Common Fertility Problems
Key Points

  • PCOS affects 1 in10 women of reproductive age.
  • Lifestyle intervention (including diet, exercise and behavioural strategies) is the first line of treatment to control symptoms.
  • Medication can be used to induce ovulation if required.
  • IVF is the last line of treatment when previous approaches have failed.

What is PCOS?

PCOS refers to Polycystic Ovarian Syndrome, a common condition affecting 1 in 10 women of reproductive age. In PCOS, the ovaries are bigger and have many follicles that contain immature eggs that never mature enough to trigger ovulation.

Altered levels of oestrogen, progesterone, FSH and LH affect egg maturation and ovulation. Oestrogen and progesterone levels are lower than usual and androgen levels are higher than usual. It is the number one cause for non-ovulation and is often associated with infertility and metabolic disorders.

Symptoms of PCOS

  • Irregular or infrequent periods (cycles less than 21 or more than 35 days; or less than 8 cycles per year).
  • Heavy periods, due to uterine lining build up for a longer period of time.
  • High levels of male hormones, which may cause physical signs such as excess hair (usually on the face, chest, back or buttocks), thinning hair and hair loss on the head, oily skin.
  • Polycystic ovaries: ovaries become enlarged and contain many fluid-filled sacs (follicles) that surround the eggs.
  • Weight gain which happens in 80% of cases.
  • Difficulty getting pregnant.

After taking clinical history and performing a physical examination, your doctor may request a blood test to check your testosterone levels and confirm a diagnosis. An ultrasound scan may be requested to identify the complete PCOS phenotype. The ultrasound must look for a follicle number per ovary of > 20 and/or an ovarian volume ≥ 10ml, ensuring no corpus luteum, cysts or dominant follicles are present.

PCOS Risk Factors

Women with PCOS present also present an increased risk of developing:
  • Cardiovascular disease. It’s recommended to have blood pressure monitored and consultations to assess weight changes and excess weight, 1-2 times a year.
  • Gestational diabetes/Impaired glucose tolerance/Diabetes type 2 are significantly increased in women with PCOS, with risk independent of, yet exacerbated by, obesity.
  • Obstructive sleep apnoea. Screening should be considered when there are symptoms, such as snoring, waking unrefreshed from sleep, daytime sleepiness, and the potential for fatigue to contribute to mood disorders.
  • Endometrial cancer, which is two to six-fold increased, often presenting before menopause.
  • Anxiety and depression. There is a high prevalence of moderate to severe anxiety and depressive symptoms in women with PCOS.
  • Eating disorders. There is an increased prevalence of eating disorders and disordered eating associated with PCOS. If eating disorders and disordered eating are suspected, further assessment, referral and treatment, including psychological therapy, could be offered by appropriately trained health professionals.

Getting pregnant with PCOS

PCOS is one of the most common causes of female infertility, representing 80% of all cases of infertility related to non-ovulation. Infertility in PCOS is not only associated with the fact that the egg is not released from the ovary, but with the fact that it may not have developed properly due to the hormonal changes.

The first line of treatment for getting pregnant with PCOS is lifestyle changes, folic acid supplements to prevent the risk of birth defects and reducing the consumption of tobacco and alcohol. Studies suggest a weight loss of just 5%-10% can lead to significant improvement in PCOS. This can be achieved by exercising regularly and eating a healthy balanced diet. Daily food intake should include at least 5 portions of fruit and vegetables, whole foods, lean meats, fish and chicken.

Women who are seeking modest weight loss, are recommended to do a minimum of 250 min/week of moderate intensity activities or 150 min/week of vigorous intensity, and muscle strengthening activities involving major muscle groups on 2 non-consecutive days/ week, and minimise sedentary, screen or sitting time.

Women who have normal weight and want to prevent weight gain, are recommended to do 150 min/week of moderate intensity physical activity or 75 min/week of vigorous intensities, including muscle strengthening activities on 2 non-consecutive days/week, activity to be performed in at least 10-minute bouts or around 1000 steps, aiming to achieve at least 30 minutes daily on most days.

Medication, namely metformin in addition to lifestyle, could be recommended in adult women with PCOS, for the treatment of weight, hormonal and metabolic outcomes.

To induce ovulation, doctors may prescribe Letrozole which is the first line pharmacological treatment for ovulation induction in women with PCOS with anovulatory infertility. Clomiphene citrate could also be used alone in women with PCOS with anovulatory infertility and no other infertility factors to improve ovulation and pregnancy rates. Gonadotrophins could be used as second line pharmacological agents in women with PCOS who have failed first line oral ovulation induction therapy.

Laparoscopic ovarian surgery (ovarian drilling) is an option for women who are not ovulating, are resistant to clomiphene and need surgery for another reason like pelvic pain. This procedure can also improve ovulation and pregnancy rates.

The third line of treatment is IVF when previous treatments have failed. The risk of OHSS is the main complication and the doctor may adjust the medication dose to prevent it.

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