Hormonal status:

• increased LH values
• ​​normal or decreased FSH; ratio LH:FSH close to 2:1
• ​​increased androgen (male) hormone levels ​​– testosterone
• normal or decreased estrogen
• ​​increased AMH levels

PCOS is caused by a combination of genetic and environmental factors. Risk factors are  obesity, lack of physical activity and the history of the disease in the family. 

Two of the following three signs are required to make the diagnosis: 

• absence of  ovulation
• elevated levels of  androgens  in the blood
• ovarian cysts.  

The presence of ovarian cysts can be determined by  ultrasound imaging. Similar symptoms are  found also in adrenal hyperplasia,  hypothyroidism  and  high levels of prolactin in the blood.

PCOS and fertility

Although PCOS can be a major obstacle to conceiving and is one of the most common causes of infertility in women, pregnancy is completely possible.

Women with PCOS produce too many androgens or male hormones (testosterone), which have a negative effect on ovulation. Thus, ovulation and periods are irregular or even completely absent.

We know several different phenotypes of PCOS, among which ovulatory PCOS can also be found. Similarly, with other phenotypes, despite oligo-anovulation (irregular ovulation), ovulation can still occur. Basically, this means that spontaneous conception is possible, but extremely difficult, and a couple can try for several years in such a situation. There are pharmacological and surgical treatments for PCOS, and some can be done by the patient herself. 

Pharmacological treatment of PCOS 

Treatment of PCOS mainly includes treatment or relief of the symptoms that the syndrome can cause – hirsutism (excessive hair growth), obesity, acne, irregular ovulation and/or menstruation.

Further approaches are most often used to regulate the menstrual cycle:

• combined contraceptive pills – contain estrogen and progestin and work by lowering the levels of androgenic (male) hormones and in this way regulate irregular bleeding, acne and hair growth, and at the same time also serve as contraception
• progestin (e.g. Dabroston) – does not protect against pregnancy and does not reduce the value of androgenic hormones, but helps regulate the cycle or triggers menstruation

The following can be used to help with ovulation:

• clomiphene (e.g. Clomid) – an anti-estrogen drug taken during the first part of the cycle; helps to or enables ovulation; 
• letrozole (e.g. Femara) is a drug registered for hormone-responsive breast cancer, which also has an anti-estrogenic effect and enables ovulation;
• metformin (e.g. Aglurab) is a drug used for treatment of diabetes, which can help women with PCOS to control their insulin levels or insulin resistance and protects against the development of type 2 diabetes; it also has a positive effect on fertility and can help with conception
• Gonadotropins (e.g. Gonal F) – hormones used to stimulate the ovaries as part of MAR procedures

Until 2019, clomiphene was prescribed as the drug of choice, while the new guidelines favor letrozole due to the following advantages:

• letrozole achieves a higher cumulative ovulation rate in women (61.7% vs. 48.3%)
• a higher rate of live births is achieved (27.5% vs. 19.1%)
• the conception rate is significantly better (61% vs. 43 %)
• a lower rate of multiple pregnancies
• no negative effect on the endometrium (thinning of the endometrium) because letrozole does not act on estrogen receptors
• fewer treatment cycles (3-5 cycles) needed to get pregnant compared to  clomiphene (4-7 cycles)
• letrozole is already used in women who develop resistance to clomiphene (even higher doses) and achieves very good results

Surgical treatment of PCOS – ovarian drilling

Ovarian drilling or laparoscopic electrocauterization of the ovaries (LEKO) is a procedure that is performed under general anesthesia and takes about 30 minutes. The operator makes 4-6 punctures into each ovary with a monopolar needle.

It is recommended for women with PCOS who, despite losing excess body weight (reducing BMI) and hormone therapy (Clomid, Femara), fail to ovulate. When the holes are created, the harder outer tissue of the ovary is penetrated and consequently lowers the level of testosterone, LH and the ratio between LH and FSH. All of these can lead to spontaneous ovulation and potential pregnancy.

The success rate of the procedure has a wide range (about 35 % to 80 %) and varies from woman to woman. The procedure has shown to be more successful in women who were under 35 years and of normal weight, and had an AFC (antral follicle count) of less than 50.

Lifestyle and PCOS – exercise

The loss of excess body weight or controlled body weight is extremely important. Even losing 5% of body weight can show extremely positive effect and can reduce insulin resistance and improve hormonal imbalance, which in turn means better fertility and better overall health and well-being of a woman.

Losing 10% of body weight can even establish regular menstrual cycles with more frequent ovulations in some women and thus enable or improves the chances of spontaneous conception.

Losing weight in PCOS is more difficult than in healthy individuals, but it is possible. Sufficient excercise is extremely important.

Weight loss can be achieved with gradual, small changes in your daily life. Exercising after a meal helps lower blood insulin levels, which is extremely important for women with PCOS, who are prone to insulin resistance and developing type 2 diabetes.

Lifestyle and PCOS – nutrition

The disease is characterized by insulin resistance or decrease of sensitivity of insulin receptors. Insulin is a hormone produced in the pancreas that helps cells in the body convert sugar (glucose) into energy. Women with PCOS often have higher insulin levels. If the body does not produce enough insulin or insulin resistance has developed, blood sugar levels may increase. Too much insulin, however, can cause the ovaries to produce even more androgenic (male) hormones, such as testosterone. 

To affect your metabolism, you may:

• give up on:
• foods with a high content of refined carbohydrates (white bread, pastries, biscuits, pastries)
• foods and drinks with a high sugar content
• foods that support the inflammatory processes in the body (processed food, processed meat such as hot dogs, salami; red, fatty meat)
• Include in the diet:
• vegetables or foods with a high fiber content (broccoli, cauliflower, red and green peppers, beans and lentils, pumpkin, sweet potatoes, berries, almonds,…)
• a good source of protein, especially lean meat (chicken, fish)
• foods with beneficial effect on inflammatory processes in the body (tomatoes, olive oil, fatty fish and foods with a high content of omega 3 fatty acids, berries, turmeric,…)