PCOS and Infertility

Polycystic ovarian syndrome (PCOS) is the leading cause of ovulatory infertility. Up to 80% of women with PCOS have fertility challenges. If you are having difficulty getting pregnant, you have a variety of treatment options. Lifestyle modifications are the first choice to improve fertility, followed by medications, hormonal treatments, and assisted reproductive procedures.

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How PCOS Affects Fertility

A hallmark sign of PCOS is irregular or absent menstrual periods. Some women with PCOS may not get a period for months, even years, while others will experience bleeding for several weeks at a time. A small percentage of women with PCOS will experience monthly cycles.

Irregular or absent menstrual cycles in PCOS are due to an underlying hormonal imbalance. Normally, sex hormones are secreted at a steady pulse rate. In women with PCOS, luteinizing hormone (LH) is secreted at a rapid pulse rate. This, in turn, sends signals to the ovaries to pump out higher levels of male hormones, such as testosterone. As a result, too much LH and testosterone throws off the levels of other sex hormones that work to control your menstrual cycle and affects ovulation.

In PCOS, instead of a follicle maturing and getting released to be fertilized for pregnancy, the follicle never fully matures and sometimes doesn’t get released from the ovary. Tiny follicles, which appear as a string of pearls on an ultrasound, sometimes surround the ovary. These follicles are called cysts due to their appearance, although they differ from the ovarian cysts that can grow and rupture.

Infertility is commonly diagnosed after a couple has been unsuccessful at pregnancy for 12 months or longer. Knowing the risk, doctors may treat women with PCOS for infertility sooner than this.

Miscarriages are also common in women with PCOS and can be due to the imbalance of sex hormones and higher levels of insulin.

While pregnancy may seem hopeless, there have been many positive medical advancements to help women with PCOS conceive.

Lifestyle Modifications

Changes in your lifestyle can make a big difference in regulating hormones and preparing your body for pregnancy. This, in turn, can improve your egg quality and ovulation, increasing your chances of getting pregnant.

If you are overweight, losing as little as 5% of your total body weight has been shown to improve fertility in PCOS. Making changes to your diet, exercise, stress level, and sleep quality can all help improve your fertility as well.

Healthy Diet

One of the best diets for PCOS is an antioxidant-rich one that focuses on moderate amounts of unprocessed carbohydrates. These include fruits, vegetables, beans, lentils, and grains such as quinoa and oats. Including fats from unsaturated sources (e.g., olive oil, nuts, seeds, fish, and avocado) is recommended.

Avoiding refined or processed sources of carbohydrates, such as crackers, white bread, white rice, pretzels, and sugary foods like cookies, brownies, and candy is suggested to bring down insulin levels and inflammation.

If you aren’t sure where to start, consider consulting with a registered dietitian who can assist you with making sustainable changes to your diet.

Regular Physical Activity

Studies show that regular exercise can improve ovulation and insulin resistance. Try and get in at least 30 minutes of physical activity each day. This amount can be divided up into three 10-minute segments or two 15-minute segments.

Walking is one of the most accessible activities available and can be scheduled in during the day.

Vitamin D

Vitamin D is not only a vitamin but a hormone as well. Vitamin D receptors have been found on women’s eggs, and the vitamin is recommended for any woman who may become pregnant, as it can prevent neural tube defects in the developing fetus.

For women with PCOS, some studies suggest vitamin D supplementation can improve symptoms by regulating anti-Müllerian hormone levels and inhibiting inflammatory progress.

Metformin

Metformin is one of the most common diabetes drugs that has been useful to reduce insulin resistance in women with PCOS. For many women with the syndrome, metformin can also improve menstrual regularity. There are studies that show that metformin may also reduce the risk of miscarriage and gestational diabetes.

However, so far, there is no evidence that metformin increases pregnancy rates in women with PCOS. The drug is not FDA-approved as a treatment for PCOS-related infertility.

