What are the treatment options for women with Polycystic Ovary Syndrome (PCOS) trying to get pregnant?

Treatment Options for Women with PCOS Trying to Conceive

For women with Polycystic Ovary Syndrome (PCOS) trying to conceive, clomiphene citrate is the first-line pharmacological treatment, with approximately 80% of patients ovulating and half achieving pregnancy. 1

First-Line Approaches

Lifestyle Modifications

• Weight management is a cornerstone of PCOS treatment, with even modest weight loss of 5% improving both metabolic and reproductive abnormalities 2, 3
• Lifestyle interventions should be the initial management strategy for obese PCOS patients seeking pregnancy 4, 3
• Focus on dietary interventions such as low glycemic index foods, caloric restrictions, and anti-inflammatory diets to improve insulin sensitivity and hormonal balance 3
• Physical activity, including both aerobic and resistance exercise, enhances insulin sensitivity and improves reproductive outcomes 3

Pharmacological Ovulation Induction

Clomiphene Citrate

• Clomiphene citrate is indicated for the treatment of ovulatory dysfunction in women with PCOS desiring pregnancy 5
• Treatment should be started on or about the 5th day of the menstrual cycle 5
• Long-term cyclic therapy is not recommended beyond a total of about six cycles (including three ovulatory cycles) 5
• Patients should be carefully selected, ensuring they:
  • Are not pregnant
  • Do not have ovarian cysts (except those with PCOS)
  • Do not have abnormal vaginal bleeding
  • Have normal liver function 5

Second-Line Approaches

Gonadotropin Therapy

• Low-dose gonadotropin therapy is recommended if clomiphene treatment fails, due to lower risk of ovarian hyperstimulation 1
• This approach requires careful monitoring to avoid multiple pregnancies and ovarian hyperstimulation syndrome 4

Laparoscopic Ovarian Drilling

• Considered an alternative to gonadotropins in patients who need laparoscopy for another reason 4
• This surgical approach can restore ovulation in women with PCOS who are resistant to clomiphene 4

Adjunctive Treatments

Insulin-Sensitizing Agents

• Metformin appears to be safe during pregnancy according to ACOG guidelines, though documentation on its effects in early pregnancy is limited 2
• Can be used in addition to lifestyle interventions for assisting with weight management and improving cardiometabolic risk factors, particularly in those with overweight or obesity 6

Advanced Reproductive Technologies

• For anovulatory PCOS patients who don't respond to other treatments, assisted reproductive techniques (ART) represent the only possible alternative to obtain pregnancy 4
• These include in vitro fertilization and intracytoplasmic sperm injection 4, 7

Important Monitoring and Considerations

• Pelvic examination is necessary prior to the first and each subsequent course of clomiphene citrate treatment 5
• Monitor for pregnancy complications that occur at higher rates in women with PCOS, including gestational diabetes 7
• Screening for hyperglycemia using a 75-g oral glucose tolerance test is recommended at preconception or within the first 20 weeks of pregnancy 6
• Preconception optimization of health, including weight management, is recommended to maximize fertility potential and improve pregnancy outcomes 7

Common Pitfalls to Avoid

• Exceeding recommended clomiphene dosage and duration 1
• Neglecting metabolic screening even in normal-weight PCOS patients 1
• Failing to exclude other impediments to pregnancy such as thyroid disorders, adrenal disorders, hyperprolactinemia, and male factor infertility before initiating treatment 5
• Overlooking the importance of properly timed intercourse in relation to ovulation 5