Polycystic Ovarian Syndrome

Polycystic ovarian syndrome — PCOS — is the commonest hormonal reason that a woman in her twenties or thirties finds it hard to conceive. It is also one of the most treatable.

If you have been told you have polycystic ovarian syndrome, you have probably also been told to lose
weight and given a leaflet. This page tries to do better than that. Here is what polycystic ovarian syndrome actually means: what the
diagnosis actually means, why it interferes with ovulation, and the order in
which treatment is normally offered when you are trying to get pregnant.

On this page

• What polycystic ovarian syndrome is
• How PCOS is actually diagnosed
• Why PCOS makes conception harder
• Three things PCOS is not
• How PCOS-related infertility is treated, in order
• The risks that need watching during treatment
• PCOS beyond fertility
• Common questions

What polycystic ovarian syndrome is

Polycystic ovary syndrome is a hormonal and metabolic condition, not a disease
of the ovaries alone. Three things tend to travel together in it: ovulation that
is irregular or absent, higher-than-usual levels of male-type hormones
(androgens), and ovaries that contain a large number of small immature
follicles.

Underneath much of it sits insulin resistance. The body produces more insulin
to do the same job, and higher insulin levels push the ovary to make more
androgen. More androgen interferes with the orderly monthly selection of a single
follicle. That is the loop, simplified — and it is why treatment so often starts
with insulin rather than with the ovary.

PCOS is a spectrum. One woman may have nothing more than slightly long cycles.
Another may have gone months without a period, with acne, hair growth and weight
that will not shift. Both diagnoses are correct.

How PCOS is actually diagnosed

PCOS is diagnosed when at least two of the following three features are
present, and other conditions that can mimic them have been excluded:

• irregular or absent ovulation — in practice, infrequent or absent
  periods;
• clinical or biochemical evidence of excess androgens — acne, excess facial
  or body hair, scalp hair thinning, or raised androgens on a blood test;
• polycystic-appearing ovaries on ultrasound.

The exclusions matter. Thyroid disease, a raised prolactin level and
congenital adrenal hyperplasia can all produce a similar picture and are treated
completely differently. A thyroid check is part of any sensible workup.

Two further points are worth knowing. In adolescents, PCOS is over-diagnosed:
irregular cycles and polycystic-looking ovaries are both normal in the years
after periods begin. And an AMH level is often high in PCOS — that reflects the
number of small follicles, not superior fertility. See
what an AMH result
means.

Why PCOS makes conception harder

In a typical cycle, one follicle is selected each month, matures, and releases
an egg. In PCOS, many follicles start but none is selected. They stall part-grown
— which is what the scan is showing — and ovulation does not happen, or happens
unpredictably.

No ovulation means no egg to fertilise. It also means you cannot time
intercourse, because there is nothing reliable to time it to. This, rather than
anything wrong with the eggs themselves, is the core fertility problem in PCOS.

Women with PCOS are generally not short of eggs. That is genuinely good news,
and it shapes the treatment plan: the task is to restore ovulation, not to
replace what is missing.

Three things PCOS is not

The “cysts” are not cysts

The small round structures seen on the scan are follicles that stopped
growing. They are not cysts in the surgical sense, they do not need to be
drained, and they do not need to be removed.

PCOD and PCOS are not two different diseases

“PCOD” is an older, looser term still widely used in India. It is not a milder
separate illness. If you have been told you have PCOD, ask which of the
diagnostic features you actually meet.

PCOS is not infertility

Many women with PCOS conceive naturally, some with no treatment at all. PCOS
describes a difficulty with ovulation, and a difficulty that responds to
treatment more reliably than most causes of infertility do.

How PCOS-related infertility is treated, in order

Treatment is a ladder. You start on the lowest rung that has a realistic
chance of working, and you move up only if it does not.

Step one — weight, insulin and the metabolic groundwork

For women carrying extra weight, a modest, sustained reduction can restore
ovulation on its own. It is the only step that treats the underlying mechanism
rather than overriding it. Metformin is sometimes added where insulin resistance
is prominent. Inositol supplements are widely used and reasonably well
tolerated.

