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Fertility for PCOS: ultimate guide to conceiving with PCOS

Polycystic Ovary Syndrome (PCOS) is a common endocrine disorder that affects fertility in individuals assigned female at birth. It is characterised by a variety of symptoms, which may include irregular menstrual cycles, excess androgen levels, and polycystic ovaries. The exact cause of PCOS remains largely unknown, but it is understood to involve a combination of genetic and environmental factors. Despite being one of the leading causes of infertility, many people with PCOS can still conceive, but some people with the appropriate medical intervention and lifestyle modifications.

The impact of PCOS on fertility is complex and includes a lot of factors, such as anovulation and insulin resistance. Anovulation, the absence of ovulation, is a common reproductive challenge in those with PCOS which disrupts the natural menstrual cycle and therefore fertility. Balancing hormonal levels and managing symptoms through both pharmacological treatments and lifestyle changes are considered key to enhancing fertility for individuals with PCOS.

Key Takeaways: fertility for PCOS

  • PCOS is a significant contributor to fertility issues, but many people with the condition can still become pregnant.
  • Hormonal balance and management of PCOS symptoms are central to improving fertility outcomes.
  • Comprehensive understanding and individualised treatment plans are essential for the effective management of PCOS-related fertility issues.

Understanding PCOS

Polycystic ovary syndrome (PCOS) is a hormonal disorder that affects individuals during their reproductive years. It is marked by a combination of symptoms and has implications for hormonal balance and fertility.

Symptoms of PCOS may include irregular menstrual cycles (irregular periods), higher levels of androgens (and therefore symptoms like excess facial or body hair, acne, oily skin, loss of hair on the head and more), and polycystic ovaries as seen on an ultrasound. It is important to recognise that diagnosis often involves meeting two out of the three criteria defined by the Rotterdam consensus: clinical or biochemical (i.e. blood tests) signs of hyperandrogenism, oligo-ovulation or anovulation, and polycystic ovaries.

Role of Hormones

Hormonal imbalances play a crucial role in PCOS. People with PCOS typically experience elevated levels of androgens, which are male hormones such as testosterone, that can disrupt the normal menstrual cycle. The exact cause of these hormonal changes is not well understood, but it is known that they can contribute to the challenges with ovulation and fertility observed in PCOS.

Insulin levels are often higher in people with PCOS which also contributes to the production of androgens.

The understanding of PCOS, its symptoms, and the hormones involved, especially the role of androgens like testosterone, is vital for the management of the disorder and its impact on the menstrual cycle and fertility.

Impact of PCOS on Fertility

Polycystic ovary syndrome significantly impacts an individual’s reproductive system, leading to various fertility problems. The condition primarily affects ovulation, the critical process for egg release necessary for conception.

Effects on ovulation

People with PCOS often experience irregular ovulation cycles or anovulation, where ovulation does not occur at all. 

Ovulation is a critical phase in a person’s menstrual cycle. It is the process during which a mature egg is released from the ovary and made available for fertilisation. For people with a “regular” 28-day cycle, the average day for releasing an egg is day 14 of the cycle i.e. 2 weeks before the period starts again.

This irregular ovulation is due to the hormonal imbalances associated with PCOS, which can prevent the ovaries from developing eggs properly or releasing them regularly. The absence of ovulation consequently reduces the opportunities for the egg to be fertilised in the fallopian tubes.

Challenges to concieve

The irregularity or absence of ovulation in people with PCOS poses significant challenges in conception. Since eggs are not released on a predictable schedule, timing intercourse to align with ovulation is often difficult. Furthermore, hormonal imbalances can lead to other issues such as the development of ovarian cysts and thickened ovarian walls, which may further hinder the egg’s release and contribute to the complexity of achieving pregnancy.

Monitoring fertility for PCOS

For individuals dealing with polycystic ovary syndrome (PCOS), effectively monitoring reproductive health is crucial. This encompasses keeping track of menstrual cycles and identifying the fertility window to optimise the chances of conception and address fertility problems.

Menstrual cycle tracking

Menstrual cycle tracking is the process of recording the start and end dates of one’s period. Due to the hormonal imbalances caused by PCOS, menstrual cycles can be irregular making it more challenging to predict ovulation. People with PCOS should regularly log menstrual cycles to identify patterns or irregularities. This tracking can be done using a traditional calendar approach or through digital apps designed for menstrual monitoring.

Fertility window

The fertility window refers to the time during the menstrual cycle when pregnancy is most likely to occur. This period often spans six days, including the day of ovulation and the five days preceding it. Identifying the fertility window in the context of PCOS may require tools like temperature charting to detect the slight rise in basal body temperature that accompanies ovulation. These methods can assist in maximising the probability of conception by identifying the optimal times for attempting to become pregnant.

