Treating infertility in women with PCOS

This article outlined the current trends and recommendations regarding fertility treatments for women suffering from polycystic ovary syndrome (PCOS).

PCOS is a common condition affecting between 5-10% of women. The main features of PCOS are menstrual abnormalities (intervals longer than 35 days between periods), the production of excess male hormones leading to acne and excess body hair, and insulin resistance, which may lead to obesity and diabetes. Women with PCOS often suffer from infertility.

The current recommendations for infertility in PCOS suggest approaching treatment in a step-wise fashion. Initial measures include lifestyle changes such as weight loss and moderate exercise. Obesity was found to negatively impact ovulation, therefore experts recommend adopting diets that are lower in total calories and which contain fewer carbohydrates (sugars).

Even a small weight reduction (just 5% of the original weight) may be sufficient to promote ovulation in women with PCOS. Metformin, an insulin-sensitizing agent, is a drug that increases the body’s sensitivity to insulin, used in the treatment of type 2 diabetes. Metformin use in PCOS should be restricted to women with insulin resistance. However, it is no substitute to lifestyle changes.

If ovulation is not achieved using lifestyle measures, medical treatment usually begins with the drug clomiphene citrate (CC). CC was found to successfully induce ovulation in 75-80% of women with PCOS. CC therapy is given in cycles, typically for a maximum of 6 cycles. Pregnancy rates were found to be approximately 22% for each treatment cycle that resulted in ovulation. Women that experience side effects with CC, can be treated with another ovulation-stimulating drug such as tamoxifen or letrozole (Femara). However, these drugs are not yet FDA approved as fertility treatments. Ovulation may also be achieved with FSH (follicle stimulating hormone) therapy. FSH is a hormone produced by the body to induce ovulation, and can be given as an ovulation stimulating drug. Medical treatment for infertility due to PCOS needs to be carefully monitored (by ultrasound and measuring hormone levels) as the ovaries may respond by producing too many eggs. This may increase the risk of multiple pregnancies (having twins or triplets) or other complications related to excessive stimulation of the ovaries.

Surgery may also be an option, especially in women with difficult access to frequent medical check-ups or those resistant to CC treatment. Laparoscopic ovarian surgery (LOS), performed through small incisions in the abdomen with the help of a video camera, involves making small punctures in the ovaries to help release eggs. LOS was found to be less effective than medical treatment and also carries a small surgical risk.  

If the above treatments fail, women with PCOS are usually referred to IVF (in-vitro fertilization). This technique involves the artificial joining of a woman's egg and a man's sperm in a laboratory dish. The resulting embryos are then implanted into the uterus. Studies have shown that women with PCOS have the same odds of becoming pregnant with IVF as women without PCOS.

Various fertility treatments are available for women with PCOS, including medical treatment with CC or FSH, surgery or IVF. These therapies are often successful but need to be tailored to individual patient characteristics. Lifestyle changes complement fertility treatments and improve pregnancy outcomes.