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Polycystic Ovary Syndrome (PCOS) and Fertility

Polycystic ovarian syndrome (PCOS) is one of the most common conditions in reproductive aged women. It is important as it can affect 8-13% of women and importantly, 70% of women that have this condition are undiagnosed. This is of significance as this condition can have detrimental effects to women over their lifetimes, as it does not just affect fertility.

PCOS is a complex condition and can be considered as an umbrella description for a whole range of conditions as it can affect fertility, metabolism and mental health.  It is important to remember that PCOS affects women differently, depending on a number of factors such as age and the clinical manifestations tend to vary throughout a woman’s lifetime.

PCOS is diagnosed according to defined criteria and requires two out of the following features:

1) Irregular or absent periods

2) Lab results or features associated with high levels of the male hormones (androgens) such as acne and excessive facial hair

3) An ultrasound scan demonstrating a high number of follicles

Some women who have PCOS may be overweight and are at higher risk of developing complications associated with sugar control such as diabetes. Ovulation induction medication or injections are usually needed to help women with PCOS fall pregnant if their periods are irregular. Most importantly, lifestyle modifications, like healthy diet and regular exercise, are very helpful for the management of PCOS.

Signs and symptoms start around puberty, though some women do not start developing symptoms until later in life. Because hormone levels vary from one woman to another, the symptoms can be mild to severe depending upon the hormone levels.

 

Irregular menstrual cycles
The reason women with PCOS may find it difficult to fall pregnant is because when periods are irregular, it may be very difficult to predict when ovulation may be occurring and therefore timing intercourse is inaccurate.

Furthermore, if the periods are irregular, the lining of the uterus (the endometrium) does not shed and regrow in a cyclical way every month. The longer the interval between periods, the lining becomes thicker and this can result in heavy and/or prolonged bleeding.  For women who do not have periods, this lining fails to shed. It is therefore very important to remember that this can result in the development of abnormal cells in the lining of the womb that may, in turn, increase the risk of endometrial overgrowth (called endometrial hyperplasia). In some cases this can lead to endometrial cancer. Therefore, if you have symptoms that you think may be associated with PCOS, it is really important you see your GP or gynecologist to give you advice and appropriate training.

 

Infertility
Women with irregular ovulations in PCOS may take more time to become pregnant.  If it has been 6 to 12 months of trying to become pregnant, and depending on your age, it is recommended that you have a fertility health assessment undertaken.  As weight may be elevated in some women with PCOS, it is important to discuss various approaches you can adopt to address this.  This is of importance not only as it will improve your chances of getting pregnant but also reduce complications associated with pregnancy and complications that can affect your health in later life as well.

A combination of excessive weight with either an insulin resistance or diabetes may increase the risk of coronary artery disease in women in later life.  The risk of this can be decreased with weight loss and good sugar management.

 

Lifestyle modifications
The most important factor to first consider is lifestyle modifications like weight loss. Losing 5% to 10% weight can help with restoring regular menstrual cycles and ovulation, with the ultimate goal that you would be able to conceive on your own without any treatment. If you do ultimately require fertility treatment however, even a modest weight drop will improve efficacy of  fertility treatments.

 

Medications
As your Fertility Specialist I may prescribe you with medications to assist with your fertility. After a thorough medical assessment and investigation, I may recommend medications to counter the effects of PCOS.

Ovulation induction medications like clomiphene or letrozole stimulate ovaries to release one or more eggs. These medications are effective in 80% of women in inducing ovulation and about 50% of these women will fall pregnant. It is important that you are monitored during this treatment so the effects of these drugs can be carefully assessed.

 

Metformin
Metformin may be prescribed on its own or in conjunction with ovulation induction medications to help increase rate of ovulation as it helps improve insulin resistance associated with PCOS.

 

Gonadotropin Therapy
Gonadotropin injections (Follicle stimulating hormone injections) may be recommenced if oral ovulation medications do not work.  FSH injections are effective therapy for inducing ovulation. About 60% of these women will become pregnant.

If these therapies do not work, then in vitro fertilization (IVF) may be the next step.