PCOS: Infertility and Assisted Reproductive Technology

Understanding PCOS and Its Implications

Polycystic Ovary Syndrome (PCOS) is a common hormonal disorder that affects women of reproductive age. It is characterized by an imbalance of reproductive hormones, leading to irregular menstrual cycles, numerous ovarian follicles, and difficulties in conceiving. In France, PCOS is the leading cause of female infertility due to infrequent or absent ovulation.

As of 2022, infertility affects approximately 3.3 million people, or nearly one in four couples (source: Government Report on Infertility, February 2022). Fertility has become a major societal issue, and while there is no magic solution, the majority of women with PCOS are able to conceive naturally or through assisted reproductive technology (ART).

Planning and Optimizing a Pregnancy Project with PCOS

Ideally, it’s best to prepare your body by stopping hormonal contraception well in advance. This allows you to observe your natural cycles, identify signs of ovulation, and take steps to optimize your chances of conception. During this period, if pregnancy is not desired, it's important to use a non-hormonal contraceptive method, preferably condoms.

Conceiving Naturally with PCOS

Step 1: Understanding the Menstrual Cycle

Conception occurs when a sperm cell (male gamete) meets an egg cell (female gamete), making it crucial to understand your menstrual cycle, especially with PCOS. Women ovulate once per cycle, so tracking ovulation is key to maximizing the chances of conception. The menstrual cycle is generally divided into four phases:

Menstrual Phase: This phase begins on the first day of menstruation and lasts about 3 to 7 days. It is characterized by the shedding of the uterine lining in the form of bleeding.
Follicular Phase: Following menstruation, the follicular phase begins and lasts around 7 to 14 days. The hypothalamus releases Gonadotropin-Releasing Hormone (GnRH), stimulating the production of Follicle-Stimulating Hormone (FSH), which promotes the maturation of ovarian follicles.
Ovulatory Phase:
- Duration: Approximately 24 to 48 hours
- Process: A peak in estrogen levels triggers the release of Luteinizing Hormone (LH) by the pituitary gland. This surge in LH causes ovulation, during which the mature egg is released from the ovary.
- Hormones: LH and estrogen levels increase, and progesterone begins to rise.
- Symptoms: Some women may experience mild ovulation pain (mittelschmerz), increased libido, and changes in cervical mucus (becoming clearer and more elastic).
Luteal Phase:
- Duration: Approximately 14 days
- Process: After ovulation, the empty follicle transforms into the corpus luteum, which produces progesterone. Progesterone stabilizes the endometrium, preparing it for embryo implantation.
- Hormones: Progesterone peaks, while estrogen is present in moderate amounts.
- Symptoms: If fertilization does not occur, progesterone and estrogen levels drop, leading to premenstrual symptoms such as headaches, tender breasts, bloating, and mood swings. If the egg is fertilized, progesterone remains elevated to support the pregnancy.

Step 2: Observing Ovulation and Using Ovulation Tests with PCOS

To maximize the chances of conception, identifying ovulation is crucial. However, for women with PCOS, irregular cycles make this challenging. Ovulation tests, which measure LH levels, may be unreliable due to consistently elevated LH levels in these women. Alternative methods, such as monitoring basal body temperature and observing cervical mucus, are more effective.

Step 3: Tracking Cervical Mucus

Cervical mucus changes throughout the menstrual cycle. As ovulation approaches, it becomes more abundant, transparent, and stretchy, signaling a fertile period. Learning to recognize these changes can help identify the optimal time for intercourse.

However, cervical mucus abnormalities are common in women with hormonal disorders like PCOS. During ovulation, cervical mucus typically increases and becomes more slippery, resembling egg whites. However, in women with PCOS, generally reduced estradiol levels can result in cervical mucus that is stickier and less elastic compared to women without PCOS. Despite this difference, tracking cervical mucus can still be a useful method for predicting ovulation in women with PCOS.

Step 4: Detecting Cycle Anomalies

It's essential to detect menstrual cycle anomalies or any hormonal imbalances.

Irregular Cycles
Severe Pain
Unusual Bleeding
Intense Premenstrual Symptoms

These could indicate underlying health issues requiring medical attention. Careful and regular observation of the menstrual cycle helps in identifying these anomalies, prompting consultation with a healthcare professional if needed.

