PCOS and fertility – How to get pregnant with PCOS?
What are PCO and PCOS?
Having polycystic ovaries (PCO) in ultrasound scan doesn’t mean you have polycystic ovarian syndrome (PCOS).
A polycystic ovary is just the description of how the ovary appears on the ultrasound scan. It certainly doesn’t have lots of cysts! That’s a misnomer. Polycystic ovaries have lots of follicles. Follicles are the egg bags, each of which contain an egg. In other words, women with polycystic ovaries have lots of eggs and considered as having high ovarian reserve. Most women with polycystic ovaries have regular periods every month and they are ovulating. Most of them do not have any symptoms like excess hair growth on face/chest or unusual hair loss or acne. So they do not have polycystic ovarian syndrome. They just have ovaries which look polycystic and their fertility is not compromised due to this.
On the other hand, some women with polycystic ovaries will have additional symptoms like irregular periods or excess hair growth on face/chest/back/legs or may have excessive hair loss/acne. They are likely having the hormonal imbalance, which is causing these symptoms and are having the polycystic ovarian syndrome. In some women the symptoms can be mild, while in some they can be quite severe.
Having irregular periods mean that you are not ovulating consistently and that might lead to difficulty in falling pregnant.
So, what hormonal changes cause PCOS?
Following two hormones are responsible for all symptoms of PCOS:
Testosterone: All women have the male hormone (testosterone) in small amount, produced by the ovaries. In women with PCOS, this hormone is found in high amount and causes the excessive hair growth, acne and irregular periods.
Insulin: This is a hormone, which regulates your sugar level. In women with PCOS, your body may not respond to insulin (insulin resistance) and this can make the sugar level go up. To keep the sugar level down, your body will produce more insulin and this can cause all symptoms of PCOS.
How can I get pregnant if I have PCOS?
If you are having difficulty in falling pregnant, see your GP to get investigated. Do not wait for 1 year if your periods are irregular or you are over 36 years of age (Ref).
Check your weight. Body fat makes the symptoms of PCOS worse. There are enough research to show that losing weight can normalise your hormonal status and regularise your periods. A regular period every 28-35 days indicates that you are ovulating and will improve your chances of getting pregnant. Try to achieve a healthy BMI of 20-25. However, even if you lose 5-10 kg, you might see the difference.
You should consider eating healthy balanced diet and doing 150 min/week of moderate intensity physical activity. If you are having difficulty in losing weight, check with your GP to get referral to a dietician.
Inofolic: This is a dietary supplement for women with PCOS, consisting of myo-inositol and folic acid. There is some evidence to show that myo-inositol taken for 24 weeks can improve insulin resistance and reduce the male hormone (testosterone) and thus improve ovarian function in women with PCOS (Ref). They have good safety profile.
However, due to lack of robust evidence they are not still included in the national guidelines and are considered as experimental (ref).
Apart from myo-inositol, metformin is a drug that also normalises the insulin resistance and has been used in women with PCOS, particularly in those who are over-weight (ref).
Ovulation induction: If your tubes are open and your partner’s sperm are normal, then all you need is to ensure that you ovulate, to get pregnant. Thankfully, there are effective medications to induce ovulation in women with PCOS, like clomiphene/letrozole. However, these drugs should never be taken without ultrasound monitoring due to the risk of growth of multiple follicles, which can lead to multiple pregnancies (twins/triplets) (ref)
If these tablets don’t make you ovulate, then hormonal injections can be given, which are highly effective. However, they should be taken strictly under medical guidance and with regular ultrasound monitoring.
Laparoscopic drilling of ovary: In women who do not respond to tablets, laparoscopy and ovarian drilling can be offered instead of taking injections. Though the name sounds quite gruesome, it basically means doing a keyhole surgery (laparoscopy) and make tiny holes in the ovary (4-5 in each ovary). For some unknown reason, it has been found to wake up the ovaries and make them ovulate on their own (ref). Additional benefit is that, during the laparoscopy, rest of the pelvis can be assessed to look for other factors like endometriosis. However, risks of general anaesthetic and surgical complications would need to be considered.
IVF: If all the above measures fail, then IVF can be done as the last resort. Women with PCOS have high ovarian reserve and they produce large number of eggs during IVF and hence they generally do well. However, there is risk of ovarian hyper stimulation.
What is the risk to my pregnancy if I have PCOS?
Women with PCOS are at increased risk of developing diabetes during pregnancy (gestational diabetes). Hence the sugar level should be carefully monitored during pregnancy.
If you are on metformin, it is safe to continue during pregnancy.
Dr Anupa Nandi MD, MRCOG, DFFP, MD, MBBS
Consultant Gynaecologist & Subspecialist in Reproductive Medicine and Surgery
Lister Fertility Clinic
Chelsea Bridge Road, London
t: +44 (0)20 7881 2027
f: +44 (0)20 7259 9039,
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