PCOS is the commonly used abbreviation for the medical condition of polycystic ovary syndrome. You may not have heard of it unless you are a sufferer, but this hormonal condition is surprisingly widespread, affecting 5% – 10% of all women. It is known as a syndrome because, unlike a single identifiable disease, it is a collection of symptoms or problems that are typically found together. There is a wide range of symptoms associated with PCOS, but for a diagnosis of PCOS to be made, a woman must have 2 out of 3 criteria.
In this IVIRMA blog article, our goal is to share everything you need to know about PCOS and your fertility: what it is, what are the causes and symptoms, and how it is diagnosed. Above all, we will address the question that is the biggest concern for many women with the syndrome: how does PCOS affect fertility?
What is PCOS?
Women with polycystic ovarian syndrome typically do not have regular menstrual cycles. While most women have menses every month, women with PCOS may go long intervals without having a period. This is usually an indication that ovulation is not occurring. The ovary is unable to make one single mature egg to release and therefore many follicles containing immature eggs build up. This build-up is a result of the eggs failing to be expelled at the time when ovulation would normally take place.
As a result, the condition is associated with chronic anovulation (long-lasting failure to ovulate) as well as an overproduction of androgens, which are the male hormones, principally testosterone, and androstenedione. The absence of ovulation means there is no mature egg available to be fertilized by a sperm, leading to an obvious detrimental impact on fertility.
Are there any other risks associated with PCOS?
There is more to PCOS than irregular or absent ovulation. It is a lifelong condition that not only affects women of childbearing age; it also frequently causes insulin resistance, in which the body is capable of making insulin but is unable to use it effectively. This increases the risk of type 2 diabetes. PCOS can also lead to other serious health problems, particularly in women who are overweight. These include:
- Gestational diabetes, which is diabetes that develops during pregnancy, increasing the risk of miscarriage, and the later development of diabetes for both mother and child.
- High blood pressure can lead to damage to the brain, kidneys, and heart, and heart disease, the risk of which increases with age. It is also associated with high LDL (the “bad” cholesterol) and low HDL (the “good” cholesterol) which also increases the risk of heart disease.
- Stroke, in which plaque formed of cholesterol and white blood cells clogs up the blood vessels, leading to blood clots which in turn can cause a stroke.
- PCOS is also associated with anxiety and depression, but doctors do not fully understand how the connection works.
What are the causes of PCOS?
Doctors are not currently certain of the exact causes of PCOS, although it is clear that the raised levels of male hormones play a role in preventing the ovaries from functioning normally. There are other risk factors that are well known. They include:
- Insulin resistance: Insulin is the hormone produced by the pancreas to convert sugar from food into energy. If the body is unable to use insulin effectively, demand for the hormone increases, and more is produced by the pancreas to compensate. This excess insulin triggers the production of more male hormones.
- Genetics: Studies have shown that polycystic ovary syndrome runs in families, and women who have a mother or sister with PCOS or type 2 diabetes are more likely to develop PCOS than those with no family history.
- Being overweight or obese: Being overweight is clearly associated with PCOS but it is not certain whether being overweight causes the syndrome or whether having PCOS causes a woman to become overweight. In addition, many women who have PCOS are not overweight and many overweight women do not have PCOS.
- Inflammation: Women with PCOS frequently have raised levels of inflammation in their bodies and being overweight can also contribute to inflammation. There have been studies that link excess inflammation to increased androgen levels.
What are the first signs and symptoms of PCOS?
If you have irregular periods, very light periods, or the loss of periods completely, you may suspect that this is a sign of PCOS. Other common PCOS symptoms include:
- Acne or oily skin and unusual hair growth (hirsutism) usually on the face, chest, or abdomen. This results from the elevated levels of androgens and can also include male-pattern baldness or thinning hair.
- Obesity along with difficulty losing weight and maintaining weight loss, as well as type 2 diabetes. These can be associated with depression, anxiety, and eating disorders.
- Difficulty in conceiving.
- Skin tags, which are small pieces of extra skin on the neck or armpits.
- Darker or thick patches of skin in the armpits, on the back of the neck, and underneath the breasts.
One of the main symptoms is not one that you could see for yourself and, apart from signs of infertility, you would have no way of knowing without medical investigation: the presence of cysts – small fluid-filled sacs – inside the ovaries. For this, you will need a visit to a doctor for tests and diagnosis.
How is PCOS diagnosed?
