The Connection Between Fertility, Infertility, and PCOS 

Medically Reviewed by
Dr. Stacy Henigsman
Nutritionally Reviewed by
Felice Ramallo, RDN

Polycystic ovarian syndrome, often shortened to just ‘PCOS,’ is one of the leading causes of infertility in the US, thanks to the disruptive effect it can have on women’s reproductive cycles. But is this relationship one of cause and effect? And if you have PCOS, is it certain that you will struggle with infertility? What’s more, if you are trying to conceive and you have been diagnosed with PCOS, what treatment options are available to you? These are the questions we’ll be tackling in this article. Though there is much research to be done in this area (women’s health is infamously underfunded and underserved), we will be taking a look at what the research says on the ‘why’ behind the connection between PCOS and infertility, as well as remedies with the most support behind their efficacy. Let’s dive in!

The Connection Between PCOS And Infertility 

Unfortunately, there does seem to be a consensus that women with PCOS are at increased likelihood, compared to women not suffering from this condition, to experience issues getting pregnant. But first, for those that don’t know, let’s quickly cover the most common symptoms of PCOS, and if you suspect you may have it, what steps you can take to discover a diagnosis. 

Here is a list of the most common symptoms of PCOS

  • Irregular, or completely absent, menstrual periods 
  • If your periods occur closer than 21 days apart, or you go more than 35 days between periods, this is a sign of an irregular cycle. If you don’t have periods at all, this may be a sign you aren’t ovulating. 
  • Acne 
  • Cystic acne persisting through your 20s, 30s, and beyond can be a sign of a hormonal imbalance that extends beyond expected acne during teenage years
  • Hair loss 
  • In particular, androgenetic alopecia is associated with PCOS, and it is characterized by a thinning of hair along the middle parting and crown, with the front hairline staying in tact
  • Skin tags 
  • Dark patches of skin
  • These are commonly found around the breasts, thighs, neck, and under the arms 
  • Unexplained weight gain  
  • PCOS, many times, appears to go hand in hand with insulin resistance (with the two having an antagonistic effect on one another); this can prompt unexplained weight gain or weight that is hard to lose 

If any of those symptoms sound familiar, we first strongly recommend you make an appointment with your primary care physician. And if you want to learn more about these symptoms, and what they mean, check out our article on how PCOS is diagnosed. Most importantly, though, the first step - if you suspect you may have PCOS - is to meet with an experienced health professional to understand the root cause behind some of these symptoms. Allara can also match you with a physician specializing in reproductive health, if you suspect you may have PCOS. 

Okay, so let’s say you have PCOS, what are the chances you may struggle with infertility? Well, the jury is still out on this question, but some research indicates the prevalence of women with PCOS who will struggle to get pregnant hovers around 70% to 80%. This number can seem really high and scary, particularly when it comes to such an emotional topic as fertility, but we urge you not to panic. There are both holistic and medical treatments that have proven quite effective in helping increase your chances of getting pregnant (which is not to discount the estimated 20-30% of women with PCOS who do not have trouble conceiving). 

Why Is PCOS Associated With Infertility?

Now we know that PCOS has a potentially antagonistic effect on fertility, we need to answer the question as to why PCOS is associated with infertility.  

This question leads us back to the root cause of PCOS: it is fundamentally a hormonal imbalance (potentially brought on, or at least exacerbated by, insulin resistance) characterized by excess androgens. These androgens - think male sex hormones, like testosterone - can subsequently impact whether your body receives the right signs and hormones to help you ovulate. These essential steps to ovulation include developing an egg, thickening the lining of your uterus, and ultimately releasing that egg to be fertilized on its journey from your ovaries to your uterus. Without ovulation, there is no chance of pregnancy. 