Unfortunately, home ovulation kits are often unreliable for people with PCOS. Home ovulation test kits detect LH (luteinizing hormone) levels in the urine. LH in the blood reaches a sharp peak just before ovulation and some LH is excreted in urine. Digital ovulation kits also often check oestrogen levels to try and determine the ovulation date.

But in most people with PCOS, LH levels are already raised. This will mean that you may get false positives during testing. Learn more about ovulation testing in our dedicated article.

6 ways to increase the chance of conception with PCOS

There are various steps you can take to improve your chances of getting pregnant with PCOS, let’s dive into them now.

Supplements for fertility for PCOS

There are a variety of supplements with differing levels of evidence that may support the chances of conception. Everyone trying to conceive should take folic acid to prevent neural tube defects.

People with PCOS may also find supplementing with vitamin D, inositol, folic acid and other supplements can improve symptoms. Always talk to your healthcare provider before trying a new supplement.

Vitamin D

Vitamin D, synthesised from sunlight exposure and found in limited amounts in food, is often deficient in individuals with PCOS, which can exacerbate PCOS-related symptoms like menstrual irregularity and infertility. A study showed significant improvement in fertility markers among PCOS patients after vitamin D supplementation, highlighting its potential role in managing PCOS. While more research is needed, daily supplementation, especially during autumn and winter in the UK, is advised due to the high risk of deficiency.

Inositol

Inositol, a vitamin-like substance, has shown promise for improving fertility in people with PCOS. Specifically, Myo-inositol and D-chiro-inositol, two forms of inositol, have been linked to better egg quality and hormonal balance, potentially enhancing ovulation and insulin sensitivity. While recent studies indicate improvements in reproductive health with inositol supplementation, further research is needed to confirm its impact on live birth rates in PCOS patients.

Folic Acid

Folic acid, the synthetic form of folate or Vitamin B9, is crucial for DNA synthesis and cell growth, making it essential for fetal development and the prevention of neural tube defects like spina bifida. People planning to conceive should take a daily supplement of 400mcg starting three months before conception and continuing through the first 12 weeks of pregnancy. Studies have shown that up to 70% of people with PCOS may have inadequate folic acid intake, and combining folic acid with myo-inositol supplementation has been linked to improved ovulation, fertilisation rates, and embryo quality, suggesting potential benefits for fertility in PCOS patients.

Read more | Best fertility supplements for PCOS

Fertility diet: fact or fiction?

There is no one set “fertility diet” for PCOS but there are certain foods or food groups which have been seen to improve fertility outcomes. Check out our article on fertility diet for PCOS to learn more.

The following foods or food groups may support conception in people with PCOS:

  • Wholegrains: Where possible choose wholegrain carbohydrates. Wholegrains contain all of the grain kernel including the bran, germ, and endosperm. Wholegrains are nutrient-dense, containing B vitamins and magnesium, which contribute to hormonal regulation. They are also rich in fibre which can help with blood glucose management, which in turn can positively impact insulin resistance. Wholegrains include quinoa, oats and brown rice.
  • Omega-3 fatty acids: Omega-3s are a group of essential fatty acids. They are essential as we cannot produce them ourselves so we have to consume them via our diet. For fertility, omega-3 fatty acids may boost fertility by improving egg quality and promoting regular ovulation. Omega-3 rich foods include oily fish like salmon, mackerel, sardines, anchovies, sprats, trout and herring, flaxseeds, chia seeds, sprouts, walnuts and hemp seeds.
  • High-fibre foods: Fibre is the component of plant-based foods that remains indigestible as it travels through the digestive system. Fibre can help with insulin sensitivity and reduce high levels of circulating insulin, improving insulin resistance. You can boost your fibre intake by adding nuts, seeds, beans, wholegrains, fruits and vegetables to your meals.
  • Folate-rich foods: Taking folic acid, the synthetic version of folate, is essential when trying to conceive. But consuming folate rich foods can also help to support conception by improving oocyte quality. Consuming folate rich foods such as wholegrain carbohydrates, beans, dark green vegetables, fruit and peanuts alongside your supplements may improve your fertility outcomes.

Foods to avoid if you’re trying to conceive

There are some foods to avoid if you’re trying to conceive to optimise your chances and prevent harm to the baby once pregnant. If you are trying to conceive avoid alcohol, caffeine and foods high in mercury.

