There are many effective treatment options for fertility issues caused by PCOS. Learn about the different options available to you.

 

By Dr. Mare Mbaye

Polycystic ovarian syndrome (PCOS) affects about 1 in 10 women of reproductive age. Its presentation can vary widely: some women are asymptomatic while others can experience weight gain, hirsutism (male-pattern hair growth such as hair on the chin and face), as well as hair loss, acne, irregular or missed menstrual periods, and infertility.

But while PCOS can cause a lot of problems to those who have it, in terms of infertility, it is actually one of the most treatable causes out there. Knowing that there are options for when the time comes to try to conceive can go a long way in relieving anxiety for women living with PCOS.

Let’s start with how PCOS is diagnosed. The S in PCOS stands for “syndrome” meaning it’s actually just a group of symptoms. There’s no single blood test for PCOS; doctors make the diagnosis based on a checklist of symptoms. To make sure there’s consistency across patients, a committee of experts met in Rotterdam, Netherlands in 2003 and agreed on certain criteria to diagnose PCOS, known as the Rotterdam criteria (creative name, right?). The three criteria that providers look for are signs of increased male hormones (called androgens), irregular release of eggs (known as ovulation), and more than 12 follicles (or cysts) on each ovary on ultrasound. At least two of these three buys you a diagnosis of PCOS. 

Polycistics ovaries

Notably, a consensus paper was published in July 2018 that combined over 100 recommendations focused on diagnosis, holistic management and safe, effective fertility treatment for women with PCOS. This paper now recommends more than 20 follicles on each ovary as a cutoff to avoid over diagnosis of PCOS in younger patients.

Now, let’s talk about how to improve fertility if you have PCOS. To get pregnant, you need three things: a normal egg, a normal sperm, and a pathway through which those two can meet. Due to the irregular ovulation in women with PCOS, that first requirement is not a guarantee every month like it is for other women. As a result, most women with PCOS will take longer to get pregnant because they are releasing an egg every few months or not at all. 

But how do you know if you are or aren’t ovulating? Well, you can use ovulation predictor kits or track how often you get a period. A monthly period means you are ovulating regularly but if your periods come every couple of months (or never), then you aren’t ovulating each month. 

Assuming that we have normal sperm and an open pathway, increasing fertility in women with PCOS is focused on regulating ovulation. There are several methods to achieve this, and we’ll go through them below.

Weight loss

Weight loss is the first step recommended for women with PCOS who are overweight or obese and trying to conceive. Weight gain is a common complaint with PCOS. Why is that? Well, the weight gain in PCOS is driven by the high levels of male hormones that the body is producing—since men tend to carry their weight in their abdomen (read: dad bods and beer bellies), so do women with PCOS. 

Obviously, this is not great news to any woman. However, in terms of getting pregnant, the good news is that women who are overweight and don't ovulate regularly can increase chances of conception by dropping their weight by as little as 5%. Additionally, while weight loss by itself is sometimes enough to restart ovulation, when you combine it with fertility medications, your chances of ovulation and giving birth become even higher than just using fertility medications alone. Being a healthy weight continues to be important after you get pregnant as well since it decreases the risk of complications like gestational diabetes, pregnancy-induced hypertension and preeclampsia. 

Obviously, weight loss is the goal if a patient is overweight or obese, but simply being more active can also help increase fertility. A review of several studies found that increased physical activity may improve pregnancy rates in women with reproductive health problems.

We all know that a healthy diet and increased exercise are the cornerstone to weight loss, but is there a preferred diet or exercise plan for those with PCOS? Unfortunately, the answer is no. However, though there is no specific type of diet that is proven to work best, trying to increase your overall exercise and decrease caloric intake is a hallmark of sustainable weight loss. It’s also generally considered a good idea to avoid too much sugar and simple carbohydrates (sorry, cupcakes). If you’re having trouble figuring out where to start, reach out to your healthcare provider to see if they can refer you to a nutritionist. They can both be great resources in achieving weight loss that is safe and effective.

Metformin

Metformin used to be considered a first-line treatment for PCOS because it increases ovulation rates when compared to placebo. It does this by improving the insulin resistance that is so commonly associated with PCOS.

Insulin resistance means the body doesn’t respond to insulin as well as it should. This leads to high glucose (sugar) levels in the blood. Over time, the body requires higher and higher amounts of insulin to deal with the rising sugar levels. After a while, this can lead to pre-diabetes, and eventually, diabetes. The high circulating levels of insulin can disrupt the hormones that your ovaries and pituitary gland (in the brain) release, leading to more ovulation dysfunction.

