PCOS and Infertility
One of the most common reasons for Infertility in women is Poly Cystic Ovarian Syndrome (PCOS). Women with PCOS do not ovulate regularly to release eggs available for fertilization and thus PCOS negatively affects fertility. PCOS affects 1 in 5 women within childbearing age. PCOS is such a common health problem in women now that it has a great impact on couples wanting to start a family. PCOS, in spite of being a common cause of infertility in women, is treatable with high rates of conception.
Hormonal imbalance and abnormal metabolism affects women with PCOS in their health and appearance. Imbalance of female hormones associated with PCOS exhibits symptoms and may lead to infertility. Irregular periods, abnormal hair growth, acne, Insulin resistance and ovaries containing multiple small cysts are usual symptoms of PCOS. It is the hormonal imbalance that interferes with the reproductive system. The Ovaries may appear enlarged in size with many cysts that contain immature eggs. Abnormal high levels of hormones inhibit egg maturation and release of eggs otherwise known as ovulation. Higher-than-normal levels of androgens that is Testosterones are produced in the body of a woman with PCOS. . These are male hormones responsible for development of male sex organs and traits, physiologically higher in men than in women. In women, the androgens are naturally converted in to oestrogen, the female sex hormone.
High levels of male hormones in women can interfere with maturation of egg follicles in the ovary. When the eggs don’t mature, they may not be released from the ovary and the cycle gets interrupted with no Menstrual period. These changes, in turn alter the hormonal balance and continues as chain reaction of irregular periods and lack of ovulation. When eggs are not released regularly, it is called anovulation. Irregular ovulation or complete stop of ovulation can make it highly difficult for women with PCOS to conceive naturally. A healthy egg is absolutely necessary for a sperm, the male reproductive unit to fertilize it and conception to be successful. So, immature eggs and absence of ovulation simply means, no pregnancy. Even on successful ovulation, if there is an imbalance in hormones, it may prevent proper development of the uterus lining called the endometrium, to allow for implantation of the mature egg. As a result, women with PCOS also have a high risk of miscarriages.
All women with PCOS are not infertile. Reduced fertility and sub fertility are also experienced in some cases wherein, it takes a longer time to conceive naturally or may need certain medical assistance in achieving pregnancy. There are many methods that can be adopted to increase the chances of natural pregnancy. 60% of PCOS women achieve pregnancy without medical help. In more unlikely cases, there are many treatment options available, to conceive with medical assistance. Timely assessment for PCOS can help target treatment and improve the chances of conceiving.
Weight management plays a significant role in achieving pregnancy in women with PCOS. Weight management would be the first line treatment for women who are overweight or obese. Just about 5 to 10% of weight loss can considerably increase chances of pregnancy. Diet and physical activity are best ways for any woman to adopt towards losing weight naturally. Healthy weight loss can also bring down the chances of complications during pregnancy.
Monitoring Ovulation – Ovulation window is created in a woman’s body when ovulation has occurred and the egg is available for fertilization. These are the days when pregnancy is possible. This is normally positioned around the middle of the menstrual cycle. Chances of pregnancy can be improved by regularly monitoring ovulation and coinciding sexual intercourse along with ovulation. Signs of ovulation if noticeable can be watched for and estimated in further cycles to improve the chances of pregnancy. Ovulation calculators and predictors are available to keep track of successive ovulation timings. Though this may be tricky in women with PCOS due to irregularity of periods, such attempts may help in improving overall conscious efforts in achieving pregnancy. Some of the signs of ovulation are:-
- Premenstrual symptoms – Breast tenderness, bloating and mood swings are common identification signs prior to the menstrual cycle.
- Abdominal pain – This is a common feature felt as a general vague pain in the abdomen or a dull ache on one side of the abdomen when ovulation occurs.
- Mucus discharge – During the time of ovulation, the vaginal discharge is thinner, slick and slippery compared to other days of menstrual cycle.
If pregnancy is not achieved within a period of six months after weight loss programme and lifestyle changes, then the doctor would refer a fertility specialist for Ovulation Induction. Ovulation Induction is generally not recommended for heavy women with PCOS having a BMI more than 35. If the woman is above the age of 35 years, it is advisable not to wait for long to achieve pregnancy. Ovulation Induction is a medical treatment aimed at stimulating the ovaries to produce more mature eggs. Medicines in the form of tablets and injections are given over a due course of time to enable ovulation. The hormone HCG is used an indicator to decide the time for ovulation induction. Ultrasounds and blood tests are diagnostic tools used to determine the suitable time to trigger ovulation. Various medicines may be used in Ovulation Induction, depending on the severity and risks involved in achieving fertility.
- Clomiphene citrate is the first choice of treatment used early in the menstrual cycle to induce the chances of an egg being released by the ovary, which is then available for natural fertilization through sexual intercourse.
- Metformin, is the next best choice of treatment that not only improves ovulation but also helps to improve the function of circulating insulin and help reduce androgen levels in the body. Metformin may be combined with other medications such as clomiphene citrate in women who fail to respond to single medication or in case of obese women with PCOS. Once pregnancy is achieved, these medications are stopped.
- Gonadotrophin injections may be necessary for couples who have already delayed conceiving. Gonadotrophins are naturally occurring hormones such as Follicle-Stimulating Hormone (FSH), Luteinising Hormone (LH), Human Chorionic Gonadotrophin (HCG) that regulate ovulation. These hormones can be used as treatments to stimulate growth and maturation of follicles within the ovary and release of eggs. The procedure involves the medication to be injected and the ovary carefully monitored by ultrasound to avoid over stimulation. Women who do not respond to treatment with clomiphene citrate can also benefit with Gonadotrophins in conceiving.
- Surgery to improve fertility in low responding cases of PCOS may require Laparoscopic Ovarian Drilling. Under the effect of Anaesthesia, small holes are drilled on the surface of the ovary to remove tissues that produce excessive amounts of androgens. Ovarian Drilling can restore fertility for a period of 6 to 12 months wherein fertilization of the egg can result in pregnancy.
- Assisted Reproductive Technology (ART) is the last resort, after other less intensive treatments have proved unsuccessful. ART procedures are often costly and demanding. This technology has proven more effective and has been successful in women who have habituated lifestyle changes first, though these changes themselves did not improve fertility.