What Causes Infertility in Women with Polycystic Ovarian Syndrome?

With the passing days, more and more people are having problems in conception. There is a huge rise in the number of people seeking fertility treatments as well. A recent study concluded that 1 in every 8 women is suffering from infertility issues, which is quite high compared to previous studies. There is also a huge rise in male factors contributing to infertility. However, for women there are various stages in which a problem can occur. Even a small deviation can result in fertility issues. In this article, we will read about how polycystic ovarian syndrome (PCOS) ranks high as a cause for infertility in women and the treatment for polycystic ovarian syndrome to restore fertility.

Infertility is inability to conceive after having regular intercourse for one year without taking any birth control measures. It also encompasses the fact of inability of a woman to carry a pregnancy to the full term. Infertility is of two types: Primary Infertility, where a woman is unable to conceive or conceives, but miscarries or gives birth to a still child; and Secondary Infertility, where a woman is unable to conceive following the last live birth of a child even after regular unprotected intercourse for a period of one or more years.

In contrary to the earlier belief that female only have a fertility problem and men are devoid of it, of late the ratio is become equal. According to a 2009 findings, the chances of a male factor contributing to infertility problems is 30%, a female factor is also 30%, 10% of the cases are of those where both the partners have a problem, the remaining 25% is attributed to facts which are unexplained (Unexplained Infertility) and 5% to other factors.

The types of female factors which can contribute to infertility are Polycystic ovarian syndrome, poor ovarian reserve, tubal blockage, pelvic inflammatory disease, uterine tuberculosis, uterine problems, endometriosis, age-related factors, tubal ligation, advanced maternal age, overweight or underweight, hormonal imbalances, thyroid problems, low sexual desire, etc. The male factors could be low count of sperm (oligozoospermia), no sperm count in semen (Azoospermia), low or no sperm motility (Asthenozoospermia), Erectile Dysfunction, Hypoactive sexual desire, testicular malformations, blockage in Vas Deference, hormonal imbalance, etc.

The combined factors are where both the partners are infertile or sub-fertile and together their infertility chances increases. Another possible reason for combined infertility could be genetic or immunological where the partners are fertile individually but as a couple they face problems in conception.

Unexplained infertility can have causes like failure of the egg to mature and rupture on time, failure of fertilization to occur, transport of the zygote to the uterus is interrupted for some reason, failure of implantation, etc. Although there must be some problem that occurs even in a case of unexplained infertility, the diagnostics tests might not be capable enough to find that in such minute details.

In spite of all these above mentioned possible reason for infertility, quality of egg and maturation and rupture of egg on time is found to be most important factors along with maternal age.

Polycystic Ovarian Syndrome (PCOS) is one of the most common problems experienced by women of all age in today’s world. Polycystic ovarian syndrome is an endocrine system disorder in women of the reproductive age which results in hormonal imbalance. Due to the hormonal imbalances, the follicles in the ovary do not grow properly and form pearl-sized cysts which again cause hormonal imbalances making it a vicious cycle which is difficult to break. An early diagnosis of this condition can help in preventing many serious complications like insulin resistance, Type 2 Diabetes Mellitus, high blood pressure, high cholesterol, and cardiovascular diseases.

The most common symptoms of polycystic ovarian syndrome is irregular periods or at times no periods without medication, prolonged periods with heavy or scanty bleeding, pelvic pain, velvety skin, excessive hair growth (Hirsutism), acne, obesity, male pattern baldness, inability to conceive, etc. Women suffering from polycystic ovarian syndrome typically produce more androgen, a male sex hormone and it is due to this hormone that these women typically develop more facial and body hair growth, acne, male pattern baldness, etc. However, apart from these general symptoms, the symptoms experienced might vary from women to women. Some women might not have any cyst in the ovaries yet have PCOS.

Although the exact cause of polycystic ovarian syndrome is not yet established, researchers have indicated a strong contribution of the genes as a predisposing factor for the onset of the disorder. A strong concordance has been found in monozygotic twins compared to the dizygotic twins. A woman can inherit that and show the symptoms of PCOS, however, a man who has inherited the gene may show some symptoms like early baldness or excessive hair or they may be silent carriers passing the gene to the next generation.

Another most important cause for PCOS is hormonal imbalance. It is thought to be a chain of hormonal changes where one hormone change triggers the change in another hormone which in turn changes the levels of yet another hormone causing a whole endocrine system problem. In spite of the genetic and hormonal imbalance as the vital causes, obesity is also found to be a very important factor contributing to the disorder. Central obesity specially increases the chances of insulin resistance and in turn increases the risk of cardiovascular diseases.

Although there are many reasons posing a problem for conception, polycystic ovarian syndrome ranks the highest among all of them. Among the female factors of infertility, 75% of them have PCOS as the reason for their anovulatory infertility.

