PCOS stands for Polycystic Ovary Syndrome. September is PCOS Awareness Month and it’s a time when we all talk more about PCOS and raise awareness about this very common condition.
I see many women every day with PCOS in our fertility centre. The simple reason for this is that PCOS is a leading cause of infertility. Now, while not every woman with PCOS will struggle to get pregnant, the sad truth is that 70% of women with PCOS will not get pregnant easily. So, it’s very important to talk about why PCOS often leads to infertility. And it’s just as important to explore the many ways you can get pregnant when you have PCOS.
The first step: Find out if PCOS is really the reason for your Infertility!
Before we start talking about PCOS in detail, we need to understand that while PCOS is one reason that a woman might struggle to get pregnant, there might be a couple of other reasons as well. At our fertility centre, more than half of the women who come to us with PCOS have a male partner with a sperm problem. So, first thing’s first, get treated as a couple: Make sure to get your partner to do a sperm test before you start any fertility treatments for your PCOS.
Just as important is the woman’s age. Many women do not realise how vital their age is in determining whether they will get pregnant. Women are born with all the eggs they will ever have. These eggs die off relatively quickly and by the age of 40 a woman has very few eggs left. This means that around this age most women are naturally infertile, whether they have PCOS or not. Most women go through menopause around the age of 52, and at this point all the eggs are long gone. Unlike men when it comes to sperm, women cannot make new eggs when they need them.
What’s more, women’s eggs have a best-before date. Eggs become less healthy over time, and this begins earlier than most people realise. A woman’s egg quality actually begins to decline from around the age of 33. In her 20s and early 30s, if a woman has normal eggs, only around one in every three or four eggs will actually be able to make a baby. From the age of 34 onwards, eggs start to become genetically damaged and less good at making babies.
By the time a woman is 37 years old, she will only have two good eggs a year. And at 40, around one in every 12 eggs is good. So, since women with regular periods only grow and release one egg a month, this means that most women at 40 only have one good egg a year. Now you can see why age is so important! What this means is that age, and not PCOS, may be the reason for your infertility.
The story takes a nose dive for women at this point. Egg quality drops dramatically after the age of 40. By 43, nature has made most women infertile, with only one in every 25 eggs able to make a baby. Once a woman is 45 years or older it is a real miracle for her to have a baby naturally with her own eggs.
Of course, egg donation treatment with IVF can change this. Many celebrities who are in their 40s and even 50s, use eggs given to them from a young egg donor to get pregnant. The sad reality is that they do not tell the world that this is what they are doing. They leave many older women, looking at their celebrity Instagram posts and wondering what they are doing wrong. Social media gives you a look into other people’s lives, but often with the real truth conveniently removed.
What makes some women with PCOS infertile?
The answer is all about your eggs. Let me explain: You probably know that a common symptom of PCOS is irregular periods – either periods coming too close together, or too far apart. Some women with PCOS find that their periods stop altogether. The happens because they have stopped growing and releasing eggs in a regular way from the ovaries.
This problem with egg growth is caused by high levels of the hormone messengers, androgen and insulin, in the blood stream. If an egg does not release and ovulate from the ovary, then the ovary gets confused and does not have the clever rise and fall of oestrogen and progesterone hormone messengers in the blood stream that ensure that periods come on.
For many women with PCOS, this failure of the normal process of growth and release of eggs may happen for nearly all the months of the year. As a result, women with this type of PCOS have much lower chances of becoming pregnant.
Watch Out! Infertility is common in PCOS, but so too are unwanted pregnancies!
A word of caution. Beware of healthcare professionals who tell you that women with PCOS never get pregnant. This is absolutely not true! As we’ve said, around seven out of every ten women with PCOS will not grow and release their eggs easily. These women do take longer to get pregnant and may need some simple fertility treatments to get pregnant.
But! Three out of every ten women with PCOS (30%) have good fertility and will conceive easily. Many of these women get caught with unwanted pregnancies as they incorrectly believe that having PCOS means infertility. Others have been given poor medical advice, having been incorrectly told that PCOS means you cannot get pregnant, so beware!
How do Doctors treat PCOS?
If you think you have PCOS, then your first step is to see a doctor for a full assessment and proper diagnosis. There is no need to rush to your doctor urgently. But at the same time, there is no need to suffer distressing symptoms in silence, without appropriate medical help.
Too many people believe that they are stuck with infertility without realising that some simple measures may get you pregnant easily. Treatment for all medical conditions should be done by a doctor, so do not diagnose or treat yourself without expert medical advice. Please don’t diagnose yourself on social media!
