PCOS, fertility and pregnancy

Having PCOS doesn’t mean you can’t get pregnant. The international guideline says many people get pregnant naturally or with help. PCOS can disrupt ovulation (the release of an egg), so some people need help with this.

PCOS now has a new name: polyendocrine metabolic ovarian syndrome (PMOS). Both names mean the same condition. This article uses PCOS because it’s the name you may already know.

When to ask about fertility

Book a GP appointment in the UK, or see your doctor in the US or elsewhere, when planning a pregnancy with PCOS. If your periods are irregular or have stopped, ask about a check early. ASRM recommends a check without delay if you have a condition known to affect fertility, including irregular or missing periods.

A fertility check can look beyond PCOS. If a male partner is providing sperm, ASRM recommends checking both partners at the same time, including a semen test where relevant. This helps find any other things that may be making it harder to get pregnant.

Ask what the first check will involve and who will arrange it. Talk about how the plan fits your situation. Bring your own plans to the conversation, including whether they involve a partner or a donor.

Letrozole and the treatment pathway

For infertility caused by not ovulating, with no other fertility problems, the international guideline recommends letrozole as the first medicine to bring on ovulation. This applies to that group of people, not to everyone with PCOS. Pregnancy needs to be ruled out before this treatment starts.

You may see different medicines named in patient information. The NHS lists clomifene, and the US Office on Women’s Health lists clomiphene. The international guideline puts letrozole first for people whose infertility is caused only by not ovulating. It also says letrozole is used off-label in many countries, which means it isn’t officially approved for this. Other options are needed where its use isn’t allowed.

Later options can include other ovulation medicines, surgery on the ovaries or IVF. This depends on your situation and how you responded to earlier treatment. The guideline puts injected hormones (gonadotrophins) and ovarian surgery mainly after the first medicines, and IVF later if needed. A fertility specialist can explain the benefits, risks and monitoring.

Treatment that stimulates the ovaries can cause ovarian hyperstimulation syndrome (OHSS), where the ovaries become swollen and painful. PCOS raises this risk during IVF. Your specialist needs to talk about this, and ways to lower the risk, before treatment.

Inositol is not a proven fertility treatment. The guideline calls its use for infertility experimental, because its benefits and risks are still too uncertain. Talk to your clinician about supplements. A fertility claim on a packet isn’t evidence that a product will help.

Planning before pregnancy

Care before pregnancy covers blood pressure, blood sugar, food, taking folate (folic acid) and checking any health conditions you have. Sleep and emotional wellbeing belong in that talk too. Ask your doctor or pharmacist which supplements suit you and how much to take.

Get your medicines reviewed before trying to get pregnant, or as soon as you find out you are pregnant. Some treatments used for PCOS can prevent pregnancy or harm a developing baby. Don’t stop a prescribed medicine without talking to your doctor.

Why extra checks are offered

PCOS is linked with higher risks of gestational diabetes (diabetes in pregnancy), high blood pressure and pre-eclampsia. The guideline also finds higher risks of miscarriage and premature birth. These risks describe patterns across groups of people. They can’t predict how your own pregnancy will go.

WHO recommends extra monitoring because of these risks. Tell your maternity team you have PCOS when arranging care, including any treatment you used to get pregnant. Ask who will arrange the extra checks and how you’ll get the results.

The international guideline recommends an oral glucose tolerance test (OGTT) when planning a pregnancy or starting fertility treatment. This test checks how your body handles sugar. If you didn’t have one before pregnancy, it recommends offering one at your first antenatal visit. It also recommends offering the test at 24-28 weeks, even if you were tested before pregnancy. If you already have diabetes, ask your maternity team about your monitoring plan. A blood pressure check is also recommended when planning a pregnancy.

Metformin hasn’t been shown to prevent gestational diabetes in pregnant people with PCOS, so it can’t promise protection against problems in pregnancy. It may be considered in some situations. Its longer-term effects on children exposed to it are still uncertain. Your prescriber needs to check what it’s being used for in your care.

Symptoms that need help now

Call 999 now (UK) or 911 (US), or your local emergency number, if you have difficulty breathing or chest pain during or after treatment to stimulate your ovaries.

Call your maternity unit now (UK), or your obstetric clinician or maternity service (US or elsewhere), if you are pregnant and get a severe headache that won’t go away, blurred vision or flashing lights, pain below your ribs, or sudden swelling of your face or hands. If you can’t reach your UK maternity unit, call NHS 111. Don’t wait until tomorrow or your next appointment, even at night.

Contact your fertility clinic urgently now if you get tummy pain and bloating, vomiting or feel faint during or after treatment to stimulate your ovaries. In the UK, call NHS 111 if you can’t reach the clinic. In the US or elsewhere, contact your local urgent medical service.

Questions to take to the next appointment

Ask which part of fertility care is being dealt with, which medicines need reviewing, and when your blood sugar and blood pressure will be checked. If you’re already pregnant, take these questions to your midwife, obstetrician or doctor. Ask who to contact with questions between appointments.