Polycystic ovary syndrome (PCOS) is a common hormonal disorder that affects up to 1 in 10 women and people worldwide, with some estimates suggesting it may affect as many as 15% of women and people of reproductive age. PCOS is a complex condition often characterised by the presence of small cysts on the ovaries, irregular periods, infertility, acne, excess hair growth, and weight gain (all the fun stuff). However, it's important to note that not all people with PCOS have cysts on their ovaries, and the symptoms can vary widely from person to person.

For women* trying-to-conceive (TTC) with PCOS, the journey can be challenging, but it's essential to understand that PCOS is one of the most treatable causes of infertility. With proper management and support, many people with PCOS can successfully conceive and have healthy pregnancies.

Understanding PCOS and Its Impact on Fertility

PCOS is a disorder of the endocrine system, and its diagnosis requires meeting at least two of the following three criteria: irregular menstrual cycles, increased male hormones (androgens), and polycystic ovaries. The condition can cause a range of symptoms, including obesity, excessive hair growth on the face and body, and skin issues. PCOS can also increase the risk of pregnancy complications, type 2 diabetes, cardiovascular disease, sleep apnea, and depression.

The primary challenge for people with PCOS when TTC is irregular ovulation, or in some cases, an-ovulation (the absence of ovulation). Ovulation is the release of a mature egg from the ovary, a critical step for conception. However, many people with PCOS experience irregular ovulation due to hormonal imbalances, making it more difficult to time intercourse or fertility treatments effectively, as if it wasn’t already complicated enough.

Types of PCOS

There are several different types of PCOS, each with its unique set of symptoms and underlying causes:

1. Insulin-Resistant PCOS: The most common type, associated with high insulin levels, which can lead to weight gain, metabolic problems, and an increased risk of type 2 diabetes.
2. Post-Pill PCOS: This type can develop after discontinuing hormonal contraceptives and is often characterised by irregular periods and hormonal imbalances.
3. Inflammatory PCOS: Associated with chronic inflammation, leading to symptoms like acne, weight gain, and insulin resistance.
4. Adrenal PCOS: Linked to high levels of androgens produced by the adrenal glands, causing acne, excess hair growth, and irregular periods.

Increasing Fertility with PCOS

Despite the challenges, many people with PCOS successfully conceive. Here are some strategies and treatment options that can help increase fertility:

Lifestyle Changes

1. Healthy Diet: A balanced diet is crucial for managing PCOS symptoms and improving fertility. Focus on whole foods, such as fruits, vegetables, whole grains, lean proteins, and healthy fats. Avoid processed foods, refined sugars, and unhealthy fats. A registered dietitian or nutritionist can help create a personalised eating plan tailored to your needs.
2. Regular Exercise: Exercise can improve insulin sensitivity, promote weight loss, and reduce stress—all of which are beneficial for managing PCOS and enhancing fertility. Aim for at least 150 minutes of moderate-intensity activity per week, including both aerobic and strength-training exercises.
3. Stress Management: High stress levels can disrupt hormone balance and interfere with ovulation. Incorporate stress-reducing activities like yoga, meditation, or deep breathing exercises into your routine to help manage stress.
4. Supplementation: Certain nutrients and supplements may support fertility in women with PCOS. Inositols, for example, can improve insulin sensitivity and regulate hormone production. We recommend taking Inositol only as needed when diagnosed with the so-called classical PCOS phenotype only. Omega-3 fatty acids, chromium, magnesium, zinc, N-acetyl cysteine (NAC), vitamin D, and maca extract can also be beneficial. NAC has been shown to improve insulin sensitivity

More on Inositol and Myo-Inositol

Inositol or Myo-Inositol is not recommended for those with low androgens (a common concern as egg cells age) because androgens are needed for egg quality, and these supplements are known to reduce androgens even further. Your ovaries must have normal testosterone levels within the ovarian micro-environment in order to produce good quality eggs at maximum numbers.

In people with premature ovarian ageing or primary ovarian insufficiency, or those suffering with the sub-type PCOS known as hypo-androgenic PCOS (H-PCOS), Inositol or Myo-Inositol is not recommended.

We recommend taking Inositol only as needed when diagnosed with the so-called classical PCOS phenotype only, where high levels of testosterone are recorded. This can be taken as a separate supplement, and even then please consult with your GP or IVF physician first. 

Medical Treatments for PCOS

1. Ovulation Induction Agents: Medications like clomiphene citrate and letrozole are commonly used to induce ovulation in people with PCOS. These drugs help stimulate the production of follicle-stimulating hormone (FSH), encouraging the ovaries to produce a mature egg. Ovulation induction is a minimally invasive and affordable option that can be very effective.
2. Injectable Medications: If oral medications fail to stimulate ovulation, injectable drugs like gonadotropins may be used. These injections can help the ovaries produce multiple eggs in one cycle, increasing the chances of conception.
3. Assisted Reproductive Technologies: For women who do not respond to ovulation induction or other treatments, assisted reproductive technologies like intrauterine insemination (IUI) or in vitro fertilisation (IVF) may be recommended. IUI involves placing washed sperm directly into the uterus, while IVF involves fertilising eggs in a lab before transferring the embryo to the uterus.
4. Ovarian Drilling: This surgical procedure, once more common, involves making small punctures in the ovaries to reduce androgen production and improve ovulation. However, it is no longer widely recommended due to potential risks, including scarring and ovarian damage.

Risks and Considerations when treating PCOS

While these treatments can be effective, it's important to be aware of potential risks:

• Medication Side Effects: Ovulation induction agents and injectable medications can cause side effects like hot flashes, nausea, headaches, mood changes, and more severe complications like ovarian hyperstimulation syndrome (OHSS).
• Multiple Gestation: Fertility treatments can increase the likelihood of multiple pregnancies (twins, triplets), which carry a higher risk of complications.
• Surgical Risks: Procedures like ovarian drilling and IVF carry risks such as infection, internal injury, and potential damage to reproductive organs.

Success Stories and Hope

Despite the challenges, many people with PCOS have successfully conceived and had healthy pregnancies. For instance, actress Jaime King was diagnosed with PCOS and Endometriosis aged 20 and took several years to have her first child but managed to successfully conceive twice. Emma Thompson, who needs no introduction, was diagnosed with PCOS and underwent a round of IVF to successfully conceive her daughter Gaia. Sasha Pieterse, of Pretty Little Liars fame, went on to conceive with PCOS quickly, despite the fears of infertility that came along. 

Key Takeaways on TTC with PCOS

PCOS can make the TTC journey more challenging, but with the right management strategies, it is possible to overcome these obstacles. By adopting a healthy lifestyle, considering targeted supplementation, and exploring medical treatments, women and people with PCOS can increase their chances of conceiving. It’s essential to consult with healthcare providers to determine the best course of action tailored to individual needs.

* We may refer to women and people and those whose sex was recorded female or male at birth