PCOS varies so much from woman to woman, there are many treatment options. Your doctor will listen to your symptoms, examine you to assess exactly how PCOS is affecting your body, find out more about your mental health and do the tests needed to confirm your PCOS diagnosis. The next step — treatment options — really depends on what you would like to achieve.
If you do not wish a pregnancy at the moment, then your irregular periods are fine to live with should you wish. If that’s not your preference, many women with PCOS like the birth control pill. This safe treatment gives you a fake and predictable period once every two to three months. The beauty of this treatment is that you can choose when to have a period. Your body needs a period about once a quarter to keep your womb healthy. If you never have any periods and have been diagnosed with PCOS, then you should use some tablets (the birth control pill or other hormones) to bring on a period at least once every three months.
Let’s talk about treatments for PCOS-related Infertilty!
There is lots of hope for women with PCOS who want a baby!
PCOS infertility is often improved with weight loss in those women who have a higher weight. Often women with PCOS can get pregnant with relatively small amounts of weight loss. Losing something attainable, like 5% of your total weight, can often help you become a mother. Weight loss can also improve period regularity and the skin and hair symptoms of PCOS as well.
There are some effective fertility pills that can work well to encourage pregnancy. In the rare cases when these pills do not work, a fertility “key-hole” procedure called laparoscopy can be a good treatment choice.
Different Medicines Fertility Doctors use to help your Eggs
There are some simple tablets and injections that work well to encourage the ovary to grow eggs. Let’s look at them one by one…
Clomiphene citrate, an old but effective treatment: Clomiphene citrate in doses of 50 to 150mg early in your menstrual cycle has been used for many years to safely achieve pregnancies for PCOS sufferers. There is a small risk of multiple births and the drug shouldn’t be used for more than 12 cycles. The main side effects of clomiphene tablets are headaches and visual disturbance. A problem with clomiphene citrate is that many women with PCOS are resistant to the medication and still do not grow eggs.
Letrozole is now the first line treatment: More recently the breast cancer-preventing drug Letrozole has been found to work well to get your eggs to grow and release if you have PCOS. It is very safe and studies have shown that it works better than clomiphene to achieve pregnancies in women with PCOS.
PCOS and Metformin: Metformin is commonly used to treat Type 2 diabetes. For some women, it may have an important part to play in the treatment of PCOS. We don’t know exactly how metformin works, but we do know that it reduces the amount of sugar put out by the liver, promotes weight loss and increases the frequency of successful egg growth and release from polycystic ovaries. It therefore has a part to play in helping women to lose weight and to get pregnant. It does have some common side effects, which is why a lot of women stop using it. These include gastrointestinal upset, flatulence, diarrhoea and bloating.
Gonadotrophin injections: These are forms of the brain hormone that stimulates the ovaries to work and grow eggs. They are used when the simpler tablets have not worked to get the eggs growing and releasing. They must be given by injection, and they carry risks of over-stimulating the ovaries and increase the chance of a multiple pregnancy.
How Surgery is used to Treat PCOS Infertility
Surgery is a second-line treatment for PCOS. It is used when the simpler tablets and injections have not worked. As is so often the case in medicine, we do not know exactly why the surgery works—but we do know that it often does work. Surgical intervention was first tried in the 1960s: Doctors found if they removed large portions of the ovaries (this is called a ‘wedge resection’) then symptoms of weight gain, unwanted hair and poor fertility sometimes improved in women with severe PCOS. Obviously removing large pieces of the ovaries is not a good thing and may lead to infertility and early menopause, which is why we no longer perform that type of destructive procedure.
We’ve come a long way since then! Today a different type of surgery is used successfully to increase fertility in PCOS women who have not responded to drug medications. The procedure is done by the less invasive “key-hole” (or laparoscopic) method and involves gentle burning of the cystic areas in each ovary. It’s important to understand that key-hole surgery is not suitable for women who already have low egg levels, and will in fact make the situation worse.
IVF is not a first-line treatment for PCOS Infertility but it is an option!
Ok, so let’s summarise: It is rare for the simple tablets or injections not to work for PCOS-related infertility. In the few women who do not get pregnant with tablets or injections, keyhole surgery is the next step and has good pregnancy success rates.
It is only when a woman with PCOS has tried these first- and second-line treatments and is still not pregnant, that IVF should be considered. IVF is therefore the third option. The exception is that IVF will be advised sooner if there are also co-existing sperm or tube problems. This is why it is vital to have a thorough fertility assessment from experts, including a sperm test for your partner, before you start any treatment for PCOS infertility.
At our Fertility Centre we have helped thousands of women with PCOS. So, here’s my message to you: Don’t give up! There are solutions and there are dedicated and knowledgeable people ready to help you on your PCOS Fertility journey. We’ll help you be a PCOS Warrior!