PCOS (Polycystic Ovary Syndrome) and Getting Pregnant

Polycystic Ovary Syndrome (PCOS) is a complex but very common hormonal disorder and a leading cause of fertility problems in women.

PCOS is thought to affect 5 – 10% of women of reproductive age although recent research suggests that the condition might be even more prevalent than this (1). Despite being such a common disorder, unfortunately many women aren’t diagnosed until they consult their doctor due to difficulty getting pregnant.

So what exactly is PCOS, what are the symptoms and what are your options, if you wish to get pregnant?

In this article:

• What is Polycystic Ovary Syndrome (PCOS)?
• PCOS Symptoms
• PCOS – Getting a diagnosis
• PCOS and the insulin connection
• Can I get pregnant with PCOS?
• Treatment options for getting pregnant
• Boost your pregnancy chances!
• A final word…

What is Polycystic Ovary Syndrome (PCOS)?

PCOS is a metabolic disorder that disrupts the normal balance of hormones. If you have PCOS, you will typically have higher than normal levels of insulin and certain sex hormones, particularly androgens (male hormones).

This imbalance of hormones can play havoc with the normal process of ovulation, amongst other symptoms. One typical feature of PCOS is anovulation (no ovulation) or oligo-ovulation (irregular ovulation), which results in few or no periods. Without the regular release of an egg each month, getting pregnant can be difficult.

The name of the condition is deceptive. Polycystic ovaries refer to multiple cysts that can be seen on the ovaries during an ultrasound investigation. But although this is a common feature of PCOS, not all women with the condition have polycystic ovaries.

In fact, symptoms can vary widely between women, so diagnosis isn’t always straightforward.

PCOS symptoms

The symptoms of PCOS vary from woman to woman and can change over time. They are usually first noticed during the late teens or early to mid twenties. Typical symptoms are listed below:

PCOS symptoms include:

• Infrequent or no periods (amenorrhea)
• Difficulty getting pregnant
• Obesity or weight gain
• Acne
• Excess hair (hirsutism), which can appear in places such as the upper lip, chin, lower abdomen and around the nipples
• Hair loss in a male pattern eg on the temples and top of the head
• Darkened, velvety skin (acanthosis nigricans) in places such as the nape of the neck, skin folds, elbows and knuckles – a sign of insulin resistance
• Depression and anxiety

Although up to 75% of sufferers are either overweight or obese, PCOS can also be diagnosed in women of healthy weight.

PCOS – getting a diagnosis

[This content is for members only.  Please see Step 3 of the Fast Track to Pregnancy Program™ for further information.]

PCOS and the insulin connection

Why and how PCOS develops isn’t well understood and researchers continue to explore possible causes. It’s now recognised, however, that insulin appears to play a major role.

Up to 80% of women with PCOS have insulin resistance and being overweight can contribute to this.

Insulin is a hormone that is released by the pancreas in response to eating food, particularly carbohydrates. Its role is to transport sugar out of the blood and into cells to be converted to energy or stored as fat. Insulin resistance means that the process for getting sugar out of the blood and into the cells is impaired – the cells are ‘resistant’ to insulin.

In this situation, the pancreas has to release more and more insulin to get sugar out of the blood and into the cells, resulting in high levels of insulin (hyperinsulinemia). These high levels of insulin cause the ovaries to make excessive amounts of testosterone which interferes with normal ovulation (release of an egg).

High insulin levels can worsen the symptoms of PCOS and increase the risk of long term health complications. Therefore, controlling blood sugar levels and insulin is key to managing PCOS, controlling symptoms and boosting fertility.

Can I get pregnant with PCOS?

Many women are unaware that they have PCOS until they consult a doctor due to difficulty getting pregnant. Subfertility or infertility is a common problem for women with PCOS.

Irregular periods (nine or fewer a year) are a common symptom and indicate that a woman is not ovulating regularly or sometimes not at all. Fewer ovulations mean less opportunity to get pregnant.

The good news is, that despite fertility problems, over 70% of women with PCOS do conceive naturally and making lifestyle changes is often all that is needed.

When lifestyle changes are not enough, ovulation inducing drugs and assisted reproduction technology (ART), can also help.

Treatment options for getting pregnant

If you have PCOS and you are ovulating and getting periods (even if they are somewhat erratic), you have every chance of getting pregnant naturally. In many cases, all that is required for an easy conception is simply an understanding of your menstrual cycle and fertility (see ‘Boost Your Pregnancy Chances’ below).

