Understanding PCOS
Polycystic ovary syndrome is one of the most common endocrine disorders affecting women of reproductive age, with an estimated prevalence of 8 to 13 per cent worldwide and notably higher rates reported across the Gulf region. Despite its name, PCOS is not fundamentally a disease of the ovaries alone; it is a metabolic and hormonal condition in which the ovaries, the pituitary gland, and the body’s response to insulin interact in a way that disrupts the ovulatory cycle.
Diagnosis is generally made using the Rotterdam criteria, which require at least two of the following three features: irregular or absent ovulation, clinical or biochemical evidence of elevated androgens, and polycystic-appearing ovaries on ultrasound. Importantly, a woman may have polycystic ovaries on a scan without having the syndrome, which is why diagnosis should always be made by a specialist rather than by imaging alone.
How PCOS Affects Fertility
The central fertility challenge in PCOS is anovulation — the failure to release a mature egg each month. Follicles begin to develop but stall before reaching full maturity, leaving the ovary with multiple small antral follicles and no dominant follicle. Without ovulation, natural conception cannot occur.
Insulin resistance compounds the problem in a substantial proportion of patients. Elevated insulin levels stimulate ovarian androgen production and suppress the liver’s production of sex hormone-binding globulin, raising free testosterone. This hormonal environment further impairs follicular maturation and is associated with irregular cycles, weight gain, acne, and excess hair growth.
First-Line Treatment Before IVF
IVF is not the first step for most women with PCOS. Where body mass index is elevated, a modest weight reduction of five to ten per cent can restore spontaneous ovulation in a meaningful number of patients and improves the response to all subsequent treatments. Structured dietary change and regular physical activity remain the foundation of care.
Pharmacological ovulation induction follows. Letrozole, an aromatase inhibitor, is now recommended internationally as the first-line agent, having demonstrated higher live birth rates than clomiphene citrate in women with PCOS. Metformin may be added where insulin resistance is documented. If several cycles of ovulation induction, with or without intrauterine insemination, do not achieve pregnancy, IVF becomes the appropriate next step.
IVF in Women with PCOS
Women with PCOS generally have a large ovarian reserve and respond strongly to stimulation, which is both an advantage and a risk. Egg yields are often high, but so is the risk of ovarian hyperstimulation syndrome (OHSS), a potentially serious complication in which the ovaries become swollen and fluid shifts into the abdominal cavity.
Modern protocols have made OHSS largely preventable. An antagonist protocol combined with a GnRH agonist trigger instead of hCG dramatically reduces risk. Where a high response is anticipated, many specialists adopt a freeze-all strategy: all viable embryos are vitrified and transferred in a later, carefully prepared frozen cycle, allowing hormone levels to normalise first. Evidence suggests this approach yields comparable or superior live birth rates in PCOS patients while substantially improving safety.
In vitro maturation (IVM), in which immature eggs are retrieved and matured in the laboratory, offers another option for selected high-risk patients, as it requires minimal or no stimulation.
Outcomes and Expectations
The outlook is encouraging. Cumulative live birth rates for women with PCOS undergoing IVF are comparable to, and in some studies better than, those of age-matched women without the condition, reflecting the larger number of eggs and embryos typically available. Age remains the strongest single predictor of success, which is why early assessment is valuable.
Patients with PCOS should also be screened for glucose intolerance, blood pressure, and lipid abnormalities before pregnancy, as the condition carries an elevated risk of gestational diabetes and hypertensive disorders. Addressing these factors in advance improves both the chance of conception and the safety of the pregnancy that follows.
When to Seek Help
Any woman with cycles consistently longer than 35 days, fewer than eight periods a year, or absent periods should be evaluated, particularly if she is trying to conceive. Women under 35 are generally advised to seek assessment after 12 months of unsuccessful attempts, and those over 35 after six months — but with known cycle irregularity, there is no reason to wait.
At New Hope IVF Hospital in Sharjah, our reproductive endocrinology team provides comprehensive PCOS assessment, individualised ovulation induction, and safety-optimised IVF protocols tailored to each patient’s metabolic and hormonal profile.