Infertility in polycystic ovary syndrome

Overview

Infertility in polycystic ovary syndrome (PCOS) is a common and distressing complication of this hormonal disorder, which affects up to 10% of women of reproductive age. PCOS is characterized by chronic anovulation, hyperandrogenism (excess male hormones), and polycystic ovaries on ultrasound. These hormonal imbalances disrupt normal ovulation, making it difficult for women with PCOS to conceive naturally. Despite the challenges, many women with PCOS can achieve pregnancy with proper medical treatment and lifestyle changes.

Causes

The infertility associated with PCOS is primarily due to ovulatory dysfunction. Several interrelated mechanisms contribute to this:

• Hormonal imbalance: Women with PCOS often have elevated levels of luteinizing hormone (LH) and androgens, which disrupt the normal development and release of eggs from the ovaries.

• Insulin resistance: Many women with PCOS have insulin resistance, which contributes to increased androgen production and further impairs ovulation.

• Irregular menstrual cycles: Infrequent or absent menstrual periods are a sign of anovulation, which directly impairs fertility.

• Polycystic ovaries: Although the presence of cysts does not directly cause infertility, they are a marker of the disrupted ovulatory process in PCOS.

Symptoms

Infertility in PCOS is typically accompanied by other clinical signs of the syndrome. Common symptoms include:

• Irregular or absent periods: One of the most prominent signs of ovulatory dysfunction.

• Hirsutism: Excess hair growth on the face, chest, or back due to elevated androgens.

• Acne and oily skin: Another result of increased male hormone levels.

• Weight gain or obesity: Especially central or abdominal weight gain, which worsens insulin resistance and hormonal imbalance.

• Thinning scalp hair (androgenic alopecia)

• Difficulty conceiving: Often the first sign that leads women to seek medical help.

Diagnosis

Diagnosing infertility due to PCOS involves evaluating the woman's reproductive history, hormone levels, and ovarian structure. Key diagnostic steps include:

• Medical history and physical exam: Assessment of menstrual irregularities, signs of androgen excess, and body mass index (BMI).

• Hormonal blood tests: Elevated LH, total testosterone, and anti-Müllerian hormone (AMH); low or normal FSH levels; exclusion of other causes like thyroid disorders or hyperprolactinemia.

• Ultrasound: Transvaginal ultrasound showing enlarged ovaries with multiple small follicles (typically more than 12 per ovary).

• Ovulation tracking: Monitoring basal body temperature, LH surge, or mid-luteal progesterone levels to assess ovulatory status.

Treatment

Fertility treatment for women with PCOS aims to restore regular ovulation. Management options include:

• Lifestyle changes: Weight loss through diet and exercise can restore ovulation in many overweight or obese women with PCOS.

• Ovulation induction: First-line treatment using oral medications like letrozole (preferred) or clomiphene citrate.

• Insulin-sensitizing agents: Metformin may be used to improve insulin resistance and support ovulation, often in combination with other drugs.

• Gonadotropin therapy: Injectable hormones used if oral agents fail, requiring careful monitoring to avoid ovarian hyperstimulation.

• Ovarian drilling: A laparoscopic surgical option in clomiphene-resistant cases to reduce androgen levels and promote ovulation.

• In vitro fertilization (IVF): Recommended for women who do not respond to less invasive methods or have additional fertility factors.

Prognosis

The prognosis for infertility in women with PCOS is generally favorable with timely and appropriate treatment. Many women are able to conceive naturally or with fertility assistance. Lifestyle modifications significantly improve hormonal balance and ovulatory function. However, untreated PCOS can lead to long-term complications such as type 2 diabetes, endometrial hyperplasia, and cardiovascular disease. Early intervention and consistent medical care are essential for optimizing fertility outcomes and overall health.