If you have extremely infrequent or no periods however, treatment is usually focused on inducing ovulation (release of an egg), so that conception is possible. The various options to achieve this are listed below:

Lifestyle Management

The preferred and most simple treatment option is lifestyle management, focusing on diet and exercise, and weight loss for those who are overweight. A healthy diet and regular exercise are key to improving chances of conceiving naturally and reducing risks during pregnancy.

A healthier lifestyle will also improve PCOS symptoms and reduce the long term risks associated with the syndrome.

Diet

The type of food that you eat plays an integral role in managing PCOS and improving chances of conception. It’s important that you avoid a diet high in refined carbohydrates, especially if you have insulin resistance. This is because a high intake of carbohydrates, especially refined carbohydrates, will cause a rapid rise in blood sugar and cause elevated levels of insulin. Refined carbohydrates include highly processed and sugary foods such as white bread, white rice, pasta, sweets, packaged snack foods and breakfast cereals.

As mentioned previously, high levels of insulin can cause problems for women with PCOS and can make symptoms worse. Eating foods with a low glycemic index (GI) and avoiding processed foods and sugary drinks is a better option. Stick to healthy whole foods such as wholegrains, vegetables, fruit and legumes. This will keep insulin levels lower, which will help to improve PCOS symptoms and boost your chances of pregnancy by helping to regulate your menstrual cycle.

There is no ‘one size fits all’ diet for PCOS. It is advised that a woman with PCOS consult with her doctor or a registered dietician, to determine an individual dietary plan.

A great book to get you started is ’The New Glucose Revolution: Managing PCOS’ By Jennie Brand-Miller, Nadir R. Farid and Kate Marsh.

Weight Loss

A high BMI (Body Mass Index) is associated with a lower chance of having a baby. Being overweight also increases insulin levels dramatically and makes PCOS symptoms worse.

The good news is, that weight loss can reduce both insulin and androgen (male hormone) levels, which in turn can lessen symptoms of PCOS. As well as promoting overall health benefits, research has shown that losing weight through exercise and diet also improves ovulation and results in pregnancy for many PCOS women.

Although weight loss can be difficult if you have PCOS, losing as little as 5 – 10% of body weight often restores ovulation, boosting fertility.

Exercise

Regular exercise is extremely beneficial for women with PCOS. Exercise can help with weight loss and is a great benefit to overall health. In addition, it improves the body’s use of insulin, promoting ovulation and increasing chances of pregnancy. Being fit will also reduce your chances of developing gestational diabetes during pregnancy.

Aiming for half an hour of moderate to vigorous exercise 2 – 3 times a week is a great start. If you are overweight (BMI of 25 or over), gradually increasing the frequency or duration of this exercise over time can help you achieve weight loss and boost your fertility.

If you are already a healthy weight however, make sure you don’t go overboard, as ironically, too much vigorous exercise can negatively affect your conception chances. Avoid high intensity exercise like running and intense gym workouts and stick to more moderate forms of exercise such as brisk walking, bike riding and yoga.

Medication

If lifestyle changes alone don’t initiate more frequent or regular cycles, medication may be needed to induce ovulation.

Clomiphene citrate (Clomid)

This is an oral anti-estrogen medication taken in tablet form. It is the first choice drug to help treat subfertility in women with PCOS. It can be used alone or in combination with metformin (below).

Metformin

This is an insulin-sensitizing agent that is also taken orally. It can be used alone or in combination with clomiphene (above).

Clomiphene citrate and Metformin combined

A combination of both clomiphene citrate and metformin is sometimes used. It is the recommended treatment for women with PCOS who are resistant to clomiphene (that is, clomiphene alone doesn’t induce ovulation) or for those who have a BMI of 35 or more).

[Opinion is divided as to the best treatment regime regarding clomiphene, metformin or the combination of both. One recent study (2) carried out in NZ concluded that there was no significant difference between these 3 options with regards to pregnancy rates (in women with a BMI < 32)].

Whatever regime is used, if the medication successfully initiates ovulation and more regular cycles, learning the fertility awareness method and charting your menstrual cycle will greatly enhance your chances of conception (see ‘Boost your pregnancy chances’ below).

Gonadotropin Therapy/FSH therapy

If the above medical treatments don’t work, a more aggressive treatment may be offered, using hormones called gonadotropins. These are usually administered at a specialist fertility clinic by injection, as part of assisted reproduction treatment (ART).

