Polycystic Ovary Syndrome (PCOS) and Fertility

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Polycystic ovary syndrome (PCOS) is a very common endocrine condition in reproductive-aged women. It affects approximately 5-10% of young women and often leads to difficulty conceiving a pregnancy. Women with this condition can experience irregular periods, abnormal hair growth, acne, and can have ovaries containing multiple small

cysts. PCOS negatively impacts fertility because women with the condition do not ovulate, or release an egg, each month due to an overproduction of estrogen by the ovaries. Because ovulation does not occur regularly, periods subsequently become irregular. In addition to the reproductive and gynecologic aspects of PCOS, women with this condition are also at risk for insulin resistance, or “pre-diabetes.”

How is PCOS Treated?

For those women trying to conceive a pregnancy, the first step in treatment of PCOS is lifestyle modification, including a healthy diet and exercise. The diets shown to be most successful in PCOS patients include those with lower carbohydrates, a reduced glycemic load. Recommended exercise in PCOS patients is at least 30 minutes of moderate exercise three times per week, with daily exercise being the ultimate goal.

Women who still have infrequent ovulation despite lifestyle modifications may require fertility medications to assist with the release of an egg from the ovary. Often a simple fertility tablet called clomiphene citrate (trade name,

Clomid) can be an effective agent in PCOS. Clomiphene citrate is a selective estrogen receptor modulator (also known as SERM) that increases the signal from the brain to the ovary to produce one or more eggs. Since clomiphene citrate can result in the ovulation of more than one egg in a month, there is an approximately 5-10% risk of twins and very small risk of higher-order multiples with use.

For some women with PCOS, fertility tablets do not result in ovulation or pregnancy, and they require fertility injections to release an egg. Fertility injections (Follistim®, Gonal-F®, Bravelle®, and Menopur®) contain the same hormone the brain releases to signal the ovary to produce eggs. Rather than producing one egg in a month, most women on fertility injections will produce two or more eggs. This treatment requires closer monitoring with transvaginal ultrasounds and several blood draws to determine the woman’s estradiol level, which is a hormone produced in the ovary. Fertility injections are also associated with an increased risk of multiple births.

In some instances, women with PCOS require in vitro fertilization (IVF) to achieve a healthy pregnancy. In this scenario, daily fertility injections are used to stimulate the ovaries to produce multiple eggs, which are harvested in a minor procedure. The eggs are fertilized in vitro, and then the embryos (fertilized eggs) are replaced into the woman’s uterus after 3-5 days of growth. This process involves more frequent monitoring with ultrasound and serial blood draws over approximately a two-week period of time.

What are the Health Risks in PCOS?

As previously mentioned, insulin resistance can occur in women with PCOS. A simple blood test can determine if a person is insulin resistant. If the test indicates insulin resistance exists, women with PCOS may be treated with a medication called metformin (trade name, Glucophage) if they do not harbor any contraindications to the medication.

Hyperlipidemia, or elevated cholesterol and/or triglycerides, can occur in PCOS women as well. Women can be screened for this condition with a fasting blood sample. Screening for hyperlipidemia is very important since this condition can lead to cardiovascular disease later in life.

Women with PCOS appear to be at increased risk for endometrial (uterine) cancer later in life due to persistently higher levels of circulating estrogens. Since menstrual periods do not occur regularly, overgrowth of the uterine lining can occur and in some cases can lead to a malignancy.


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