PCOS delays conception because it disrupts ovulation. Getting ovulation to happen in a reliable, sustainable manner is the mainstay of treatment, and it works for close to half of patients. The other half have significant egg quality issues and will need further diagnosis and treatment within the IVF level of care.
What PCOS is
PCOS is polycystic ovarian syndrome or disease. It is a nebulous diagnosis mysteriously avoiding clear definition since Stein and Leventhal published their original findings as the classic case. It is really a heterogeneous group of women suffering from conception delay due to ovulation disorders, typically having irregular cycles, which is the sine qua non for not ovulating. This leads to simple inefficiency in reproduction. Not knowing when to time intercourse or have insemination leads to very low pregnancy rates either on your own or under medical care.
One of the most serious impacts of PCOS is a disruption in the release of a woman's eggs. While the ovaries' follicles have eggs, they fail to develop and mature properly, meaning there is no ovulation or release of eggs — also known as anovulation. PCOS is the most common cause of anovulation, the leading endocrine disorder in women, and one of the main causes of female infertility.
Common symptoms
With PCOS the ovaries produce a higher amount of androgen hormones, which can disrupt normal follicular development. While symptoms vary from patient to patient, the more common ones include:
- Heavy, long, intermittent, unpredictable, or absent periods
- Infertility
- Acne or oily skin
- Excessive facial or body hair
- Male-pattern baldness or hair thinning
- Weight gain, especially around the belly
How PCOS is diagnosed
Lab tests can support the diagnosis, such as high AMH, a low FSH to LH ratio, and a sonogram showing multiple studding of the ovary with small primordial follicles. Some patients have metabolic syndrome with higher BMI and high triglycerides or abnormal hemoglobin A1C. Thyroid imbalance and prolactin disorders must be ruled out as well. If you have not yet been evaluated, this all forms part of a standard fertility testing workup.
PCOS patients are likely to be insulin-resistant, and a significant number are estimated to become diabetic or prediabetic before age 40 from associated metabolic syndrome.
Treatment: ovulation induction and IUI
Logically, getting ovulation accomplished in a reliable sustainable manner is the mainstay. This can be best accomplished with medications: oral in the form of clomiphene citrate, or letrozole; or injectable such as FSH gonadotrophin. Fundamentally, once a patient is on fertility medications, she needs to be monitored with serial ultrasounds and estrogen blood levels for safety and timing of the trigger with HCG. The trigger shot is critical for timing to be precise and the program to succeed. This is where your fertility doctor makes the difference in management — experience does matter. Where insemination is used alongside medication, see ovulation induction and IUI.
When IVF is the next step
This approach helps almost half of patients. The other half have significant egg quality issues and will need further diagnosis and treatment within the IVF with a freeze-all approach level of care. Egg retrieval and culture of embryos will allow clear understanding of the extent of the egg quality issues and lead to several successful strategies in embryo selection. Further enhancement of hormone supplementation for the endometrial lining before returning the embryos to the uterus will also augment pregnancy rates. One published indication for PGT-A in our practice is to improve implantation in PCOS patients undergoing elective frozen embryo transfer.
If you have PCOS and are interested in trying for a pregnancy, or if you have experienced recurring miscarriages, please contact the fertility specialists at Chelsea Fertility of New York City.