Women with PCOS might not ovulate every month. The reason behind this is the hormonal imbalance. The tiny follicles that develop every month in the ovaries need a number of hormones to grow, develop, mature and rupture. In women with PCOS the ovaries does not produce some of the hormones in sufficient amount. These women also have problem in the hormone levels of Follicle Stimulating Hormone (FSH) and Luteinizing Hormone (LH) and the abnormal ratio of these two hormones also pose difficulty for the follicles to grow. The hormonal sufficiency and imbalance creates a lot of disturbance leading to under-maturation of the follicle which stays in the ovaries in the form of a cyst. These cysts in turn do not produce enough progesterone and cause irregularities in the menstrual cycle. The androgen produced in women with PCOS due to problems in insulin regulation also poses a problem in ovulation. The cycle continues leading to no ovulation and delayed menstrual cycle which is the chief reason for infertility for women with PCOS.

Women who had polycystic ovarian syndrome are often at higher risk for various complications during pregnancy. A woman with PCOS must be educated by the physician about these risks. Higher rates of miscarriage, pregnancy induced high blood pressure, gestational diabetes, and premature deliveries are the common effects of PCOS on a woman who has achieved pregnancy. Moreover, a child born to a woman with PCOS are found to spend longer time in NICU and are at higher risk of dying before, during or just after birth and these chances are even higher in multiple-birth babies.

Polycystic ovarian syndrome though cannot be cured completely due to its genetic base for some; it could be managed very easily. Depending on the focus of treatment or the goal, the treatment plan may vary.

• Birth Control Pills: Birth control pills helps in controlling the menstrual cycles, lower the male hormones which pose a block in ovulation and also help to clear acne. It also helps in clearing the ovaries from the remaining tiny under-matured follicle staying in the ovaries as cysts. Thus, many physicians prescribe birth control pills for a few months to women who are willing to conceive so that the ovaries are cleared and the menstrual cycles come to normal which in turn better promotes the process of conception. A physician might also prescribe only Progesterone hormone pills to regulate the menstrual cycle instead of contraceptive pills. The purpose served is same for both.
• Medication to reduce insulin resistance and increase fertility: Since women with PCOS are prone to insulin resistance, physicians prescribe medicine like metformin (Glucophage) to control the insulin level in the body and decrease the insulin resistance. Once the insulin is under control, it helps in reducing the excess androgen level in the body and the symptoms produced by androgen. When taken for months, the normal menstrual cycle might be restored and thus restore normal ovulation.
• Medications to Induce Ovulation and Boost Fertility: Anovulation is the basic cause for women with PCOS to not conceive. Thus, medications can be prescribed to induce and stimulate ovulation, maturation and rupturing of the follicle. The types of medication prescribed are Clomiphene, Metformin along with clomiphene and Gonadotrophin. Gonadotrophins are generally available as injection and are much expensive. This is generally given depending upon the hormonal levels and also for those who are not reacting optimally to the oral drugs. However, fertility medications raise the risk of multiple births as they tend to stimulate more than one follicle which if ruptured and fertilized can result in twins and triplets.
• Weight Loss: Although the fact that either obesity induces PCOS or PCOS increases obesity is not yet established statistically, yet researchers have confirmed that 50% of women with PCOS are obese. Moreover, studies have also confirmed that even a 5% loss in weight can reduce the androgen levels in the body by 20 percent. The dropping down of androgen levels helps in enhancing ovulation and regularizing the menstrual cycle. Studies also suggest that the 60% of women who could achieve ovulation by losing weight have higher chances of conception in the following 3-4 months. Thus weight loss and management is very important in boosting your fertility.
• Lifestyle Changes: A change in lifestyle and diet is also very important. Diet which is rich in wholegrain, fruits, vegetables and lean meat provides a lot of fiber to the body, and promotes weight loss. Processed and refined foods and foods with added sugar should be avoided as they increase the sugar content in the body and thus increase PCOS. A good diet along with regular exercise works great in managing PCOS. Regular exercise regimen also helps in keeping the insulin level under control.
• Surgery: If all the above treatments fail to give adequate results or the severity of PCOS is beyond the level to be controlled by medications, the last resort is surgery. The surgery that is usually done is ovarian drilling in which the ovary is punctured at certain sites where too many cysts are present. This helps in reducing the androgen levels and many women post ovarian drilling attains spontaneous ovulation or ovulation is attained with some additional Clomiphene medications. However, the effect of ovarian drilling often lasts only for a few months. A side effect that occurs due to this surgery is that the sites at which the puncture is done often develop scar tissue which can create complications later.
• Assisted Reproductive Technologies to Aid Fertility Problems: If the above treatments fail to give a pregnancy, these women have the boon of advanced technologies like ovulation induction, Intrauterine Insemination (IUI), In-vitro Fertilization (IVF) etc.

A healthy and wholesome diet along with regular exercise and medication can help in reducing the effects of PCOS and restore a normal life while boosting your fertility.

Even though a woman is diagnosed with PCOS, other male and female factors contributing to infertility should also be ruled out. Although polycystic ovarian syndrome has a genetic base for many, for others it might be purely due to hormonal imbalance, obesity or due to some other disorder which triggered the condition. If any other factor is also contributing to the fertility problem, those should be taken care of alongside PCOS. Thus, a conservative, integrative and a combination of treatment can very effectively manage polycystic ovarian syndrome, its effect on fertility and also the long term threat it can bring in a woman’s life like cancer.

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