How to Get Pregnant With PCOS

Although polycystic ovary syndrome (PCOS) is one of the most common causes of infertility—the Centers for Disease Control and Prevention (CDC) reports it affects up to 5 million people in the U.S.—it remains commonly misunderstood and likely underdiagnosed. But the good news is advances are being made and pregnancy is certainly possible despite a PCOS diagnosis.

A scroll through TikTok proves that with pregnant people and new parents showcasing their success stories. But getting a diagnosis for the hormonal disorder is important in order to get there. 

Here’s what hopeful parents need to know about PCOS and pregnancy. 

PCOS Symptoms Are Important to Know 

There are three key symptoms doctors look for in a PCOS diagnosis, according to Pinar Kodaman, M.D., Ph.D., a reproductive endocrinologist and infertility specialist at Yale Medicine in Connecticut. Those include irregular or lack of periods, elevated levels of testosterone (which can result in excess facial or body hair, hair thinning at the scalp, or acne), and an appearance of polycystic ovaries.

"Doctors would look for at least two of the three symptoms," explains Dr. Kodaman. "But PCOS is also a 'diagnosis of exclusion,' meaning there are other hormonal issues that can cause these same symptoms which must first be ruled out."

That process is often started with one’s primary care physician, OB-GYN, or a pediatrician if it’s a younger patient. But if cases are complicated or a diagnosis is unclear, patients might be referred to a specialist, says Dr. Kodaman. For young patients, that would be a pediatric endocrinologist. For older ones, a medical or reproductive endocrinologist can help. The latter can also assist with fertility treatments.

Despite the name and the appearance of the ovaries, Dr. Kodaman points out the ovarian growths are not actually cysts. "This is just an excess of accumulated egg follicles because of the lack of regular ovulation,” explains Dr. Kodaman.

It’s this menstrual irregularity that leads to infertility that people experience with PCOS, adds Dr. Kodaman. Infertility is defined as one year of trying to get pregnant without success for those under 35 and six months for those 35 and older.

Getting Pregnant with PCOS

When ovulating regularly, the chances of getting pregnant hovers around 20-30% per cycle when under the age of 35, says Kimberly Keefe Smith, M.D., OB-GYN at Brigham and Women's Hospital Center for Infertility and Reproductive Surgery in Boston. That percentage typically decreases as a patient gets older. But with PCOS making ovulation unpredictable—or missed entirely—it's difficult to time intercourse, she says. That’s why PCOS can make pregnancy challenging, but it’s possible with the following information.

Treating insulin resistance

Many people with PCOS also have resistance to insulin, an essential hormone the pancreas produces which regulates blood glucose (sugar) levels. When someone is insulin resistant, says Dr. Kodaman, the pancreas makes accommodations by producing extra insulin to overcome that resistance. But over time, the pancreas can't keep up and this can lead to significant increases in blood sugar. 

Insulin resistance can impact ovulation, hormones, and weight. Health care providers usually try to treat it by improving metabolic health first. They often target weight loss, especially since elevated weight is also associated with ovulation trouble. "Insulin resistance promotes weight gain and weight gain promotes insulin resistance, so it really is a vicious cycle,” says Dr. Kodaman. “It's important to address that first."

Dr. Keefe Smith agrees, adding, "Even a 5-10% weight loss can be associated with improvement.” Patients are encouraged to eat a healthier diet and add more exercise to their daily routine. Exercising a minimum of 30 minutes per day, at least five days a week (both weight-bearing and cardiovascular exercise) is recommended, says Dr. Kodaman.

Lifestyle changes aren't always the answer, especially since the condition can be purely genetic, says Dr. Keefe Smith. Plus, not all those with PCOS are overweight or obese. That’s where medications, including metformin (an insulin sensitizer), can help, as well as certain supplements like myo-inositol. It’s also a good idea to seek nutritional counseling to learn about which foods spike sugar and therefore insulin levels. “Simple carbs, sweets, and even some fruits and vegetables with a high glycemic index, should be minimized or avoided,” says Dr. Kodaman. 

Fertility treatments

If treating insulin resistance doesn't help you conceive, the next step is fertility treatments. Often that starts with medications to induce ovulation. “Women with PCOS have successful outcomes in terms of fertility treatments because they have a lot of eggs,” says Dr. Kodaman. “They just need help with ovulation and the timing of intercourse or insemination, accordingly.”

Health care providers usually opt for Letrozole, a medicine normally used to treat breast cancer. “This is not actually FDA-approved for the treatment of infertility or ovulation, so we are using it off-label in this case," says Dr. Keefe Smith, adding Clomid, an older medication, is available for patients who prefer an FDA-approved option. Letrozole, though, has been found to produce higher live birth and ovulation rates for infertile people with PCOS.

If ovulation medication is unsuccessful, Dr. Keefe Smith says patients can do in vitro fertilization (IVF). 

For people who aren't ready to take that route just yet, injectable medications used with IVF can be offered to those timing sex for pregnancy. “[We’d] watch closely to see how the body responds,” says Dr. Keefe Smith. “Then intercourse can be timed right around the release of the egg." 

Overall, there’s about a 22-25% rate of conception with ovulation induction and about 60% with IVF, says Dr. Kodaman. But success rates also depend on factors like age and other comorbidities.

The Journey to a PCOS Diagnosis

Getting a PCOS diagnosis can be a long journey for many patients. Dr. Keefe Smith says the variations in presentation can make it a very individualized situation.

"It's important to be clear that not all PCOS is created equal," she continues. “If a patient does not present with the classic symptoms, coming to a diagnosis can be challenging. It's not uncommon for women to see multiple doctors before receiving the proper diagnosis and treatment."

Other conditions have to be ruled out and patients present in different ways, adds Dr. Kodaman. Some may not even know they have any issues. “During adolescence, some patients start birth control pills which might also mask some of the symptoms that would otherwise raise red flags,” says Dr. Kodaman. “Then, their whole workup might be delayed until they are off birth control and trying to get pregnant.”

Dr. Keefe Smith explains birth control can manage several issues, including acne and heavy or irregular periods. When people come off of it, ovulation may not restart reliably.

“It is normal to take a few cycles to restart, but more than three months or irregularity should be evaluated,” she says. “I’ve found many folks wait a full year before they seek help, but they should not wait.” 

Keep in mind, Dr. Kodaman adds, there is a strong genetic component to PCOS, so if a first-degree relative has already been diagnosed and a patient has symptoms, it’s beneficial to start the diagnosis process early.

Even after a diagnosis, it can also take some time to choose the best treatment path as some may respond to treatments better than others, says Dr. Keefe Smith. That’s why the earlier the process is started, the better. "The good news is that people are talking about it more," says Dr. Keefe Smith.

In the past, Dr. Keefe Smith says patients would even wait years before seeking help with ovulation. Increased awareness is helping to change that. 

“The best advice I could offer is, don't wait,” says Dr. Keefe Smith. “We do have the tools to build families and, with the right intervention, can be very successful."