Infertility with PCOS Polycystic Ovaries
Advanced Fertility Center of Chicago
Gurnee & Crystal Lake, Illinois
Diagnosis, testing and treatments for polycystic ovaries
We are PCOS Doctors
Our IVF live birth success rates
Background
PCOS, short for polycystic ovarian
syndrome, is a common cause of anovulation and
female infertility. What are the chances that you have PCOS? It is estimated that PCOS affects about 8-10% of women of
reproductive age.
Women with polycystic ovaries and infertility do not release an egg (ovulate) regularly and have ovaries with
multiple small cystic structures, about 2-9 mm in diameter. In a normal menstrual cycle
with ovulation, a mature follicle, which is also a cystic structure, develops. A
mature follicle that is ready to ovulate is usually 18-28mm in diameter. In a polycystic ovary, the numerous small cystic
structures, also called antral follicles, give the ovaries a characteristic "polycystic" (many cysts) appearance on ultrasound. Laparoscopic
surgery and ultrasound pictures of polycystic ovaries are shown below.
PCOS is also referred
to as PCO, or PCOD - polycystic ovarian disease. Women with PCOS and infertility usually have very irregular menstrual cycles (oligomenorrhea), and sometimes a total lack of
periods, called amenorrhea.
Surgery photo of an enlarged PCOS ovary at laparoscopy
A
typical, enlarged polycystic ovary
The numerous small cysts are just under the thickened outer capsule
Ultrasound picture of a typical polycystic ovary
Blue circle is around the ovary
Numerous small cysts, or antral follicles, about 2-9mm diameter are visible
For comparison, an ultrasound photo of an ovary with a
mature follicle (here 20mm) at midcycle in a woman that ovulates monthly
Blue circle is around the ovary, the black area is the fluid in the follicle
The wall of the follicle contains a microscopic egg
(not visible with ultrasound)
Ultrasound image of a
polycystic ovary in an infertile woman with blocked and dilated fallopian tubes - hydrosalpinx
She has 2 causes of her infertility - anovulation related to her polycystic
ovaries and tubal
factor infertility
Ovulation
Problems and Hormone Levels With Polycystic Ovarian Syndrome
The basic problem is that
although the polycystic ovaries contain many follicles with eggs, the follicles do not develop and
mature properly so that they do not ovulate. Women without polycystic ovaries
normally develop one
mature follicle each month which ovulates (releases) one egg.
The FSH and LH levels in PCOS are often not in the proper balance. FSH (follicle
stimulating hormone) and LH (luteinizing hormone) each need to be present at
certain levels at specific times during the normal menstrual cycle in order for
proper follicle and egg development to proceed. Many (but not all) women with
PCOS have an abnormal FSH to LH ratio. Normally this ratio is about 1:1 -
meaning the FSH and LH levels in the blood are similar. In women with polycystic
ovaries the LH to FSH ratio is often higher - for example 2:1, or even 3:1. FSH
and LH are often both in the range of about 4-8 in young fertile women. With
PCOS we often see the FSH in that same range - but with LH levels of 10-20.
Testing FSH and LH hormone levels is not all that helpful when trying to make a
diagnosis of PCOS because it is also common for women that clearly fit the
syndrome in other ways to have normal FSH and LH levels and a normal FSH to LH
ratio.
Women with polycystic
ovaries are often hyperandrogenic as well. This means that PCOS ovaries produce an excess
amount of the male hormones testosterone and androstenedione resulting in high
testosterone levels in the blood. PCOS with high testosterone can cause
increased hair growth, called hirsutism, and sometimes other problems as well.
A common scenario in women with polycystic ovaries is irregular menstrual cycles, onset of excess
hair growth in the teens or early 20s, and gradually worsening excess hair growth over the years.
Infertility
Treatments With Polycystic Ovaries, and Pregnancy Success Rate Statistics with PCOS
Can I conceive with PCOS?
When they try to
get pregnant, women with polycystic ovaries usually will have difficulty.
Some PCO women will ovulate (release a mature egg) occasionally,
others do not ever ovulate. In order to conceive, sperm must find
and fertilize a mature egg. Therefore, women with polycystic ovaries will usually need to undergo induction of
ovulation to be able to get pregnant.
The good
news is that the chances of pregnancy with PCOS after treatment are very good. The large
majority of women with polycystic ovarian syndrome will be able to have a baby with fertility treatment.
