PCOS, short for Polycystic Ovarian Syndrome, is a common cause of anovulation and female infertility. It is estimated that PCOS affects about 8-10% of women of reproductive age, and is characterized by a excess body hair, acne and/or oily skin, and a tendency to be overweight. PCOS patients are also at much higher risk to develop diabetes or other long-term health problems such as cardiovascular disease. When they try to get pregnant, women with polycystic ovaries usually will have difficulty. Some PCOS women will ovulate (release a mature egg) occasionally, others do not ever ovulate. In order to conceive, sperm must find and fertilize a mature egg. Therefore, women with polycystic ovaries will usually need to undergo induction of ovulation to be able to get pregnant. PCOS is commonly misdiagnosed unless a complete fertility workup is performed by a reproductive endocrinologist/infertility specialist.
PCOS treatment includes ovulation induction with Clomid (clomiphene citrate) and/or Metformin. The vast majority of Clomid pregnancies will occur in the first 3-6 ovulatory cycles and Clomid therapy beyond this period is rarely recommended. Metformin can be added to the fertility drug regimen in PCOS patients who fail to ovulate in response to Clomid. Metformin is often used to normalize ovulation in insulin resistant PCOS patients. Metformin increases the cells sensitivity to insulin thus correcting hyperinsulinemia. The reduction in insulin reduces androgen production by the ovaries allowing ovulation to resume. If metformin alone is not effective, it may be used in combination with Clomid.
If Clomid/metformin therapy(s) is not effective in treating the PCOS patient, the next treatment step may be ovulation induction with follicle-stimulating hormone (FSH). These patients should always be treated by a reproductive endocrinologist fertility specialist with training in using injectable FSH. PCOS patients are more likely to have exaggerated responses to fertility drugs that can lead to serious side effects including ovarian hyperstimulation syndrome. They must be carefully monitored and frequent dosage adjustments may be necessary. These shots directly stimulate the ovaries, but must be used carefully because patients with PCOS can have an excessive response to these medicines and make too many eggs, increasing the risk of multiple pregnancies including the possibility of triplets or higher order pregnancies. Therefore these medicines must be monitored carefully by a trained Fertility Specialist (Reproductive Endocrinologist). Some patients will benefit from In Vitro Fertilization (IVF), where eggs are removed from the ovaries after stimulation with fertility shots, then mixed with sperm in a dish in the laboratory to create embryos that are then replaced back into the uterus. A limited number of embryos can be replaced, and the remaining embryos frozen if desired, to limit the risk of higher order multiple pregnancies (triplets or more).
Obese PCOS patients may resume ovulation after completing a weight loss program, however, it is very difficult for PCOS patients to lose weight because of hormonal imbalances. A low carbohydrate approach seems to work best and patients are encouraged to seek the counsel of a nutritionist.
Finally, in younger PCOS patients with a low tolerance to fertility drugs, multiple births can be a large risk. In these situations, our doctors may recommend IVF in order to control the number of embryos placed into the patient’s uterus. This can give an excellent pregnancy rate while limiting the number of high order multiple births.