PCOS

Jun 10, 2021

PCOS and Fertility

40% of women with PCOS go through infertility. It doesn’t mean you can’t have a baby, but the process can be difficult.

Julie Rosenberg

Does PCOS mean you can’t birth a baby? Absolutely not. However, it can make the process more challenging.

Infertility is defined as the inability to conceive after 12 months of having unprotected sex. [1] For women above the age of 35, this criteria is slightly modified, with infertility being the inability to conceive after 6 months of unprotected sex. The main causes of female infertility are ovulation problems, blockage of the Fallopian tube and endometriosis.[2]

For women with PCOS, infertility can naturally be a source of worry as PCOS can be accompanied with problems in ovulation. [2] ~40% of women with PCOS go through infertility and approximately 80% of women who suffer from anovulatory fertility have PCOS. In many cases, due to low awareness about the condition, women don’t realise they have PCOS until they face problems conceiving. However, there is no reason for panic as with the right interventions and in some cases, treatments, most women with PCOS are able to have kids, if they so wish to.

PCOS and Ovulation

Ovulation is the process of releasing a mature egg from the ovary which then travels down the Fallopian tube to get fertilised by a sperm. This is typically a normal part of the menstrual cycle, and takes place once a month. In the event that the egg is fertilised by the sperm, pregnancy takes place, otherwise, the uterine lining is shed and menstruation occurs. Most couples trying to conceive, are advised to time their intercourse to a five day window around ovulation.

In the case of PCOS, ovulation may not happen as usual. The ovary in the absence of correct signals from the pituitary does not produce the hormones it needs for any of the eggs to fully mature. Some researchers think this is caused due to of high insulin levels. Since no egg matures or is released, ovulation does not occur in that month and instead the ovaries develop small cysts. The fluctuations in hormones can lead to an unpredictable ovulation schedule, making conception hard to time for successful pregnancy.

It is also important to note that obesity is shown to increase infertility and pregnancy complications, both independently and by exacerbating PCOS. When treating PCOS-related infertility, first line efforts are often focused on encouraging weight-loss in patients, as even a slight drop in weight can have significant positive results on ovulation. [3]

Does PCOS mean I won’t be able to have a baby?

No. Not all women with PCOS experience infertility issues. And even for those who do have troubles ovulating, there are effective treatment options available such that most women with PCOS are able to have kids if they so wish to. Broadly speaking, the treatment options can be divided into two buckets: non-pharmacological changes and pharmacological changes.

Non-pharmacological changes (Lifestyle changes)

Given the link between high insulin levels, weight gain and anovulation, the principle infertility treatment revolves around lifestyle changes -  making positive changes in diet, movement and stress management. Encouragement of physical exercise, identification of risk factors (including tobacco use and alcohol consumption), reduced consumption of processed foods are usually good starting points. A 5 to 10% weight loss over a period of six months is also shown to significantly improve hyperandrogenism and ovulation rate. We recognise that losing weight with PCOS is not easy and you shouldn’t be hesitant to seek additional support.

Medication & Procedures

Pharmacological treatment for PCOS-driven infertility is typically divided into three stages. The first stage consists of a Clomiphene Citrate (CC) treatment for timed intercourse. Clomiphene is orally administered to help stimulate the release of the FSH and LH hormones. This indirectly causes eggs from the ovary to mature and get released. Clomiphene Citrate treatment is recommended to be limited to 6 ovulatory cycles and women treated with CC are more likely to have twins or triplets than women who get pregnant naturally. [4][5]  Letrozole is another drug that can be used to slow estrogen production and causes the body to make more follicle-stimulating hormone (FSH), a hormone needed for ovulation. Lastly, Metformin (a insulin-sensitising drug) can be administered individually or in combination with clomiphene for stimulating ovulation in insulin-resistant PCOS. The efficacy of metformin in getting pregnant is still unclear as studies indicate mixed results. The FDA has not cleared metformin for treating PCOS-induced infertility. [5]

Second line treatments typically involve either the use of gonadotropins or laparoscopic ovarian surgery, and are only recommended if lifestyle changes or first-line pharma treatments have failed. Gonadotropins are hormones that are given as shots to induce ovulation. This is an expensive treatment method and brings with it a higher risk of multiple pregnancies than with CC. In laparoscopic surgery (ovarian drilling), the surgeon punctures and destroys a small part of the ovary to lower androgen levels and improve ovulation. This surgery while, does not seem to increase the risk of multiple pregnancies, does carry the chance of scarring the ovaries. [5]

Third line treatment for infertility in women with PCOS centers around in-vitro fertilization (IVF). In some cases, IVF and lifestyle changes maybe suggested as first line treatment options.

Other pregnancy complications

Having PCOS can result in other complications around pregnancy, outside of infertility. Miscarriage, gestational diabetes, preeclampsia (sudden increase in blood pressure after the 20th week of pregnancy), premature delivery of babies and increased chances of caesarean deliveries are all important outcomes that warrant discussions with physicians and gynaecologists. [6] Reading the above may have caused anxiety, but we want you to know that these can be planned for!

Key takeaways:

  • 40% of women with PCOS go through infertility and approximately ~80% of women who suffer from anovulatory fertility have PCOS.
  • But having PCOS shouldn’t be a cause of panic for those looking to get pregnant.
  • Most women with PCOS, with non-pharmacological or pharmacological treatments are able to have kids, if they so wish to.
  • Pharmacological treatments include clomiphene citrate, laparoscopic ovarian surgery, gonadotropins and finally IVF.

References:

Centers for Disease Control and Prevention. (2021, April 13). Infertility. Centers for Disease Control and Prevention.

Ghahiri, A., Malekzadeh, B., & Tehrani, H. G. (2017, November 30). Comparing the Frequency of Endometritis in Unexplained Infertility and Anovulatory Infertility. Advanced biomedical research.

L;, T. H. D. A. M. (n.d.). Polycystic ovary syndrome: a complex condition with psychological, reproductive and metabolic manifestations that impacts on health across the lifespan. BMC medicine.

Melo, A. S., Ferriani, R. A., & Navarro, P. A. (2015, November). Treatment of infertility in women with polycystic ovary syndrome: approach to clinical practice. Clinics (Sao Paulo, Brazil).

U.S. Department of Health and Human Services. (n.d.). Treatments for Infertility Resulting from PCOS. Eunice Kennedy Shriver National Institute of Child Health and Human Development.

Rodriguez Paris, V., & Bertoldo, M. J. (2019, August 28). The Mechanism of Androgen Actions in PCOS Etiology. MDPI.

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