Navigating your fertility journey often starts with lots of planning, no matter what your situation is. But when you have a reproductive health condition like polycystic ovary syndrome (PCOS), you may find yourself planning out more steps in your journey than you’d anticipated.
PCOS is a very common hormonal disorder and a leading cause of infertility because of one of its hallmarks: irregular ovulation. While irregular ovulation can make getting pregnant trickier, you can work with your healthcare provider to build a medical plan and increase your chances of conception.
We recently held a virtual PCOS panel with OB-GYN (and Modern Fertility medical advisor) Dr. Jennifer Conti, MD, MS, MSc and reproductive endocrinologist (REI) Dr. Temeka Zore, MD, FACOG. Here’s what we learned about trying to conceive when you have PCOS.
How does PCOS affect you when you’re trying to conceive?
Dr. Conti and Dr. Zore explain that fertility is affected by PCOS because of the hormonal imbalance related to the condition, often marked by very high testosterone levels and irregular pulsatile secretions of FSH, or follicle stimulating hormone, which is necessary for follicular growth. This imbalance disrupts ovulation, which is a necessary step in getting pregnant.
PCOS makes it difficult to plan timed intercourse or insemination
If you’re trying to conceive, you’re likely tracking ovulation so that you can plan intercourse or insemination around your fertile window. For ovulation to occur, your brain has to produce LH (luteinizing hormone) and FSH (follicle-stimulating hormone), which then send signals to your ovaries. Dr. Conti refers to this as a “smooth cycle of hormonal communication,” ending with ovulation and a follicle releasing an egg each month to get fertilized.
When you have PCOS, that communication becomes “fragmented,” or never happens at all. This hiccup in the process means you can’t ovulate regularly or release an egg 12 times a year. Someone with PCOS might only get a period every few months, or may have anovulatory cycles — meaning you don’t ovulate at all.
This kind of irregular bleeding makes it difficult to conceive because you can’t “predict on your own when you’re going to be in the fertile part of your cycle since you can’t predict when you’re going to ovulate,” Dr. Conti says. If you’re unsure whether or not you ovulate, you can assess common ovulatory signs such as egg-white discharge. Additionally, Dr. Zore explains, you’re probably ovulating each month if your cycle is regularly between 21-35 days. If you have a longer cycle — for example, you only get a period once every 2-4 months — it’s harder to predict if/when you may be ovulating.
Treating PCOS with birth control can make understanding your cycle trickier
Hormonal birth control is sometimes said to “mask” PCOS symptoms because it increases your estrogen and/or progesterone levels, which then balances your hormones and regulates your period. If you started taking birth control pills in your early teens to manage your symptoms, you may not remember what your cycle is like without them. “Then when people start trying to conceive, they realize all over again that their periods were actually irregular at baseline,” Dr. Conti says. As you begin your fertility journey, expect some cycle irregularity and prepare to discuss potential treatments with your healthcare provider.
If you were on hormonal birth control in your early days of menstruation, then you may have never had the chance to notice that your cycles are irregular in the first place. When you stop taking birth control and wait a few months for your body to adjust to hormonal changes, you might end up never resuming regular menstruation. In this case, talk to your healthcare provider about fertility hormone testing. If the test reveals abnormal hormone levels, you may be diagnosed with PCOS after other potential causes are eliminated. (The Modern Fertility Hormone Test, which measures the same hormones they would at a fertility clinic, can also help you start a conversation with your doctor about PCOS.)
Treatments that can help if you’re trying to conceive with PCOS
While you’re commonly prescribed hormonal birth control to treat PCOS, that’s obviously incompatible with your goals if you’re trying to get pregnant. So, when trying to conceive, the purpose of treatment is to induce ovulation and time intercourse or insemination around that, rather than to regulate your cycle long-term. You can sometimes get these induction medications directly from an OB-GYN, but your OB-GYN can also refer you to an REI right away if they think that’s more appropriate.
If you already know that you have PCOS and know that you do not ovulate regularly or at all, Dr. Zore stresses that you should not wait to speak with your doctor about the possibility of ovulation-inducing medications. You’ve probably heard general advice that, after more than 12 months of trying and not getting pregnant, you should go see a doctor — but that timeline is recommended if you’re not yet sure of your body’s ability to conceive naturally. If you already know that your PCOS diagnosis includes irregular ovulation and you want to get pregnant, then there is no need to delay treatments that can help you conceive.
