrieved from the ovaries, combined with healthy sperm in a lab, and if fertilization is successful, an embryo is transferred into the uterus [14]. 

IVF tends to be one of the more expensive fertility treatments, ranging from $15,000 to $30,000, depending on your location, medications, clinician, and more. 

Ovarian Drilling

Another option for those with PCOS is a surgery known as ovarian drilling. The name doesn’t make this option sound very appealing, but it can be a useful alternative for those with irregular menstrual cycles or anovulation who are trying to conceive. Ovarian drilling aims to break through the outer surface of the ovaries in order to lower the amount of testosterone being created [11]. Lowering testosterone may help improve cycle regularity, ovulation, and may even decrease some PCOS symptoms such as acne and excess hair growth [11]. This surgery is minimally invasive and uses tools that enter the body through small incisions. Ovarian drilling is no longer recommended as first line therapy and is not performed by all healthcare providers.  It is not recommended for everyone due to limited benefit and potential risks including scarring, damage to the ovary, and other surgical risks [11]. 

Risks of fertility treatments

It’s important to note that all fertility treatments, medications, and surgeries come with their own set of risks. Your healthcare provider should go over all of your options and potential risks before you make a decision. A few things to consider are:

Medication side effects

Oral ovulation induction agents and injectable medications may cause minor or severe side effects, including hot flashes, cervical mucus changes, nausea, headaches, mood changes, and sore breasts [12]. There is little data on incidence, but the FDA does warn of potential fetal abnormalities, ovarian neoplasms, and cancer risks associated with some oral induction drugs [15]. There is also the risk of ovarian hyperstimulation syndrome (OHSS), a condition that occurs as a result of high hormone levels. OHSS may lead to pain, bloating, nausea, vomiting, diarrhea, blood clots, weight gain, and more [12]. 

Multiple gestation

Use of fertility medications may result in multiple eggs being released, which increases your chances of multiple gestation. Multiple gestation or multiple pregnancies means multiple embryos have been fertilized and implanted into the uterus. This can lead to an increased occurrence of twins or triplets, which is accompanied by an increased risk of pregnancy complications and preterm birth. 

Surgical risks

Procedures such as ovarian drilling or IVF may result in additional risks, including bleeding, infection, internal injury, infertility. IVF may increase the risk of complications, preterm delivery, fetal abnormalities, and more [11,14]. 

Key Takeaways

• PCOS impacts up to 15% of reproductive aged women and is one of the leading causes of infertility in women.

• Diagnostic criteria for PCOS include increased male hormones, irregular menstrual cycles, and polycystic ovaries. 

• PCOS can make it difficult to conceive because of irregular menstrual cycles and anovulation, but in terms of infertility, it is actually one of the most treatable causes.

• If ovulation isn’t occurring or is occurring irregularly, ovulation induction or assisted reproductive technology may be necessary. 

• General recommendations for TTC with PCOS include weight loss, taking prenatal vitamins, and other supplements such as inositol with a healthcare provider’s approval.

• Oral agents can help induce ovulation and are one of the most affordable options for TTC with PCOS.

• Other fertility methods include injectable medications, IVF, IUI, and in resistant cases, possible ovarian drilling (although no longer mainstream). 

• There are side effects associated with ovulation induction medications and fertility procedures, so it’s important to discuss all options with a healthcare provider before proceeding.

References:

1. Collée J, Mawet M, Tebache L, Nisolle M, Brichant G. Polycystic ovarian syndrome and infertility: overview and insights of the putative treatments. Gynecol Endocrinol. 2021;37(10):869-874. doi:10.1080/09513590.2021.1958310
2. Polycystic Ovary Syndrome (PCOS). ACOG. Last updated: January 2022. Accessed February 22 2022. URL.
3. Boomsma CM, Fauser BC, Macklon NS. Pregnancy complications in women with polycystic ovary syndrome. Semin Reprod Med. 2008;26(1):72-84. doi:10.1055/s-2007-992927
4. Reed BG, Carr BR. The Normal Menstrual Cycle and the Control of Ovulation. [Updated 2018 Aug 5]. In: Feingold KR, Anawalt B, Blackman MR, et al. URL. 
5. Jones K, Sung S. Anovulatory Bleeding. [Updated 2022 Sep 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. URL. 
6. Laganà AS, Vitagliano A, Noventa M, Ambrosini G, D'Anna R. Myo-inositol supplementation reduces the amount of gonadotropins and length of ovarian stimulation in women undergoing IVF: a systematic review and meta-analysis of randomized controlled trials. Arch Gynecol Obstet. 2018;298(4):675-684. doi:10.1007/s00404-018-4861-y
7. Pacchiarotti A, Carlomagno G, Antonini G, Pacchiarotti A. Effect of myo-inositol and melatonin versus myo-inositol, in a randomized controlled trial, for improving in vitro fertilization of patients with polycystic ovarian syndrome. Gynecol Endocrinol. 2016;32(1):69-73. doi:10.3109/09513590.2015.1101444
8. Angela Sacchinelli, Roberta Venturella, Daniela Lico, Annalisa Di Cello, Antonella Lucia, Erika Rania, Roberto Cirillo, Fulvio Zullo, "The Efficacy of Inositol and N-Acetyl Cysteine Administration (Ovaric HP) in Improving the Ovarian Function in Infertile Women with PCOS with or without Insulin Resistance", Obstetrics and Gynecology International, vol. 2014, Article ID 141020, 5 pages, 2014. https://doi.org/10.1155/2014/141020
9. Lake R. How much does IVF cost? Investopedia. Published September 6, 2022. Accessed February 23, 2023. URL. 
10. Lake R. How much does IUI cost? INvestopedia. Published September 6, 2022. Accessed February 23, 2023. URL. 
11. Ovarian Drilling for Infertility. American Society For Reproductive Medicine. 2014. URL. 
12. Derman SG, Adashi EY. Adverse effects of fertility drugs [published correction appears in Drug Saf 1995 Mar;12(3):208]. Drug Saf. 1994;11(6):408-421. doi:10.2165/00002018-199411060-00003
13. Ovarian Drilling for Infertility. American Society For Reproductive Medicine. 2014. URL
14. Choe J, Shanks AL. In Vitro Fertilization. [Updated 2022 Sep 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK562266/
15. Sharma M, Balasundaram P. Ovulation Induction Techniques. [Updated 2022 Sep 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK574564/
16. Allahbadia GN. Intrauterine Insemination: Fundamentals Revisited. J Obstet Gynaecol India. 2017;67(6):385-392. doi:10.1007/s13224-017-1060-x
17. Good Health Before Pregnancy. ACOG. Last updated: December 2021. Accessed February 22 2022. URL.