Fertility - management & treatment

Last updated 06 May 2016 — Last reviewed 05 March 2014

Below you will find information on the different ways to increase the likelihood of becoming pregnant if you are having difficulties with fertility. Learn about weight and fertility, monitoring ovulation, different medications you can try, ovulation induction, surgery and assisted reproductive technology.

High levels of androgens (‘male’ hormones such as testosterone) and high insulin levels can affect the menstrual cycle and prevent ovulation (the release of an egg from the ovary). When an egg is not released on a regular basis, this is called anovulation. Ovulation can stop completely or it can occur irregularly.  This can make it more difficult for women with PCOS to conceive naturally, and some women may also have a greater risk of miscarriage. However, this does not mean all women with PCOS are infertile. 

Some women with PCOS may experience reduced fertility or “sub fertility” where it may take longer to conceive or they may need further medical assistance to achieve a pregnancy. There are a number of things you can do to increase the likelihood of becoming pregnant and treatments are available if you need medical assistance. Sixty per cent of women with PCOS become pregnant without medical help.

As there are many reasons a woman may have difficulty becoming pregnant, see your doctor to determine whether PCOS is affecting your fertility.

Weight management

Small reductions in weight can assist with fertility, so if you are above a healthy weight, weight management and physical activity is the first treatment option. Even a five to ten per cent loss of weight has been shown to greatly improve the chances of becoming pregnant.

Current international recommendations are to either achieve a healthy weight or modest weight loss before pregnancy. This will reduce the risk of complications during pregnancy.

To help you lose weight:

  • See our webpage on good nutrition – including a well-balanced and nutritious diet of whole grains, fruits, vegetables, low fat dairy and lean meats and fish and what to limit
  • See our webpage on physical activity
  • Consult your doctor and consider referral to a dietitian and/or exercise physiologist

Monitoring ovulation

Monitoring ovulationThere are days in a woman’s menstrual cycle when pregnancy is possible. This is generally around the middle of the cycle. If ovulation has occurred a ‘fertile window’ creates an opportunity to conceive.

To improve the chance of becoming pregnant, ovulation needs to be monitored and sexual intercourse timed to coincide around ovulation.

To help improve the chance of becoming pregnant watch for the following signs that ovulation is occurring or about to occur:

Mucus changes Around the time of ovulation a woman may notice her vagina’s mucus is slick and slippery.
Abdominal pain Some women experience pain during ovulation. This pain may be general or on one side of the abdomen.
Premenstrual symptoms

Symptoms such as:

  • breast tenderness
  • abdominal bloating
  • moodiness
may accompany ovulation

Estimate your ovulation time

As PCOS can affect the regularity of periods it can be tricky to estimate your ovulation time. For more information on possible different methods that may be helpful, please see our webpages on the natural family planning method. An ovulation calculator and an ovulation predictor kit may help you work out when you may be ovulating.

Ovulation induction

If lifestyle and weight loss have not helped improve your fertility after three to six months, then your doctor may recommend medication to encourage ovulation.

Called ovulation induction, the treatment is designed to stimulate the ovary to increase egg production. Ovulation induction uses tablets or injections over a period of time. Ultrasounds and blood tests are performed to determine the best time to trigger ovulation using a hormone called HCG. Once ovulation has been triggered, semen is introduced either by sexual intercourse or inter-uterine insemination when collected semen is placed directly into the uterus through the cervix.

Ovulation induction is not recommended for women with PCOS who have a BMI greater than 35.

Clomiphene citrate

Clomiphene (Clomid) is a tablet that is the most common medication for ovulation induction. It is often recommended as the first option for improving fertility in women with PCOS who are infertile and do not ovulate.

How it works Possible side effects
  • Clomiphene citrate 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
  • It can be used either by itself or in combination with other drugs (e.g. insulin sensitisers such as metformin) to increase its effectiveness
  • It can be associated with a higher risk of multiple births (twins, triplets) as more than one egg often develops

  • There is 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)

  • There may be some physical and emotional side effects associated with use of clomiphene citrate including: headaches, blurred vision and mood swings.  

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

Metformin

Metformin can be used for treating infertility in women with PCOS who don’t ovulate and who have no other reasons for infertility.

How it works Possible side effects
  • Metformin helps to improve the function of circulating insulin, can reduce androgen levels and can improve ovulation rate
  • Metformin can be combined with other medications (such as clomiphene citrate) if women aren’t responding to those medications or if they are obese
  • Some women who take metformin have some temporary gastrointestinal side effects (nausea, abdominal bloating, vomiting and loss of appetite)
  • Metformin treatment can be started at lower doses to reduce the severity of these side effects
  • The slow release form of metformin, taken at night, has less severe side effects than standard metformin treatment

There are currently no guidelines for the use of metformin during pregnancy, and the usual recommendation is to stop metformin once pregnancy is achieved, unless your doctor advises otherwise.

Gonadotrophins

Gonadotrophins are hormones involved in regulating ovulation such as:

  • follicle-stimulating hormone (FSH)
  • luteinising hormone (LH)
  • human chorionic gonadotrophin (hCG)
How they work Possible side effects
  • These hormones can be used as treatments to stimulate growth and release of eggs
  • The medication is injected and the ovary carefully monitored by ultrasound to avoid over stimulation
  • These can also be used for treating infertility where women have not responded to clomiphene citrate
Women using gonadotrophins are more likely to have multiple pregnancies – dosage is carefully regulated to reduce the risk 

Surgery for improving fertility

Ovarian drilling is a surgical procedure that can increase ovulation. This is performed using a laparoscope. It is a minimally invasive procedure where an incision is made 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 androgens (male hormones such as testosterone). Following ovarian drilling, ovulation is often restored for up to 6-12 months.

As surgery is a more intensive treatment than taking medication or lifestyle treatment, ovarian drilling is not commonly used and is primarily used after other lifestyle or medical treatment has proved ineffective.

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.

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 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.

This web page is designed to be informative and educational. It is not intended to provide specific medical advice or replace advice from your health practitioner. The information above is based on current medical knowledge, evidence and practice as at March 2014.

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