Numerous strategies are available for women with PCOS wishing to achieve pregnancy.

For overweight women, simply losing 10-15% of total weight may be enough to allow spontaneous ovulation to occur. If so, then fertility medications would not be needed.

If fertility medications are required, the first and simplest step is to use the fertility pill Clomid (Clomiphene Citrate). We typically start treatment with the lowest dose (50 mg/day), and once a dose which achieves ovulation is determined, we remain on this dose for future cycles.

If ovulation is not achieved using a dose of 200 mg/day, then other strategies have to be investigated. These strategies include using injectable medications (gonadotropins), which are administered using a "low-slow" protocol. When using injectable medications we must be careful to use enough mediation to have one or two eggs grow, but not so much medication that too many eggs grow. This strategy of using low doses of medications, with slow incremental increases in dosage, describes the "low-slow" protocol.

If this strategy proves ineffective, then pursuing in vitro fertilization (IVF) is the next treatment option.

In 1935, Stein and Leventhal originally described the syndrome we now call PCOS. Their strategy for treatment was to surgically reduce the size of the ovaries by performing a "wedge resection" (removing a wedge of ovarian tissue). This procedure would result in a decrease in male hormone production by the ovaries, and would allow approximately 80% of the patients to ovulate. Today, we can surgically perform a similar operation called "ovarian cautery or drilling", which is performed by laparoscopy. This procedure is a treatment option for women who fail medications (Clomid or gonadotropins), and who may not want to pursue other available options. Ovarian cautery provides approximately an 80% chance of spontaneous ovulation. Patients who are not spontaneously ovulatory may be more Clomid "sensitive". Therefore, resuming Clomid therapy may bring about ovulatory cycles after the procedure.

For patients diagnosed with insulin resistance, there is another treatment strategy. Insulin-sensitizing medications can be used to decrease insulin levels, which may help restore the normal ovarian hormone profile (i.e. reduce male hormone), thus allowing for spontaneous ovulation to occur in about 75% of patients. The most commonly used medication is Metformin (Glucophage). There are newer insulin-sensitizing medications available, though these have not been studied extensively in PCOS patients (rosiglitazone maleate (Avantia), pioglitazone hydrochloride (Actos)). Studies with Metformin indicate that most women with PCOS and IR will spontaneous ovulate after 3 months of treatment, or if not ovulatory, will become Clomid "sensitive". One must be carefully screened prior to a course of Metformin, and must be monitored during treatment. Side effects are mostly gastrointestinal (nausea, vomiting, diarrhea).

As with any endocrinologic disorder, patients need a full and complete workup with a physician experienced in that particular disorder. Your reproductive endocrinologist will review old medical records and may ask you to have additional testing. Once all of this information is available, and once a full infertility evaluation is completed (eg. semen analysis, hysterosalpingogram as needed), then treatment options can be reviewed. When you and your partner have decided on the best initial plan, we can proceed with treatment.