General tips for improving fertility

• Ovulation (the release of an egg from the ovary) needs to be monitored and sexual intercourse timed to coincide around ovulation.
• Over-the-counter kits are available to measure Luteinising Hormone (LH), which increases during ovulation and can guide prediction of ovulation (note: if your cycles are irregular, LH tests are not always effective).
• Temperature charting can show ovulation change but is not as reliable an indicator
• A progesterone level taken about seven days after expected ovulation will determine if ovulation has occurred (day 21 progesterone in a 28 day cycle).
• If ovulation is irregular, even modest lifestyle change (exercising 40 minutes three times a week) and weight loss can effectively improve ovulation (Lifestyle Management of PCOS).
• Obesity increases both infertility and risks during pregnancy.  Current international recommendations for obesity and pregnancy are to either achieve a healthy weight or modest weight loss before pregnancy. It is not recommended to lose weight during pregnancy; but it is critical to avoid further weight gain if overweight during pregnancy.
• Referral to a fertility specialist is necessary for further treatment if these strategies are not successful.

Ovulation induction

Medications to induce ovulation may be required. Ovulation induction is the use of medication to stimulate the ovary to increase egg production.

Ovulation induction uses follicle stimulating hormone which is injected into the stomach over a period of time. Ultrasounds and blood tests are performed to determine the best time to trigger ovulation by using a hormone called HCG. Timed intercourse or interuterine insemination is then performed to try to achieve a pregnancy.

Clomiphene citrate

The most common medication for ovulation induction is clomiphene citrate. This is used early in the menstrual cycle to increase the chances of an egg being released by the ovary, which can then be fertilised naturally. Clomiphene citrate increases ovulation and pregnancy in PCOS and is recommended as the first option for improving fertility in women with PCOS who are infertile and do not ovulate. Clomiphene citrate can be used either by itself or in combination with other drugs (e.g. insulin sensitisers such as metformin) to increase its effectiveness.

Possible side effects

Clomiphene citrate has some potential problems associated with it. It can be associated with a higher risk of multiple births (twins, triplets) as more than one egg often develops. There is also a small, but increased risk of ovarian cancer associated with its use long-term so it should only be used in the short-term (no longer than six to nine months). Women taking clomiphene citrate should be monitored by their clinician.

There may be some physical and emotional side effects associated with use of clomiphene citrate including:

• Headaches
• Blurred vision
• Mood swings

Not all women with PCOS are responsive to clomiphene citrate and may have to use combinations of clomiphene with other drugs (such as metformin) to gain the most benefit.

Metformin

Metformin is a drug used to treat insulin resistance and diabetes which reduces circulating insulin levels and androgens and can also be used to improve ovulation rate and pregnancy. Metformin can be used for treating infertility in women with PCOS who don’t ovulate, who aren’t obese and who have no other reasons for infertility. Metformin can also be combined with other medications (e.g. clomiphene citrate) where women aren’t responding to those medications or where women are obese.

Gonadotrophins

Gonadotrophins are hormones involved in regulating ovulation such as follicle-stimulating hormone (FSH), luteinsing hormone (LH) or human chorionic gonadotrophin (hCG). These can be used as treatments to stimulate growth and ovulation of eggs. These are more intensive treatments as they involve injection of the medication and careful monitoring of the ovary by ultrasound to avoid over stimulation of the ovary. These can also be used for treating infertility in PCOS, particularly where women have not responded to clomiphene citrate. Gonadotrophin therapy has some potential problems associated with it. Women using gonadotrophins are more likely to have multiple pregnancies. Dosage is carefully regulated to reduce the risk of this.

Aromatase inhibitors

Aromatase inhibitors include medications such as letrozole and anastrozole. They act through reducing the amount of oestrogen produced in the body which can help in regulating ovulation. Some side effects of using aromatase inhibitors can include gastrointestinal disturbances, lack of energy, hot flushes, headache and back pain. There is also some evidence that they can lead to a higher risk of congenital malformations although other research has not confirmed these findings. Aromatase inhibitors are currently not recommended for ovulation induction or improving fertility in women with PCOS.

Assisted reproductive technology

For women who have not been able to conceive naturally or by using medications or lifestyle treatment to improve their fertility, another option is assisted reproductive technology. This includes treatments such as IVF (in vitro fertilisation). Referral to a fertility specialist is necessary for these treatments.

Assisted reproductive technology is best tried after other less intensive treatments (lifestyle or medical) have proved unsuccessful, as it is often costly and demanding. This technology is also more successful in women who have instituted lifestyle change effectively first, even if these changes have not improved fertility by themselves. For example, it has been shown that overweight women with PCOS who lose a modest amount of weight (5-10 kg) before starting assisted reproductive technology have greater success than those who do not.

Surgery for improving fertility

Ovarian drilling is a surgical procedure that can increase ovulation. This is performed laparoscopically (a minimally invasive procedure through an incision in the abdomen) under a general anaesthetic. Small holes are drilled in the surface of the ovary to remove tissue that produces excessive amounts of male hormones (androgens such as testosterone). Following ovarian drilling, ovulation is often restored for up to 6-12 months.

Possible side effects

Side effects associated with ovarian drilling include a small risk of scar formation around the ovaries and damage to the bladder, bowel or blood vessels. As surgery is a more intensive treatment than taking medication or lifestyle treatment, ovarian drilling is not commonly used today and is primarily used after other lifestyle or medical treatment has proved ineffective.

Content updated 25 August 2011