Regulating the Cycle and Improving Egg Quality with PCOS

Lifestyle Changes

Balanced Diet: Adopt a diet rich in nutrients, fiber, and omega-3 fatty acids. Reduce refined sugars and simple carbohydrates to stabilize insulin levels.
Regular Exercise: Engage in moderate to intense physical activities, such as cardio and strength training, to improve insulin sensitivity and help regulate menstrual cycles.
Stress Management: Practice stress management techniques like yoga, meditation, and deep breathing to minimize the impact of stress on hormones.

Dietary Supplements

Incorporating these supplements into a healthy lifestyle can help improve fertility in women with PCOS:

Myo-Inositol and D-Chiro-Inositol - Luminaissance
- Description: These two forms of inositol are often used together to enhance insulin sensitivity and regulate menstrual cycles.
- Recommended Dosage: 2 to 4 grams per day.
- Benefits: Reduces insulin resistance, improves ovarian function, and increases the chances of ovulation.
Folic Acid (Vitamin B9) - Olympia
- Description: Essential for cell division and embryonic development.
- Recommended Dosage: 400 to 800 micrograms per day.
- Benefits: Reduces the risk of congenital anomalies, supports egg quality.
Coenzyme Q10 (CoQ10) - Olympia
- Description: A powerful antioxidant that plays a crucial role in cellular energy production.
- Recommended Dosage: 100 to 300 milligrams per day.
- Benefits: Improves egg quality, protects against oxidative damage.
Omega-3 Fatty Acids - Neptune
- Description: Found in fish oils, these essential fatty acids are important for cellular health.
- Recommended Dosage: 1000 to 2000 milligrams per day.
- Benefits: Reduces inflammation, improves hormonal balance, supports reproductive health.
Vitamin D - Rising D3
- Description: Essential for calcium absorption and bone health, Vitamin D also plays a role in hormone regulation.
- Recommended Dosage: 1000 to 2000 IU per day.
- Benefits: Improves fertility, supports ovarian function.
Vitamin E - Olympia
- Description: An antioxidant that protects cells from oxidative damage.
- Recommended Dosage: 400 IU per day.
- Benefits: Improves egg quality, supports reproductive health.
Selenium - Olympia
- Description: An essential trace mineral with antioxidant properties.
- Recommended Dosage: 55 to 200 micrograms per day.
- Benefits: Protects against cellular damage, improves fertility.
Zinc - Olympia
- Description: A crucial mineral for immune function and cell division.
- Recommended Dosage: 8 to 25 milligrams per day.
- Benefits: Improves egg quality, supports hormonal balance.
N-Acetylcysteine (NAC) - Olympia
- Description: An amino acid precursor to glutathione, a powerful antioxidant.
- Recommended Dosage: 600 to 1800 milligrams per day.
- Benefits: Reduces insulin resistance, supports ovarian health.

Assisted Reproductive Technology (ART) Treatments for PCOS-Related Infertility

What is an ART Journey?

When dealing with infertility due to PCOS, management typically includes lifestyle adjustments, addressing overweight or obesity, and managing associated metabolic disorders. Depending on the patient's condition and response to initial treatments, various treatment options may be offered.

An Assisted Reproductive Technology (ART) journey aims to help a woman overcome infertility challenges to achieve pregnancy. This medical pathway includes regular medical monitoring, support, and sometimes treatments such as In Vitro Fertilization (IVF). ART offers different techniques, including artificial insemination, IVF, and embryo adoption. This process is strictly regulated both legally and medically, requiring the patient to meet certain criteria based on the law and the medical team’s decision.

Step 1: Simple Stimulation

Clomid (Clomiphene Citrate)

Action: Stimulates ovulation by tricking the brain into producing more Follicle-Stimulating Hormone (FSH).
Administration: 1 tablet/day for 5 days (from the 2nd to the 6th day of the menstrual cycle).
Monitoring: Mid-cycle ultrasound to check follicular growth and avoid multi-follicular responses. Progesterone levels are checked in the second half of the cycle to confirm ovulation.
Effectiveness: Approximately 20% chance of pregnancy per cycle, with a cumulative rate of 60% after several cycles.

