PCOS, fertility and pregnancy

Having PCOS does not mean you cannot get pregnant. The international guideline says pregnancy can often be achieved naturally or with help. PCOS can disrupt ovulation, so some people need help with the release of an egg.

PCOS is now called polyendocrine metabolic ovarian syndrome, or PMOS. Both names refer to the same condition; this article uses PCOS to match the name you may already know.

When to ask about fertility

Book a GP appointment in the UK, or see your doctor in the US or elsewhere, when planning pregnancy with PCOS. If your periods are irregular or absent, ask about assessment early. ASRM recommends evaluation without delay when a condition known to affect fertility is present, including irregular or absent cycles.

A fertility assessment can look beyond PCOS. If a male partner is contributing sperm, ASRM recommends assessment of both partners at the same time, including semen analysis when applicable. This helps identify other factors that may be contributing to fertility difficulties.

Ask what the first assessment will involve and who will organise it. Discuss how the plan fits your circumstances. Bring your own plans to the discussion, including whether they involve a partner or donor.

Letrozole and the treatment pathway

For infertility caused by lack of ovulation, with no other infertility factors, the international guideline recommends letrozole as the first medicine for inducing ovulation. The recommendation applies to this group of people, rather than everyone with PCOS. Pregnancy needs to be excluded before ovulation-induction treatment.

You may see different medicines named in patient information. The NHS lists clomifene, and the US Office on Women’s Health lists clomiphene. The international guideline gives letrozole priority for people whose infertility is caused by lack of ovulation alone. It also says letrozole is off-label in many countries and alternatives are needed where its use is not allowed.

Later options can include other ovulation medicines, ovarian surgery or IVF, depending on the circumstances and response to earlier treatment. The guideline places injectable gonadotrophins and ovarian surgery mainly after initial medicine treatment, and IVF later when appropriate. A fertility specialist can explain the benefits, risks and monitoring.

Ovarian stimulation can cause ovarian hyperstimulation syndrome (OHSS), in which the ovaries become enlarged and painful. PCOS increases the risk during IVF, so your specialist needs to discuss this and ways to reduce the risk before treatment.

Inositol is not an established fertility treatment. The guideline describes its use for infertility as experimental because benefits and risks remain too uncertain. Discuss supplements with your clinician rather than treating a fertility claim on packaging as evidence that a product will help.

Planning before pregnancy

Preconception care includes blood pressure, blood glucose, nutrition, folate supplementation and review of existing health conditions. Sleep and emotional wellbeing belong in that discussion too. Ask your doctor or pharmacist which supplements are appropriate for you and what amount you need.

Arrange a medicines review before trying to conceive, or as soon as you find out you are pregnant. Some treatments used for PCOS can prevent pregnancy or harm fetal development. Do not stop a prescribed medicine without talking to your doctor.

Why extra checks are offered

PCOS is associated with higher risks of gestational diabetes, high blood pressure and pre-eclampsia during pregnancy. The guideline also identifies increased risks of miscarriage and preterm birth. These risks describe patterns across groups of people. They cannot predict how your pregnancy will go.

WHO recommends additional monitoring because of these risks. Tell your maternity team about PCOS when arranging care, including any treatment used to conceive. Ask who will coordinate the extra checks and how you will receive the results.

The international guideline recommends an oral glucose tolerance test (OGTT) when planning pregnancy or seeking fertility treatment. If an OGTT was not done before pregnancy, it recommends offering one at the first antenatal visit. It also recommends offering the test at 24-28 weeks, even if testing was done before pregnancy. If you already have diabetes, ask your maternity team about your monitoring plan. Blood pressure assessment is also recommended when planning pregnancy.

Metformin has not been shown to prevent gestational diabetes in pregnant people with PCOS, so it cannot guarantee protection against pregnancy complications. It may be considered in selected circumstances, while longer-term effects of exposure on children remain uncertain. Your prescriber needs to review what it is being used for in your care.

Symptoms that need help now

Call 999 now (UK) or 911 (US), or your local emergency number, if you develop breathing difficulty or chest pain during or after ovarian stimulation.

Call your maternity unit now (UK), or your obstetric clinician or maternity service (US or elsewhere), if you are pregnant and develop a severe persistent headache, blurred vision or flashing lights, pain beneath your ribs, or sudden swelling of your face or hands. If you cannot reach your UK maternity unit, call NHS 111. Do not wait until tomorrow or your next appointment, even at night.

Contact your fertility clinic urgently now if you develop belly pain and bloating, vomiting or faintness during or after ovarian stimulation. In the UK, call NHS 111 if the clinic is unavailable; in the US or elsewhere, contact your local urgent medical service.

Questions to take to the next appointment

Ask which part of fertility care is being addressed, which medicines need review and when blood glucose and blood pressure will be checked. If you are already pregnant, take these questions to your midwife, obstetrician or doctor. Ask who to contact with questions between appointments.