For women under age 35, the real question is more about which PCOS
treatment will be effective - and not whether any treatment will ever work. PCOS
pregnancy statistics are difficult to give out without knowing the details of
the individual case. However, women under 35 with PCOS will have about a 10%
chance of pregnancy per month with Clomid treatment (for at least 3 months) - if
the are ovulating with the Clomid (sperm and
fallopian tubes must be normal for these statistics to
apply). For PCO women that try to conceive using injectable gonadotropins,
pregnancy rate statistics of about 15% per cycle can be expected (beware of
multiple birth risks with this treatment option). Details about use of these
fertility drugs are on the induction of ovulation page.
In our
in vitro fertilization program we see PCOS pregnancy
statistics of about 70% for a pregnancy with one IVF attempt and 60% for a live
birth rate (miscarriages account for the difference between these rates).
Our IVF
Pregnancy Success Rate Statistics
Clomid pills as treatment for PCOS and infertility
Many women
with PCOS can get pregnant using treatment with Clomid pills or tablets to induce ovulation.
Clomiphene citrate, or Clomid, is given by general gynecologists, or by infertility specialists. About 75% of women with infertility and PCOS ovulate with
clomiphene, but only about 40% will get pregnant with it. In other words, although most women with PCOS ovulate with clomiphene, only about half of
those that do ovulate will be able to get pregnant with it.
Clomid and metformin or Glucophage for PCOS
A newer
method of trying to induce ovulation in women with polycystic ovarian syndrome is with oral
medications such as metformin (brand name Glucophage) in conjunction with Clomid. Metformin
is an "insulin sensitizing agent" primarily used to control diabetes. In recent years, it has been found to
help stimulate ovulation in some women with PCOS. Unfortunately, metformin has unpleasant gastrointestinal side effects
such as diarrhea in about 25% of patients.
PCOS and metformin for infertility with clomiphene resistant
polycystic ovaries
Fertility drugs after
Clomid
Injectable
Gonadotropin Treatment for PCOS
There are
other fertility drugs that can be used after Clomid. If Clomid fails after
about 6-9 ovulatory cycles, the next step used to be to give
injectable
gonadotropins (injectable FSH hormone). About 90% of women with infertility
with PCOS will be able to develop mature follicles and ovulate with this
medication. Most of them would be likely to get pregnant as well. However, this
step has often been skipped in recent years because of the high risk for multiple births, particularly
the risk of triplets and higher. Although we can get almost all women to develop mature follicles and
eggs with injectable FSH drugs, the problem is that there will quite often be
several mature follicles, not just one. Proceeding with intercourse or
intrauterine insemination with these multiple mature
follicles has a significant risk of ending up with triplets, or more. Such
high-order multiple pregnancies are very high risk for the babies because of
premature birth related deaths and disabilities. Because of these risks,
many couples and infertility specialists move directly to IVF if clomiphene
treatment is not successful. If the injectable FSH drugs are used for ovulation
induction and timed intercourse or insemination, they should be used cautiously
and in the lowest possible effective dosage by an experienced specialist in
order to minimize the number of mature follicles that develop. In this way the
risk for twins, triplets, and higher order pregnancies can be minimized.
More
about multiple birth risks with ovarian stimulation drug treatments
IVF Treatment for PCOS - In Vitro
Fertilization
The large
majority of women with PCOS that have not gotten pregnant with other treatments
will have a baby with IVF if they are under 40 years of age
and have IVF at a high quality clinic. IVF clinics are not all the same -
learn more about IVF pregnancy rates. Recent
advances in IVF technologies
have resulted in the ability to maintain high pregnancy rates while controlling
multiple pregnancy risk. Blastocyst embryo transfer
is a variant of the standard IVF treatment that is useful in controlling
multiple birth rates. In general, IVF success rates are excellent in cases with
infertility caused by PCOS. We specialize in treating women with PCOS and use an IVF protocol for PCOS that
combines metformin, oral contraceptive pills, and the
Lupron down-regulation ovarian stimulation protocol.
We have been a part of many IVF PCOS success stories.
Other Health Issues Related to Polycystic Ovarian Syndrome
Women with PCOS are known to be at
increased risks for developing certain other medical problems. The insulin
resistance seen in PCOS is believed to be at least partially responsible for the
increased risk for developing these conditions which are mainly cardiac and
metabolic in nature. The chances of developing diabetes, or hypertension, or of
having a heart attack or a stroke are higher in women with a history of having
polycystic ovaries as compared to women that never had PCOS. There is also evidence that mothers and
sisters of women with PCOS are more likely than the general population to have
PCOS as well. Fathers and brothers of women with polycystic ovaries appear to be
at increased risk for developing insulin resistance and type 2 diabetes. It
has been suggested that family members of women with PCOS should be screened for
insulin resistance, hypertension and diabetes. Research is continuing in this
area so that guidelines for early screening for these conditions can be
developed.
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