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What is PCOS and What Are the Options for Fertility Treatment?

By: Dr. Sony Sierra, MD, FRCSC, REI

Polycystic Ovarian Syndrome is a fairly common condition that affects about five to seven percent of women. Essentially, PCOS involves both a structural and a hormonal change in the function of the ovary. Ovaries in women who have PCOS are bigger in volume, they’re denser in tissue and they are hormonally active in different ways. For example, they have far more follicles than is typical. Follicles are little pools of fluid that contain immature eggs. Women who have polycystic ovaries will have over 12 to 15 follicles in each ovary, whereas someone with normal ovaries will have somewhere in the range of about seven. The presence of these multiple follicles and the change in the tissue surrounding them can lead to a range of presentations that may include irregular cycles, elevated androgens and infertility. Women with PCOS may also present with extra hair growth on the body and face (known as hirsutism), hair loss or acne. They may also struggle with weight concerns, sugar and insulin metabolism and a higher risk of an eventual diagnosis of diabetes. In terms of fertility, these hormone changes can cause women with PCOS to have irregular or absent menstrual cycles which can lead to difficulty conceiving. 

In women with PCOS, cycles that are irregular or absent can be called “anovulatory”. This means that no egg is being released. Fertility treatments can generally correct this by changing the hormonal balance.

Regulating hormones for ovulation induction can be accomplished in a few different ways: Usually, the first option will include lifestyle modification, especially in women with PCOS and issues with weight, or glucose and insulin metabolism. This modification is going to include a conversation about healthy diet, healthy body weight, and regular exercise. For women with PCOS who may be struggling with extra weight, there are many benefits to losing even a few pounds, bringing them towards a normal weight. These include more regular cycles, a more normal ovulatory response, a reduced risk of early pregnancy loss and a decreased risk of long term complications like diabetes and obesity.

However, in some women, diet and exercise is not enough to correct ovulatory dysfunction. We then often turn to ovulation induction agents such as letrozole. 

There are some minor, transient side effects with letrozole, however it is generally well tolerated. Additionally, there is a small chance of multiples with letrozole (6-8%). However your fertility physician will discuss this with you, taking into account your previous medical history. 

While most of our patients with PCOS do well with ovulation induction, there are some women with PCOS who advance to IVF for a variety of reasons. These patients include women whose ovaries are resistant, that is, they don’t respond to the low risk ovulatory induction agents. These women may require stronger ovulation induction medications. However, stronger treatment always means more follicles, which means a higher risk of multiples. To avoid the risk of multiples, we often counsel these women to move towards IVF. This approach gives us more control and a better pregnancy rate by allowing us to transfer one embryo at a time, leading to one healthy baby at a time. 

If you have been diagnosed with PCOS, please speak with your TRIO physician about the fertility plan that is best for you.