Perhaps you already have a polycystic ovary syndrome (PCOS) diagnosis and a doctor has told you that you’ll likely have a hard time getting pregnant. Or maybe you’ve been trying to get pregnant for a while and are beginning to wonder if an underlying condition like PCOS is the reason it hasn’t happened yet.
PCOS is “a complex disorder that is very common — impacting [approximately] 10% of people with ovaries,” Dr. Lucky Sekhon, a reproductive endocrinologist and OB-GYN at Reproductive Medicine Associates of New York, told HuffPost.
“It is one of the most common causes of female infertility,” Dr. Christina Mitchell, an OB-GYN fertility specialist at the University of North Carolina School of Medicine, told HuffPost.
PCOS is a hormonal imbalance that prevents regular ovulation, but it manifests differently from one person to the next, and there are different criteria for diagnosis.
Sekhon explained that her clinic uses the Rotterdam criteria, meaning a person can be diagnosed with PCOS when they present with at least two of the three main symptoms: many cysts on the ovaries, which can hinder ovulation; irregular or absent periods; and/or signs of excess androgens, which are hormones like testosterone that can affect menstruation.
Obesity and insulin resistance ― a condition in which your body does not respond well to insulin, potentially leading to Type 2 diabetes ― are also common in people with PCOS. It is important to note, however, that not all obese people with ovaries have PCOS, and people who aren’t obese or overweight can develop PCOS, too.
Whether you’re trying to get pregnant or not, it’s important for a doctor to tailor a treatment plan to your individual needs.
How does PCOS affect fertility?
You can’t get pregnant without ovulating, or releasing an egg. If you’re not ovulating at all, pregnancy won’t happen without some intervention. If you’re ovulating irregularly, you might get pregnant, but it can be a challenge to figure out when you’re nearing ovulation in time for intercourse or insemination.
“PCOS results in few or no ovulatory events and thus infrequent opportunities to conceive,” Mitchell said.
In addition to a lack of cycle regularity making it difficult to know when ovulation will occur, “ovulation predictor kits can be less accurate in people with PCOS,” Sekhon said. “The ovulation predictor kits detect a rise in luteinizing hormone levels in the urine ― these levels tend to run high throughout the menstrual cycle in people with PCOS and can lead to confusing false-positive results that are all over the map.”
Infrequent ovulation means fewer attempts to conceive, explaining why many people with PCOS have a hard time getting pregnant. That said, you still can get pregnant even if your ovulation is irregular, and you should use birth control when you want to avoid a pregnancy.
What fertility treatments are available for people with PCOS?
The good news is that many people with PCOS are able to get pregnant with lifestyle modifications, medications or fertility treatments.
Some people improve their odds of pregnancy by losing weight — and the weight loss often doesn’t need to be huge. “Losing only about 5-10% of their body weight can restore normal ovulatory patterns, improving the chance of conception without any medical intervention,” Mitchell said.
However, a catch with this is that it’s often extremely challenging for people with PCOS to lose weight. The condition can sometimes even lead to weight gain.
Metformin, a Type 2 diabetes drug that sensitizes the body to insulin, can also be effective in regulating the menstrual cycles of people with PCOS.
In addition, there are drugs that induce ovulation. The two most commonly used are Clomid (clomiphene citrate) and Femara (letrozole). The medication is taken for five consecutive days at the beginning of your cycle, and then your doctor will do an ultrasound to see if your body is responding to treatment by preparing an egg for ovulation.
This ultrasound can also determine if the medication has worked too well. It’s important “to make sure you will not ovulate too many eggs if you have an overly robust response, which could increase the risk of twins,” Sekhon said.
Your doctor may also prescribe an injection of HCG (human chorionic gonadotropin — the hormone detected by pregnancy tests) to trigger your ovary to release the egg. This can help you more precisely time intercourse or insemination.
Injectable fertility medications, like the ones used in IVF cycles, can also be used to induce ovulation, “but this is now viewed as very aggressive, as it often leads to many follicles releasing eggs and leading to a higher risk of twins or triplets,” Sekhon said.
IVF offers the highest odds of success, although it is expensive and may not be fully covered by your insurance. It is also a more involved process, requiring many visits to the fertility clinic for monitoring via ultrasounds and blood tests.
What are my chances of success with these treatments?
“I tend to think of patients with PCOS as having a good prognosis, as irregular ovulation can most often be directly addressed with medication and lifestyle changes,” Sekhon said.
If weight loss, metformin, Clomid or Femara works and you ovulate, then you have the same chances of getting pregnant as any other ovulating person your age.
“Typically, for the average patient, we say there is approximately a 15% chance of conceiving with each ovulated egg,” Sekhon explained, adding that a person in their 20s has about a 20% chance of getting pregnant each cycle but that this drops to less than 5% for people over 40.
Injectable fertility drugs increase the number of eggs you ovulate, which in turn increases your odds of pregnancy — but also of having twins or higher-order multiples, which brings significant risks both to the pregnant person and the babies.
The likelihood of success with IVF depends both on your age and how many eggs you produce in response to the medications. People with PCOS often produce a high “egg count” on IVF drugs, leading to more chances for conception to occur.
Doctors can then fertilize all the mature eggs you produce to see which ones produce healthy embryos. An embryo that has been tested and proven to be genetically normal has a 50% to 70% chance of resulting in pregnancy. Doctors now generally transfer only one healthy embryo into the uterus at a time, virtually eliminating the risk of twins. If a cycle produces more than one healthy embryo, they can be frozen and thawed for later use.
That said, not every IVF cycle will produce any genetically normal embryos, and the odds of this outcome increase with age. Odds of success for fertility treatments are also lower if you or your partner has other fertility issues.
Why is it important to know that I have PCOS, even if I’m not trying to get pregnant?
If infertility is the symptom that brought you to your PCOS diagnosis, you may wonder why else it would matter. But PCOS affects more that just your reproductive system.
“Specifically, it increases the risk of metabolic disease, including high blood pressure, diabetes and high cholesterol — even in women who are not obese. Women with PCOS should have regular health screening for these conditions in order to prevent and/or treat them,” Mitchell said.
Because PCOS prevents the regular shedding of the uterine lining (aka your period), it can increase a person’s odds for pre-cancer or cancer of the uterus. There are treatments, such as birth control, to resolve this issue.
In addition, “many women with PCOS suffer from various bothersome symptoms, such as heavy or unpredictable vaginal bleeding, abnormal hair growth on their face or chin, and cystic acne. These can be treated very effectively with hormonal therapies, such as birth control pills, if the underlying cause is diagnosed,” Mitchell said.
And it isn’t just your physical health that matters, of course.
“Mental health issues — depression and anxiety — have been shown to be more common in women with PCOS,” Sekhon said. So it’s also important to be regularly screened for these, too.