PCOS and Fertility
Yes, you can get pregnant with PCOS. Here's how.
The Good News
- PCOS is treatable: Most women with PCOS can conceive with proper treatment
- High success rates: ~80% ovulate with medication; ~50% conceive within 6 cycles
- Lifestyle matters: Weight loss of 5-10% can restore ovulation in many women
- Multiple options: From lifestyle changes to Letrozole to IVF, there's a path forward
What Is PCOS?
Polycystic Ovary Syndrome (PCOS) is a hormonal disorder affecting 8-13% of women of reproductive age. It's one of the most common causes of infertility—but also one of the most treatable.
PCOS Involves:
- Irregular or absent ovulation: The primary fertility issue
- Elevated androgens: Higher levels of "male" hormones like testosterone
- Polycystic ovaries: Many small follicles that don't mature properly (visible on ultrasound)
- Insulin resistance: Present in many (not all) women with PCOS
Common Symptoms
- Irregular periods (cycles longer than 35 days or fewer than 8 periods per year)
- Acne, oily skin
- Excess facial or body hair (hirsutism)
- Thinning hair on the scalp
- Weight gain or difficulty losing weight
- Difficulty getting pregnant
🔬 The "Cysts" Aren't Really Cysts
The name is misleading. The "cysts" in PCOS are actually immature follicles that haven't released an egg. They're not true ovarian cysts and don't need to be removed.
How PCOS Affects Fertility
The main fertility issue in PCOS is anovulation—not releasing an egg regularly. Without ovulation, pregnancy isn't possible.
Why Ovulation Doesn't Happen
In a typical cycle, follicles develop, one becomes dominant, and it releases an egg. In PCOS:
- Multiple follicles begin developing
- Elevated androgens and LH prevent a dominant follicle from emerging
- The follicles stall and don't release eggs
- Without ovulation, no progesterone is produced
- Periods become irregular or absent
Other PCOS Fertility Factors
- Higher miscarriage rates: Some studies show elevated risk, though this may be related to insulin resistance
- Egg quality concerns: Prolonged time in follicles may affect egg quality
- Endometrial issues: Without regular periods, the uterine lining may not develop optimally
💡 The Silver Lining
Women with PCOS often have high AMH (ovarian reserve) because of all those small follicles. This means you typically have plenty of eggs—they just need help releasing. PCOS is one of the most responsive causes of infertility to treatment.
Getting Diagnosed
PCOS is diagnosed using the Rotterdam criteria. You need 2 out of 3:
- Irregular or absent ovulation: Evidenced by irregular periods
- Clinical or biochemical hyperandrogenism: Acne, excess hair, or elevated testosterone on blood tests
- Polycystic ovaries on ultrasound: 12+ follicles in one ovary, or increased ovarian volume
Other conditions that cause similar symptoms (thyroid disorders, prolactin issues, congenital adrenal hyperplasia) should be ruled out first.
Common Tests
| Test | What It Checks |
|---|---|
| FSH & LH | LH:FSH ratio often elevated in PCOS |
| Testosterone (total & free) | Often elevated |
| DHEA-S | Androgen from adrenal glands |
| AMH | Usually high in PCOS |
| Fasting insulin & glucose | Checks for insulin resistance |
| TSH | Rules out thyroid issues |
| Pelvic ultrasound | Checks for polycystic ovaries |
Treatment Options
Treatment typically follows a step-wise approach, starting with the least invasive options:
Lifestyle Modifications
For women who are overweight, losing just 5-10% of body weight can restore ovulation in many cases. This is often tried first or alongside medication.
Success rate: Up to 75% of overweight women with PCOS resume ovulating after modest weight loss.
Letrozole (Femara)
Now considered first-line treatment for PCOS ovulation induction. Letrozole is an aromatase inhibitor that lowers estrogen, prompting the body to produce more FSH and stimulate ovulation.
How it works: Take pills for 5 days early in your cycle; ovulation typically occurs 5-12 days after the last pill.
