Stress, infertility ‘interwoven’ in PCOS, but treatments may improve odds for pregnancy

Key takeaways:

• The most common reason women with PCOS struggle to conceive is irregular and unpredictable ovulation, not infertility.
• Stress and mental health may impact fertility for women with PCOS.

Women with polycystic ovary syndrome have a higher likelihood of experiencing infertility and subfertility, which can harm mental health and trigger stress, but not everyone with this disorder will require assisted reproduction to conceive.

“Both infertility and subfertility are very common, so they often overlap,” Lora Shahine, MD, FACOG, reproductive endocrinologist at Pacific Northwest Fertility, told Healio. “Infertility occurs in one in six people worldwide and PCOS can occur in as many as 10% of people who are of reproductive age with ovaries and a uterus.”

Healio spoke with Shahine about how women with PCOS deal with fertility concerns and some of the myths about PCOS and infertility.

Healio: Why do women with PCOS sometimes struggle to conceive?

Lora Shahine

Shahine: It is multifactorial. We are still learning a lot about infertility in general, but when people have PCOS, one of the most common reasons that they are struggling to conceive is often associated with irregular and unpredictable ovulation. For someone who has been trying to conceive but cannot figure out when they are ovulating or do not know when their period comes, the timing can be very difficult and tricky, especially if someone is not having monthly, predictable periods. They may not have as many chances of conceiving within a year if they are only ovulating every 2 to 3 months.

Insulin resistance also impacts fertility for women with PCOS. Insulin is intimately involved with ovulation, blood sugar control, overall health and well-being. Not everybody with PCOS will experience changes in their weight, but the metabolism and hormonal conditions that can fluctuate with PCOS, especially with overweight, can alter the chances of getting pregnant. Despite these challenges, there are ways to help.

Healio: How does the stress from being unable to conceive impact women with PCOS?

Shahine: The question is: Is it the stress that is causing infertility or is the infertility and inability to start a family causing the stress? These are interwoven and absolutely related. Some people can be in an extremely “typical” stressful situation — such as war or famine and still conceive. Other people may have a roof over their head, meals, a job and people could say they are not as stressed as someone else, yet they are really feeling the stress, impact and frustration with infertility. I never want to tell someone that there is anything black and white in this situation. Stress is intimately involved in our overall health. I also do not want to tell my patients to stop stressing, because then they are going to stress about stressing. We are all dealing with stress, and it is very individualized. When we are stressed, we throw off our hormones, our cortisol levels will go up, our fight or flight response increases. Stress affects our sleep, metabolism and ovulation. We can help people learn stress management techniques that can help them with long-term, overall well-being.

Healio: Among women with PCOS who struggle to conceive, how many will become pregnant on their own and approximately how many move on to assisted reproduction?

Shahine: It is difficult to provide exact numbers, because those with PCOS conceiving on their own are not coming to see me or receiving medical attention. As long as someone is ovulating and there is sperm exposure, anything is possible. I am seeing people presenting to me that are struggling.

I do help a lot of women with PCOS become pregnant and there are options. Sometimes, pregnancy occurs with simple ovulation induction and timing sperm exposure.

Some women with PCOS do move toward IVF to become pregnant. I do not want people to assume that just because they have PCOS, the only way that they can get pregnant is with IVF, but it is the best technology, and it controls the most variables. Many of my patients with PCOS do conceive with IVF.

I cannot tell you how many women come to me in their mid-30s and say, “When I was diagnosed, I was told I will have infertility and I will have to undergo IVF to have a baby.” That perception is even within the medical field, and it is being passed on. It is an incorrect assumption. Yes, IVF is a tool and an option, but it is not the only means to become pregnant.

Healio: How have fertility treatments improved over the years for PCOS?

Shahine: We have learned so much about the process of stimulating ovaries in a safe way. One of the biggest risks of someone going through IVF who has PCOS is ovarian hyperstimulation syndrome. Everyone who undergoes IVF is hyperstimulated because we are recruiting more eggs. For someone with PCOS and a very high egg supply, we could use a moderate amount of medication and still recruit many eggs. The patient may feel bloated, experience pain and nausea. It is one of the biggest, most serious risk factors of IVF. When I was in fellowship at Stanford, about 20 years ago, we used to have to round on people admitted to the hospital with ovarian hyperstimulation syndrome These patients almost always had PCOS. This just does not happen as often anymore. We have learned so much. You can still have an excellent outcome without those side effects.

Another huge change in IVF is the success with freezing embryos. For someone with a very high egg supply, their hormone levels are elevated and they feel bloated. By performing a fresh embryo transfer 5 days later, when they are still not recovered from stimulation, is a setup for feeling worse. Now, we can separate stimulating the ovaries, recovery and then getting pregnant, dramatically reducing adverse effects and improving the process for people with PCOS.

Healio: How early in the family planning process should a reproductive endocrinologist be looped in?

Shahine: It is never too soon to have a consult and get some testing. It does not always have to be with a reproductive endocrinologist, but it is never too soon for asking questions with your primary care doctor, your OB/GYN and undergoing some initial testing.

Textbooks might state a patient needs to attempt pregnancy for 1 year before undergoing any testing; however, that is misleading, especially for someone with PCOS and irregular, unpredictable menstrual cycles. For my “Baby or Bust” podcast, I interviewed Karen Jeffries, author of Hilariously Infertile. She discussed how she stopped her birth control, did not get a period for a year and spent so much money on pregnancy tests because she assumed she was pregnant because she was not getting a period. She waited a whole year, only to then learn that she had PCOS.

A woman with PCOS experiencing regular, predictable cycles can try to conceive for up to 1 year if under the age of 35 years and, if aged 35 years or older, consider undergoing testing after 6 months without conceiving. If a woman is not having regular periods, has a history of diagnosis of PCOS, endometriosis or some other condition that could impact fertility, get testing right away and do not waste that time.

It is difficult to strike a balance between trying to explain to people that fertility struggles for women with PCOS are real, but also stay positive because, yes, people can become pregnant when they are 45 years old and have beautiful babies. But the reason we are so excited about it is because it is unusual. You cannot assume you are going to be that person.

If a woman with PCOS is hesitating to make that first appointment with a reproductive endocrinologist, they should talk through any fears with your OB/GYN or clinician. There are also educational resources where women can ask questions anonymously, without judgment, like fertilityoutloud.com.

Healio: Is there anything else you’d like to add about PCOS and fertility?

Shahine: PCOS is a lifelong condition and a PCOS diagnosis does not mean a woman will always have difficult conceiving. People with PCOS are also at higher risk for insulin resistance and developing type 2 diabetes later in life. There is also higher risk for thyroid disorders, metabolic disorders, obesity and cardiovascular disease. By learning more about PCOS and their cardiometabolic risk, women can take steps to improve their health and improve their odds of conceiving. PCOS is also associated with mental health disorders, like anxiety and depression. Women may feel frustrated because their body is not “working” like their friends. The hormonal imbalance related to PCOS itself may be associated with more anxiety and depression. Awareness of that is important. Mental health is key to overall reproductive health. One of the main reasons people stop fertility treatment is not because of lack of resources, but because of depression, anxiety and lack of support for mental health. Addressing mental health for my patients helps them continue their family journey.

• Fertility Out Loud. Available at: www.fertilityoutloud.com. Accessed Sept. 19, 2024.