Everything You Need to Know about PCOS and IVF

Polycystic ovarian syndrome (PCOS) is a reproductive hormone condition that affects between 6% to 13% of women. However, the World Health Organization reports that up to 70% of those with PCOS aren’t yet diagnosed. If you have PCOS, you might have irregular periods, don’t ovulate regularly, and might have trouble getting pregnant. PCOS is the most common reason women experience infertility.

Fortunately, PCOS is a well-studied cause of infertility and can usually be treated successfully. While first-line treatments such as Letrozole or Clomid with intercourse or intrauterine insemination (IUI) often can be enough to achieve pregnancy, this article will focus on treating PCOS with in vitro fertilization (IVF).

What is PCOS?

PCOS can look different for everyone. You might have different symptoms than someone else with the same diagnosis, and your lab values can also differ. PCOS is a complex health condition. There isn’t one test or lab value that can tell you if you have PCOS. Instead, your fertility specialist will do a physical exam, blood tests, and ultrasound to make a diagnosis.

To be diagnosed with PCOS, you need to meet two of the three criteria:

1. Higher than normal levels of androgens in your blood. 
2. Irregular or missed periods because you’re not ovulating. 
3. Numerous small cysts on the ovaries that can be seen on an ultrasound. In 2023, the American Society of Reproductive Medicine amended these guidelines to include the use of anti-mullerian hormone (AMH) in testing. An AMH blood test can replace the need for an ultrasound since having a higher-than-normal AMH level might show you have PCOS.

Can I do IVF if I have PCOS?

IVF usually isn’t the initial step for treatment in getting pregnant when you have PCOS, unless there are other fertility concerns such as poor sperm quality in a male partner. You might try other treatment cycles first using fertility medications such as Letrozole or Clomid, in combination with timed intercourse or IUI. But in some cases, IVF can be necessary to become pregnant.  

Deciding to do IVF can seem overwhelming. It’s more expensive than other fertility treatments but is also one of the most successful in achieving pregnancy. When you use fertility medications in timed intercourse or IUI cycles, there is a risk of the follicles releasing more than one egg at once, which increases the chances of multiples. In IVF, you can get many high-quality embryos each cycle, where you can then freeze and transfer back one at a time as necessary. IVF treatment protocols can also be personalized to you and your needs to have the best chances of a successful pregnancy.  

IVF protocols for PCOS

During IVF, medications help stimulate the ovaries to make multiple mature eggs. The most common IVF protocols for PCOS are low-stimulation antagonist protocols. Higher stimulation antagonist protocols, as well as downregulation protocols, are other options, but they are not as common. Letrozole can reduce the chances of multiple pregnancies compared with gonadotropins.  

Low Stimulation Antagonist Protocols (Mini IVF) 

Antagonist protocols use gonadotropins (FSH and sometimes LH) for around 10 days to stimulate egg growth. Gonadotropin-releasing hormone (GnRH) antagonists are added around the 6th day to prevent premature ovulation.

Mini IVF is a non-standardized term used to describe an IVF protocol that uses a low dose of FSH and or Clomid/Letrozole to stimulate the ovaries. The goal of mini IVF is to make slightly less mature eggs than a standard protocol but prevent overstimulating the ovaries, which those with PCOS are at high risk for. Mini IVF is also substantially lower in cost compared to traditional IVF protocols.

CNY Fertility commonly uses two mini IVF protocols for those with PCOS. Both of these protocols are the same outside of the addition of LH to one of them. 

• Mini Protocol 1: This protocol uses FSH (for about 10 days) and Letrozole (for about 5 days) to stimulate egg development.  Once your fertility provider sees the eggs are at a good size, a GnRH antagonist like Cetrotide or Ganirelix will be used to prevent the eggs from ovulating before the IVF egg retrieval.
• Mini Protocol 2: Same as the above, only LH is also taken for 10 days alongside FSH. This can come in the form of a Micro-dose hCG injection or Menopur.

Down-regulation protocol

Down-regulation protocols are rarely used today due to their inefficiency and risks when compared to well-controlled antagonist protocols.

Down-regulation protocols involve taking a medication called Lupron, starting the cycle before the IVF cycle, and continuing during the use of FSH to “downregulate” the hormones and prevent the eggs from ovulating too early. 

This may be beneficial for some, but requires more injections, is generally costlier, and can increase the chances of ovarian hyperstimulation (OHSS). OHSS is a serious medical condition where the ovaries make too many follicles. The ovaries can swell, leaking fluid into other areas of the body. If you have PCOS, your ovaries are already likely producing too many follicles. People with PCOS also tend to have high AMH levels which increases the chances of OHSS as well.  

If you have PCOS and are using a down-regulation protocol, your fertility provider might add a medication such as metformin to help prevent OHSS. It’s also why it may be safer to do a low stimulation protocol instead.

PCOS and IVF success rates

For many people with PCOS, IVF is successful. But since PCOS can be a complex diagnosis, there are different factors to consider when it comes to your chances of pregnancy. 

IVF success rates from 2020 data from the Society for Assisted Reproductive Technology (SART) show that for IVF in women under age 35, the percentage of life births using the person’s own eggs is about 51%. The percentage decreases as your age goes up. In women ages 38 to 40, the percentage is about 25%. So what does this mean for people with PCOS?

The good news is, a study in the journal Fertility and Sterility found the pregnancy rates in people with PCOS were similar in those without PCOS.

However, researchers also uncovered that while a “high” AMH can show you have a lot of eggs to use, those with PCOS and very high AMH levels may have a harder time getting pregnant. Confusingly, while those with PCOS tend to have higher AMH levels than the general population, AMH levels decrease more rapidly with age in those with PCOS. Low AMH numbers might mean you have a lower egg supply, which can also make getting pregnant more challenging.

The Bottom Line on PCOS and IVF

Having PCOS doesn’t mean you can’t get pregnant. There are many treatment options available, including IVF, and working with your care team can help you manage your symptoms, take charge of your fertility, and get pregnant. 

Give us a call today or request an appointment online with one of our CNY Fertility specialists. We’ll review your options and develop a treatment plan tailored to you and your family.