If you have polycystic ovary syndrome and you are thinking about having a baby, the first thing to know is that PCOS and fertility are not opposites. PCOS is one of the most common reasons women need some help to conceive, and it is also one of the most treatable. Most women with PCOS who want a child will have one, and many will do so with tablets rather than anything more involved.
This guide explains how PCOS affects your chances, how it is diagnosed, the treatment options in the order a specialist would consider them, and what the success rates look like at each step.
How does PCOS affect fertility?
Mainly by interrupting ovulation. In a typical cycle one follicle in the ovary matures and releases an egg roughly once a month. In PCOS, a hormonal imbalance, often involving higher levels of luteinising hormone (LH) and insulin, means many small follicles start to develop but none reaches the point of releasing an egg. Without regular ovulation there is no regular window in which you can conceive.
That is why irregular, infrequent or absent periods are the most common fertility-related sign of PCOS. If your cycles are longer than 35 days, or you have fewer than eight or nine periods a year, you are probably not ovulating every month. Some women with PCOS do ovulate, just less predictably.
PCOS affects around one in ten women in the UK, according to the NHS, and it is the single most common cause of ovulation problems. It does not usually affect the fallopian tubes or the womb, and egg numbers are often good. The task is usually to get ovulation started, not to work around damage.
Does PCOS mean you cannot get pregnant?
No. PCOS lowers the chance of conceiving in any given month because ovulation is unreliable, but it does not remove the possibility. Many women with PCOS conceive naturally, and the great majority of those who need help respond to the simplest treatments.
There is one practical difference from the usual advice to try for a year before seeking help. If you have PCOS and irregular cycles, the likely cause is already identifiable, so there is little to gain from waiting. Seeing a specialist after six months, or sooner if your periods are very infrequent, means treatment can start while time is on your side.
How is PCOS diagnosed?
By meeting two of three criteria, known as the Rotterdam criteria, once other causes of similar symptoms have been ruled out:
Irregular or absent ovulation, usually shown by irregular or missing periods.
Signs of higher than usual levels of androgens (male-type hormones), either on a blood test or as symptoms such as excess hair growth, acne or thinning scalp hair.
Polycystic ovaries on an ultrasound scan, meaning a higher than usual number of small follicles, or a raised AMH level in adults, which international guidance now accepts as an alternative to the scan.
Two points confuse people. Polycystic ovaries on a scan alone is not PCOS; around one in five women have ovaries that look this way without the syndrome. And you do not need to be overweight to have PCOS: many women with the condition are a healthy weight, and the diagnosis rests on the criteria above, not on appearance.
At a fertility consultation the assessment usually includes hormone blood tests timed to your cycle, thyroid and prolactin checks, a pelvic ultrasound and, if you have a partner, a semen analysis. A consultant specialising in PCOS treatment will also look for features such as insulin resistance that shape which option to try first.
Treatment options, from least to most invasive
Fertility treatment for PCOS follows a clear ladder. Most women never need to climb past the first two rungs.
Weight, insulin resistance and lifestyle
Insulin resistance, where the body needs more insulin than usual to control blood sugar, is present in many women with PCOS regardless of weight, and higher insulin levels feed the hormonal imbalance that stops ovulation. Anything that improves insulin sensitivity can help: regular activity, a balanced diet with steady carbohydrate intake, good sleep and, in some cases, metformin.
For women who carry extra weight, a reduction of around five to ten per cent of body weight can restore ovulation in a proportion of cases and improves the response to the treatments below. This is one factor among several, not a test to pass before help is offered. PCOS makes weight harder to manage, not easier, so a specialist will discuss lifestyle alongside treatment rather than instead of it. Our nutrition and complementary therapies service offers dietitian-led support for exactly this reason.
Ovulation induction
Ovulation induction uses tablets to prompt the ovary to mature and release an egg, and it is the first-line medical treatment for PCOS. The two drugs used are letrozole and clomifene. The international PCOS guideline, which the RCOG endorses, and current UK practice in line with NICE fertility guidance now favour letrozole as the first choice, because it produces slightly higher live birth rates and fewer twin pregnancies than clomifene. Clomifene remains a well-established alternative.
The tablets are taken for five days early in the cycle, with a scan around day 10 to 12 to confirm a follicle is developing and that only one or two are responding. Around three quarters of women with PCOS ovulate on these tablets, and treatment is usually offered for up to six ovulatory cycles. If tablets do not work, the next step is low-dose injections of follicle stimulating hormone (gonadotrophins), which are very effective but need closer monitoring because of the risk of a multiple pregnancy. You can read more about how we approach ovulation induction and IUI.
IUI
Intrauterine insemination (IUI) places prepared sperm directly into the womb around the time of ovulation. It does not treat PCOS itself, but it is often added to ovulation induction when there is also a mild male factor, when timing has been difficult, or when donor sperm is being used. Where sperm results are normal, well-timed intercourse in a stimulated cycle is usually just as effective.
