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Treating PCOS

PCOS and Pregnancy Part Three

In the first part of our series on polycystic ovarian syndrome (PCOS) and pregnancy,  we asked the question, “How do I know if I have PCOS?“  Then we looked at the relationship between PCOS and difficulty getting pregnant. In this final part of the series, we examine possible treatments for PCOS that may help you to get pregnant.

What treatments might help me?

Despite the increased difficulties in getting pregnant, the good news is that at least 60% of women with PCOS are able to conceive within a year (Brassard, 2008). There are a variety of treatment options which may help to optimize your chances of a “take home baby.”

Modest weight loss

In one study of 263 women with PCOS, those who were overweight (e.g., BMI of 25 or more) had more irregular menstruations than those who weighed less (Kiddy, 1990).  This fact correlates with the known improvement in fertility seen when women with PCOS lose weight. While I usually suggest to women that a loss of 15% of current weight will improve ovulation functions, there are studies which have found benefit in losing only 5-10% of current body weight.

One small study, which utilized six months of diet and exercise, found that a majority of subjects resumed ovulating with only 2-5% of body weight reduction (Huber-Buchholz, 1999). Twelve of thirteen non-ovulatory, obese women were able to restore ovulations when the average weight loss was only 14 pounds. This was achieved with six months of gradual dietary changes and regular exercise (Clark, 1995). In a German study 29% of obese, non-ovulating women conceived after a mean weight loss of 22.5 pounds (Hollmann, 1996). By contrast, rapid weight loss (9% weight loss over 6 weeks) was found to impair fertilization rates in obese women undergoing in vitro fertilization (Tsagareli, 2006).

The exercise program successfully used by Clark (1995) included one hour twice weekly of a low impact aerobics group session coupled with one hour twice a week of exercise of the woman’s choice. There is apparently no specific inhibition preventing those with PCOS from exercising. Thompson and colleagues (2009) compared heavyset women with and without PCOS for both muscles strength and aerobic capacity. Women with PCOS were able to exercise to the same extent as a weight matched control group.

Based on the studies of weight loss and return of ovulation, the most recent consensus statement from the Androgen Excess and PCOS Society (Moran, 2009) states, “Lifestyle management should be used as the primary therapy in overweight and obese women with PCOS for the treatment of metabolic complications. For reproductive abnormalities, lifestyle modification may improve ovulatory function and pregnancy.”  In the event that moderate weight loss does not yield your desired pregnancy, medications may be utilized.

Clomiphene citrate (“Clomid”)
For women with PCOS, Clomid is the recommended first choice of drug treatments to induce ovulations (Thessaloniki ESHRE/ASRM). Clomid pills are given for only five days following a menstrual period. For example this could be cycle days 5 through 9 after either a “natural bleed” or one induced by taking progesterone. Clomid is believed to induce ovulations by increasing levels of FSH. Among women with PCOS utilizing Clomid, ovulation rates are about 75% with single babies born to 25% of those (Homburg, 2005).

Metformin (“Glucophage”)
Many overweight women with PCOS have “insulin resistance (IR).” IR means that the liver and muscles do not respond to the normal amounts of insulin produced. This in turn can force the pancreas to create ever higher amounts of insulin. Metformin is one of the most common insulin sensitizing medications used in both type 2 diabetics and PCOS. It lowers fasting insulin levels which can lower levels of male hormones, and may increase incidence ovulations.

The utility of metformin as a method of inducing ovulations is being re-evaluated. One hundred and fourteen women with PCOS were randomly assigned to either metformin or a placebo pill paired with a diet and exercise program. After six months there were no differences in rates of ovulation between the two groups (Ladson, 2010).

In a much larger study of 626 infertile women with PCOS, Dr. Richard Legro (2007) and fellow researchers compared metformin to Clomid to a combination of both medications for pregnancy rates. The live birth rate for metformin alone was 7.2%, 22.5% for Clomid alone, and 26.8% for the metformin plus Clomid group.  Despite the increase of 4% there was no statistically significant advantage for adding metformin to Clomid.

Laproscopic Ovarian Surgery
For women who do not respond to Clomid, a surgery on the ovaries may be helpful. Laproscopic ovarian surgery (LOS) utilizes a laser or cautery device to put four to ten punctures in the ovary. Nicknamed the “whiffle ball” procedure, these small holes drilled in the surface of the ovary decrease the excessive amounts of LH produced by a polycystic ovary. About 50% of women receiving this treatment will ovulate, the remainder may need other infertility medications (Thessaloniki ESHRE/ASRM).

When 282 women with PCOS were randomly assigned to LOS or Clomid plus metformin, pregnancy rates after six months were similar (15-17%). Yet there were four twin pregnancies in the Clomid plus metformin group (Abu Hashim, 2010). Given that all the women in this study did not respond to Clomid initially, the take home message is that pregnancy can be achieved with the use of another treatment.

In summary, PCOS can be defined by the medical profession in a number of ways. Yet one of the defining characteristics is known to be erratic or missed menstrual periods — which usually means missed ovulations. If you have been having a hard time getting pregnant, ovulation problems caused by PCOS may be the reason. Should this be true, there are things you can do on your own such as modest weight loss through better diet and four hours of exercise a week. After six to twelve months of trying on your own, it is time to see a GYN or clinic to consider a trial of medications.

Here are some additional sources of information which may be helpful to you:

Best wishes in conceiving soon!

Yours,

Jane

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