Inducing ovulation when you’re trying to conceive
If you’re trying to get pregnant and blood tests have confirmed you have PCOS and you are not ovulating regularly, the first step is figuring out the right ovulation-inducing medication for you.
There are three different medications commonly used to induce ovulation in people with PCOS: clomiphene (Clomid), letrozole (Femara), and metformin (Glucophage, Riomet, or Glumetza).
1. Clomiphene (aka Clomid): This is an oral medication that you’ll take for five days, starting around day 2-5 day of your natural or induced period. (When periods aren’t happening naturally, your healthcare provider can induce bleeding with progesterone, which is the hormone that rises before menstruation.) Dr. Zore explains that Clomid works by tricking your brain into thinking that your estrogen levels are low so that it will release more FSH, which then helps stimulate your ovary to produce one or more follicles. The hope is for one of these follicles to release a mature egg, and you’d pair this treatment with insemination or timed intercourse to fertilize that egg.
2. Letrozole (aka Femara): This is another oral medication with a similar purpose to Clomid. It‘s also taken for five days, starting on days 2-5 of a natural or induced period, and works by inhibiting an enzyme, aromatase, which converts androgens to estrogens in the peripheral (fat) tissue. Your body perceives the estrogen levels to be low and subsequently increases FSH production, which leads to ovulation.
Dr. Zore says more doctors are prescribing letrozole to PCOS patients because it can be more effective. A New England Journal of Medicine study shows letrozole may result in a slightly higher increased rate of ovulation (61.7% vs 48.3%), and an increased rate of patients able to conceive and have live births (27.5% vs 19.1%).
Dr. Zore mentions that, when starting on letrozole, your doctor will let you know about a previous abstract that found the medicine could potentially increase the risk of heart defects in infants. But because that study was never published and the results have never been reproduced, many doctors now safely prescribe letrozole.
3. Metformin (aka Glucophage, Riomet, or Glumetza): This oral medication also helps induce ovulation, but has been shown in a randomized controlled trial to be less effective than Clomid when used alone. Additionally, it may be used in women with glucose intolerance to reduce the risk of developing type 2 diabetes.
If you take one of these medications, Dr. Zore says your REI will ask you to come back for a visit around the tenth day of your cycle to get an ultrasound. This allows the doctor to watch your follicle development and give you medication that triggers ovulation once the follicle has matured enough to release an egg.
An OTC option that works for some: myo-inositol
Myo-inositol is a supplement that can increase the rate of ovulation in patients with PCOS, and it’s often compared to metformin. In one 2010 study looking at the results of metformin versus myo-inositol, researchers found that metformin induced ovulation in 50% of participants and myo-inositol (plus folic acid) induced ovulation in 65% of participants. That said, Dr. Zore emphasizes that current findings about myo-inositol are “not conclusive or a cure-all.” She recommends thinking of myo-inositol as a first step to inducing ovulation if you don’t yet want to pursue other medical treatments.
Whenever you consider taking a supplement, Dr. Zore says to remember there are not a lot of studies available to prove the efficacy of these products. Make sure you talk to your doctor about potential side effects, and if someone has recommended a supplement to you, look into where that recommendation is coming from. “Do your research,” Dr. Zore says. “The only supplements I would recommend for everyone are prenatal vitamins, folic acid, and DHA (a fatty acid). Talk to your doctor about everything else.”
Possible next steps if ovulation-inducing medications don’t work
If you have PCOS but the rest of your fertility workup is normal, then Dr. Zore says you might undergo 3-6 cycles of ovulation induction before any other treatment is considered. Your doctor wants to give you a chance to ovulate and conceive naturally before directing you toward something like in-vitro fertilization (IVF). However, it’s important to “balance this recommendation with the emotional energy each cycle takes,” Dr. Zore says.
If you find yourself getting frustrated because ovulation induction alone isn’t resulting in pregnancy, then it might be time to think about IVF — especially if that fits in with your individual goals and where you are in your fertility journey. For example, are you 35 or older? Do you want to have more than one child? Talk to your healthcare provider about what makes the most sense timeline-wise for you and your goals.
After reading all this, the most important thing to take away is that you can get pregnant even if you have PCOS. For more insight from Dr. Conti and Dr. Zore, watch the full virtual PCOS panel below — and be on the lookout for more panels, info sessions, and live Q&As with Modern Fertility.
This article was reviewed by Dr. Jennifer Conti, an OB-GYN who serves as a Modern Fertility medical advisor and is also an adjunct clinical assistant professor at Stanford University School of Medicine.