Infertility in Micropolycytic Ovarian Syndrome (PCOS)

Micropolycystic ovary syndrome (PCOS) is the most common endocrinopathy in women of childbearing potential, affecting approximately one in ten women

The causes of micropolycytic ovary syndrome are not yet well understood but a certain familiarity has been observed.

The syndrome encompasses a wide spectrum of manifestations and to make a diagnosis it is necessary to have at least two of the following three characteristics.

1. Clinical or bioumorale imperandrogenism

Hyperandrogenism means excess of male hormones that we women also produce to a small extent at the level of the ovary and adrenal gland. Clinical signs of hyperandrogenism are, for example, acne, hirsutism (growth of dark hair in typically male areas such as the chin) and alopecia in the fronto-temporal region.

Biohumoral hyperandrogenism can be highlighted by hormonal dosages. The hormone that is most frequently increased is androstenedione, an androgen produced by the ovary.

Hyperandrogenism can lead to increased appetite which in turn leads to weight gain. Excess weight (which includes both overweight and obese women) leads to the formation of a vicious circle in which the fatter you get, the more male hormones are produced, the more the syndrome gets worse.

Untreated PCOS predisposes to the future development of diabetes , dyslipidemia , and cardiovascular disease .

2. Chronic anuovulation

The inability of the ovary to complete a full ovulation each month but only once in a while.

This alteration often manifests itself with changes in the duration of the menstrual cycle which can start from 40 days in the mildest forms up to a real amenorrhea (absence of the menstrual cycle for more than 6 months) in the more important forms.

This is the main cause of infertility in these women.

3. Micropolycystic ovary

It can be highlighted by a transvaginal ultrasound which demonstrates an enlarged ovary with numerous follicular cysts with a diameter of 4-7mm inside. Follicular cysts are not dangerous, they are just follicles that have failed to fully mature. It is important not to confuse these cysts with all other possible ovarian cysts such as endometriotic cysts or luteal cysts which often have a considerably larger diameter and are treated differently.

So it is not necessary to have all these manifestations to have PCOS but only two out of three, for example: a 25-year-old woman of normal weight with acne, her biohumoral tests perfectly normal, regular cycles and an ultrasound which highlights the small cystines in this category.

It is important that a doctor formulates a diagnosis as there are other much rarer endocrinopathies that can give hyper-androgenism, obesity and anovulatory cycles such as, for example, 21-hydroxylase deficiency (adrenal disease), pituitary adenomas, ovarian tumors or androgen secreting adrenal glands.

Therapy

PCOS cannot be cured completely but it can be well controlled so as not to cause long-term consequences.

The very first measure to take in case of overweight/obesity is to follow a balanced diet with moderate physical exercise in order to lose 5-10% of the weight. This is often enough to restore regular and ovulatory menstrual cycles.

If this is not enough, the doctor can prescribe metformin or inositol for a limited period of time , which favor a faster and more effective adjustment of carbohydrate and lipid metabolism.

On the other hand, when the weight is normal there are other very effective drugs, both on the metabolism and on the aesthetic aspect, which include mild antiandrogens such as spironolactone or estrogen-progestin pills containing a progestin with anti-androgenic activity.

Even these therapies must be done not continuously but in cycles to obtain the maximum result with the minimum toxic effect on our body.

In case of pregnancy

In the event that the desire for a pregnancy arrives, all these drugs that I have told you about must be suspended because they are harmful to a possible baby on the way.

The therapies must be done first, in “preparation”. It often happens that despite all the efforts made, the cycles continue to be irregular and that the pregnancy is late in arriving.

In these cases, the doctor can help the patient by prescribing a drug, clomiphene, which given in the first part of the cycle stimulates follicular growth and ovulation, possibly adding a progestin in the second phase of the cycle to make it as physiological as possible.

Remember that up to a year of intercourse aimed at getting pregnant is considered a normal time for a couple without fertility problems to conceive.

In my experience all women with PCOS are able to have children. Exceptions are cases in which several fertility problems coexist at the same time (for example: advanced age of the woman, PCOS, previous pelvic infection, pelvic surgery, endometriosis …) or cases in which a major fertility problem overlaps in the male partner.