Someone holding an ovulation test, looking down on result.

Illustration by Marta Pucci

PCOS

PCOS and pregnancy

by Laurie Ray, DNP, Science Writer at Clue
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Top things to know

  • Ovulation may not happen regularly each month for people with PCOS, making it a common reason for infertility

  • People with PCOS can become pregnant without the use of fertility treatment, so using birth control is important if you don’t want to become pregnant

  • Treatments are available that can help regulate periods and induce ovulation

How PCOS affects fertility

It’s common for people diagnosed with polycystic ovary syndrome (PCOS) to worry about their ability to become pregnant, even if they don’t want to be pregnant any time soon (1-4). Knowing that there are options available to become pregnant can help reduce anxiety.

Ovulation (the release of an egg from the ovary) typically happens about once a month. People with PCOS may ovulate less frequently or predictably, and may be more prone to miscarriages, which is why PCOS is a common cause of infertility. For people trying to become pregnant, PCOS can make it harder to time sex to the fertile days of their menstrual cycle, when ovulation happens. It can also take longer to become pregnant if ovulation is only occurring every few months.

People with PCOS are more likely to seek out and require fertility treatments than people who don’t have it. But research shows that over their lifetimes, both people with and without PCOS have a similar number of pregnancies and children (5,6). In fact, the majority of people with PCOS who are trying to conceive will become pregnant and give birth without any fertility treatment at least once in their life (6).

However, people with PCOS use birth control at lower rates than people without PCOS. This is true even when those people don’t want to become pregnant and are having sex that could lead to pregnancy (penis-vagina sex) (5). Some people with PCOS think they’re unable to become pregnant, but this isn’t true. Ovulation can still happen even if it’s not on a predictable schedule. It’s important for people who have PCOS to use some form of birth control if they don’t want to be pregnant and are having sex that could lead to a pregnancy.

Body weight, PCOS, and fertility

Obesity and PCOS are connected. Obesity can make the symptoms of PCOS worse and make it harder to become pregnant (7). Weight loss is usually recommended as a first step for people with PCOS who are overweight or obese and trying to conceive.

Weight loss can increase the chance of ovulation and of having regular periods (8-10). Weight loss alone is sometimes enough to restart ovulation, but also increases the chance of ovulation and giving birth when combined with fertility medications compared to using fertility medications alone (11,12). Being a healthy weight is recommended for anyone trying to become pregnant to decrease the risk of complications like gestational diabetes, pregnancy-induced hypertension, and preeclampsia.

Weight loss can be difficult—especially for someone with PCOS—and there’s no single best way to do it. Often weight loss is encouraged through increasing exercise and decreasing the amount of calories consumed each day. Nutritionists, healthcare providers, and personal trainers can be great resources in achieving weight loss that is safe and effective. Losing weight takes time, but even small changes can make a difference.

Medications and treatments for PCOS

After other reasons for infertility—such as blocked fallopian tubes, fibroids, or low sperm count—have been ruled out, a healthcare provider may prescribe medications to induce ovulation in someone with PCOS who is trying to conceive.

Insulin resistance is common in people with PCOS. Insulin is a hormone that is released from the body to regulate the amount of glucose (sugar) in the bloodstream. Insulin resistance occurs when the body’s cells don’t respond normally to insulin, resulting in too much of it in the body (7). The excess insulin disrupts the hormones produced by the ovaries and pituitary gland, and this interferes with ovulation (7).

Metformin is a medication that makes it easier for the body to use the insulin it makes, decreasing the amount of insulin in the bloodstream. Metformin is used for people with PCOS to stimulate ovulation (7,13). Metformin has the added benefit of sometimes helping people lose weight, but can also cause abdominal pain and diarrhea (7).

Clomiphene and letrozole are medications that induce ovulation (13). Clomiphene blocks the body’s response to estrogen and letrozole suppresses the production of estrogen. The low levels of estrogen or lack of response to it cause the pituitary gland to produce more follicle stimulating hormone (FSH), which promotes the growth of the follicles containing eggs within the ovary. Both medications can cause hot flushes as a side effect, and generally they should not be used for more than six cycles (13).

Metformin and clomiphene used together result in higher rates of ovulation, pregnancy, and birth than either medication used alone (13). Letrozole results in higher rates of ovulation, pregnancy, and birth compared to clomiphene (14).

If you’re trying to become pregnant, It’s important to time sex to ovulation when using these medications. Ovulation is likely to occur 13-15 days before the start of the next period (15). Tracking your cycle, your basal body temperature daily, and taking at-home ovulation tests that measure luteinizing hormone (LH) can help you determine your fertile window and ovulation.

If weight loss and ovulation stimulation with medications are not successful, there are other options. Surgery performed on the ovaries called laparoscopic ovarian drilling involves a surgeon making small holes in the ovary with heat or a laser (16). This surgery is as effective as medication at increasing the rates of ovulation and pregnancy, and is sometimes used as an option when medication alone hasn’t worked (16). Another option is in vitro fertilization (IVF) where eggs are retrieved from the ovaries surgically, combined with sperm in a laboratory to create an embryo that is then transferred to the uterus (13).

Herbs and supplements Some herbs and dietary supplements have been studied in people with PCOS and have been shown to help with fertility.

There is some evidence that the use of the herb Cimicifuga racemosa (black cohosh) may help increase pregnancy rates when used alone or in combination with clomiphene (17,18). More research is needed on this and other herbs that may help people with PCOS who are trying to conceive.

Inositol is a non-prescription dietary supplement that has been shown to increase the likelihood of ovulation as well as menstrual regularity in people with PCOS, but it may cause mild abdominal discomfort (19). Vitamin D supplements can help increase the chance of ovulation on their own and can make menstrual cycles more regular when combined with metformin (20). More research is needed here.

Healthy pregnancy considerations

Some studies show an increase in the chance for miscarriage in people with PCOS, while others attribute the increase to other factors like being overweight or obese, increased age, or use of fertility treatments (5,6,21,22,23).

People with PCOS who are pregnant are at an increased risk for gestational diabetes, pregnancy-induced hypertension, preeclampsia, and preterm delivery (21,23). Being a healthy weight before becoming pregnant and limiting the amount of weight gain during pregnancy can help avoid these complications (22).

If you’re trying to become pregnant, track sex, cervical fluid, and ovulation test results in Clue.

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