PCOS and Infertility

Polycystic ovarian syndrome (PCOS) is the leading cause of ovulatory infertility. Up to 80% of females who have PCOS experience associated fertility challenges. If you are having difficulty getting pregnant, you have a variety of treatment options. Certain 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 people 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 those with PCOS will experience monthly cycles.

Irregular or absent menstrual cycles in PCOS are due to an underlying hormonal imbalance.

Normally, sex hormones like luteinizing hormone (LH) are secreted at a steady pulse rate. In PCOS, LH is secreted at a rapid pulse rate.
The LH secretion pattern sends signals to the ovaries to pump out higher levels of male hormones, such as testosterone.
Excess LH and testosterone trigger negative feedback loops, which alter the release of hormones that control ovulation and menstruation.
The follicle that would normally be released to be fertilized in pregnancy never fully matures and sometimes doesn’t get released from the ovary.

Tiny follicles appear as a string of pearls on an ultrasound, sometimes surrounding 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 when a couple has been unable to conceive after 12 months or longer or after 6 months or longer for females age 35 and older. Knowing the risk, doctors may evaluate and treat people who have PCOS for their infertility sooner than this.

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

While pregnancy can be challenging, there have been many positive medical advancements to help fertility in PCOS.

Lifestyle Modifications

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

Making changes to your diet, exercise, stress level, and sleep quality can all help improve your fertility.

If you are overweight, losing as little as 5% of your total body weight has been shown to improve fertility in PCOS.

Healthy Diet

One of the best diets for PCOS is an antioxidant-rich diet 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 it is a hormone as well. Vitamin D receptors have been found on unfertilized eggs. The vitamin is recommended for anyone who may become pregnant, as it plays an important role in the development of fetal bones and teeth, skin, and eyesight. Correcting deficiencies can also prevent neural tube defects in the developing fetus.

For people 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 people with PCOS. For many people 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 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 lifestyle modifications are not effective for improving fertility in PCOS. Clomid (clomiphene citrate) has traditionally been given to improve ovulation. 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 treating infertility associated with PCOS, and it is considered the first-line treatment for ovulation induction for people who have PCOS.

Unlike Clomid, letrozole doesn't raise estrogen and instead makes you produce more follicle-stimulating hormone (FSH). It improves the uterine lining and is associated with fewer multiple births than Clomid.

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

Gonadotropins

Gonadotropins are also used to improve the chances of conception in PCOS. 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 those who have had the surgery get pregnant during the first year after surgery. An 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 sperm 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.
The general success rate for IVF is 31.6% and is the same for those who have PCOS and those who don't.

The success rate varies based on a number of factors, such as your age, type of ovarian stimulation, and motility of sperm, among others.

When to Seek Help

If you have been struggling to get pregnant, you may want to seek the advice of a reproductive endocrinologist. These doctors specialize in assessing the factors that contribute to fertility.

The American College of Obstetrics and Gynecology ACOG recommends an infertility workup when a couple has been unsuccessful at pregnancy for 12 months or longer, or 6 months or longer if the female is 35 years old or older.

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.