  • Alcohol: Alcohol should be avoided for anyone trying to conceive. Even light drinking has been found to reduce fertility outcomes in those trying to get pregnant.
  • Caffeine: The evidence surrounding caffeine and conception is conflicting. Aim to be sensible with your caffeine intake to prevent spikes in cortisol levels as this may impact hormonal health and therefore fertility. Ideally consume less than 200 to 300 mg of caffeine daily.
  • Foods high in mercury: High mercury food such as shark, swordfish and king mackerel can inhibit fertility and harm the developing foetus upon conception. Choose low-mercury seafood options where possible.

Movement for fertility

Generally, regular exercise is good for us – whatever you choose to do! Regular movement may help with the restoration of ovulation and the regularity of menstrual cycles. A review of eight studies found that moderate physical activity was correlated with improved ovulation in people with PCOS.

There is no “best” movement for conception but you may want to engage in a variety of exercises that you enjoy. Remember, the movement you enjoy will be the one you stick to regularly!

Types of movement for fertility:

  • Aerobic exercises: Activities like walking, swimming, and cycling can help in improving cardiovascular health, and aiding insulin sensitivity.
  • Resistance training: Strengthening muscles can enhance metabolism, and it is theorised that increasing muscle mass can help with glucose clearance from circulation, consequently supporting the management of insulin resistance.
  • Yoga: Besides physical benefits, yoga can also support stress relief, which is vital since stress can exacerbate PCOS symptoms.

Reduce stress and improve emotional wellbeing

Stress is linked to PCOS in a variety of ways. People with PCOS tend to have higher cortisol levels and people with PCOS tend to be more sensitive to the effects of stress too. Stress alone doesn’t cause infertility but stress can impact the chances of conceiving.

It may seem easier said than done but try to be conscious of actively lowering your stress levels through proactive and reactive stress management techniques.

For people with PCOS, emotional well-being is intricately connected with their condition, particularly due to the mental health challenges and stress associated with fertility problems.

Depression and stress are common in individuals dealing with PCOS. The intricate link between PCOS and mental health issues is manifest, as seen in a study exploring the emotional disturbance in people with PCOS, indicating lower quality of life in various aspects. The relationship between PCOS and high depression rates is not fully understood, but the stress associated with fertility problems and body image issues significantly contribute to mental health challenges.

The role of support networks cannot be overstated, especially for individuals grappling with the psychological impacts of PCOS. Therapy has demonstrated potential in helping to improve the psychological well-being of those with PCOS. Access to supportive therapies can alleviate some of the emotional burdens, particularly when combined with strategies to manage fertility problems, thereby improving overall emotional well-being. 

If you are struggling with infertility and the stress, anxiety and depression linked to this then speak to a mental health provider or your doctor for tailored support

Read more | Top tips for PCOS stress management

Treatment Strategies

Effective management of PCOS-related infertility hinges on a tailored approach, including pharmacological interventions, assisted reproductive technologies, and potential surgical solutions to enhance ovulatory function and increase the likelihood of conception. There are many fertility treatments available and you should speak with your healthcare team to determine the best route to support fertility alongside polycystic ovarian syndrome.

Medications

If you are not pregnant after trying for 12 months (or six months if you are aged over 35 years), go and see your doctor for bespoke advice. They can discuss medical treatments that can help, or refer you to a fertility specialist.

First-line treatment for fertility in individuals with PCOS typically involves the use of clomiphene citrate (Clomid) or letrozole (Femara), both of which act to stimulate ovulation. Clomiphene, an ovulatory stimulant, is often the initial choice due to its track record in effectively inducing ovulation.

Metformin, a medication traditionally used for type 2 diabetes, is also prescribed to improve insulin resistance and has been noted to show benefits regarding menstrual regularity and ovulation. However, it is not primarily a fertility treatment.

In addition, gonadotropins, injectable hormones, are other ovulation induction medications which may be used when other medications are not successful.

Engage in fertility treatments

If lifestyle changes don’t result in conception, your doctor or healthcare team may recommend infertility treatments such as laparoscopic ovarian surgery or IVF.

Laparoscopic ovarian surgery

Laparoscopic ovarian surgery is considered a second-line treatment for infertility associated with PCOS. Because of its invasive nature, high costs and need for anaesthesia, it is usually only done in people who require a laparoscopy for another reason (such as investigating pelvic pain).

Laparoscopic ovarian surgery is the action of ovarian drilling and this technique can be performed using monopolar electrocautery or laser techniques.

In terms of efficacy, this treatment was observed to contribute to an ovulation rate between 54 and 76% in the 6 months after the procedure and 33 and 88% in the 12 months after the procedure in one observational study.

