General tips for improving fertility

• Ovulation (the release of an egg from the ovary) needs to be monitored and sexual intercourse timed to coincide around ovulation.
• Over-the-counter kits are available to measure Luteinising Hormone (LH), which increases during ovulation and can guide prediction of ovulation (note: if your cycles are irregular, LH tests are not always effective).
• Temperature charting can show ovulation change but is not as reliable an indicator
• A progesterone level taken about seven days after expected ovulation will determine if ovulation has occurred (day 21 progesterone in a 28 day cycle).
• If ovulation is irregular, even modest lifestyle change (exercising 40 minutes three times a week) and weight loss can effectively improve ovulation (Lifestyle Management of PCOS).
• Obesity increases both infertility and risks during pregnancy.  It is critical to avoid further weight gain if overweight and to optimise weight loss prior to pregnancy.
• Referral to a fertility specialist is necessary for further treatment if these strategies are not successful.

Ovulation induction

Medications to induce ovulation may be required. Ovulation induction is the use of medication to stimulate the ovary to increase egg production.

Ovulation induction uses follicle stimulating hormone which is injected into the stomach over a period of time. Ultrasounds and blood tests are performed to determine the best time to trigger ovulation by using a hormone called HCG. Timed intercourse or interuterine insemination is then performed to try to achieve a pregnancy.

Clomiphene citrate

The most common medication for ovulation induction is clomiphene citrate. This is used early in the menstrual cycle to increase the chances of an egg being released by the ovary  which can then be fertilised naturally. Clomiphene citrate can be used either by itself or in combination with other drugs (such as insulin sensitisers (metformin)) to increase its effectiveness.

Possible side effects

Clomiphene citrate has some potential problems associated with it. It can be associated with a higher risk of multiple births (twins, triplets) as more than one egg often develops. There is also a small, but increased risk of ovarian cancer associated with its use long-term so it should only be used in the short-term (no longer than six to nine months).

There may be some physical and emotional side effects associated with use of clomiphene citrate including:

• Headaches
• Blurred vision
• Mood swings

Not all women with PCOS are responsive to clomiphene citrate and may have to use combinations of clomiphene with other drugs (such as metformin) to gain the most benefit.

Assisted reproductive technology

For women who have not been able to conceive naturally or by using medications or lifestyle treatment to improve their fertility, another option is assisted reproductive technology. This includes treatments such as IVF (in vitro fertilisation). Referral to a fertility specialist is necessary for these treatments.

Assisted reproductive technology is best tried after other less intensive treatments (lifestyle or medical) have proved unsuccessful, as it is often costly and demanding. This technology is also more successful in women who have instituted lifestyle change effectively first, even if these changes have not improved fertility by themselves. For example, it has been shown that overweight women with PCOS who lose a modest amount of weight (5–10 kg) before starting assisted reproductive technology have greater success than those who do not.

Gonadotrophins (follicle-stimulating hormone (FSH), luteinsing hormone (LH) or human chorionic gonadotrophin (hCG)) are other treatments that can be used to stimulate growth and ovulation of eggs. These are more intensive treatments as they involve injection of the medication and careful monitoring of the ovary by ultrasound to avoid over stimulation of the ovary.

Metformin (an insulin sensitising drug used to treat type 2 diabetes) also increases menstrual regularity and ovulation.

Surgery for improving fertility

Ovarian drilling is a surgical procedure that can increase ovulation. This is performed laparoscopically (a minimally invasive procedure through an incision in the abdomen) under a general anaesthetic. Small holes are drilled in the surface of the ovary to remove tissue that produces excessive amounts of male hormones (androgens such as testosterone). Following ovarian drilling, ovulation is often restored for up to 6-12 months.

Possible side effects

Side effects associated with ovarian drilling include a small risk of scar formation around the ovaries and damage to the bladder, bowel or blood vessels. As surgery is a more intensive treatment than taking medication or lifestyle treatment, ovarian drilling is not commonly used today and is primarily used after other lifestyle or medical treatment has proved ineffective.

Content updated July 31, 2009