Positive PCOS

A positive and practical information resource on polycystic ovary syndrome

How to manage fertility & menstrual issues in PCOS

PCOS is one of the leading causes of female infertility
Photo: Pixabay.com

PCOS is one of the leading causes of female infertility. The primary reason for infertility in one-third of infertile couples is due to anovulation, which is when a woman doesn't ovulate. Ovulation is essential to get pregnant and PCOS is the most common cause of anovulation (1). PCOS can also cause other menstrual issues such as irregular or absent periods. Each woman with PCOS presents differently, however, and it's important to remember that lots do conceive and go on to have healthy pregnancies.

What menstrual and fertility difficulties can a woman with PCOS experience?

  • Anovulation: Women with PCOS may not be ovulating due to hormonal imbalances caused by the condition.
  • Oligomenorrhea: Infrequent or irregular periods i.e. less than 9 periods a year, or an abnormal cycle which lasts less than 24 days or longer than 35 days with day 1 being the first day of your last period.
  • Amenorrhoea: Having previously had a period, they have stopped for at least 6 months.

If you have irregular periods and are not trying to get pregnant currently you can skip to the next section here.

Do you have PCOS and experiencing difficulty getting pregnant?

The information below is provided to enable you to make informed decisions about treatment options to meet your needs and discuss with your medical practitioner/healthcare professional if you're experiencing difficulties conceiving. There are additional factors which may also influence a woman's chances of conceiving, such as age, and male fertility issues, which are not covered in this section. If you have any fertility concerns or specific queries, these should be discussed with a relevant medical professional.

Ovulation: Firstly, if you have periods, are they regular? If they are, it's important to maximise your chances of conceiving by knowing when you're most fertile.

Women typically ovulate once in every menstrual cycle. Luteinising hormone (LH) and follicle stimulating hormone (FSH) trigger the release of an egg from the ovarian follicle. The egg then travels down the fallopian tube where it may be fertilized by a sperm (2).

Ovulation usually occurs around 12 to 14 days before your period starts. It is easier to calculate your most fertile times if you have a 28 day or regular menstrual cycle and the first day of your period is counted as day one. There are many ovulation calculators available online to work out your fertility window. However, women who have irregular cycles can find it hard using this method to work out when they're most fertile.

You can learn to spot the signs that you are due to ovulate:

  • Change in cervical mucus: Throughout your cycle, cervical mucus changes texture and you are at your most fertile when it becomes clear, slippery and stretchy. The mucus protects and speeds the sperm up through the uterus and into the fallopian tubes to meet the egg.
  • Increased body temperature: You won't notice it yourself but a basal thermometer can detect a raised body temperature. You are most fertile 2-3 days before your temperature spikes so charting your body temperature can help detect a pattern to work out when you're likely to ovulate.
  • Ovulatory pain: Some women feel aching or twinges of pain in their lower abdomen when they ovulate. Monitor when you feel this ovulatory activity as it can indicate your fertility.
  • Ovulation prediction kits: These are available to buy and indicate which days of the month you are most likely to ovulate.
Lifestyle modifications, such as diet and exercise, should be first line therapy in managing infertility and regulating your periods. Photo: Unsplash.com

Diet and Exercise: Lifestyle modifications are absolutely key to improving reproductive health and function for both overweight and lean women with PCOS (5,9). Diet and exercise are also ways to treat symptoms without adverse effects and have been found to reduce the long term health risks associated with PCOS (2). No single diet has been proven to work however, a low glycemic one has been found to increase insulin sensitivity and improve ovulation (9). Eating a larger breakfast and smaller dinner has also been shown to increase ovulation. You can read more about PCOS & Nutrition and PCOS & Exercise here.

Being obese or underweight can significantly impact your ability to get pregnant both naturally and with assistance (5,9). If you're overweight, losing as little as 5% of your total body weight can improve insulin sensitivity and restore ovulation. It is recommended that women make the appropriate lifestyle changes for 6 months to lose weight. In fact, achieving a Body Mass Index (BMI) of less than 30 is advised before considering any ovarian stimulation drugs or medical intervention (3). You can work out your own BMI here.

Conventional medicine: As mentioned previously, if a woman is overweight, changes to diet and exercise is recommended for 6 months to preferably achieve a BMI of less than 30 before any medical intervention is started (5,3). If this doesn't result in pregnancy, oral medications are the second-line treatment (9). The current medical treatment for anovulation caused by PCOS is a drug called clomifene. If ovulation isn't induced with clomifene alone, some literature suggests it should be combined with another insulin sensitising drug, metformin (3). However, metformin is no longer used routinely in the UK due to associated higher rates of miscarriage and being significantly less effective in treating anovulation than clomifene (5). If ovulation is not restored at this stage, another treatment that may be considered is laparoscopic ovarian drilling, a surgical treatment performed to trigger ovulation. For women who have been unable to conceive naturally or with other less invasive treatments, in-vitro fertilization (IVF) may also be explored under the guidance of a fertility specialist.

Supplements: Used as an adjunct to maximise health, supplements are not a substitute for a healthy diet and lifestyle. There is some research supporting the use of supplements to help manage PCOS symptoms. For example, myo-inositol, a member of the B complex vitamin group, has been found to improve ovulatory function, menstrual regularity and insulin sensitivity (9). Omega-3 fish oil and vitamin D are associated with improved insulin resistance (9). It is recommended that women should take folic acid before and during pregnancy to reduce the risk of birth defects (2) or a prenatal vitamin for 3 months or more before trying to get pregnant (9). Speak with a medical or health professional to choose safe supplements which meet your individual needs.

