The presence of ovarian cysts is a common concern when trying to conceive. An ovarian cyst does not automatically mean a person is infertile, but it does require a careful, individualized approach to conception. Understanding the specific type of cyst and its biological impact is the first step toward a successful strategy. The path to pregnancy often involves managing the underlying condition before moving on to specific fertility treatments.
Ovarian Cysts and Their Effect on Ovulation
Ovarian cysts are fluid-filled sacs that develop on or inside an ovary, and their impact on fertility depends entirely on their origin. The most common type, functional cysts, form as a normal part of the menstrual cycle, such as follicular cysts or corpus luteum cysts. These cysts generally resolve on their own within a few weeks and do not prevent conception; their presence confirms that the ovary is actively attempting to ovulate.
Pathological cysts are those that affect fertility, often indicating an underlying condition. Endometriomas, or “chocolate cysts,” are endometriosis growing on the ovary, posing mechanical, inflammatory, and hormonal challenges. They can physically distort the ovary and fallopian tubes, hindering egg release and capture. The tissue also creates a chronic inflammatory environment in the pelvis, which can negatively influence egg quality and embryo implantation.
Polycystic Ovary Syndrome (PCOS) involves a collection of small follicles. The issue is not the cysts themselves, but the hormonal imbalance causing them. High levels of androgens and insulin resistance prevent ovarian follicles from maturing and releasing an egg, leading to chronic anovulation. The resulting accumulation of small, underdeveloped follicles is seen on an ultrasound, and the primary obstacle to pregnancy is the lack of regular egg release.
Medical Approaches to Managing Cysts Before Trying to Conceive
The first step in management is a period of observation, or “watchful waiting,” for any simple or functional cyst found on a baseline ultrasound. Since the majority of these cysts are benign and temporary, a physician will typically schedule a follow-up ultrasound within one to three months to confirm that the cyst has decreased in size or disappeared. Intervention is avoided during this time, as it is often unnecessary and carries risks.
Management for pathological cysts focuses on stabilizing the underlying condition before attempting conception. For PCOS, first-line management involves lifestyle changes, including weight loss, to improve insulin sensitivity and hormonal balance. Medications like Metformin are often prescribed to address insulin resistance, which can help regulate the menstrual cycle and sometimes restore spontaneous ovulation. If these steps fail, Laparoscopic Ovarian Drilling (LOD) can be considered, which involves creating small punctures in the ovary to reduce androgen production and promote ovulation.
Managing Endometriomas
For endometriomas, the decision to intervene surgically is complex because removing the cyst carries the risk of inadvertently removing healthy ovarian tissue, which can diminish the ovarian reserve. Surgery (laparoscopic cystectomy) is generally reserved for large cysts (greater than 4 to 5 centimeters), cysts causing significant pain, or if malignancy is suspected.
If a person plans to proceed directly to In Vitro Fertilization (IVF), many specialists recommend avoiding surgery. Surgical removal does not consistently improve IVF outcomes and may reduce the number of eggs retrieved. In some cases, a GnRH agonist may be used for about three months before starting fertility treatment to suppress the endometriosis and improve the environment for conception.
Fertility Strategies When Cysts Are Present
Once the cyst situation is stable or managed, specific fertility treatments can begin. For anovulation related to PCOS, the first line of treatment is typically ovulation induction using oral medications. Letrozole is often preferred over Clomiphene Citrate, as studies show it is associated with higher rates of ovulation and live birth in women with PCOS. These medications work by altering hormone levels to encourage the growth and release of a single, mature egg.
These oral medications are often used in conjunction with timed intercourse or Intrauterine Insemination (IUI), where concentrated sperm is placed directly into the uterus. If a small, simple cyst is present at the start of an IUI cycle, the cycle can often proceed if the cyst is hormonally inactive, meaning it is not producing excessive estrogen that could interfere with the medication. However, a large or hormonally active cyst will typically lead to cycle cancellation to prevent a poor response to the stimulation medication.
When advanced treatments like In Vitro Fertilization (IVF) are required, the presence of cysts requires careful planning. If a functional cyst persists at the start of an IVF cycle, the physician may aspirate the fluid using an ultrasound-guided fine needle. This simple outpatient procedure prevents the cyst from interfering with follicle growth or physically blocking access during egg retrieval. For endometriomas, if they remain, the specialist will carefully navigate around the cyst during retrieval to aspirate healthy follicles, avoiding puncture due to infection risk.