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Treating PCOS and Infertility
Women who have polycystic ovarian syndrome (PCOS) typically have ovaries that contain many small follicles, which are often called "cysts." The eggs in these follicles don't grow normally, which is why women with PCOS ovulate less frequently and have trouble getting pregnant. The many small follicles in the ovaries produce androgens, male hormones that not only lead to an imbalance that affects a woman's ability to conceive, but can also lead to conditions such as high blood pressure and diabetes.
Patients with PCOS who are trying to get conceive should have a complete fertility work-up in order to determine if there are factors other than PCOS that may be contributing to infertility, according to Anuja Dokras, MD, PhD, a reproductive endocrinologist with Penn Fertility Care, and director of the Penn Polycystic Ovary Syndrome Center. "If they have PCOS only, then the focus is to help them ovulate," she says. "But I would make sure there are no other factors, such as male factor or tubal factor., etc."
If the fertility doctor finds the only cause of the infertility is PCOS, the first-line treatment is to educate the patient about weight loss. "If you are able to lose weight, your periods may come more regularly," Dr.Dokras says. "You may not need any fertility medications, or you may need a low dose medication, and your pregnancy will be safer if you're lower in weight. So the discussion about weight loss is always the first thing when you're trying to get pregnant."
In women with PCOS, the underlying problem is insulin resistance. Losing weight helps drop the insulin levels and help you ovulate more regularly. A patient may also be given Metformin, a diabetes medication used to control blood sugar and insulin levels. Metformin can also help reduce androgen levels and make ovulation normal.
If periods are still irregular even with weight loss, fertility drugs are the next step. "Usually tablets by mouth that will help them ovulate each month," Dr. Dokras says. "Clomid or Letrozole. We are part of a multi-center study funded through the National Institutes of Health comparing these two drugs head to head."
Dr. Dokras says that for the percentage who don't respond to the oral fertility drugs, they go on to injections with gonadotropins (FSH injections). "It's the same jormone that is secreted by the brain; it's just a higher dose to help form the eggs and release them," she says.
When the less invasive treatments do not succeed, ovarian drilling is a laparoscopic procedure that is sometimes used to treat PCOS and infertility. Patients with PCOS typically have ovaries with a thick outer surface. Ovarian drilling breaks through the thick outer surface and reduces the amount of testosterone the ovaries make.
"With laparoscopy, one could look at both the ovaries and with a very low dose current, one can cauterize small areas of the ovary on both sides or one side, the idea being the ovaries have these excessive follicles, and that is where the male hormone is coming from," says Dr. Dokras. "So if you burnt off little areas, maybe you drop the levels, and the woman would start ovulating. The studies show that that can happen, and it does happen in fair proportion, but for a short time. Once the areas heal over again, the majority of the women go back to their original menstrual pattern."
Women who are experiencing infertility because of PCOS and no other reason typically do not need in vitro fertilization, Dr. Dokras says. "If the only reason [they are not getting pregnant] is they are not able to ovulate, then the great majority will be pregnant either with weight loss or with Clomid or with injections."