Now, contrary to popular belief, there are times when you can ovulate and not have a period, and there are times when you can have a period and not ovulate. This sounds confusing, but know that - the majority of the time - if you ovulate, a period typically follows. To be sure, though, there are certain ways of tracking whether you ovulate. These include tracking your period and cervical mucus using a fertility app, taking your temperature throughout your cycle, and taking ovulation tests, which you can find at the drugstore (these are highly accurate and can detect LH levels in your urine; LH levels typically spike 36 hours before an egg is released). 

Given that PCOS interferes with ovulation, the key to overcoming roadblocks to conception would then revolve around improving your chances of ovulation. Of course, it’s also worth noting that whether you have PCOS is not the only factor in determining how easy or not it may be to conceive. Factors such as the following also play a big role: 

  • Age 
  • For a woman between the ages of 20 to 24, her chances of conceiving within a year hover around 96%, and from ages 25 to 29, as well as ages 29 to 35, the chances are around 86% (though in that latter age bracket the chances of miscarriage at age 30 rise from 10% to 20%). 
  • Around age 35 is when “egg quality” and ovarian reserves decrease quite strongly, and it can take approximately 30% of women between ages 35 and 40 to get pregnant within a year. This is why doctors and specialists, for women over age 35, like to loop in a fertility doctor earlier on in the pregnancy journey. 
  • Weight 
  • Though BMI is a flawed metric that has several problems surrounding it, it is still favored in many studies as a gauge for ‘health,’  and so often appears in the discussion on fertility. According to research, neither high BMI nor low BMI are optimal for getting pregnant, with individuals in the ‘normal’ range having the best possible chances. Even if your weight doesn’t fall into the ‘normal’ range, one of the most critical things you can do for fertility and your health is incorporate healthy lifestyle behaviors, like good stress management, sleep, nutrition, and exercise habits. Again, since BMI is incredibly two-dimensional and fails to take into account muscle mass and one’s overall health, we recommend taking this information with a grain of salt. Only yourself and your doctor know what your best weight is, and what healthy means for you. 
  • Lifestyle 
  • According to the FDA, smoking can not only reduce fertility, but can also negatively affect hormone production and harm the reproductive system. For men who smoke, smoking can also damage the DNA in sperm. 
  • Other medical conditions 
  • Endometriosis (a painful condition characterized by a growth of uterine tissue outside the uterus) can lead to infertility, especially if this growth takes place in the fallopian tubes; ‘structural problems’ within the reproductive system, such as issues with the fallopian tubes, as well as fibroids (noncancerous tumors) can also have a negative impact on one’s chances of conceiving easily. 

PCOS would fall under the category of a medical diagnosis that can hamper fertility; for this reason, if you do plan on getting pregnant or are trying to conceive in the near future, we highly recommend you work with a trusted and experienced physician in order to put yourself at the best possible chance of conceiving. Though most couples only see a fertility specialist after 1 year of trying to get pregnant with no success, for those who have more complex histories, it may be less stressful to receive specialist support as early on in your pregnancy journey as possible. 

Fertility Treatments For Those With PCOS 

First off, it is important to understand there is no ‘silver bullet’ for fertility. There are, however, steps you can take to increase your chances of ovulating. These actions can feel as incremental as improving your diet (check out our article exploring the connection between nutrition and fertility), and be as big as signing up for IVF treatment. When first trying to conceive, it may be worth considering the following, in conjunction with working with your primary care doctor

  • Tracking your period 
  • This includes monitoring cervical mucus at different stages of your cycle (here is what your body is telling you, when it comes to cervical mucus) 
  • Taking at-home ovulation tests 
  • These are useful if you are unsure whether you ovulate or not. These tests will check for the presence of elevated LH levels, which signal you are about to ovulate. You don’t need to check LH levels everyday; typically you would start measuring LH levels 10 to 14 days after you started your period, or what you estimate to be the ‘first half’ of your cycle). 
  • Noting down descriptions of PCOS symptoms and dates 
  • If you suspect you have PCOS, or you have been diagnosed with PCOS, keeping track of symptoms can help your physician in understanding what may exacerbate your PCOS (for instance stress, certain foods, and so on), and what is working in terms of managing your symptoms. 

