PCOS and Fertility Treatments

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Trying to conceive

Many women with Polycystic Ovarian Syndrome (PCOS) are very concerned with their ability to have children. The absence of menses makes timing impossible. Hormone imbalances can cause at-home ovulation test kits to give false results. Pregnancies in women with PCOS are more likely to result in miscarriage. Most women who have tried for several months without success approach their doctors for medical assistance. Depending on the mother’s health and the doctor’s preferred methods, several options are available.

Metformin (Glucophage)

Although not currently Food and Drug Administration (FDA) approved for use in patients with PCOS, many physicians are starting to realize the value that Metformin has for some women. Metformin lowers elevated testosterone levels in women with PCOS by helping the body properly synthesize insulin. Lowering testosterone can assist in balancing out hormones responsible for ovulation, thus allowing conception to occur. Research conducted on women with prior miscarriages taking Metformin during pregnancy suggests that it may help the body’s hormones stay balanced, preventing miscarriage.

A FDA pregnancy category B medication, Metformin appears to not cause any harm to an unborn baby. While there are many studies being conducted that seem to suggest that Metformin is useful in aiding with ovulation, conception, and sustaining pregnancy, few of these studies are complete.

Metformin may be given as a first choice by some physicians (due to not increasing the risk of multiple births, which come with a higher complication rate), while others prefer to try Clomiphene first on its own, only adding Metformin if Clomiphene fails to induce ovulation.

The side-effects of Metformin are most commonly related to gastrointestinal disturbances, such as diarrhea. Metformin does not cause patients to become hypoglycemic or diabetic.

Clomiphene (Clomid, Serophene)

Clomiphene is used during a woman’s menstrual cycle. A period may need to be induced (using progesterone or similar) to begin the process if the patient is entirely annovulatory. It is usually given on the second day of a woman’s cycle, during which follicle-stimulating hormone (FSH) is rising, and follicles are developing. The follicles produce estrogen, which signals the brain to continue the cycle. Clomiphene blocks this estrogen from sending those signals, and the body reacts by thinking a low level of estrogen is present. The pituitary begins to produce more FSH and lutenizing hormone, creating even more follicles. These follicles then rupture during ovulation, releasing more eggs. This increases the chance of conception, but also the chance of multiple pregnancy.

Several side effects are reported during Clomiphene use, including abdominal pain, ovarian enlargement (this will reverse after treatment when hormones return to normal levels) and cyst formation. Woman may experience blurred vision or hot flashes. In rare cases, Ovarian Hyperstimulation Syndrome can occur. Symptoms of OHSS include abdominal pain (mild to severe), problems with urination, nausea, vomiting, diarrhea, and bloating. Shortness of breath, lack of urination, and leg and chest pains can occur in severe cases. While not fatal, the only option for OHSS is to cease treatment and allow hormones to normalize. Hospitalization to treat symptoms may be necessary if hydration is required.

Gonadotropin Injections

When Clomiphene and/or Metformin have failed to induce ovulation, the physician may try gonadotropin injections. These medications, including Femara and Letrozole, contain follicle stimulating hormone that is injected directly into the muscle (generally the thigh). These injections begin early in the cycle and continue for eight to fourteen days, when the ovaries are then viewed via ultrasound. If healthy follicles are found on the ultrasound, an HGC trigger shot is given, and ovulation occurs within the next 36 hours. Combined with IUI (intra-uterine insemination), pregnancy rates can increase up to 15%.

This treatment also carries the risk of Ovarian Hyperstimulation Syndrome. The risk of multiples is also much higher. To avoid choosing procedures such as selective abortion in causes of high multiples (more than five fetuses greatly decreases the chance of live birth), the physician can help the patient determine whether or not to give the trigger shot during a cycle in which many follicles are present.

Gonadotropin Injections are very expensive, and often not covered by insurance.

These injections are tried for three to six cycles, and usually the last course of action before moving on to IVF (In-vitro fertilization).

In-vitro Fertilization

In-vitro fertilization requires more time than other fertility treatments. Several appointments are required to complete the process. The woman’s egg reserve is tested using a baseline follicle-stimulating hormone test on day three of her cycle. If the FSH is extremely elevated, the expected egg quantity is usually lowered. Antral follicles, or follicle visible on an ultrasound, are counted and measured. The higher the number of follicles, the higher the chance of success will be.

After the ovaries are examined to determine their health and ability to respond well to the procedure, injectible medications are given to help development of the follicles, similar to gonadotropin injections. Blood work and ultrasounds are done every one to three days to monitor the development of each follicle. Three is generally considered the minimum number of follicles required to continue with the procedure.

When the follicles are mature, egg retrieval begins. Under anesthesia, a small needle is placed through the vaginal wall into the ovary. The fluid surrounding the egg is sucked out through the needle; the egg detaches from the wall of the follicle and is pulled out through the needle. This usually takes less than twenty minutes.

After the eggs are removed, they are rinsed and kept in a specialized incubator. After four to five hours, sperm is mixed with the eggs, or directly injected into the egg. They will be checked the following morning to fertilization, and if successful, placed into the woman’s uterus within two to five days. Two weeks later, a blood test to confirm pregnancy hormones are present is conducted.

Side effects from the injections and trigger shot are the same as those for other injected fertility medications. Waiting to hear whether all of the work was successful, and feeling let down when it is not can be exhausting and stressful.

IVF is the most expensive fertility treatment. In the United States it can cost from $9000 - $15,000 USD.


Advanced Fertility: In-vitro Fertilization

Mayo Clinic: Infertility Treatments and Drugs