Letrozole

Action: An aromatase inhibitor that reduces estrogen levels, thereby stimulating FSH production.
Administration: 1 to 2 tablets/day for 5 days (from the 2nd to the 6th day of the menstrual cycle).
Availability: Commonly used abroad and sometimes in France (off-label), with pregnancy rates equivalent to or higher than Clomid.

Step 2: Stimulation by Injection or Ovarian Drilling

FSH Injections

Action: Injections of FSH to stimulate the development of a dominant follicle, with regular ultrasound and blood test monitoring.
Administration: Progressive injections, sometimes followed by an HCG injection to trigger ovulation.
Effectiveness: Over half of the patients achieve pregnancy after several cycles.

Ovarian Drilling

Action: A laparoscopic surgical procedure where small perforations are made on the ovary to improve ovulatory function.
Indication: Suggested for thin patients with elevated LH levels who did not ovulate with Clomid.
Effectiveness: About 50% of patients regain regular cycles, increasing the chances of spontaneous pregnancy.

Step 3: In Vitro Fertilization (IVF) and Intrauterine Insemination (IUI)

IVF is a highly effective option for women with PCOS to improve their chances of pregnancy, especially when combined with other techniques such as:

ICSI (Intracytoplasmic Sperm Injection): This technique is used to address issues with egg quality by injecting a single sperm directly into the egg.
Preimplantation Genetic Diagnosis (PGD): This procedure screens embryos for genetic abnormalities, achieving a success rate of approximately 50% for transferred embryos.

Maintaining a healthy lifestyle with a balanced diet can also help regulate cycles and improve the response to IVF treatment for women with PCOS.

IVF Protocol:

Ovarian Stimulation: The growth of multiple follicles is induced using higher doses of gonadotropins.
Ovulation Trigger: An injection is administered to trigger ovulation.
Egg Retrieval: Collection of eggs and sperm is performed.
Fertilization: The eggs are fertilized with sperm in the laboratory.
Embryo Culture: The embryos are allowed to develop before transfer.
Embryo Transfer: One or more embryos are implanted in the uterus.
Freezing: Any remaining embryos are frozen for future use.

Effectiveness: More than half of the patients achieve pregnancy following this protocol.

Adopting a Fertility-Enhancing Diet

Adopting a diet that supports fertility requires some knowledge. It’s essential to assess current dietary habits to detect deficiencies and identify areas for improvement.

For overweight women struggling to conceive, losing a few pounds can increase the chances of pregnancy. However, strict diets leading to rapid weight loss should be avoided as they can cause nutritional deficiencies. A gentle, gradual dietary adjustment that ensures high nutritional quality is preferable.

Principles of Dietary Adjustment:

Low Glycemic Index: Helps limit blood sugar fluctuations, reducing cravings and fat storage, particularly beneficial for women with PCOS or endometriosis.
Rich in Vitamins and Minerals: Consuming a variety of fruits and vegetables ensures optimal nutrient intake.
Minimally Processed Foods: Guarantees a low glycemic index, a good quality of fats, and minimizes additives.

The Role of Diet in an ART Journey

Whether undergoing ART or trying to conceive naturally, adopting dietary habits that support fertility is crucial. An ART journey can be psychologically and physically challenging, with significant emotional and financial investments. Therefore, optimizing the chances of success by following a fertility-enhancing diet is essential. Many gynecologists recommend their patients adopt healthier lifestyle habits (such as reducing tobacco and alcohol consumption, increasing physical activity) and switch to a more balanced diet to aid conception.

Importance of Diet for Men in ART

In an ART journey, men's diet is equally important for boosting fertility. Certain foods can improve sperm quality and motility. Men undergoing ART should limit their intake of processed foods, caffeine, saturated fats, and trans fats. To improve sperm quality, it’s recommended to consume fruits and vegetables, whole grains, fish, and omega-3-rich oils like walnut oil.

Lifestyle Tips for Men in ART:

Overweight and Obesity: Lose excess weight.
Alcohol Consumption: Reduce or eliminate alcohol intake.
Tobacco: Quit smoking.
Anabolic Steroids: Avoid recreational drugs and steroids.
Exercise: Engage in regular physical activity.
Stress: Manage stress effectively.
Testicular Temperature: Monitor and avoid elevated testicular temperatures.