How does PCOS affect female fertility?

At a Glance:

What is PCOS?

 PCOS is a gynecological condition characterized by abnormal levels of hormones which are responsible for ovulation and maintaining secondary sexual characteristics in women.

Ovaries are the primary organ in the female reproductive system. Ovaries perform various functions in the female body including production of eggs and hormone secretion. The hormones secreted by the ovaries include estrogen, progesterone and a small quantity of testosterone.

Ovulation is the process of release of an egg from the ovaries every month. The production and maturation of the egg are controlled by the hypothalamus of the brain and the hormones secreted by the pituitary gland. These hormones are Follicle Stimulating Hormone (FSH) and Luteinizing Hormone (LH).

For effective ovulation, a specific range of LH to FSH ratio is required. In PCOS, the LH to FSH ratio gets disrupted and this disruption is enough to create a problem in ovulation. Further, there is an increased surge of testosterone that also adds up the complexity.

PCOS is a quite common endocrine disorder in the female of childbearing age and is also one of the most prominent factors for female infertility. It is estimated that the roughly 10% women in the child bearing age may be affected by PCOS in India.

PCOS means Poly Cystic Ovary Syndrome. The nomenclature of this disease indicates that various cysts or fluid-filled sacs containing immature eggs are seen in the ovary (polycystic condition) due to disruptive ovulation.

The women suffering from PCOS generally experience symptoms such as ovarian cysts, dominating level of male hormones and menstrual irregularity or heavy menstrual bleeding.

What are the causes of PCOS?

Although the exact cause of the PCOS remains unknown, some of the factors that contribute to the development of PCOS are:

Genetics: The link between the genes and the development of PCOS is a complex phenomenon. Till date, the studies in this arena indicates that it is a multigenic disorder with a high level of complexity. The immediate relative such as sister or daughter, of the women suffering from PCOS is significantly at higher risk of developing this condition. Further, families with a high incidence of PCOS are also at increased risk of developing type 2 diabetes. Women between the age group of 15-30 years are often diagnosed with PCOS.

Insulin resistance: The hormone Insulin is required to maintain an optimum level of sugar in the blood. However, if the body becomes insulin resistant i.e the cells of the body stop responding adequately to insulin, the body is not able to maintain the blood sugar level. Due to this, more insulin is secreted leading to a condition known as hyperinsulinemia which is also an important contributor to the development of PCOS. An increased blood level of insulin leads to increased synthesis of androgens such as testosterone. Insulin resistance is seen in approximately 80% of women suffering from PCOS. Lifestyle also plays an important role in insulin resistance. Women with insufficient physical activity and poor eating habits are at increased risk of altered insulin levels.

Sedentary lifestyle and Obesity: Low levels of activity and being overweight also results in the development of PCOS. Scientific studies report that the symptoms of PCOS start appearing once the women gain weight. Obesity is strongly linked to hyperinsulinemia and increased risk of type 2 diabetes

What are the symptoms of PCOS?

Some of the common symptoms experienced in PCOS are:

•    Menstrual irregularity or heavy bleeding
•    Increased production of oil and sebum in the skin leading to acne
•    Increased hair growth in the face, back, belly, and chest.
•    The appearance of male pattern baldness
•    Overweight or obesity
•    Darkening of the skin of the neck and surrounding area of the breast.
•    Headaches
•    Psychological effects such as depression and anxiety
•    Reduced fertility

What are the effects of PCOS on the body?

Normal hormonal level, especially in females, is one of the prerequisites for sound health. PCOS interrupts the physiology of the body in the following manner:

Infertility: Fertilization of the egg with the sperm is an essential phenomenon for pregnancy. In PCOS, the ovulation process is disturbed and there is no release of the egg from the ovary which leads to infertility. PCOS is considered to be one of the important cause for infertility.

Sleep apnea: Women with PCOS may develop sleep apnea or interruption in sleep. The condition is characterized by obstruction of the upper respiratory system while sleeping followed by bouts of pauses in breathing. This may partially be due to the excessive thickening of the neck due to deposition of fatty tissue in obese people.