However, oral ovulation induction agents are much more effective than metformin and are now considered the better option. Metformin can sometimes help with early weight loss however, so it may be something that your provider discusses with you.

Ovulation induction agents

Let’s say you’ve lost the weight your doctor recommended and you still haven’t gotten pregnant. Your doctor may suggest ovulation induction agents at this point. These are safe medications that can be prescribed to...well, induce ovulation. There are two that are widely used: clomiphene citrate (Clomid) and letrozole (Femara).

Clomid works by blocking the body’s response to estrogen while letrozole suppresses estrogen production. The lack of response to estrogen with Clomid and the low levels of estrogen from letrozole prompt the pituitary gland to produce more follicle stimulating hormone (FSH), which does exactly what its name says: stimulates the growth of follicles containing eggs in the ovary. Both medications are generally not used for more than six cycles.

Unfortunately, ovulation induction doesn’t always work. Some women will experience what has been dubbed “Clomid resistance,” where Clomid does not trigger ovulation as expected. In this case, Metformin and Clomid together have been successfully used to gain higher success rates than with either medication alone. 

Clomid used to be the one that doctors chose first but studies have now shown that Letrozole has higher ovulation, pregnancy, and birth rates so many doctors now choose to go straight to Letrozole.

Gonadotropins 

Next on the list is injectable fertility drugs, also known as gonadotropins. These are made of the follicle-stimulating hormone (FSH), luteinizing hormone (LH), or some combination of the two. These can be given alone but are often given as part of a regimen that includes one of the above ovulation induction agents.

These regimens are typically started with the lowest effective dose to avoid one of the potential risks of gonadotropin use: ovarian hyperstimulation syndrome (OHSS). This can be a very serious complication in which the ovaries overreact to the fertility drugs and become dangerously filled with fluid. This fluid can leak into the belly and chest leading to other problems. Women with PCOS are at a higher risk of developing OHSS. Symptoms like rapid weight gain, severe abdominal pain and nausea, shortness of breath, or trouble urinating could be a sign that you’re getting OHSS and should prompt you to call your doctor immediately.

Surgery

When medication alone has proved unsuccessful, surgery becomes one possible option. In this case, the surgery is known as laparoscopic ovarian drilling, and it involves a surgeon making small holes in the outer portion of ovary with heat or a laser. This procedure has been found to be as effective as medication at increasing the rates of ovulation and pregnancy. Not all infertility specialists perform this surgery so if you’re considering it, it’s important to speak to your provider about it. Ovarian wedge resection is another procedure that used to be performed for PCOS, but has fallen out of favor and is rarely performed now. This surgery involved removal of part of the ovary, which was thought to help regulate periods and promote normal ovulation. However, most physicians now recommend against this surgery due to the high risk of scarring.

IUI and IVF

IVF, or in vitro fertilization, is generally well known nowadays, but IUI (intrauterine insemination) may not be something you’ve heard of unless you or someone you know has been through it. 

IUI is an assisted reproductive technique during which specially washed semen is placed directly into the uterus using a small catheter after you have been given low dose ovulation induction agents to try to produce a couple more eggs per cycle rather than just the usual one. The idea is to stack the deck in your favor by placing as much sperm as possible as close as possible to where it needs to be. The semen could be from a sperm donor or your partner. This method is generally done for about three cycles before moving on to IVF.

IVF involves using injectable fertility drugs to stimulate the ovaries so that they will provide as many mature eggs as safely possible. The eggs are retrieved from the ovaries during an in-office procedure known as an egg retrieval (during which you are put to sleep). Those eggs are then combined with sperm in the lab with the hopes that the sperm will fertilize some of the eggs. Fertilization of half those eggs is considered a success. After about three to five days of growing, the embryos are either frozen for later use or one (possibly two) of them is transferred into the uterus during what is known as an embryo transfer. Two weeks later, a pregnancy test is done to see if the cycle worked.

So there you have it, a crash course in getting pregnant with PCOS. There is obviously a bit more nuance to choosing one or more of these options, especially because every woman is different, as is their PCOS. It’s important to remember this when talking to your doctor about which of these methods will be best for you, your partner, and your specific situation. Try to be open-minded, and don’t be afraid to ask questions! 

Looking for more resources on how to get pregnant? Check out A Quick Guide to Getting Pregnant Faster.

 

Photography by Parker Fitzgerald.