Polycystic ovarian syndrome (PCOS)

Polycystic ovarian syndrome (PCOS) is a very common reason of infertility. Together with sperm problems, fallopian tube problems and endometriosis PCOS is one of the most important reasons why women visit the fertility clinic. PCOS is by far the most common reason for ovulation problems. It is however more than just a fertility problem. PCOS can be the cause of significant health problems and if not properly managed, it can lead to additional health problems later in life.

The most common symptoms in women with PCOS are:

  1. Irregular menstruation or no menstruation at all. Some women may also experience other bleeding problems such as very prolonged and heavy menstruation.
  2. Problems with the male hormones. This presents as unwanted and abnormal hair growth, acne and oily skin.
  3. Decreased fertility and recurrent miscarriages.
  4. Weight problems: being overweight, rapid weight gain and difficulty to lose weight.
    Associated health problems, especially problems with the sugar metabolism, and high blood pressure.

Women with Polycystic ovarian syndrome have a chronic medical condition. It is an endocrine disease of the ovaries. There are no cysts on the ovary, and it can be compared to other chronic medical problems such as asthma or diabetes. There is no known definite cure for PCOS. However like asthma and diabetes it can be very well managed. PCOS is a genetic disease and runs in families.

One of the corner stones of the treatment for polycystic ovarian syndrome is weight loss. This is beneficial both to prevent long term health problems and to increase the chance of conception. Weight loss is difficult but it is possible with an adequate diet and exercise.

The diet should be seen as a permanent life style change, and not as a temporary measure. A high protein diet is recommended and patients are advised to stay away from foods with a high glycaemic index. Fresh food is recommended while processed food is discouraged. Fresh fruits and vegetables are ideal and the proteins can be obtained from fish, chicken or vegetarian options. Fizzy drinks with sugar as well as fruit juices are not recommended at all.

There is also misconception regarding exercise. The best way to lose weight is not long aerobic workouts but High-intensity interval training (HIIT). A HIIT session consists of a warm up, followed by four to ten repetitions of very high intensity workout. This is separated by medium intensity exercise to recover. It ends with a period of cool down. HIIT is has been shown to burn fat more efficiently than conventional long aerobic exercises. HIIT also significantly lowers insulin resistance and improves glucose metabolism. This is a crucial benefit for women with PCOS.

Studies have shown that losing 5% of the body weight is often enough to make a significant difference to symptoms, and will increase the chance of conception. Therefore it is important to understand that every kilogram of weight loss is beneficial.

Birth control pills (BCP) are often recommended to women with PCOS. The BCP provides regular and normal menstruation and can also improve symptoms such as acne and unwanted hair growth. However, it does not cure the problem and the underlying hormonal imbalances. So once the BCP is stopped the symptoms will likely return. Contraceptive pills are of no benefit for women who want to conceive, and they should not be used for infertility.

There are a number of fertility drugs available to induce ovulation. The most common prescribed drug is clomiphene citrate (Clomid, Fertomid). This is successful in stimulating ovulation in around 70% of all patients. But it is only successful in attaining pregnancy in around 50 % of patients. Women who do not ovulate in response to clomiphene may be offered other drugs like letrozole (Femara) or injections with gonadotrophins (Gonal-F, Menopur). The injections are very effective but must be carefully monitored by a fertility specialist. Another approach to inducing ovulation is a surgical procedure known as a laparoscopic ovarian cautery. This brings about regular ovulation, but usually only temporarily. So it is not a cure for PCOS, only an alternative way of stimulating the ovulation. It should only be performed if the oral fertility drugs are not effective.

If other treatments fail there is always the final option of in vitro fertilisation (IVF). However, most women with PCOS will not need IVF if there are no other causes for the fertility problem.

Fertility therapy should only be provided by a fertility specialist that provides professionally monitoring of the above treatments. This will prevent the risks of multiple pregnancies and ovarian hyperstimulation syndrome. Women with PCOS may respond very sensitively to the drugs and are significantly at risk for ovarian hyperstimulation syndrome and multiple pregnancies.

Key points:

  1. PCOS is a chronic endocrine disorder of the ovary.
  2. There are no cysts on the ovary.
  3. PCOS is a leading cause of infertility.
  4. PCOS can have other symptoms such as weight gain and skin problem.
  5. Weight loss is a cornerstone in the treatment of PCOS.
  6. Fertility drugs are effective but must be monitored carefully.