Top Fertility Treatments for Women with PCOS

Polycystic ovary syndrome (PCOS) is a leading cause of infertility, affecting up to 6–13% of women of childbearing age. And yet, according to WHO, globally up to 70% of cases remain undiagnosed.

Unfortunately, PCOS is also the most common cause of anovulation and a leading cause of infertility.

However, not all is lost. While it is a lifelong chronic condition with no known cure, women with PCOS can and do go on to conceive naturally or with support from a fertility specialist.

With the right mix of lifestyle changes, medical intervention, and professional guidance, PCOS can be treated and pregnancy can be achieved.

Understanding PCOS and Its Impact on Fertility

What Is Polycystic Ovary Syndrome (PCOS)?

Polycystic ovary syndrome (PCOS) is a endocrine (hormonal) disorder that affects ovulation and overall reproductive health. While its exact cause remains unknown, researchers believe contributing factors include insulin resistance, genetics, and hormone imbalance. Some studies find that a family history of the condition or type 2 diabetes significantly increases the risk.

In a typical ovulatory cycle, the pituitary gland releases follicle-stimulating hormone (FSH), which promotes the growth of a dominant follicle in the ovary. As this follicle matures, it produces rising levels of oestrogen, which thickens the uterine lining in preparation for potential implantation.

Once oestrogen reaches a certain threshold, it signals the pituitary to release luteinizing hormone (LH), triggering ovulation and the release of the mature egg.

Why does having too many follicles in the ovaries interfere with ovulation?

In women with PCOS, however, multiple small follicles (often referred to as a “polycystic” appearance) each produce low levels of oestrogen. The cumulative effect of these small amounts causes a modest but persistently elevated baseline oestrogen level.

This disrupts the feedback mechanism to the pituitary gland, inhibiting the proper secretion of FSH. And so, without adequate FSH stimulation, no single follicle becomes dominant, and ovulation often fails to occur in women with PCOS.

Polycystic Ovary Syndrome PCOS Symptoms

PCOS presents with a range of symptoms that may vary from person to person. These can include:

Menstrual and Reproductive Symptoms that include

• Irregular, heavy, prolonged, infrequent, or absent periods
• Anovulation, which is the lack of ovulation
• Infertility or difficulty conceiving

Dermatological Symptoms like

• Acne or oily skin
• Excessive facial hair growth
• Body hair (hirsutism)
• Male-pattern baldness, hair loss, or hair thinning

Metabolic and Physical Symptoms like

• Weight gain, particularly around the abdomen
• Difficulty losing weight
• Increased risk of insulin resistance or type 2 diabetes (may not be immediately symptomatic)

PCOS Diagnosis and Exclusion of Other Conditions

As a fertility specialist, I diagnose PCOS based on what’s known as the Rotterdam criteria. This includes three key features:

1. Polycystic-appearing ovaries, defined as more than 20 follicles per ovary;
2. Irregular periods or absent menstrual cycles;
3. Clinical or biochemical signs of excess androgens, or male hormones.

To make the diagnosis, we need at least two out of the three. We also need to ensure a couple of other conditions are excluded first. For example, conditions like thyroid disorders or adrenal abnormalities can also mimic these symptoms.

So, before confirming PCOS, we will rule out other causes through blood tests and an ultrasound scan.

How PCOS Affects Ovulation and Fertility Problems

In women with PCOS, the delicate hormonal balance is disrupted.

Multiple small follicles form but fail to mature. The elevated baseline oestrogen levels falsely signal to the brain that a mature follicle is already present, disrupting the release of FSH, leading to irregular or absent ovulation.

Additionally, elevated levels of male hormones (androgens) and insulin resistance further disrupt menstrual cycles, making it harder to conceive.

Healthy Lifestyle Changes That Can Improve Fertility

There are quite a few treatment options for women suffering from ‘anovulatory infertility’ (that is, women who are not ovulating or not ovulating properly.) The first plan is to look at some simple lifestyle measures, like diet or exercise. Sometimes, just a modest reduction in weight or BMI can send someone from not ovulating to ovulating.

1. Healthy Weight and Diet

A modest reduction in body weight or BMI (typically 5–10%) can significantly improve hormonal regulation and restore ovulation in women with PCOS. Being in the healthy weight range will reduce insulin resistance, which in turn helps normalise the hormonal feedback loop critical for follicle development.