With that being said, here are some of the most promising first, second, and third-line treatments worth exploring for those with PCOS who are trying for pregnancy: 

  • Metformin
  • Since insulin resistance and PCOS often go hand in hand, with insulin resistance potentially aggravating the excess production of androgens, improving insulin resistance can have the knock-on effects of helping to balance hormones. Metformin essentially works by boosting the body’s ability to effectively use insulin, in the process helping to encourage ovulation. 
  • Diet and exercise 
  • Improving diet and taking part in exercise can not only be immensely beneficial for your mental health, but also your physical health. Exercise is anti-inflammatory, and since PCOS promotes inflammation, exercise can help offset this. Opting for a diet that provides high levels of vitamins, nutrients, and minerals, as well as fatty acids, has been shown to positively correlate to improved fertility
  • One review points out that lifestyle changes, such as diet and exercise, should be a first-line treatment. This means that this avenue has been tried and tested before any of the other second and third-line treatments on this list. Taking steps such as quitting smoking, reducing your intake of processed sugars, reducing excess alcohol consumption, and prioritizing eating unprocessed foods all sound like ‘unsexy solutions,’ but can be immensely helpful in increasing ovulation rates. 
  • Clomiphene citrate
  • Although PCOS is often associated with excess androgen levels, what might be lesser known is that it also impacts estrogen levels, causing too-high levels of this hormone as well. 
  • Clomiphene citrate is known as an ‘ovulatory stimulant’ which works by ‘blocking estrogen feedback to the brain.’ This tricks your body into thinking it is not making enough estrogen, which then prompts the pituitary gland to make more FSH and LH. High levels of FSH trigger the ovaries to make an egg follicle (or multiple), while LH stimulates ovulation.
  • Typically, women with PCOS take this medication orally for the first 5 days for their cycle, starting at the lowest dose. 
  • Letrozole
  • This is a medication that is an ‘aromatase inhibitor,’ and research indicates use of this line of treatment is promising. Letrozole is used to jump-start ovulation in women with PCOS, and it again works by blocking estrogen production and increasing the release of FSH to stimulate ovulation. 
  • IVF 
  • Often, this is considered a ‘third-line treatment’ for many couples, since IVF can be expensive and stressful. That being said, because of how powerful IVF can be, researchers make a note that for ‘highly anxious’ couples or those for whom timing is of the essence (i.e. older couples), IVF will be explored with differing levels of urgency. The efficacy of IVF stands at around 20-35% per cycle.  
  • Unfortunately, IVF is not often covered by insurance, however, some companies do have better ‘fertility benefits’ than others. Spotify, Facebook, Netflix, and other tech companies are now offering ‘family forming benefits,’ such as partially covering adoption, fertility treatments, and childcare costs. Of course, this is not an egalitarian option offered to the vast majority of couples and is contingent on the company you work for, but for those whose employer offers this benefit, it may be well worth exploring.  

To sum up, there is a strong relationship between PCOS and having difficulty conceiving, but it is by no means a certainty. If you plan on getting pregnant in the near future and you suspect you have PCOS, the first thing to do is start a conversation with a qualified medical professional to begin the journey of reaching a definitive diagnosis. Once in discussion with a primary care physician you trust, you can decide on the respective treatment plans (if necessary) that are right for you and your lifestyle, and place you at the best chance of getting pregnant. 

Allara Health provides personalized treatment for hormonal, metabolic & gynecological conditions that utilizes a holistic plan that merges nutrition, lifestyle, medication and supplementation, and ongoing, expert support to heal your body.

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“I was given an explanation of how my hormonal imbalance was affecting me as a whole- body & mind- & tools so that we could start to manage my condition. I am happy to announce after a year of trying, I found out that I was pregnant & I couldn’t be happier!”

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