There is no single test for PCOS but when you visit the doctor, he or she will gather information and run a series of diagnostic tests. Your doctor will take a detailed medical history and will ask you about your menstrual cycle as well as other possible symptoms such as acne, difficulty losing weight, or unusual hair growth.
The physical examination will include measurements of height and weight in order to calculate your Body Mass Index. A transvaginal ultrasound scan enables the doctor to see whether the ovaries have the features typical of PCOS, which would normally show up as multiple immature follicles on the ovaries (cysts).
Blood tests will be needed to help the doctor reach a final diagnosis, especially measuring the levels of certain hormones. FSH (Follicle Stimulating Hormone), LH (Luteinizing Hormone), and AMH (Anti Mullerian Hormone) all have a part to play in signaling that ovulation is due. Knowing the levels of these hormones can help the doctor evaluate the state of your fertility.
The most important hormone that your doctor will be looking out for is AMH. This is the hormone that a woman’s follicles release as they mature. As women with PCOS have more follicles that are maturing at the same time (although incompletely), their AMH levels will be higher than a woman without PCOS.
The blood work will also look at levels of estrogen and testosterone, as well as screening for insulin resistance.
How PCOS affects fertility
The absence of ovulation is the major difference between PCOS and a normal ovulation cycle. But why does the hormonal disruption occur and why don’t the follicles grow in the normal way?
In a regular menstrual cycle, hormones are secreted by the hypothalamus and the pituitary glands located in the brain, and these work together with the ovaries to stimulate the growth of the small fluid-filled sacs, each containing one tiny immature egg, on the ovaries. Once a month, a single follicle matures to the point where it is able to release an egg. The remaining follicles degrade in a natural process known as atresia.
When a woman has PCOS, this monthly cycle is interrupted. Although the follicles begin their growth, none of them comes to the point of maturity where they can release an egg, and so many small follicles remain on the ovaries. Without the presence of a mature egg, ovulation cannot take place, and therefore there is no possibility of a natural pregnancy.
Can I still get pregnant with PCOS?
Women with PCOS can still ovulate occasionally, and therefore it is possible to get pregnant on their own. However, some women with the syndrome will never ovulate spontaneously. Even if ovulation is occasionally occurring the chances of getting pregnant on your own are much lower than for women without PCOS.
Infertility in women who have PCOS runs at a level between 70% and 80% and so the converse of that figure would be a PCOS fertility rate, without fertility treatment, of between 20% and 30%.
How can I improve my fertility with PCOS?
Even starting with such low odds, there are still some things that women can do to optimize their chances of pregnancy. Changes to levels of activity as well as a healthy diet can certainly help in losing weight with a resulting reduction in symptoms. Dietary improvements can also help your body use insulin more efficiently which will reduce blood glucose levels and encourage ovulation.
Weight management and exercise
You don’t need really drastic changes to improve your chances: losing even 5 – 10% of your body weight can help your menstrual cycle regulate itself and lead to an improvement in PCOS symptoms. As a bonus, weight loss will probably also improve cholesterol levels and lower insulin, as well as reducing the risk of diabetes and heart disease.
If you’re thinking of making changes with a PCOS diet for fertility improvement, it’s worth knowing that studies comparing the effectiveness of different diets for PCOS have shown that a low glycemic index (GI) regime, in which you get most of your carbohydrates from whole grains, fruit, and vegetables, helps regulate the menstrual cycle more than regular weight-loss diets.
Learn more about fertility nutrition and diet.
PCOS fertility vitamins
You could also consider vitamin supplements specifically intended to improve PCOS symptoms in addition to improvements in diet and exercise. A study published in the US National Library of Medicine, a part of the National Center for Biotechnology Information, found that vitamin or mineral supplements can have an impact. They can have a positive benefit on the familiar symptoms of PCOS like immature eggs, high levels of insulin and androgens, high BMI, and cardiovascular disorders. They can also have a beneficial effect on mental and psychological health. You should consult your doctor about the best choice of supplement in your particular case.
Does folic acid help with your fertility? Yes! Learn more at our blog.
Using technology to predict ovulation
In addition to the self-help measures outlined above, you could consider using a PCOS fertility tracker app, which is the same thing as an ovulation predictor kit. A quick search will identify many that are available.
The problem with ovulation predictor kits is that they work by identifying increased levels of LH which shows a surge just before ovulation. But as women with PCOS are likely to show high LH levels to start with, these kits may not be as reliable as they are for women without PCOS.
It is worthwhile to try all of the recommended techniques to improve your fertility when you have PCOS but in reality, the bottom line is that to get pregnant with PCOS, the best way for most women is to seek fertility treatment.