Surgery

Laparoscopic ovarian drilling (LOD) is used to stimulate ovulation and prompt normal menstrual cycles. It is performed during a laparoscopy under a general anaesthetic.

It can be an option for women who don’t respond to clomiphene (and/or metformin), as an alternative to gonadotropin therapy. This option is not commonly used however, and it is not practiced in all countries.

For more details on these various methods of treatment and the success rates, please refer to ‘Your Guide to – Polycystic Ovary Syndrome’ in Step 2 of the Fast Track to Pregnancy Program™.

Boost your pregnancy chances!

One of the most common symptoms of PCOS is irregular or infrequent periods. This can be extremely frustrating if you want to become pregnant, because it can be very difficult pinpointing ovulation or knowing in fact, if ovulation is even occurring.

Learning the Fertility Awareness Method and charting your fertility is a very simple, non-invasive way to greatly enhance your chances of conception. Having PCOS often means that there are fewer opportunities to get pregnant because ovulation typically occurs less frequently. Knowing when your fertile days are each cycle can be crucial and mean the difference between getting pregnant relatively quickly or facing a long wait.

With PCOS, ovulation can be very delayed and in this situation you may not be fertile for several weeks after your period. Ovulation can occur as late as Day 50 of the cycle or beyond. Charting your fertility will help you find out if you are ovulating and when your most fertile days are, so that intercourse can be timed appropriately.

Fertility awareness can also be used alongside treatment with metformin or clomiphene (see above) to assist conception. It can help confirm that the medication is inducing ovulation and ensure that intercourse is timed appropriately to maximise your chances of conception each cycle.

A final word…

Although there is no ‘cure’ for PCOS, a diagnosis brings the opportunity to take control of the situation by educating yourself and taking positive steps to help manage the condition. There are many helpful books and websites now available on PCOS, which provide support, advice and information.

It’s important to have the condition diagnosed and monitored by a health professional because women with PCOS are at a higher risk of developing certain conditions over time, such as Type II diabetes, high blood pressure, heart disease and stroke. Pregnancies with PCOS also carry a greater risk of developing complications, including a higher risk of miscarriage.

Managing the condition with diet, exercise and weight loss (if necessary) can significantly reduce these risks.

Resources

March WA, Moore VM, Willson KJ, Phillips DIW, Norman RJ, Davies MJ. The prevalence of polycystic ovary syndrome in a community sample assessed under contrasting diagnostic criteria. Human Reproduction, Vol.25, No.2 pp. 544 – 551, 2010
http://www.managingpcos.org.au/about-pcos/pcos-risks
Harris C, Cheung T. The Ultimate PCOS Handbook
Dr John Eden. Polycystic Ovary Syndrome A woman’s guide to identifying and managing PCOS
OBGYN PCOS and diet. http://www.obgyn.net/pcos/pcos.asp?page=articles/pcos_and_diet.mckittrick
Managing PCOS The Jean Hailes Foundation for Women’s Health
Mayo Clinic staff. Polycystic ovary syndrome. MayoClinic http://www.mayoclinic.com/health/polycyctic-ovary-syndrome/DS00423
eMedicine, Endocrinology. Polycystic Ovarian Syndrome http://emedicine.medscape.com/article/256806-overview
Vause, TDR, Cheung AP. Ovulation Induction in Polycystic Ovary Syndrome; SOGC Clinical Practice Guideline. JOGC May 2010
Legro RS, Barnhart HX, Schlaff WD, et al. Clomiphene, metformin, or both for infertiity in the polycystic ovary syndrome. N Engl J Med. 2007:356:551-566
Deeks, A., M. Gibson‐Helm, and H. Teede. Negative body image and lower self‐efficacy in women with polycystic ovary syndrome. in Australian Society for Health and Behavioural Medicine, Proceedings: Abstracts. 2010. Brisbane
Frincu-Mallos, C, PhD. ‘Endo 2009: Obesity can be managed in women with PCOS. Medscape CME
Johnson NP, Stewart AW, Falkiner J, Farquhar CM, Milsom S, Singh VP, Okonkwo QL, Buckingham KL. PCOSMIC: a multi-centre randomized trial in women with Polycystic Ovary Syndrome evaluating metformin for infertility with clomiphene. Hum Reprod. 2010 25(7):1675-1683
The Evidence-based guideline for the assessment and management of polycystic ovary syndrome. 2011. The Jean Hailes Foundation for Women’s Health and PCOS Australian Alliance