PCOS and Getting Pregnant: What Works, Step by Step

Polycystic ovary syndrome (PCOS) is common, and it is one of the most treatable causes of difficulty getting pregnant. The core problem for fertility is usually ovulation: when you don’t release an egg regularly, there are fewer chances to conceive each year. This guide covers how PCOS affects fertility, what to track, and the treatment order set out in the 2023 International Evidence-based PCOS Guideline, which was developed in partnership with ASRM, the Endocrine Society and ESHRE.¹

How does PCOS affect fertility?

PCOS affects an estimated 10% to 13% of women worldwide using the Rotterdam criteria.² Under the Rotterdam criteria the guideline uses, diagnosis in adults rests on two of three features: irregular cycles or ovulatory dysfunction, signs of androgen excess, and polycystic ovaries on ultrasound or a high AMH in adults.² The fertility effect comes mainly from the first: ovulation that is infrequent or absent.

The guideline defines irregular cycles, from three years after the first period until perimenopause, as cycles shorter than 21 days or longer than 35 days, or fewer than 8 cycles a year.² It also notes ovulatory dysfunction can occur even when cycles look regular, and that a serum progesterone test can confirm whether ovulation is happening.²

Can you get pregnant with PCOS?

Yes. Many people with PCOS conceive, with or without treatment. What changes is timing. ASRM says you do not need to wait the usual 12 months: diagnostic testing should start without delay with irregular cycles, infrequent periods or no periods.⁴ The guideline also advises ruling out pregnancy and starting a prenatal vitamin when ovulation induction begins.²

Tracking ovulation with PCOS

Knowing whether and when you ovulate makes everything else easier.

• LH test strips detect the hormone surge before ovulation. With long cycles you may need to test for many more days per cycle, so cost per strip matters.
• Multi-hormone monitors and temperature trackers add estrogen, progesterone metabolites or temperature to show the whole cycle.
• A luteal progesterone blood test is the simplest confirmation. ASRM says a progesterone level above 3 ng/mL, drawn about a week before the expected period, is presumptive evidence of ovulation.⁴

If you rarely get a period, or never see an LH surge, that is the information your clinician needs. Tracking is not a substitute for an evaluation.

Treatment: the order the guideline recommends

For people with PCOS who do not ovulate and have no other fertility factors, the 2023 guideline sets out a clear sequence.²

From the guideline’s infertility recommendations.²

Why letrozole first?

The guideline’s letrozole recommendation is based on high-quality evidence.² The landmark trial, published in the New England Journal of Medicine in 2014, randomized 750 women with PCOS to letrozole or clomiphene.³ Live births were 27.5% with letrozole and 19.1% with clomiphene, and cumulative ovulation was 61.7% versus 48.3%.³ Twin pregnancies were 3.4% with letrozole and 7.4% with clomiphene, and pregnancy loss did not differ significantly.³

Letrozole was not originally developed for fertility, and the guideline notes its use for ovulation induction remains off-label in many countries.² It is a prescription medicine: your clinician sets the dose and decides whether ultrasound monitoring is needed.

Clomiphene and metformin

Clomiphene works and has a long track record, but it raises the chance of multiple pregnancy, so cycles may need ultrasound monitoring.² Metformin on its own can be used, but the guideline says people should be told that more effective ovulation agents exist.²

When to move to IVF

IVF is third-line in PCOS, offered when first- or second-line ovulation induction has not worked.² Other findings in the workup, such as blocked tubes or a sperm problem, can change that order, which is one more reason to test both partners early. For costs and how it compares with IUI, read IUI vs IVF and IVF cost.

PCOS and AMH

People with PCOS often have a high AMH, because they have many small follicles. The 2023 guideline allows serum AMH to be used to define polycystic ovarian morphology in adults, as an alternative to ultrasound, but says it should not be used as a single test to diagnose PCOS, and not yet in adolescents.² A high AMH is not a sign of better fertility, and a normal AMH does not rule PCOS out. For what the test means more generally, see AMH explained.

What to bring to your first appointment

• Dates of your last six to twelve periods, or a note that they are absent
• Any LH test results or tracker charts, including cycles with no surge
• Any past hormone results (AMH, testosterone, TSH, prolactin)
• Your weight and blood pressure history, and any medications
• Your partner’s semen analysis, if done, or a plan to get one

That list maps onto what the guideline and ASRM ask clinicians to check before ovulation induction.²⁴

Don’t forget the other partner

PCOS explains ovulation, not everything. Before or alongside ovulation induction, a semen analysis should be part of the workup when a male partner is involved, and tubal testing may be advised.⁴ An at-home kit is an easy start, and semen analysis results explains the numbers.

Supplements and lifestyle

The guideline puts healthy lifestyle and emotional wellbeing at the center of PCOS care and asks clinicians to be aware of weight stigma.¹ Excess weight is linked with lower pregnancy and live birth rates and higher miscarriage rates after fertility treatment.² Myo-inositol is widely marketed for PCOS; read myo-inositol for fertility for the evidence. Supplements are not reviewed by the FDA before sale.

PCOS and pregnancy

The 2023 guideline considers pregnancy with PCOS higher risk, with increased rates of gestational diabetes, hypertensive disorders and preeclampsia, preterm birth, miscarriage and cesarean birth.² Assisted reproduction does not appear to add risk beyond that in people without PCOS.² Tell your prenatal team about your diagnosis so they can screen early.

When to see a doctor

With PCOS and irregular or absent periods, you can see a clinician now. ASRM’s definition of infertility also covers anyone whose history or test findings point to a problem, not only those who have tried for 12 months.⁵ Bring your cycle records and any ovulation test results. Read when to see a fertility specialist and irregular periods, and see the Investigate hub for the full workup.