In-vitro fertilisation

In-vitro fertilisation (IVF) is a third-line treatment for infertility associated with PCOS unless other factors are present. It is a common treatment route for people with PCOS with a good success rate.

IVF involves the injection of fertility drugs to stimulate the ovaries to produce mature eggs. These eggs are retrieved from the ovaries in an egg retrieval.

These eggs are then added with sperm into Petri dishes in the hope of fertilisation. After the eggs have had between 3-5 days to divide and mature, they are placed into the uterus in an embryo transfer.

Frequently Asked Questions: fertility for PCOS

In addressing fertility challenges for individuals with PCOS, understanding treatment options, age-related considerations, specific medications, early symptoms, lifestyle impacts, and probabilities of conception are crucial.

What are the most effective treatments to enhance fertility in individuals with PCOS?

The most effective treatments to enhance fertility in individuals with PCOS often include a combination of lifestyle changes, such as diet and exercise, and medical treatments, including fertility medications like clomiphene citrate and metformin. Assisted reproductive technologies (ART) like in-vitro fertilisation (IVF) may be considered in certain cases.

At what age does fertility typically decline for those suffering from PCOS?

Fertility can begin to decline at varying ages, but individuals with PCOS typically experience a decreased ovarian reserve as they reach their mid to late 30s, similar to the general population, though PCOS can extend the age of fertility decline due to prolonged periods of anovulation.

How does clomiphene citrate work as a treatment for PCOS-related fertility issues?

Clomiphene citrate is a selective oestrogen receptor modulator that induces ovulation by prompting the pituitary gland to release more follicle-stimulating hormone (FSH), which stimulates the growth of ovarian follicles necessary for ovulation.

What early indicators suggest the presence of PCOS?

Early indicators of PCOS include irregular menstrual cycles, excess androgen levels resulting in symptoms like hirsutism, and polycystic ovaries detectable by ultrasound.

Can lifestyle modifications improve fertility outcomes for those with PCOS?

Yes, lifestyle modifications such as achieving a healthy weight, engaging in regular physical activity, and adhering to a balanced diet can improve fertility outcomes by reducing insulin resistance and improving menstrual regularity in individuals with PCOS.

Is it possible to conceive at the age of 30 for someone with PCOS, and what factors may influence this?

It is possible to conceive at the age of 30 for someone with PCOS, especially with proper management and treatment. Influencing factors include the severity of symptoms, the presence of obesity or insulin resistance, and whether there are other infertility causes besides anovulation.

What is the best age to get pregnant with PCOS?

There is no single “best” age to get pregnant with PCOS. Fertility can vary greatly from one person to another, and PCOS can affect people differently. However, fertility tends to decline with age, so people with PCOS who want to become pregnant may find it easier to do so at a younger age, typically in their 20s and early 30s. This is because ovarian reserve (the number of available eggs) decreases as we get older, which can complicate conception for any person, not just those with PCOS.

What is the PCOS pregnancy success rate?

The pregnancy success rate for people with Polycystic Ovary Syndrome (PCOS) can vary widely and is influenced by several factors, including the severity of the condition, the presence of other underlying health issues, the age of the person trying to conceive, and the specific treatments used to assist with fertility.

Success rates for women with PCOS who are trying to conceive will depend on the approach taken and individual circumstances. Although two-thirds of people with PCOS take longer or require more interventions to become pregnant, evidence suggests that people with PCOS have the same number of children as those without PCOS.

Is pregnancy safe with PCOS?

Pregnancy can be safe for people with PCOS but there are increased risks of certain health conditions such as gestational diabetes, preeclampsia, hypertension and even early birth. Ensure you inform your doctor and healthcare team that you have PCOS so you can be monitored and treated if required, to reduce the risk of adverse health outcomes.

Can you get pregnant if you have both PCOS and endometriosis?

It is possible to become pregnant if you have PCOS and endometriosis. Natural conception is possible with PCOS and endometriosis but you may require support from your doctor to improve your chances of conceiving. Speak with a healthcare professional about your options.

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Alex Okell ANutr Founder and Editor

Founder and Editor | Registered Associate Nutritionist

  Founder of Be The Collective LTD [The PCOS Collective & The Endo Collective] Alex Okell ANutr is a London-based reproductive health nutritionist with experience in research, private practice and digital media. She holds a Master’s degree in Nutrition from King’s College London and has co-authored papers with the University of Cambridge, King’s College London, The Food Foundation and the Food Standards Agency. Alex offers 1:1 PCOS support in our virtual PCOS clinic.

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