PCOS, or Polycystic Ovarian Syndrome, is a condition that often consists of menstrual irregularities (typically absent or sporadic menses), signs of increased androgens (hair growth, acne or hair loss) and the presence of multiple ‘cysts’ on an ovary. It’s common for women who seek treatment at a fertility clinic to have long or absent cycles secondary to delayed or lack of ovulation.
The critical part of trying to conceive is timing intercourse (or an insemination) near the time of ovulation. Obviously, if an individual is not ovulating at regular intervals—or at very delayed intervals—it can lower their chances of conceiving significantly.
The underlying mechanism causing menstrual irregularities for those with PCOS stems from the presence of an imbalance of androgens (i.e. testosterone). Although androgens are critical in the production of estrogen (a pivotal hormone involved in the menstrual cycle), an overproduction of androgens can result in an imbalance making the ovary unable to ovulate at regular intervals. Studies have shown that there is a direct correlation between insulin levels and androgen levels, indicating that elevated insulin levels result in higher levels of androgens. It is unclear which one comes first (elevated androgens leading to elevated insulin vs elevated insulin leading to elevated androgens) but we do know they are tied together, which is why Metformin was first introduced as a way to help regulate the menstrual cycle in women with PCOS.
Randomized trials have shown that in patients who aren’t ovulating regularly and have PCOS, the addition of Metformin (when compared to a placebo) helped initiate ovulation, increasing pregnancy rates. Although promising, the findings showed that it was Metformin in conjunction with diet and lifestyle changes that were the cause of these improved outcomes.
Taking Metformin, in addition to Clomid, for ovulation induction has not been clearly shown to significantly improveme outcomes, but there might be some patients who could still benefit from it.
After a careful discussion about the risks, benefits and possible side effects with your doctor, a thoughtful decision about whether Metformin—or any other treatment—is the appropriate next step for you and your fertility journey is a good idea when PCOS is part of your family-building journey.