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Troubling Getting Pregnant? You Might Have PCOS or Endometriosis

There are 2 medical conditions that may explain why women face infertility while lifestyle changes may lessen the struggle.

With Gloria Richard-Davis, MD, and Mary Jane Minkin, MD

Everyone talks about “what to expect when you’re expecting,” but what about when you want to be pregnant but you just can’t seem to get there. Fertility problems are one of those things we learn not to talk about, but about 12% of women of all ages are known to have difficulty conceiving or carrying the pregnancy to term.1 Two of the most common causes of fertility in women are endometriosis and polycystic ovarian syndrome (PCOS).1

To better understand how each condition impacts the ability to get and stay pregnant, EndocrineWeb spoke with two fertility experts: Gloria Richard-Davis, MD, FACOG, a specialist in infertility and reproductive endocrinology, and Mary Jane Minkin, MD, a clinical professor of obstetrics and gynecology at Yale University School of Medicine.

Can't get pregnant? PCOS or Endometriosis may be to blame.If you have been trying to get pregnant for months, ask your doctor if PCOS or endometriosis might be the cause of your infertility. Photo: 123rf.

Struggling with Infertilty—Could the Cause Be PCOS Or Endometriosis?

Endometriosis is a condition in which the tissue that lines the inside of your uterus grows outside the uterus but continues to act as it normally would: thickening, breaking down, and inducing bleeding as part of the monthly menstrual cycle.2

Three telltale symptoms of endometriosis are:

  • Painful periods (dysmenorrhea)
  • Pain with intercourse
  • Difficulty conceiving

If you experience at least two of these symptoms, you might consider discussing the need to be tested for endometriosis, says Dr. Richard-Davis. With regard to miscarriages, both doctors emphasized that endometriosis is an unlikely cause of miscarriages on its own but when occurring with at least one other sign, it may suggest the need to discuss your concerns with your healthcare provider. In addition, other signs such as heavy bleeding or bleeding between periods and pain during urination or bowel movements can also point to endometriosis. 

Polycystic ovary syndrome, more commonly known as PCOS, is a multifactorial disorder that impacts hormonal, metabolic, and reproductive functions. PCOS is characterized by what Dr. Richard-Davis calls “a very specific constellation of symptoms related to irregular menstrual cycles and excess circulating androgens.” Androgens are the sex hormones that are usually higher in men and are responsible for excessive hair growth as well as adult acne in women.

Even with Endometriosis or PCOS, Pregnancy is Not Impossible

Either way, there’s no cause for alarm. “Having endometriosis or PCOS doesn’t disqualify a woman from having a successful pregnancy; these women just may need to work harder and be more aware,” says Dr. Minkin. Both endometriosis and PCOS can interfere with ovulation, but typically only PCOS will threaten a pregnancy after conception.

Therefore, if you are concerned about infertility, the experts suggest using a home ovulation tracker (eg, First Step), or a fertility monitor; these tests assess the level of luteinizing hormone, which spikes at 24 to 48 hours prior to ovulation. This is a simple and proactive step you can take to help inform your gynecologist about the regularity of your cycles and may be a good conversation starter at your next visit.

If you do decide to do one of these tests, it’s helpful to do the test first thing in the morning, or at least the same time each time you do it. And, reduce your liquid intake for at least four hours before taking the test to get the more accurate hormone readings.

Zeroing In On Specific Effects of Endometriosis On Pregnancy

To be clear, there are a few things you should know about endometriosis and pregnancy. Endometriosis isn’t a one-size-fits-all condition. Rather, the severity of excess endometrial tissue growth, including how much excess tissue and its location, will impact the degree to which endometriosis effects pregnancy.

The first thing Dr. Minkin recommends to a patient with endometriosis who wishes to be pregnant is to attempt pregnancy on her own. “After you have tried but are still struggling to get pregnant, then we can intervene,” she says.

