The Patient's Guide to Embryology

The harsh reality of IVF for PCOS sufferers

Women with PCOS are more sensitive to IVF drugs. PCOS can also affect egg quality, egg maturity, and the environment inside the uterus.

What is PCOS?

PCOS stands for Polycystic Ovary Syndrome. It is a hormonal disorder which causes the ovaries to produce higher than normal levels of male hormones (androgens) such as testosterone. While it is essential for women to have some androgen production, an imbalance can cause a range of symptoms, including irregular periods, acne, excessive hair growth and weight gain. PCOS is also associated with insulin resistance causing the pancreas to produce extra insulin, which leads to a further increase in androgen production that exacerbates PCOS symptoms.

The exact cause of PCOS is not known, but it is thought to be related to a combination of genetic and environmental factors. There is no cure for PCOS, but symptoms can be managed through a combination of lifestyle changes, medications, and other treatments.

How does PCOS impact IVF?

Women with PCOS are more sensitive to IVF drugs

The hormone imbalance caused by PCOS changes the way the body responds to IVF drugs. Women with PCOS typically have higher levels of LH and lower levels of FSH – two key hormones responsible for follicle development and ovulation. It means that the ovaries are very sensitive to the hormone treatments used in IVF which stimulate the ovaries to produce multiple egg-containing follicles.

IVF drugs can cause the ovaries to produce a dangerous number of follicles in the ovaries of PCOS women, which increases the risk of ovarian hyperstimulation syndrome (OHSS). OHSS is a potentially serious complication where the ovaries become swollen and painful, and can lead to fluid build-up in the body. To minimize the risk of OHSS, doctors may adjust the dose of ovarian stimulation medication used during IVF, or use alternative ovarian stimulation protocols.

PCOS affects egg maturity

In women with PCOS, the hormonal imbalances that affect follicle growth can prevent the eggs from maturing correctly.

During a normal menstrual cycle, the body produces the hormones: LH and FSH, which stimulate follicles to grow in the ovaries. As the follicles grow, they produce estrogen which is essential in the egg maturation process. Women with PCOS have a high level of LH which causes the follicles to produce androgens instead of estrogen and prevents the eggs from maturing properly. The result is ovaries that are full of cysts and small follicles containing immature eggs. Women with PCOS having IVF, often have lots of eggs collected from their ovaries, but a high proportion are immature and cannot be used.

PCOS can affect egg quality

As well as a higher number of immature eggs, women with PCOS are at risk of having eggs which are poor quality. High levels of male hormones circulating in the body affect the way follicles grow and mature in the ovaries which can have a negative effect on the egg inside them. Poorer quality eggs are less likely to fertilize normally and less likely to make healthy embryos. However, there is some evidence to suggest that modified IVF protocols, such as using lower doses of medication or a shorter duration of treatment may improve the quality of eggs in women with PCOS.

PCOS can affect the environment in the uterus

The environment inside the uterus must be correctly prepared to receive an embryo for it to implant and form a pregnancy. It is thought that women with PCOS may have an altered uterine environment that can affect implantation and make it more difficult to get pregnant.

Some studies have suggested that women with PCOS may have a thinner endometrial lining, which can make it more difficult for the embryo to implant. Drugs are given in IVF to help thicken the lining of the uterus which can help to avoid this problem.

Additionally, women with PCOS may have hormone imbalances that can affect endometrial receptivity. The lining of the uterus expresses specific genes when it is ready to receive an embryo and this is known as the ‘window of receptivity’. One study found that women with PCOS were twice as likely to have a non-receptive uterus meaning that the embryo is not able to implant. A treatment called ERA testing can be used to find the optimum time to implant an embryo to give the best chance of success.

How PCOS can affect your pregnancy

Higher risk of miscarriage

Women with PCOS have a higher risk of miscarriage compared to women without PCOS. The exact reasons for this are not fully understood, but it may be related to hormonal imbalances, insulin resistance, or inflammation. However, with proper management and monitoring many women with PCOS have successful pregnancies.

Higher risk of pregnancy complications

Insulin resistance is a common feature of PCOS, which can lead to elevated levels of insulin in the bloodstream. This can result in pregnancy complications such as gestational diabetes and pre-eclampsia. Women with PCOS may need to monitor their blood sugar levels and follow a healthy diet and exercise plan to manage these risks.

How can people with PCOS improve their chance of success in IVF?

Optimize your lifestyle: Making lifestyle changes can help to improve your chances of IVF success. This includes maintaining a healthy body weight, eating a balanced diet, and getting regular exercise. Women with PCOS are at higher risk of insulin resistance and metabolic syndrome, so it’s important to manage these conditions through diet and exercise.

Use alternative IVF protocols: Some studies have shown that using lower doses of medication or a shorter duration of ovarian stimulation may improve IVF outcomes in women with PCOS. These protocols also reduce the risk of ovarian hyperstimulation syndrome (OHSS) and can improve egg and embryo quality.

Mature the eggs outside the body: A process known as in vitro maturation (IVM) involves collecting immature eggs from the ovaries and maturing them in the lab before fertilization. The process is similar to IVF but it uses fewer hormone drugs, making it a good alternative for women with PCOS who are at risk of OHSS or who have not responded well to conventional IVF treatments.

Consider alternative treatments: Some studies have suggested that certain adjunct treatments, such as using metformin to manage insulin resistance or using acupuncture to improve blood flow to the ovaries and uterus, may improve IVF outcomes in women with PCOS. However, more research is needed to confirm these findings.

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