Fertility Foods: Further research is needed before definite recommendations can be made about a 'fertility diet' to improve your chances of getting pregnant. However, studies have indicated that certain foods may help. For example, reducing animal protein in your diet and eating vegetable sources instead, as well as eating plenty of fruit and vegetables (2).

Acupuncture: Many women with fertility problems are looking for alternatives to medications typically offered in Western medical treatments (4). The efficacy of acupuncture is increasingly being demonstrated in research studies for its ability to stimulate ovulation, regulate the menstrual cycle and balance hormonal levels (6). It can work by normalising the production of luteinising hormone and follicle stimulating hormone which stimulate the ovaries to release an egg. Acupuncture has also been found to be a low-risk treatment with no increased risks of multiple pregnancy (6).

Herbal Medicine: Used as an alternative to conventional medicine, or in combination with it, herbal medicine has been shown to help regulate periods for those with irregular or no periods, normalise hormonal imbalance and improve insulin sensitivity. For example, vitex agnus-castus is a herb that has been found to significantly improve female fertility and menstrual regularity (4, 7). Positive PCOS recommends taking advice from a qualified medical herbalist belonging to a professional body, such as The National Institute of Medical Herbalists in the UK.

Experiencing difficulties getting pregnant can take its toll emotionally on some relationships. Photo: Unsplash.com

Managing stress: You may have already received the well-meaning advice to, "Just relax, it will happen". Although it's not always as straightforward as that, stress can potentially interfere with conception. It's normal to experience some anxiety when experiencing difficulties getting pregnant but try to find time to do things that you find relaxing. Keep making plans in your life which don't revolve around conceiving and make time to look after yourself. Our thoughts and emotions have an impact on our bodies. For example, instead of focusing on your 'infertility', focus more positively on your 'fertility'. You can read more about positive affirmations and how they work here.

Looking after your emotional health: Experiencing difficulties getting pregnant or having a healthy pregnancy can understandably be devastating and take its toll emotionally on a couple. Potential feelings of disappointment, shock, anger, sadness, guilt and isolation can all be normal responses when struggling to conceive. It's important that you look after your emotional wellbeing and have the appropriate support around you. There are online resources providing information, support and advice to women experiencing difficulty conceiving such as Resolve, the national US infertility association, and Infertility Network UK which is the UK's leading charity.

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Do you have irregular periods and are not trying to get pregnant currently?

Diet: the impact of lifestyle and nutritional choices on PCOS symptoms, regardless of how much you weigh, should not be underestimated - the benefits are huge. A balanced and nutritious diet can alleviate, or even get rid of, PCOS symptoms. You can read more about PCOS & Nutrition here.

Exercise: Found to reduce risk factors associated with the condition, such as insulin resistance, and improve overall health, exercise is strongly recommended for all women to help manage their PCOS. You can read more on why exercise is so important for women with PCOS here.

Conventional medicine: The oral contraceptive pill is often used for women who are not trying to get pregnant to regulate their periods, reduce the risk of developing endometrial cancer, and to treat acne and excessive hair growth. There are concerns that the pill may actually aggravate insulin resistance and increase long-term risks of heart disease and diabetes. Further research examining the risks of women with PCOS taking the pill is needed as the amount of existing research is limited. Each woman's case needs to be treated individually with consideration of her risk factors for diabetes and heart disease (8), and discussed fully with a medical practitioner.

Manage stress: Significant levels of stress can impact your menstrual cycle. Learn more about the effects of stress on your body and the link between our mind and bodies.

Alternative therapies: Acupuncture and herbal medicine have both been shown to be effective in regulating periods.

Supplements: Used as an adjunct to maximise health, supplements are not a substitute for a healthy diet and lifestyle. There is some research supporting the use of supplements to help manage PCOS symptoms: myo-inositol, a member of the B complex vitamin group has been found to improve ovulatory function, menstrual regularity and insulin sensitivity; omega-3 fish oil and vitamin D are associated with improved insulin resistance (9). Speak with a medical or health professional to choose safe supplements which meet your individual needs.

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1: A.J.Polotsky & S. Houston. November 2009. Is there such a thing as a "fertility diet"? Contemporary ob/gyn. 37-42

2: M. Stankiewicz & R. Norman. 2006. Diagnosis and management of polycystic ovary syndrome: a practical guide. Drugs. 66 (7): 903-912

3: The Jean Hailes Foundation for Women’s Health on behalf of the PCOS Australian Alliance. 2011. Evidence-based guideline for the assessment and management of polycystic ovary syndrome. Copies available to download at www.jeanhailes.org.uk. Last accessed on 12/01/15

4: S. Arentz et al. 2014. Herbal medicine for the management of polycystic ovary syndrome (PCOS) and associated oligo/amenorrhoea and hyperandrogenism; a review of the laboratory evidence for effects with corroborative clinical findings. BMC Complementary & Alternative Medicine. 14: 511

5: A. Balen & A.J. Rutherford. 2007. Managing anovulatory infertility and polycystic ovary syndrome. British Medical Journal. 335: 663–666

6. D.C.E. Lim et al. 2011. Acupuncture for polycystic ovarian syndrome. Cochrane Database Systematic Review. 8: CD007689

7: P. Kantivan Goswani et al. 2012. Natural Remedies for Polycystic Ovarian Syndrome (PCOS) : A Review. International Journal of Pharmaceutical & Phytopharmacological Research. 1 (6): 396-402

8: E. Diamanti-Kandarakis et al. 2003. A modern medical quandary: polycystic ovary syndrome, insulin resistance, and oral contraceptive pills. Journal of clinical endocrinology and metabolism. 88 (5): 1927-32

9: C.M. Bergh et al. 2016. Evidence-based management of infertility in women with polycystic ovary syndrome. Journal of Obstetric, Gynecologic & Neonatal Nursing. 45: 111–122

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