Hormone levels are at play. Estrogen promotes endometrial growth while progestin, which is produced during ovulation, stops this growth. When you get and stay pregnant, progestin levels stay elevated, explains Dr. Richard-Davis. So in a sense, pregnancy is the best treatment for endometriosis. That said, the first line of treatment for endometriosis symptoms is typically an oral contraceptive because it mimics the hormonal state of pregnancy, which of course, is counterproductive if you are trying to become pregnant.

For women who haven’t yet been able to conceive or who face several miscarriages, it’s important to understand that endometriosis may reduce the ability to conceive when the overgrowth of tissue blocks the fallopian tubes, preventing fertilization from taking place. In cases of mild endometriosis where there is no tubal disturbance, fertility drugs and/or insemination are often effective in supporting conception as the first line of treatment. when intervention is indicated.

The gold standard of treatment is laparoscopy, which is also the preferred procedure when diagnosing endometriosis, Dr. Richard-Davis tells EndocrineWeb.  However, the procedure is only a temporary solution since endometrial tissue likely will grow back, requiring that you explore different options with your doctor. 

As you might expect, trying to get pregnant immediately following laparoscopy may work for some women, while others may consider in vitro fertilization (IVF). In fact, IVF is very effective; with the only caveat that age is a factor. Dr. Richard-Davis sees the highest IVF success rates in patients who are under 35 years of age, although women ages 35-39 years still have good success rates. 

So if you are 40 years or over, it may take a few extra cycles of IVF treatment, and you may need to be more proactive in trying to conceive. According to a 2016 evaluation of the Assisted Reproductive Technologies Database,3 women with endometriosis at a mean age of 34.5  years had high success rates, averaging at 42.5% using IVF.

Lifestyle interventions, while not a cure for endometriosis, may help some women.  Since endometriosis is an inflammatory condition, factors that increase inflammation including stress, lack of sleep, poor diet, and excess weight, can worsen symptoms. Conversely, reducing stress, getting better quality sleep, eating whole, unprocessed foods that promote a healthy weight may help reduce symptoms of endometriosis.4

While the effectiveness of other complementary and alternative approaches remain controversial, any effort to improve your wellbeing, and reduce stress, increases the likelihood of helping, not lessening, your chances of getting and staying pregnant, say the experts.

In particular, one option that has been beneficial to many of Dr. Minkin’s patients is acupuncture. “I think it’s a pretty reasonable thing to try; after all, if it helps, great,” she says. Anything you can do to reduce tension and stress is bound to help so consider meditation, which has some supportive evidence of benefit.5

Remember, having endometriosis does not eliminate the possibility of a successful pregnancy; should you have concerns, approach your doctor with your concerns, so you can reduce your worries and get help finding a solution.

When PCOS May Challenge Your Ability to Be Pregnant

Women with PCOS may have trouble conceiving because excess circulating hormones (androgens) can inhibit ovulation. Women with PCOS also typically have insulin resistance and higher levels of insulin-like growth factor that promote androgen production, compounding the problem, by leading to weight gain and type 2 diabetes. This constellation of symptoms places women with polycystic ovary syndrome at higher risk for gestational diabetes.

While it is well known that excess weight can exacerbate the symptoms of PCOS and the hormonal imbalances driving PCOS can promote weight gain, no one knows for sure which comes first. Experts have recently termed this conundrum—metabolic inflexibility.6

One thing is certain, if you have PCOS, achieving weight loss—albeit easier said than done—represents one of the best solutions available to increase your prospects for fertility. In a recent National Institutes of Health-funded study, women who achieved modest weight loss with a change in diet and addition of exercise improved their rates of fertility substantially.6 Dr. Richard-David agrees, and suggests that her patients aim to lose just ten percent of their current body weight, which is enough to significantly increase your chances of conceiving, and improving your pregnancy outcome and that of your baby; even losing just two percent of your body weight will help.