Additionally, implementing a low-glycemic index (low-GI) diet rich in whole foods also supports insulin regulation and enhances metabolic and reproductive outcomes.

2. Exercise and Stress Management

Regular moderate-intensity exercise helps improve insulin sensitivity and support metabolic function. Pairing this with stress management techniques like yoga or mindfulness may help with hormonal regulation by reducing hypothalamic-pituitary-adrenal (HPA) axis activation.

3. Quality Sleep

Quality sleep and reducing alcohol and smoking are essential for fertility.

Medical Help: Fertility Treatment Option

When lifestyle changes do not help, we recommend medical help through hormonal treatment.

Option 1: Ovulation Induction Medications

The first-line treatment for inducing ovulation in women with PCOS often involves Letrozole, which blocks the conversion of androgens to oestrogens.

The use of Letrozole for five days can temporarily drop a woman’s oestrogen level. The brain senses that oestrogen is low, so it then releases its own FSH, and it brings through one of those follicles that will then go and ovulate.

It’s quite effective and has a lower rate of multiple pregnancies than Clomiphene citrate, which was a previously common first-line medication.

Other options include metformin, particularly for women with insulin resistance. And for patients who do not respond to oral medications, FSH injections may be recommended to stimulate follicle development directly.

Occasionally, ovulation induction may be combined with intrauterine insemination (IUI).

Option 2: In Vitro Fertilisation (IVF)

In Vitro Fertilisation IVF is an effective next step for women with PCOS if there are other factors like tubal issues or male infertility, or additional complications.

During IVF, eggs are retrieved from the ovaries, fertilized in a lab, and then transferred into the uterus. For women with polycystic ovary syndrome, IVF protocols are carefully tailored to reduce the risk of ovarian hyperstimulation syndrome (OHSS), a potential side effect where the ovaries over-respond to fertility medications.

Clinics often use “low and slow” stimulation protocols or freeze-all cycles (where embryos are frozen and transferred later) to minimise this risk. Despite the complexity, IVF has high success rates for women with PCOS, especially when combined with proper hormonal support and embryo monitoring.

Option 3: Laparoscopic Ovarian Drilling

Laparoscopic Ovarian Drilling is a bit of an older technique. By burning small holes in the ovary, doctors can restore ovulation in some women with PCOS.

Laparoscopic ovarian drilling involves using heat to destroy small portions of ovarian tissue, reducing androgen levels and allowing ovulation to resume naturally. It may be suitable for women who cannot tolerate medication or who have high androgen levels that interfere with ovulation.

However, because it involves surgery and may affect ovarian reserve, it’s usually considered after other fertility treatment options have been exhausted.

Comparing Different Treatments for Women with PCOS

Here’s a detailed table comparing the different options and their benefits and possible risks. It’s important to remember that not all women respond the same way to a treatment and some may need a combination of treatments to help them fall pregnant.

Getting Pregnant with PCOS

The good news is that many women with PCOS do conceive naturally through lifestyle changes and ovulation tracking. A pre-pregnancy health assessment is a great step and can help reduce pregnancy complications.

PCOS increases the risk of:

• Gestational diabetes
• High blood pressure
• Miscarriage

This is why pregnant women who have PCOS should work closely with their healthcare team to monitor blood sugar, blood pressure, and foetal development.

When to See a Fertility Specialist

If you and your partner have been trying to fall pregnant for 6–12 months without success, it may be time to see a fertility specialist. A fertility specialist can share a customised plan that can help improve your chances of conceiving while also helping you manage any long-term risks like endometrial cancer.

Key Takeaway

While PCOS may cause infertility, it is not a barrier to parenthood.

With a combination of healthy lifestyle choices, medical treatment, and compassionate care, most women with a PCOS diagnosis can conceive naturally or with assistance.

There are lots of good options. Even simple steps like weight loss or Letrozole can make a big difference. And when needed, we have effective treatments like IVF or ovarian drilling to help.

If you suspect you have polycystic ovarian syndrome and are experiencing PCOS symptoms like extra hair growth, thinning hair or irregular menstrual cycles, consult a fertility expert early. A proactive approach can make all the difference.