This step is slow and it is the one patients most want to skip. It is also the
one that makes every later step work better, because a stimulated cycle in a
woman with untreated insulin resistance is harder to control. See
weight and fertility.

Step two — ovulation induction with tablets

The aim is to make one follicle mature and release an egg. Letrozole is now
generally preferred to clomiphene citrate as the first-line drug in PCOS.
Treatment is given for a few days early in the cycle, and follicle growth is then
tracked on ultrasound so that intercourse can be timed and so that the response
can be checked rather than assumed. See
ovulation
problems.

Step three — injectable stimulation, with or without IUI

If tablets do not produce ovulation, low-dose gonadotropin injections may be
used instead. PCOS ovaries are unusually sensitive to these drugs, so doses start
low and are increased slowly, with close ultrasound monitoring. Where the sperm
sample is adequate and the tubes are open, this is often combined with
IUI.

Step four — IVF

IVF
is considered when the earlier steps have not worked, or when there is another
factor as well — blocked tubes, significant male factor, or age. Women with PCOS
often produce a large number of eggs in an IVF cycle, which is an advantage for
embryo numbers and a risk for hyperstimulation at the same time. A freeze-all
approach, with transfer in a later cycle, is frequently the safer route.

Where ovarian drilling fits

Laparoscopic ovarian drilling is a keyhole procedure that can restore
ovulation in women who do not respond to tablets. It is used selectively now
rather than routinely, because it involves surgery and because it can reduce
ovarian reserve if overdone.

The risks that need watching during treatment

• Ovarian hyperstimulation syndrome (OHSS). PCOS is the
  single biggest risk factor. This is why doses are kept low and monitoring is
  frequent. Report abdominal swelling, nausea, reduced urine output or
  breathlessness at once.
• Multiple pregnancy. A stimulated PCOS ovary can release
  several eggs. A cycle with too many mature follicles should be cancelled, not
  continued.
• Pregnancy complications. PCOS carries a higher likelihood
  of gestational diabetes and high blood pressure in pregnancy, so antenatal
  screening should be arranged early.

PCOS beyond fertility

PCOS does not end when you conceive. It is a lifelong metabolic condition
associated with type 2 diabetes, abnormal cholesterol and, where periods are very
infrequent, a thickened uterine lining over time.

Two practical things follow. Cycles should not be left absent for long stretches
without a plan to induce a bleed. And periodic checks of blood sugar, blood
pressure and lipids are worth doing, whatever stage of life you are at.

Common questions

Can I get pregnant naturally with PCOS?

Yes. Many women with PCOS conceive without treatment, particularly where
cycles are only mildly irregular. Difficulty conceiving is common in PCOS, but it
is not the rule.

Does PCOS mean I will need IVF?

No. IVF sits at the top of the ladder, not the bottom. Most women with PCOS
who need help ovulating respond to weight management, tablets, or low-dose
injections, and never reach IVF.

Will losing weight cure my PCOS?

Weight loss does not cure PCOS, but in women carrying extra weight it often
restores ovulation and makes every other treatment easier to manage. It is worth
doing on its own terms, whether or not it is enough by itself.

Do the cysts need to be removed?

No. They are stalled follicles, not true cysts. Surgery to remove them is not
a treatment for PCOS and can damage healthy ovarian tissue.

My AMH is very high. Is that good?

A high AMH in PCOS reflects the large number of small follicles, not better
egg quality. It usually predicts a strong — sometimes excessive — response to
stimulation, which is useful to know before a cycle is planned.

How long should I try before seeing a fertility specialist?

If your periods are irregular or absent, do not wait a year. Irregular cycles
are themselves a reason to be assessed, because there is a treatable problem to
find and time spent waiting is time you cannot get back.

The NHS overview of polycystic ovarian syndrome covers the same diagnostic ground in plain language, and ESHRE publishes the international guideline clinicians work from.

Written and medically reviewed by Dr. Vani Sundarapandian, MD, DGO, FRCOG
(UK) — founder and Medical Director, Jananam Fertility Centre, Chennai.