Success rates:
- ~80% of women ovulate
- ~40-50% conceive within 5 cycles
- Lower risk of twins compared to Clomid
Clomid (Clomiphene)
The traditional ovulation-induction medication. Still effective but now typically second-line after Letrozole for PCOS specifically.
How it works: Blocks estrogen receptors, tricking the body into producing more FSH.
Success rates:
- ~70-80% ovulate
- ~30-40% conceive within 6 cycles
- Higher twin rate (~10%) than Letrozole
Metformin
An insulin-sensitizing medication that can help restore ovulation, especially in women with insulin resistance. Often used alongside Letrozole or Clomid.
Best for: Women with clear insulin resistance, elevated BMI, or who don't respond to Letrozole alone.
Gonadotropins (Injectable FSH)
If oral medications don't work, injectable hormones directly stimulate the ovaries. Requires careful monitoring due to risk of multiple follicles.
Success rates: Higher than oral medications but also higher risk of multiples.
IVF
If other treatments fail, IVF bypasses ovulation issues entirely. Women with PCOS often respond very well to IVF stimulation (many eggs retrieved).
Consideration: Higher risk of ovarian hyperstimulation syndrome (OHSS), so protocols are often modified.
⚠️ Letrozole vs Clomid for PCOS
The landmark PPCOS II trial showed Letrozole resulted in significantly higher live birth rates (27.5% vs 19.1%) and lower twin rates in women with PCOS. That's why Letrozole is now recommended as first-line for PCOS.
Lifestyle Modifications for PCOS
Lifestyle changes are powerful—and sometimes sufficient on their own:
Weight Management
Even modest weight loss (5-10%) can:
- Restore regular ovulation
- Improve insulin sensitivity
- Lower androgen levels
- Increase success rates with fertility treatments
Diet
Focus on low-glycemic foods to manage insulin:
- Emphasize: Non-starchy vegetables, lean proteins, healthy fats, whole grains
- Limit: Refined carbs, sugar, processed foods
- Consider: Mediterranean diet or low-carb approaches
- Strategy: Always pair carbs with protein or fat to slow glucose absorption
Exercise
Regular physical activity improves insulin sensitivity independent of weight loss. Aim for:
- 150 minutes of moderate activity per week
- Combination of cardio and strength training
- Consistency over intensity
Supplements
Some supplements show promise for PCOS:
Myo-Inositol + D-Chiro-Inositol
Inositols improve insulin sensitivity and may help restore ovulation in PCOS. The 40:1 ratio of myo:d-chiro mimics the body's natural ratio. Studies show improved ovulation rates and egg quality.
Theralogix Ovasitol
Pre-measured packets of myo-inositol and d-chiro-inositol in the optimal 40:1 ratio. Unflavored powder that mixes easily. Third-party tested for purity.
Tracking Ovulation with PCOS
Standard tracking methods can be tricky with PCOS:
OPKs
Challenge: Many women with PCOS have consistently elevated LH, leading to multiple "positive" OPKs or always-dark lines.
Solution: Look for a significant surge rather than just a positive. Digital OPKs that detect estrogen (like Clearblue Advanced) may help identify the true fertile window.
BBT Charting
Challenge: Without regular ovulation, charts may be erratic.
Benefit: Can confirm if and when ovulation actually occurred—useful for knowing if treatment is working.
Cervical Mucus
Challenge: May have less fertile-quality mucus, or it may appear multiple times during a long cycle.
Tip: Still worth tracking as one data point among many.
Monitoring During Treatment
When on Letrozole or Clomid, your doctor will likely monitor with:
- Ultrasound: To track follicle growth
- Blood tests: To check estrogen and confirm ovulation
- Trigger shot: Sometimes used to time ovulation precisely
The Bottom Line
PCOS is one of the most common causes of infertility—but also one of the most treatable. With the right approach (lifestyle changes, medication, or both), most women with PCOS can conceive.
Start with your doctor to get properly diagnosed and create a treatment plan. Don't lose hope—the odds are in your favor. 💚