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The usual pharmaceutical intervention to jumpstart ovulation in women diagnosed with infertility is typically clomiphene citrate, with administration of exogenous gonadotropins, as an alternative or secondary treatment.7 Because taking clomiphene typically has a negative effect on blood sugar and glucose regulation, women with PCOS may have a more difficult time staying pregnant and puts women undergoing this treatment at a higher risk for gestational diabetes. 

Adjusting Lifestyle Strategies Can Improve Fertility

As such, it bears repeating— making adjustments to improve your eating habits, and increasing your level of exercise are important lifestyle factors for women who wish to become pregnant but are struggling.

One suggestion that Dr. Richard-Davis emphasizes is that you adopt a healthy eating pattern along the lines of the Mediterranean diet. She also has a registered dietitian/nutritionist on staff in her practice so women can receive guidance in creating a personalized diet plan, which will improve the potential for successful weight loss and long-term health.

You can find a dietitian on your own by calling your insurance company and requesting the name of a few in-network dietitians, or you can search for someone at the National Academy of Nutrition and Dietetics website: eatright.org.

Recently, practitioners have begun focusing on the benefits of prescribing metformin to women with PCOS, including those with PCOS-related infertility. Metformin works by treating the hyperinsulinemia responsible for increased androgen production and helps you to maintain healthy glucose levels.8

In particular, researchers conducted a prospective cohort study over 2 years,8 following 119 women with PCOS who received metformin. All women receiving metformin showed improvements in the regularity of their menstrual cycles whether they were overweight or at a healthy weight.

Dr. Richard-Davis says that it's becoming common for doctors to prescribe a combination of metformin and fertility drugs for women who seek medical intervention for their infertility.  Finding a treatment approach that feels right to you is an important and personal choice best determined in consultation with your doctor.      

Autoimmune Diseases May Confound the Prospect of Pregnancy

Women with diabetes or other metabolic disorders are at increased risk of having other conditions that will likely add another layer of complexity to pregnancy, endometriosis, and PCOS. As if having PCOS or endometriosis isn’t enough of a challenge, women who have thyroid disorders may face an even more complicated path to pregnancy. Women who have hypothyroidism may find the effort to lose excess weight more difficult, and even subclinical hypothyroidism can interfere with ovulation.9

In exploring the reasons behind your infertility, the experts recommend that you have your thyroid hormone levels checked if you haven’t already had your blood work done. It’s important to work with your doctor to achieve a healthy thyroid function before attempting pregnancy.

Autoimmune disorders like systemic lupus can cause complications for women with endometriosis. Women who are under treatment for lupus usually receive steroids and immunosuppressant agents, which can worsen endometriosis symptoms by reducing the body’s ability to fight the growth of excess endometrial tissue. If you have these or other confounding conditions, you’ll be in good hand if you work with a team of specialists who can guide you to make decisions that are safest and most sensible for your health and pregnancy goals.

Pregnancy Planning Requires Patience, Perseverance, and Positive Lifestyle Strategies

Endometriosis and PCOS are two of the most common reasons behind infertility for some women, but neither condition bars you from pregnancy. To address your concerns, the best suggestion, say the experts, is “Be proactive.”  And while increasing age can be an additional challenge, remember that age also brings wisdom and grit. 

For women under 35 years, Dr. Minkin and Dr. Richard-Davis recommend seeing a fertility specialist after you’ve tried unsuccessfully to conceive for a full year; and for women over age 35 years, after trying to achieve pregnancy for six months.

Of course, if you are experiencing symptoms of endometriosis or PCOS, schedule an appointment with your doctor right away. It’s important to know that routine gynecological screenings do not check for PCOS or endometriosis, and often findings by ultrasound or an MRI cannot confirm a diagnosis of these conditions either.

No matter what your circumstances, play an active role in your health. Establish an approach to eating and adjust your physical activity to meet your health goals, and do ask for help if you need it. Equally important, find ways to incorporate stress-busting strategies that fit easily into your day and seek out support from friends, family, and your medical provider. Fertility is something we should all be able to talk about, rather than struggle with.

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