You have PCOS; what are the options for treatment?
For women who are not planning to become pregnant, birth control pills can be an effective treatment for PCOS. They can help regulate the menstrual cycle, reduce androgen levels, and even reduce acne.
Medication for diabetes is also used to reduce insulin resistance in women with PCOS. It can also have a beneficial effect on reducing hair growth and promoting more regular ovulation. But if you are hoping to become pregnant, birth control pills are not going to help! What are your PCOS fertility treatment options?
PCOS fertility medications
Medication to encourage ovulation is usually the first treatment for infertility caused by PCOS. Oral medication such as clomiphene citrate (Clomid) or Letrozole might be an initial treatment that your doctor may prescribe to help regulate ovulation. If these were to prove unsuccessful, the next step would be fertility medications delivered by injection.
These are gonadotrophins that are used to stimulate the growth of an egg. However, very careful medical supervision is required with these medications to make sure that the response is not too strong, as it could cause the production of several eggs at once. This needs to be avoided as it would increase the risk of multiple births.
Another possibility that could be recommended by your fertility specialist may be a drug that lowers your blood sugar by improving the way your body uses insulin, such as metformin. The improvement in insulin use can improve ovulation for some women with PCOS and could also reduce the risk of developing diabetes.
Intrauterine insemination (IUI)
Ovulation-inducing medications could also be used in combination with IUI. In this process, the ovulation-stimulating medication is prescribed a few weeks in advance of the procedure. In a follow-up visit, egg development is checked with ultrasound to determine the best time for the IUI.
On the scheduled day, a prepared semen sample is inserted directly into the uterus and a follow-up pregnancy blood test takes place a few weeks afterward. For a couple having IUI each month, success rates could be up to 15% per cycle, depending on the individual case. However, pregnancy rates are not as high as those from IVF.
You can check out more details about the IUI procedure here.
In vitro fertilization (IVF)
IVF fertility treatment can be an option if PCOS fertility medications are not successful. Compared with taking medication on its own, IVF results in higher rates of pregnancy and gives better control of the risk of multiple births because the technique allows doctors to transfer a single embryo into your uterus. IVF treatment involves several key steps:
Ovarian stimulation over a period of around 8 – 12 days stimulates the growth of multiple eggs in the ovaries. Once these have reached an adequate number and size, an injection of hCG triggers the final maturing process.
Egg retrieval takes place 36 hours later in a 30-minute process in the doctor’s office, with an anesthetic to avoid any discomfort.
The eggs are fertilized in the laboratory using sperm from the partner or a donor. This is followed by extended embryo culture over the following 5 – 6 days until they reach the blastocyst stage. While awaiting any necessary genetic testing to be done, the embryos are frozen. This is the standard of care in all of our RMA clinics as it has been shown to lead to improved outcomes.
The following menstrual cycle, the patient begins estrogen and progesterone medications to prepare the uterus to receive the embryo.
When the time is right, a selected embryo is transferred to the patient’s uterus, where, if all goes well, it will implant and develop into a healthy pregnancy and delivery.
You can research more about IVF fertility treatment on our website.
Surgery as a fertility treatment for PCOS
Surgery could be considered if other treatments do not work. Your fertility doctor will arrange for a vaginal ultrasound scan and there may be a need for further testing before deciding whether reproductive surgery is required. If surgery is recommended to improve your chances of conception, your doctor will go through all the details with you.
Pregnancy and PCOS
Although many women do successfully achieve a pregnancy with PCOS, they need to make sure that they are very carefully monitored at every stage because complications are more likely. Women with PCOS are at higher risk of miscarriage, gestational diabetes, and preeclampsia, and are more likely to require a C-section. However, there are some steps you can take to reduce your risks and avoid problems during pregnancy. These include:
Reaching and maintaining a healthy weight in advance of pregnancy and being aware of the amount of weight you should be gaining during the course of the gestation period.
Achieving good blood sugar levels before becoming pregnant is also important. This can be done with healthy eating habits and regular exercise leading to weight loss and possibly through the use of medications such as metformin.
Taking folic acid is essential for every woman intending to become pregnant but could be particularly important for you. You should consult your doctor about how much folic acid you need to take.
Getting in touch with us at RMA
If you have or suspect you have PCOS, don’t lose heart and don’t give up on your dream of starting a family. True, it is more likely that you will need some fertility treatment to help you on your way, but success rates are good and there are plenty of reasons for optimism. You can find your nearest RMA office through our website, or contact us directly through our online contact form.