Psychological condition issues: More than 50% of PCOS women suffer from anxiety and depression. This is due to low confidence, reduced self-image, and low esteem while coping with the symptoms of PCOS such as hirsutism (excessive facial hair), alopecia, moderate to severe acne and obesity.

Metabolic effects: Women suffering from PCOS are at increased risk of developing type 2 diabetes, dyslipidemia, cardiovascular disorders, and stroke.

Endometrial cancer: The endometrial lining which is the lining of cells in the uterus, should be shed during each menstrual cycle and a new lining is formed in the next cycle. Due to the irregular period, the previous lining remains unshed leading to the build-up of the endometrial lining. This increases the risk of endometrial cancer.

Acanthosis nigricans: Darkening of skin is seen in these women and the area most affected are the neck, groin, and tissue surrounding breasts.

How is PCOS diagnosed?

 The gynecologists are able to diagnose PCOS by undertaking a detailed medical history of the person followed by:

Physical examination: During the physical examination, the gynaecologist assesses the physical signs such as alopecia, hirsutism and PCOS acne. The doctor may also ask the family history of the patient and recent changes in the body such as recent weight gain or menstrual irregularity.

Pelvic examination: Manual inspection and assessment of the reproductive organs are done for identifying any abnormal mass or tissue growth.

Blood tests: Complete hormonal panel test is advised by the gynecologist to evaluate the level of hormones. The hormones of primary importance are estrogen, testosterone, FSH, LH and the ratio of LH to FSH.

Imaging technique: PCOS is characterized by the cysts in the ovary which can often be visualized in the ultrasound of ovary.

How does polycystic ovaries affect pregnancy?

Female infertility is the major consequence of PCOS. About 70-80% of the female suffering from PCOS are unable to conceive. But this link of PCOS and infertility is not a great cause of concern because, through the advanced treatment strategies, most women are now able to conceive.

PCOS also significantly increases the risk of pregnancy complications. There is an increased risk of miscarriage and development of gestational diabetes which may lead to large babies. Also increased is the risk of preeclampsia, premature delivery and increased chance of C-section.

Through proper medical care, medical nutrition, vitamins, and mineral supplementation and sufficient level of antenatal care, the risk of such complications are minimized.

Diet and lifestyle tips to manage PCOS

Lifestyle changes are considered as the first line treatment strategy for PCOS patients. These lifestyle tips are helpful if one wants to know how to increase fertility with PCOS.

•    Maintaininga healthy weight andreducing weight helps in regularizing the menstrual periods and ovulation. Reducing weight also helps to reduce the risk of metabolic disorder such as diabetes and dyslipidemia and also reduce cardiovascular risks.
•    Diet should be a low glycemic indexdiet in which the carbohydrate consumption is restricted, and a significant portion of carbohydrate should be obtained from fruits and grains.
•    Moderate intensity exercise should be performed at least thrice a week to maintain regular menstrual periods and ovulation.

Common medical treatments available for infertility

Various treatment strategies for PCOS may be adopted by the gynecologists depending on the case and as per PCOS infertility guidelines.The treatment depends upon the age of the woman, severity, presentation of symptoms and whether the treatment is directed for infertility or to ease the symptoms. Some of these are:

Combined hormonal pills: The patient is prescribed with the pill containing the combination of estrogen and progesterone. This will ease the symptoms of PCOS such as excessive hair growth, thinning of hairs, alopecia, and acne by normalizing the hormonal level. These pills will also reduce the risk of endometrial cancer in the female with an irregular menstrual cycle. It should be kept in mind that the effect of these medicines are temporary and reversible once the treatment stops. It should also be noted that this treatment is not for the women who are undergoing PCOS treatment for getting pregnant as the combination will act like contraception and will prevent ovulation.

Medications for management of insulin resistance: Hyperinsulinemia is one of the major causes of PCOS as it helps to increase the level of testosterone. Insulin resistance management drugs are prescribed in the effective treatment of increased insulin level. Studies have concluded that better management of menstrual cycle, weight and sugar level is attained when such a medication is added to exercise and diet changes.

