If you've been diagnosed with polycystic ovary syndrome (PCOS), you might be worried about your chances of having a baby. The good news: PCOS is highly treatable, and the vast majority of women with PCOS who want to conceive are able to do so.
Let's understand what PCOS is, how it affects fertility, and what you can do about it.
What Is PCOS?
Polycystic ovary syndrome is a hormonal disorder characterized by:
- Irregular or absent ovulation
- Elevated androgens (male hormones)
- Polycystic-appearing ovaries on ultrasound
Despite the name, PCOS isn't really about "cysts"âthe "polycystic" appearance comes from many small follicles that don't mature properly, not actual cysts.
Rotterdam Criteria for PCOS Diagnosis
You need 2 of these 3 criteria for diagnosis:
Irregular or Absent Periods
Cycles longer than 35 days, fewer than 8 periods per year, or no periods at allâindicating infrequent or no ovulation
Signs of High Androgens
Clinical signs like excess hair growth (hirsutism), acne, or male-pattern hair lossâOR elevated androgens on blood tests
Polycystic Ovaries on Ultrasound
12+ follicles measuring 2-9mm in each ovary, OR ovarian volume >10mL (updated criteria use 20+ follicles)
How PCOS Affects Fertility
The primary way PCOS impacts fertility is through anovulationânot ovulating regularly or at all. If you don't release an egg, you can't get pregnant that cycle.
Here's what happens in PCOS:
- Hormonal imbalances (high androgens, often high insulin) disrupt normal follicle development
- Multiple follicles start developing but none reaches full maturity
- Without a mature follicle, the LH surge doesn't trigger ovulation
- The uterine lining may not develop properly without the hormonal signals from ovulation
The key insight: PCOS doesn't damage your eggs. Women with PCOS often have plenty of eggsâthey just don't ovulate them consistently. Once ovulation happens (naturally or with help), pregnancy rates are similar to women without PCOS.
Because the problem is ovulation (not egg quality or quantity), PCOS-related infertility is highly treatable. The goal of treatment is simply to help you ovulateâonce that happens, conception often follows.
Other Fertility Impacts of PCOS
Beyond anovulation, PCOS can affect fertility through:
Insulin resistance: About 70% of women with PCOS have insulin resistance, even if they're not overweight. High insulin levels worsen hormonal imbalances and may affect egg quality and implantation.
Endometrial issues: Without regular ovulation and the progesterone it produces, the uterine lining may not develop optimally for implantation.
Higher miscarriage rates: Some studies suggest slightly higher miscarriage rates in PCOS, possibly related to insulin resistance or hormonal factors. Proper management may reduce this risk.
Pregnancy complications: Women with PCOS have higher rates of gestational diabetes and preeclampsia. Managing PCOS before and during pregnancy helps reduce these risks.
Lifestyle Changes: The First Line of Treatment
For many women with PCOSâespecially those who are overweight or have insulin resistanceâlifestyle modifications alone can restore ovulation. This is why it's considered first-line treatment.
Weight Management
Even a 5-10% weight loss can restore ovulation in overweight women with PCOS. Weight loss improves insulin sensitivity and reduces androgens. Not everyone with PCOS is overweight, but for those who are, this is powerful.
Low-Glycemic Diet
Reduce refined carbs and sugars; emphasize protein, fiber, and healthy fats. This improves insulin sensitivity. Some women benefit from very low-carb or Mediterranean-style diets. Work with a dietitian familiar with PCOS.
Regular Exercise
Both cardio and strength training improve insulin sensitivity. Aim for 150+ minutes of moderate activity per week. Exercise helps even without significant weight loss by improving how your body uses insulin.
Sleep & Stress
Poor sleep and chronic stress worsen insulin resistance and hormone imbalances. Prioritize 7-9 hours of quality sleep. Find healthy stress management strategiesâyoga, meditation, whatever works for you.
"Lifestyle changes aren't just preliminary steps before 'real' treatmentâfor many women with PCOS, they ARE the treatment, and they work."
Supplements for PCOS
Several supplements have research supporting their use in PCOS:
Inositol: The supplement with the most evidence for PCOS. Myo-inositol and D-chiro-inositol improve insulin sensitivity, support ovulation, and may improve egg quality. Studies show pregnancy rates comparable to metformin.
