I Have PCOS and I Don’t Ovulate. What’s the Best Fertility Treatment for Me?

It is not uncommon for women with PCOS to have a problem with ovulation. Typically, the over-the-counter ovulation predictor kits do not work for PCOS patients because many PCOS patients will get false positive tests and it may appear that you are ovulating all the time. So how do you know if you have a problem with ovulation?

One easy way to determine if you are probably not ovulating is the frequency of your periods. If the beginning of your period (day 1) to the beginning of the next period (day 1) is either less than 21 days or more than 35 days, there is a good chance that you are not ovulating. Another way to determine if you are not ovulating is a medical approach: by testing a progesterone level.

You will only produce a significant amount of progesterone if you are ovulating. If you are not ovulating regularly you should see an infertility specialist sooner than is usually recommended. There is no point in trying to conceive for a whole year if you are not ovulating because you can’t get pregnant if you are not releasing an egg from the ovary regularly.

So see an infertility specialist. The first time you visit us, we will complete a basic infertility evaluation prior to starting fertility treatment. This evaluation consists of an evaluation of your hormones, uterine cavity and tubes for patency, and a semen analysis from your partner. Bring any records of tests already done so that you do not have to repeat them.

You May Actually Have Lots of Eggs!

During the evaluation, we will typically do an ultrasound and look at your ovaries. The good news is that women with PCOS in general have a lot of follicles in the ovaries. Some have called these follicles ovarian cysts, thus, the name polycystic ovary syndrome. But these small follicles are not cysts. These small follicles (usually measuring 2-9 mm) are fluid filled sacs that contain eggs!

So you have lots of eggs! But why don’t they ovulate? That is the million dollar question. We do not know why women with PCOS do not regularly ovulate. We have several theories but no consensus. It is sufficient to be aware that PCOS patients typically do not ovulate regularly. As long as everything else is normal (besides not ovulating regularly), then we discuss treatment.

Medications for Inducing Ovulation: What Works?

This brings us back to the original question: “What is the best fertility treatment for me?” Women with PCOS patients tend to respond well to fertility treatments. We want to give you a medication to get you to ovulate regularly but not release too many eggs at one time. Our goal is to get you pregnant with one healthy baby at a time.

There are 2 relatively inexpensive oral fertility medications that can be used to induce ovulation. These medications are letrozole (or Femara) and clomiphene citrate (or Clomid). Which medication is better? Letrozole is better. The best clinical information is based on Cochrane Reviews which evaluate published clinical trials and Letrozole use in PCOS patients have resulted in better ovulation rates, better pregnancy rates, and better live birth rates when compared to clomiphene citrate.

The clinical pregnancy rate is 40% better with Letrozole than with Clomiphene citrate. The risk of twin gestation is about the same with either medication (about 7-10%). Fortunately, higher order pregnancies (more than twins) is very uncommon (<0.5%).

Letrozole is an "Off-Label" Treatment

One additional thing to know about Letrozole is that it is not approved by the FDA for ovulation induction. There are many medications that physicians use that are not FDA approved for the specific indication that is being prescribed.

The American College of Obstetricians and Gynecologists (ACOG) stated this year (2018) that Letrozole should be the first line medication for ovulation induction for PCOS patients. The package insert for both medications states that they are contraindicated in pregnancy and you should not take this medication if you are already pregnant.

What to Expect During Letrozole Treatment

Letrozole is typically given for 5 days starting on cycle day 3, 4, or 5. Then, we monitor for ovulation and time intercourse or insemination. If ovulation does not occur, then we increase the dosage up to a maximum of 7.5 mg/day for 5 days. About 60% of PCOS women will ovulate on this medication and we will typically give this treatment for 3-6 cycles to give you a good pregnancy rate!