By Allison Scheinfeld, MS, RD, CDN
The views and opinions expressed are those of the authors and should not be considered medical advice. Always consult your doctor, or a mental health professional, for the most appropriate treatment.
What is PCOS & how does it cause infertility?
Polycystic ovary syndrome (PCOS) is a common endocrinological disorder that affects women of reproductive age. PCOS is often associated with what’s known as “anovulatory subfertility.” Anovulation is when an ovary does not release an egg during a woman’s menstrual cycle, meaning ovulation does not happen. It is estimated that about 25% of women with infertility have an irregular period or absent ovulation. PCOS is responsible for 70% of anovulation cases.
In order to be diagnosed with PCOS, one must have 2 of the following: irregular menstrual cycles, high androgens (male hormones, including testosterone), and cysts on the ovaries seen on ultrasound. Common symptoms of PCOS, besides irregular menstrual periods, are insulin resistance and weight gain concentrated around the abdomen. Other symptoms of PCOS are difficulty losing weight, hirsutism (excess hair growth, especially facial hair), hair loss, acne, and mood disorders, including depression and anxiety.
Insulin resistance can contribute to infertility, as it plays a role in the hormones needed to have a successful pregnancy. The hormones that control ovulation are affected by “hyperinsulinemia” (high insulin). When a woman is insulin resistant, the body will produce more insulin. The high levels of insulin will trigger the ovaries to produce testosterone, which will disrupt the egg development in the follicles. As a result of this, ovulation may be impeded.
What lifestyle changes can help PCOS-related infertility?
The first line of treatment for some women with infertility related to PCOS may be a change in lifestyle. Recommended lifestyle changes often include incorporating exercise and physical activity, making dietary changes, and getting therapy or counseling for behavior changes. A combination of these changes can improve metabolic function and insulin resistance, reduce androgens and testosterone, and promote weight loss with a focus on the central abdomen.
Exercise & physical activity for PCOS
Multiple studies conducted have shown exercise can have clinical outcomes in certain patients with PCOS, specifically in improving menstrual regularity and ovulation. Moderate exercise can also improve insulin resistance and promote a healthy weight.
PCOS guidelines recommend 150 minutes (or more) per week of moderate exercise, or 75 minutes (or more) of vigorous exercise. Some examples of this physical activity include:
- Moderate-intensity exercise: brisk walking, biking at 10-12 miles per hour, doubles tennis, mowing the lawn, heavy cleaning
- Vigorous-intensity exercise: hiking, jogging at 6 miles per hour, soccer, singles tennis, biking at 14-16 miles per hour
If a woman exercises for longer than 1 hour a day (rigorous exercise), this can cause anovulatory infertility (meaning ovulation doesn’t happen and therefore you cannot get pregnant), but exercise for 30 to 60 minutes per day can reduce this risk. It is important to strive for the right balance.
It is also important to find a physical activity that you actually enjoy doing. This will increase the likelihood that the exercise plan will be long term. Some ideas are walking, jogging, Pilates, strength training, Vinyasa flow yoga, or Barre. There are many online platforms that can get you started and provide useful information.
Diet for PCOS
A healthy diet is highly recommended for women with PCOS. This diet is typically one that has moderate carbohydrates and high fiber. There should also be an ideal ratio of mono and polyunsaturated fats, and an intake of lean proteins. Frequent small portions are preferred. Examples of moderate carbs to consume are sweet potatoes, brown rice, quinoa, and sprouted whole grain bread. All of these carbs are high in fiber as well. Other high-fiber items include beans, legumes, vegetables, and fruits. Healthy fats are found in avocado, olive oil, nuts, seeds, and fatty fish, such as salmon and sardines. Lean protein could be eggs, Greek yogurt, tofu, fish, or chicken breast.
The combination of a low glycemic index (or low-GI) diet and Mediterranean diet is often recommended for PCOS patients. A low-GI diet is based on how food will affect blood glucose (sugar) level, and ranks foods from 1-100, with the lower numbers having little effect on blood glucose. The Mediterranean diet focuses on whole grains, fruits, vegetables, legumes, nuts, seeds, and healthy fats, including avocado, salmon, mackerel, and olive oil. In addition, fish, poultry, and dairy are consumed in moderation, while red meat and sugary foods are consumed only on occasion. In addition to your fertility specialist, a registered dietitian can help with a personalized PCOS diet plan.