May 28, 2020: The FDA has requested that manufacturers of certain formulations of metformin voluntarily withdraw the product from the market after the agency identified unacceptable levels of N-Nitrosodimethylamine (NDMA). Patients should continue taking their metformin as prescribed until their health professional is able to prescribe an alternative treatment, if applicable. Stopping metformin without a replacement can pose serious health risks to patients with type 2 diabetes.

Clomid and Femara

Sometimes women with PCOS still need help improving their ovulation despite diet and lifestyle changes. Clomid (clomiphene citrate) has traditionally been given to women to improve ovulation, and it is considered to be the first-line treatment. It has a cumulative pregnancy rate of 60% to 70% in six cycles.

Newer research shows that Femara (letrozole) may work better than Clomid for women with PCOS. Letrozole doesn’t raise estrogen like Clomid, but instead makes you produce more follicle-stimulating hormone (FSH). It improves the uterine lining and also seems to result in fewer multiple births.

The American Association of Clinical Endocrinologists recommends treatment with either Clomid or Femara.

Gonadotropins

The use of gonadotropins can also help women with PCOS conceive. Gonadotropins are made of FSH, LH, or a combination of the two. Your doctor may suggest combining these hormones with fertility drugs (for example, letrozole with a “trigger” shot of LH mid-cycle) or using them on their own.

Another option your doctor may recommend is using gonadotropins with an intrauterine insemination (IUI) procedure.

A major risk of gonadotropins is ovarian hyperstimulation syndrome (OHSS). This is when the ovaries overreact to the fertility medication. If untreated or severe, it can be dangerous.

Ovarian Drilling

When you have PCOS, your ovaries have a thicker outer layer than normal and make more testosterone. This laparoscopic surgery makes several tiny holes in the outer layer of the ovaries (why it is sometimes called "whiffle ball" surgery) which reduces the amount of testosterone made by the ovaries.

About half of women get pregnant in the first year after surgery. A big advantage is that the procedure is only done once, so it can be less expensive than gonadotropin treatment. Another advantage is that it doesn't increase the risk of multiple pregnancies.

Assisted Reproductive Technology

There are two main procedures you might consider if other strategies have not worked—IUI and IVF.

Intrauterine Insemination (IUI)

Intrauterine insemination (IUI) is a fertility procedure timed to coincide with ovulation. Your partner will be asked to produce the semen specimen or you can get one from a sperm donor. The semen is then “washed” (separated from other elements of the semen) and gathered into a smaller, more concentrated volume. The specimen is then placed into a thin, sterilized, soft catheter and ready for insemination.

A speculum, like one used during a gynecological exam, is placed in the vagina and your cervix is gently cleansed. Your doctor will insert the catheter in the vagina and release the sperm into your uterine cavity. Your doctor may ask you to remain lying down for a few minutes after the insemination.

In Vitro Fertilization (IVF)

In vitro fertilization (IVF) is a more invasive and costly fertility procedure that is sometimes used if all other fertility treatments fail. IVF involves using injectable fertility drugs to stimulate the ovaries so that they will provide a good number of mature eggs. The eggs are then retrieved from the ovaries and combined with sperm into Petri dishes.

If the eggs become fertilized, one or two are transferred into the uterus. This procedure is known as an embryo transfer. Two weeks later, your doctor will order a pregnancy test to see if the cycle was a success.

Fertility Treatment Success Rates in PCOS

Overall success rates for IUI are as good or better for those with PCOS as those with other causes of fertility challenges: approximately 15% to 20% per cycle. This varies based on a number of factors, such as your age, type of ovarian stimulation, and motility of sperm, among others.

The general success rate for IVF is 31.6% and is the same for those who have PCOS and those who don't.

When to Seek Help

If you have been struggling to get pregnant, you may want to seek the advice of a reproductive endocrinologist, also called a fertility doctor. These type of doctors specialize in sex hormones and tend to have in-office ultrasound machines that can be used to help determine the cause of your fertility concerns so proper treatment can be provided.

Coping with fertility troubles is hard on women and couples—especially if it seems that everyone around you is getting pregnant easily. If you find infertility has taken an emotional toll, consider working with a trained mental health professional or joining an infertility support group in your area.