PCOS and fertility: everything you need to know

PCOS, short for the polycystic ovarian syndrome, is a common condition related to hormones, in which the ovaries don’t always release an egg every month. It can lead to difficulty getting pregnant.

What is Polycystic Ovarian Syndrome (PCOS)?

PCOS, short for the polycystic ovarian syndrome, is a common condition related to hormones in which the ovaries don’t always release an egg at the end of the menstrual cycle (the start of a period to the start of the next one). It can lead to difficulty getting pregnant. It is thought to be very common, affecting about 1 in every 5 women in the UK.

If you have polycystic ovaries (PCO):

·         Your ovaries are slightly larger than normal

·         you have many more follicles (the fluid-filled pockets on the ovaries that release the eggs when you ovulate)

Having polycystic ovaries does not mean that you have PCOS. PCO means your ovaries are slightly different from most women's ovaries, while PCOS is disorder linked to having hormone levels that are not balanced.

Symptoms of PCOS

Having PCO does not mean that you have PCOS. To be diagnosed as having PCOS you would have PCO and some of the following symptoms:

·         irregular periods or none

·         more facial or body hair

·         less hair on the head

·         difficulty losing weight or rapid weight gain

·         acne or oily skin

·         difficulty getting  pregnant

Periods are ‘irregular’ if the length of your cycle (the gap between your periods starting) keeps changing. The average length of  menstrual cycle is 28 days, although it's normal for it to be a bit shorter or longer than this.

You may have some of these symptoms of PCOS but they vary from woman to woman, with some women having milder symptoms and others more severe.

What are the causes of PCOS?

The exact cause of PCOS is not known but it may be genetic as you are more likely to have it if any of your relatives (mother, aunts, sisters) have it.

The symptoms of PCOS are linked to hormones:

·         Women with PCOS have slightly higher than normal levels of testosterone - this is linked to many of the symptoms, such as more facial hair.

·         If you have PCOS, your body may not respond to insulin (this is known as insulin resistance), High levels of insulin can lead to weight gain, hyperandrogenism(excess levels of testosterone) and fertility problems. If you are diagnosed with PCOS, you are at increased risk of developing diabetes in later life

Do I have PCOS?

Women who have mild symptoms often only realize they have PCOS when they start trying for a baby, particularly if their weight goes up and down.

Using the combined oral contraceptive (‘the pill’) can stop you noticing you have PCOS because:

·         Many of them have a pill-free 7 days every month and a withdrawal bleed, which can be mistaken for a period (It is not a true period as it is unrelated to egg production or thickening of the lining of the womb). 

·         Women cannot tell whether their period is regular or not.

·         The pill has hormones that can help the symptoms of PCOS. It can improve acne and lessen excess hair growth. (It is a standard treatment for PCOS when women are not seeking to get pregnant.)

   A diagnosis of PCOS is made when you have any two of the following:

·         irregular periods or none

·         A transvaginal scan (in which a probe is put inside your vagina) showing polycystic ovaries

·         An increase in facial or body hair or test results showing you have excess levels of testosterone.

If you think you have PCOS visit a GP to get a referral to a gynecologist.

How does normal ovulation work?

In a normal menstrual cycle with ovulation a number of eggs mature in follicles in your ovaries. The ripest egg is released near one of your fallopian tubes, where it meets the sperm  and the process of fertilization starts.

If you have PCOS although the polycystic ovaries contain follicles with eggs in them, the follicles do not develop and mature properly - so there is no ovulation or release of eggs. This is called Anovulation.

Many women do not find out they have PCOS until they try to conceive, particularly if they were using contraception that uses hormones, which masks irregular or no periods, because it allows for a monthly bleed.

What is the treatment for PCOS if you are trying to conceive?

There is no treatment for PCOS in itself but the symptoms can be treated. If you have a BMI of over 30, you will be advised to lose weight with healthy eating and exercise. This alone may get your body ovulating. Even if it does not do this, it will allow your medication to work better, and will cut down on risks during pregnancy.

There are a number of different medicines that help with conceiving with PCOS

·         Clomifene citrate  or Letrozole (there are plenty of brands available in India) – they stimulates your ovaries to release eggs

·         Metformin is used to correct insulin resistance, which may also be present with PCOS

·         A combination of the above.

If you are taking clomifene citrate tablets:

·         you will have a transvaginal scan in the first cycle of treatment to check whether it is the correct dose for you. The scan will look at your follicles to see how they are developing.

·         You will not be given it for more than six months as it increases your risk of ovarian cancer.

If clomifene citrate doesn't work then you may be offered:

·         gonadotrophins (a fertility drug that is based on the gonadotrophin hormones, which stimulate your ovaries to produce and ripen eggs). These are more likely to overstimulate your ovaries and cause a multiple pregnancy but you will have regular scans to check on developing follicles.

 In resistance and severe cases, IVF/ICSI is the the best option as the ovaries can be handled more efficiently and we can avoid excess response (ovarian Hyperstimulaion).

In most cases effective ovulation induction can get us pregnancy but Reproductive specialist’s skills and experience do matter in ovarian stimulation in PCOS cases.