What are the recommendations for women with Polycystic Ovary Syndrome (PCOS) who are planning to become pregnant?

Recommendations for Women with PCOS Planning Pregnancy

For women with PCOS planning pregnancy, lifestyle modifications including weight loss of 5-10% through a 500-750 kcal/day deficit diet and 250 minutes of weekly exercise should be implemented first, followed by clomiphene citrate as first-line medication for ovulation induction if needed. 1

Preconception Management

Lifestyle Modifications (First-Line)

• Weight management: Even modest weight loss of 5-10% can restore ovulation and improve fertility 1
  • Implement caloric deficit of 500-750 kcal/day
  • Focus on low glycemic index foods, high fiber, and omega-3 fatty acids
  • Aim for at least 250 minutes of moderate-intensity physical activity weekly
  • Include strength training 2-3 times per week

Preconception Screening

• Metabolic assessment: 1, 2
  • Blood pressure monitoring
  • 75g oral glucose tolerance test (OGTT)
  • Lipid profile
  • Thyroid function
  • Evaluate for insulin resistance

Ovulation Induction Protocol

First-Line Pharmacological Treatment

• Clomiphene citrate: 1, 3
  • Start on day 5 of the menstrual cycle
  • Begin with lowest effective dose
  • Expected outcomes: 80% ovulation rate, 50% conception rate
  • Monitor for ovarian hyperstimulation syndrome (OHSS), particularly in PCOS patients who may be unusually sensitive to treatment
  • Limit treatment to approximately six cycles (including three ovulatory cycles)
  • Important safety note: Discontinue immediately if visual disturbances occur

For Clomiphene-Resistant Patients

• Metformin: 1, 2

  • Starting dose: 500 mg/day with meals
  • Gradually increase to 1000-1500 mg/day in divided doses
  • Benefits: Improved insulin resistance, regularized menstrual cycles
  • Can be used as adjunctive therapy with clomiphene

• Letrozole: 2

  • Considered first-line for anovulatory infertility in PCOS by some guidelines
  • May be more effective than clomiphene in women with PCOS

Pregnancy Monitoring

High-Risk Pregnancy Management

• Increased monitoring for: 1, 4, 2
  • Gestational diabetes (screen early and repeat at 24-28 weeks)
  • Preeclampsia and hypertensive disorders
  • Preterm birth
  • Fetal growth abnormalities

Common Pitfalls and Caveats

• Ovarian hyperstimulation risk: Women with PCOS are particularly susceptible to OHSS during ovulation induction 3

  • Warning signs: abdominal pain/distention, nausea, vomiting, weight gain
  • Can progress rapidly within 24 hours to severe form
  • Start with lowest effective dose of clomiphene
  • Do not continue treatment if ovarian enlargement occurs

• Visual disturbances with clomiphene: 3

  • Can include blurring, scotomata, phosphenes
  • Usually reversible but can be prolonged or potentially irreversible
  • Discontinue treatment immediately if visual symptoms occur

• Metabolic considerations: 1, 2

  • Oral contraceptives used for cycle regulation before conception attempts may worsen metabolic parameters
  • Combined lifestyle modification with weight loss appears to eliminate these adverse effects 5

• Treatment duration limits: 3

  • Long-term cyclic clomiphene therapy is not recommended beyond approximately six cycles
  • Consider alternative approaches if pregnancy not achieved within this timeframe

By following this structured approach prioritizing lifestyle modifications first and then appropriate pharmacological interventions when needed, women with PCOS can optimize their chances for successful conception and healthy pregnancy outcomes.