Vitamin D: Many women with PCOS are vitamin D deficient. Supplementation may improve insulin resistance and ovulation. Test your levels and supplement if low.
Omega-3 fatty acids: May help reduce inflammation and improve lipid profiles in PCOS. General health benefits make it a reasonable addition.
NAC (N-Acetyl Cysteine): Some studies suggest NAC improves ovulation and insulin sensitivity in PCOS. May be used alongside other treatments.
Medical Treatments for PCOS Infertility
If lifestyle changes and supplements aren't enough, several effective medical treatments exist:
An aromatase inhibitor that reduces estrogen, prompting the brain to release more FSH and stimulating ovulation. Now considered first-line over Clomid for PCOS due to better pregnancy rates and lower multiple pregnancy risk.
A selective estrogen receptor modulator (SERM) that blocks estrogen receptors in the brain, triggering increased FSH release. Effective and well-established, though letrozole is now often preferred for PCOS specifically.
A diabetes medication that improves insulin sensitivity. Can restore ovulation in some women, especially when combined with lifestyle changes or ovulation induction medications. Not as effective as letrozole/Clomid alone but helpful as combination therapy.
Injectable hormones (FSH) that directly stimulate the ovaries. Used when oral medications don't work. Requires careful monitoring due to risk of overstimulation (OHSS) and multiple pregnancyâboth higher in PCOS.
Reserved for when other treatments fail or when there are additional fertility factors. Women with PCOS often respond very well to IVF stimulation (sometimes too wellâOHSS risk is higher). Single embryo transfer is often recommended to avoid multiples.
The Treatment Ladder
Fertility treatment for PCOS typically follows this progression:
- Lifestyle modifications (weight loss if applicable, diet, exercise, supplements like inositol)âtry for 3-6 months
- Letrozole or Clomidâtypically 3-6 cycles, often combined with timed intercourse or IUI
- Gonadotropins with IUIâif oral medications don't work, with careful low-dose protocols
- IVFâif other treatments fail, or if there are additional factors like male factor infertility or tubal issues
The good news: most women with PCOS conceive at steps 1 or 2. IVF is rarely necessary for PCOS alone.
Not Sure What's Right for You?
Our quiz can help you understand your situation and suggest resources.
Take the Fertility Quiz âTracking Ovulation with PCOS
Standard ovulation tracking methods can be trickier with PCOS:
OPKs: May show false positives because LH can be chronically elevated in PCOS. Some women see multiple "surges" without actual ovulation. Use with caution and confirm with other methods.
BBT charting: Can work but may be harder to interpret with irregular cycles. Look for the temperature shift to confirm ovulation actually occurred.
Cervical mucus: Can still be helpful. Egg-white cervical mucus indicates estrogen is risingâbut doesn't guarantee ovulation will follow.
Best approach: Use multiple methods together, and consider ultrasound monitoring (especially during medicated cycles) to confirm whether ovulation actually occurs.
Pregnancy with PCOS: What to Expect
Once you conceive, PCOS doesn't go away, and it can affect pregnancy:
- Higher miscarriage risk: Some studies show 20-40% vs. 10-15% in general population. Managing insulin resistance may help reduce this.
- Gestational diabetes: Risk is 2-3x higher. Early glucose screening and careful monitoring are important.
- Preeclampsia: Elevated risk requires blood pressure monitoring throughout pregnancy.
- Preterm birth: Slightly elevated risk.
The key is awareness and proactive management. Work with an OB who understands PCOS, and don't skip prenatal appointments or recommended screenings.
The Bottom Line
PCOS is one of the most common causes of infertilityâand one of the most successfully treated. Key takeaways:
- PCOS affects ovulation, not egg qualityâonce you ovulate, pregnancy rates are normal
- Lifestyle changes workâeven modest weight loss can restore ovulation
- Inositol supplements have strong evidence for PCOS and are worth trying
- Letrozole is now first-lineâbetter than Clomid for PCOS specifically
- Most women conceive with simple treatmentsâIVF is rarely needed for PCOS alone
- Pregnancy requires extra monitoringâbut healthy pregnancies are absolutely achievable
Don't let a PCOS diagnosis discourage you. With the right approach, the vast majority of women with PCOS who want to become mothers do so successfully.