PCOS and Fertility—All You Need to Know

PCOS and Fertility—All You Need to Know

A PCOS diagnosis can come with a slew of anxieties and grievances, not the least of which is the big F word: fertility. If you’re facing the syndrome with worry over future family planning, take heart. The prognosis for women with PCOS that hope to get pregnant is bright, and even when medical assistance is required, there are many options.

We chatted with renowned OB/GYN, reproductive endocrinologist and infertility expert, Dr. Andy Huang, MD, FACOG, to learn exactly how PCOS functions clinically, how you can tweak your lifestyle to boost fertility, and what fertility treatments patients with PCOS can consider. 

Keep reading for your complete guide.

What is PCOS?

To begin, it’s important to understand that, PCOS, or Polycystic Ovarian Syndrome, is one of the more common endocronopies for women of reproductive age, affecting as many as 5 million women of reproductive age, according to the CDC.

"The definition, by textbook, is women with very irregular cycles in conjunction with one of the following: high levels of testosterone or normal hormone levels but clinical signs of high testosterone levels–including acne, oily skin, or excess hair growth,” Dr. Huang says. 

polycystic ovary syndrome
A condition in which the ovaries produce an abnormal amount of androgens, male sex hormones that are usually present in women in small amounts. The name polycystic ovary syndrome describes the numerous small cysts (fluid-filled sacs) that form in the ovaries.

“The diagnosis of PCOS isn't just about infertility. Women with PCOS also have an elevated risk of diabetes,” Dr Huang explains. Also keep in mind that “when a woman has PCOS her cycles are very irregular. Having irregular periods—to the point of no periods—increases the risk of certain endometrial cancers.”

fertility and PCOS

How Does PCOS Affect Fertility?

For some women, PCOS can affect the function of ovulation, and thus, make it harder to get pregnant. How is ovulation affected, exactly? When there are elevated testosterone levels in the body, “testosterone gets converted to estrogen. When you have elevated levels of estrogen your body doesn’t know what to do, and as a result it prevents you from ovulating. Having high levels of estrogen is kind of like taking birth control pills, it breaks the feedback loop of a woman’s ovulatory cycle,” Dr. Huang says. 

More specifically, there are two types of ovulatory dysfunction. First, “there’s anovulation, which means a woman does not ovulate. Typically her symptoms are, she has a period every three to six months. Just by having no periods, you know that this woman with PCOS is probably not ovulating,” Dr. Huang explains. 

Anovulation happens when an egg (ovum) doesn't release from your ovary during your menstrual cycle.

“But having periods doesn’t mean you’re ovulating either. Sometimes it’s not black and white. Sometimes it’s oligoovulation. Oligoovulation is when you ovulate every two to three months instead of every month. Some women will have a period one month, then no period for two months, then a period for one month, then no period for three months. That’s somebody who is oligoovulatory.” How can a woman know which hand she’s been dealt? “It just depends on where on the spectrum for PCOS you lie,” Dr. Huang concludes. 

Oligoovulation is a condition that causes irregular or infrequent periods.

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What Lifestyle Changes Should a Woman with PCOS Consider?

The first step on any PCOS fertility journey should be thoughtful lifestyle changes, Dr. Huang suggests. Specifically, it is important to “hit the ideal body weight—not over or underweight. People associate PCOS with being overweight, but there is a subset of women with PCOS that are underweight, and for them they need to gain a little bit of weight. When you hit that ideal body weight, the body says: Okay, I’m in a good place, I can ovulate.” Dr. Huang explains.

How can women best do this? “By maintaining a healthy lifestyle, one that’s not overly aggressive in terms of exercise routine, and also includes eating a well-balanced diet full of antioxidants, and somewhat low-carb, because with PCOS you can be a little bit insulin resistant,” Dr. Huang advises. 

What Fertility Treatments Can Help Women with PCOS?

Before considering any other treatments, Dr. Huang suggests that the “first line of fertility should always be lifestyle changes—losing weight, eating better, trying a low carb diet, taking vitamins for PCOS, exercise—all these things should be the first line with PCOS.”

“The first line of fertility should always be lifestyle changes."

Beyond those changes, "for women with PCOS who are not ovulating—we just need to get them to ovulate,” Dr. Huang says. To do that, a specialist might use “a certain set of oral medications that are utilized for ovulation induction. Some of these medications include Clomid, which we have been using for decades, and Letrozole, which we’ve been using for a decade. When those fail, then we use Gonadotropins, specifically FSH, which we can inject into a woman to get her to ovulate.” Gonadotropins are peptide hormones that regulate ovarian function.

“The way that Letrozole and Clomid work is that they trick the brain. They make the brain think that the woman has no estrogen, and then it steps on the gas a little bit by making FSH to get a woman to ovulate,” Dr. Huang explains. 

What Should Women Know About These Drugs?

The perfect drug is the drug that only does one thing. No drug only does one thing. Clomid, for example, will stimulate one thing and inhibit another. It’s just the way that medications do it. So, Clomid will help a woman ovulate better, but sometimes it will negatively affect cervical mucus so the sperm doesn’t get past the cervix and now we have to do insemination. Sometimes Clomid will make you ovulate better but it will thin your uterine lining, making it harder for implantation to occur,” Dr. Huang explains. “Recent studies have shown Letrozolel has less side effects,” he adds. “The other side effects that come with any type of pill are heachaches and hot flashes. But overall, oral medication side effects are low.”

“Inevitably when you take medications, some women are very sensitive to Clomid and Letrozole, and the body’s natural response to more FSH is to ovulate two or three eggs. So, the risk of twins and triplets does increase a tiny bit any time you take medication,” Dr. Huang explains. How likely is this to happen? Clomid and Letrozole increase the risk of twinning to about seven percent.

"Very manageable, says Dr. Huang. "93 percent of the time when you get pregnant with Clomid or Letrozole it will be a singleton. Twins do bear increased risk in pregnancy, so it is something to be mindful of."

“If you move onto injections, the next line, now it’s stronger, more expensive, and a direct stimulation. So a patient makes more eggs but the chance of having twins goes up to about 15 to 20 percent. So that’s why we like to try Clomid and Letrozole before we move on to more aggressive shots,” Dr. Huang says. 

What about efficacy? “Some women with severe PCOS are resistant to these oral medications. So there’s a small subset of patients that just don’t respond to the medications, but for the most part they do respond,” Dr. Huang says. 

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Written by Jessica Lopez. Jessica Lopez is a freelance writer, digital content creator, and mother. You can follow her @Jessica.H.Lopez.

This article is for informational purposes only. It is not, nor is it intended to be, a substitute for professional medical advice, diagnosis, or treatment and we recommend that you always consult with your healthcare provider. To the extent that this article features the advice of physicians or medical practitioners, the views expressed are the views of the cited expert and do not necessarily represent the views of Perelel.