Ovulation inducing medications: Ovulation induction agents are medication which helps in the formation of the egg in the ovary. There is a risk for multiple pregnancies if more than one egg develops. The drug should be taken as and when prescribed by the doctor. Ovulation stripsor follicular scan studies compliment this drug to identify the days of ovulation, so as to increase  the chances of pregnancy.

Hair removal medicines: To get rid of the symptom of hirsutism, various hair removal creams are available in the market. These creams have the disadvantage of regrowth of hair after stopping the treatment. The topical cream can be combined with Laser hair removal to avail maximum benefit.

Surgery: Last option available when the other options fail to manage symptoms or treat infertility. A most common surgery for PCOS is ovarian drilling.

Ovarian drilling involves puncturing of the  the ovary with a thin heated needle. The procedure is done through laparoscopy. Ovarian drilling helps to normalize the hormonal levels and reduce the production of testosterone.

Fertility treatment options for those who are anxious to conceive:

Ovulation inducing medications with follicular study and timed intercourse:  This is the first line of treatment when the other factors for infertility are excluded.

IUI (Intrauterine insemination): This option is recommended to patients who are unable to achieve pregnancy through ovulation induction  or when  the male partner has a low sperm count and motility.

IVF (In-vitro fertilization) or ICSI (Intra-cytoplasmic sperm injection): This is the treatment done when the patients suffer from other conditions such as blocked fallopian tubes, endometriosis or the male partner has a very low sperm count/ motility and even in cases of repeated failed IUI cycles. In this process, the fertilization of egg and sperm is done outside the body and the embryo is then transferred into the uterus.

When should a woman consider seeking medical help for infertility or PCOS?

A woman should  visit a gynecologist if she experiences:

•    Irregular menstrual cycles.
•    Persistent pelvic pain
•    Symptoms such as facial hair growth, acne or weight gain.
•    Inability to conceive naturally.
•    Symptoms of diabetes, such asincreased thirst, fatigue or increased frequency of urination.

Conclusion

PCOS is caused due to abnormal hormonal levels and a high level of testosterone. A woman with PCOS may experience symptoms such as obesity, acne and hair growth. Various treatment options are available for the management of PCOS such as lifestyle changes, ovulation inducers, and surgery.

Even though infertility due to PCOS is often a cause of concern for many women, there are options available that can help increase fertility with PCOS. Lifestyle management is an important way that includes a healthy diet and weight management. Medications like ovulation inducers help the release of the egg from ovary and surgery such as ovarian drilling is the last option. With proper treatment strategy, adherence to treatment, and quality antenatal care, the PCOS pregnancy success rate when done under expert supervision is extremely encouraging as more than 50% of the women end up delivering a healthy baby.

References:

• US National Library of Medicine National Institutes of Health. Prevalence of polycystic ovarian syndrome in Indian adolescents. https://www.ncbi.nlm.nih.gov/pubmed/21600812. Accessed on March 03, 2019
• Medscape. Polycystic Ovarian Syndrome. Available at: https://emedicine.medscape.com/article/256806-overview. Accessed on March 03, 2019
• Jean Hailes. Symptoms & causes. Available at: https://jeanhailes.org.au/health-a-z/pcos/symptoms-causes. Accessed on March 03, 2019
• National Institute of Health. How do health care providers diagnose PCOS? Available at:  https://www.nichd.nih.gov/health/topics/pcos/conditioninfo/diagnose . Accessed on March 03, 2019
• PCOS Awareness Association. PCOS Pregnancy and Delivery Complications. Available at:  https://www.pcosaa.org/pcos-pregnancy-and-delivery-complications. Accessed on March 03, 2019
• American Society for Reproductive Medicine. Ovarian Drilling for Infertility. Available at:  https://www.reproductivefacts.org/news-and-publications/patient-fact-sheets-and-booklets/documents/fact-sheets-and-info-booklets/ovarian-drilling-for-infertility/. Accessed on March 03, 2019