Polycystic Ovary Syndrome (PCOS) is the most common cause of infertility resulting from a lack of ovulation, known as anovulatory infertility. This endocrine disorder affects approximately 6 to 13% of women of reproductive age, often leading to irregular menstrual cycles and hormonal imbalances. A structured, tiered approach involving lifestyle changes and medical interventions offers high rates of success for achieving pregnancy.
Foundational Lifestyle Adjustments
Addressing metabolic dysfunction is often the first step for women with PCOS seeking to improve fertility. Insulin resistance, which affects many women with the condition, can disrupt the hormonal signals necessary for ovulation. Losing 5–10% of initial body mass has been shown to significantly improve insulin sensitivity and lead to more regular menstrual cycles.
Dietary strategies should focus on managing blood sugar levels by adopting a low glycemic index approach. This involves prioritizing complex carbohydrates, such as whole grains and fiber-rich foods, which are digested slowly. Limiting refined carbohydrates and sugary beverages helps prevent the sharp blood sugar spikes that exacerbate hyperinsulinemia. Regular physical activity enhances the body’s ability to use insulin, further regulating hormone balance.
Medications to Induce Ovulation
When lifestyle modifications alone do not restore regular ovulation, pharmacological treatment is the next step. The goal of these medications is to encourage the ovaries to mature and release an egg. Letrozole, an aromatase inhibitor, has emerged as the preferred first-line treatment for anovulatory PCOS.
Letrozole works by temporarily blocking estrogen production, signaling the brain to increase the release of Follicle-Stimulating Hormone (FSH). This surge in FSH stimulates the growth of ovarian follicles without the negative effect on the uterine lining often seen with older medications. Studies demonstrate that Letrozole leads to a higher live birth rate compared to other oral ovulatory agents.
The traditional first-line drug, Clomiphene Citrate, is a selective estrogen receptor modulator that tricks the body into thinking estrogen levels are low. While effective at inducing ovulation, its anti-estrogenic action can sometimes thin the endometrial lining, which may hinder implantation. Metformin, typically used for Type 2 diabetes, is frequently used alongside these ovulatory drugs for women with insulin resistance. Metformin works by making the body more sensitive to insulin, reducing high insulin levels that interfere with normal ovarian function.
Advanced Fertility Procedures
If conception does not occur after several cycles of oral ovulation induction medications, the treatment progresses to more intensive procedures. The next step typically involves combining injectable gonadotropins with Intrauterine Insemination (IUI). Gonadotropins (hormones like FSH and Luteinizing Hormone) directly stimulate the ovaries to produce multiple follicles.
During IUI, a concentrated sample of sperm is directly placed into the uterus around the time of ovulation. This approach carries an increased risk of multiple pregnancies due to the strong ovarian stimulation. If these cycles are unsuccessful, In Vitro Fertilization (IVF) is usually recommended.
IVF offers the highest success rate, especially for women with PCOS, because it allows for precise control over ovarian stimulation and fertilization. Specialists often use specific protocols, such as GnRH antagonist cycles, to minimize the risk of Ovarian Hyperstimulation Syndrome (OHSS). Many centers utilize a “freeze-all” strategy, where embryos are cryopreserved and transferred in a subsequent, non-stimulated cycle, which optimizes the uterine environment for implantation.
Monitoring and Managing PCOS Pregnancy
Once pregnancy is achieved, women with PCOS require specialized monitoring due to increased risks. The underlying metabolic and hormonal imbalances contribute to a higher likelihood of complications. Women with PCOS have an elevated risk of developing Gestational Diabetes Mellitus (GDM), a condition of impaired glucose tolerance that begins during pregnancy.
There is also an increased risk for hypertensive disorders, including preeclampsia, which involves high blood pressure and signs of organ damage after the 20th week of gestation. Some physicians recommend starting low-dose aspirin early in pregnancy to mitigate the risk of preeclampsia. The risk of preterm birth is also higher, necessitating closer surveillance. Continued use of Metformin may be recommended during pregnancy, especially for women at high risk of GDM, to help maintain blood sugar control.