The combination of exercise and diet can improve insulin resistance in women with PCOS. This is key for promoting fertility, as insulin resistance can cause anovulation. As discussed earlier, this is because high insulin can cause changes in hormones, which can halt ovulation.
Behavior changes for PCOS
It is important not to forget the mental health aspect when treating PCOS. Dealing with PCOS and its symptoms, including infertility, can lead to depression. Studies have shown that cognitive behavior therapy can improve quality of life. Counseling and therapy should focus on stress reduction, as high stress can cause hormonal imbalances with gonadotropin-releasing hormone (GnRH), luteinizing hormone (LH), and follicle-stimulating hormone (FSH). All of these hormones are involved in ovulation. Mindful meditation can also have an effect on lowering androgens and decreasing psychological distress through calming the adrenal glands.
What supplements can help with PCOS?
When it comes to women’s health, many seek out alternative supplements and herbs to treat PCOS, such as inositol, berberine, turmeric, omega-3 fatty acids, alpha lipoic acid (ALA), and vitamin D. Some of these may help generally with PCOS, while others may help with improving fertility. It is important to use supplements that have been studied and proven to show benefits. Always consult your healthcare provider before taking any supplements or herbs.
What are pharmacological (medicated) treatment options?
If lifestyle changes and supplements do not bring desired results, there are multiple pharmacological (medicated) options that women with PCOS can try. Some commonly recommended medications for PCOS include one that acts as an insulin sensitizer and helps with lowering androgens. Some of these medications may not be safe to take while pregnant and should be discussed with a healthcare professional. When it comes to fertility and PCOS, there are medications available that help eggs mature and release (for ovulation), and others that help to decrease estrogen production and increase the body’s ability to produce FSH (also to encourage the ovulatory phase during the menstrual cycle). A fertility specialist can help determine which is best to use.
What other interventions are used for fertility & PCOS?
Beyond supplements and medication, there are other interventions that can be done. These interventions are sometimes used alongside the medications discussed above.
- Laparoscopic ovarian drilling is a surgery that can lower androgens (male hormones), which can then improve ovulation. By using a laparoscope, a surgeon will puncture the ovary with a needle. This intervention is usually done if lifestyle changes and other medications have not worked
- Intrauterine insemination (IUI) is a process where a catheter is used to place sperm directly in the uterus. This increases the chance that sperm can reach the fallopian tubes to fertilize an egg. IUI is less expensive than IVF but has a lower success rate.
- In vitro fertilization (IVF) is when an egg is fertilized with sperm outside a woman’s body, and then the embryo is placed in the uterus. Before fertility treatment starts, a complete diagnostic workup is done. The first step of the IVF treatment can involve taking birth control or estrogen. After this, a woman will take hormones that will help eggs mature. This is called ovarian stimulation. During this time, a woman is closely monitored. When the eggs are mature, a “trigger shot” is given to finalize the maturation of the eggs. An egg retrieval, which takes eggs from the follicles, is done 36 hours later. The eggs are then fertilized by incubating sperm and egg together or by a sperm injection in the lab. If the eggs become fertilized by the sperm, they are now called embryos. The embryos are monitored for 5-6 days, and then are either transferred back into the uterus (fresh) or frozen to be transferred at a later date
In summary, PCOS is a multifactorial hormonal disorder, meaning it has many different factors or causes. It should be noted that not all women with PCOS will have difficulty conceiving, as the symptoms vary greatly from person to person. Fortunately, more studies are being done on how to treat PCOS, and more health professionals are learning about how to help. It may seem overwhelming to implement all of the lifestyle changes recommended. Discuss them with your healthcare provider and choose what’s best for you. You can even just pick one aspect to focus on at a time, like altering your food choices, taking a walk daily, or seeking out support from a fertility coach. Small changes can yield big results.
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