Laparoscopic ovarian drilling
Laparoscopic ovarian drilling is a keyhole procedure in which the surgeon makes a small number of tiny punctures in the surface of each ovary using heat or laser. It reduces the ovary’s production of androgens and can restore regular ovulation for months or years afterwards. NICE recommends it as an option for women who have not ovulated on clomifene, and it has one clear advantage over injections: it does not increase the chance of twins. It is a day case under general anaesthetic, carried out by our laparoscopic surgery team.
IVF
IVF becomes the right option when ovulation induction has not led to a pregnancy after a reasonable number of cycles, when there is another factor such as blocked tubes or a significant sperm problem, or when time is a concern. Women with PCOS usually respond strongly to stimulation and produce good numbers of eggs, which is an advantage, but it raises the risk of ovarian hyperstimulation syndrome (OHSS). Modern protocols manage this well with gentler stimulation, a different trigger injection and, where needed, freezing all embryos for transfer in a later cycle. Our IVF and ICSI page explains the process step by step.
What are the success rates for each option?
Higher than most people expect, and they build as you move through the options. The table gives typical ranges rather than promises.
| Treatment | Who it suits | Typical results |
|---|---|---|
| Lifestyle and insulin support | All women with PCOS, alongside other treatment | Restores ovulation in a proportion of women who carry extra weight; improves the response to every option below |
| Ovulation induction tablets (letrozole or clomifene) | First line where tubes are open and sperm results are normal | Ovulation in around 70 to 80% of women; pregnancy in roughly 30 to 40% over six cycles, higher with letrozole |
| Gonadotrophin injections | Tablets have not produced ovulation | Cumulative pregnancy rates of around 40 to 50% over several cycles; needs close scan monitoring |
| IUI in a stimulated cycle | Added mild male factor, timing difficulties or donor sperm | Roughly 10 to 15% per cycle for women under 35, falling with age |
| Laparoscopic ovarian drilling | No ovulation on clomifene; wish to avoid a multiple pregnancy | Ovulation in around half of women; pregnancy rates similar to gonadotrophins over 12 months |
| IVF or ICSI | Other factors present, or earlier steps unsuccessful | Around a third of embryo transfers lead to a live birth under 35, falling with age (HFEA national data) |
These figures come from population studies and the HFEA’s national data; your own chances depend on your age, how long you have been trying and your partner’s results. In fertility terms PCOS is a good diagnosis to have: because egg supply is usually plentiful, women with PCOS tend to do at least as well as other patients of the same age once ovulation is addressed.
PCOS and miscarriage risk
Women with PCOS have a somewhat higher risk of early miscarriage than women without the condition. The reasons are not fully understood, but insulin resistance, higher LH levels and higher body weight are all thought to contribute. Keep it in proportion: the majority of pregnancies in women with PCOS continue normally.
The practical steps are the same ones that improve the chance of conceiving: improving insulin sensitivity before pregnancy and taking folic acid. PCOS also raises the risk of gestational diabetes and high blood pressure in pregnancy, which is why the RCOG advises a glucose test and closer antenatal monitoring. Tell your midwife you have PCOS at your booking appointment so this is arranged.
Frequently asked questions
Can you get pregnant naturally with PCOS?
Yes. Many women with PCOS conceive without treatment, especially if they ovulate some of the time. The difficulty is predicting when: urine ovulation tests can mislead in PCOS because LH is often raised throughout the cycle. If you have been trying for six months with irregular cycles, have ovulation checked rather than continue guessing.
Does metformin help with fertility in PCOS?
On its own, only modestly. Metformin improves insulin sensitivity and can help regulate cycles, but it is less effective than letrozole or clomifene at achieving a live birth. It is most useful alongside ovulation induction in women with insulin resistance or a higher BMI, or where clomifene alone has not worked.
How long does ovulation induction take to work?
Each cycle lasts about a month, and most women who are going to ovulate on tablets do so within the first two or three cycles, sometimes after a dose adjustment. Treatment normally continues for up to six ovulatory cycles before the next option is considered, so allow six to nine months for a full course.
Is IVF more likely to fail if you have PCOS?
No. Live birth rates from IVF in women with PCOS are similar to, and in some studies slightly higher than, those in women of the same age with other diagnoses, because PCOS usually comes with a good egg supply. The main extra consideration is the risk of over-response and OHSS, which is managed with tailored stimulation and, where appropriate, a freeze-all approach.
Does losing weight actually improve PCOS fertility?
For women carrying extra weight, yes: a modest, sustained reduction can restore ovulation in some women and improves the response to treatment in most. It is not a prerequisite for help, and it is not relevant if you are already a healthy weight. Treat it as one part of a plan agreed with your specialist, ideally with dietetic support, rather than something to attempt alone first.
About the reviewer
Dr Edmond Edi-Osagie is a Consultant Gynaecologist and the Medical Director of Aurora Healthcare, with more than 20 years’ experience in assisted conception and advanced laparoscopic surgery. He established and leads the BSGE-accredited endometriosis centre at Aurora and is a Senior Lecturer in Gynaecology at the University of Manchester.
A plan built around your PCOS, not a generic one
PCOS affects everyone differently, and the right first step depends on your cycles, your hormone results, your age and your partner’s results together. If you would like to know where you stand, book a consultation with our Manchester team. There is no obligation to go ahead with treatment, and for many women the answer is simpler than they feared.
