Some researchers in America have again put to test the theory that if a woman with PCOS loses weight than she is more likely to get pregnant. Yes, this isn’t anything new, but the research is new and has compared the effectiveness of losing weight on fertility to one of the old favourites of fertility specialists out there, the oral contraceptive pill.
There has been a lot of information published on polycystic ovary syndrome (PCOS) both on the internet in general and in peer reviewed journal articles in specific. And this is probably because there seem to be a lot of women who have it with incidence reported at being up to 15% in women of child bearing years (1).
THE STUFF YOU PROBABLY KNOW ABOUT PCOS
Most of the ladies here will be familiar with the diagnostic criteria for PCOS but just to give a quick recap, PCOS is a syndrome that is diagnosed when a woman has 2 out of the following:
- High levels of androgens (male hormones). This is why women with PCOS can have too much body of facial hair, thinning on the scalp or acne
- Ovulation that is either absent, irregular or takes its sweet time. Generally menstrual cycles longer than 35 days are counted as fulfilling one of the diagnostic criteria
- Enlarged ovaries with many small cyst, often forming a ‘chain’ around the ovary, obviously you would generally only find this if you have a scan… and you are likely to only of had a scan if something has already aroused your suspicion to seek medical advice (2)
THE VISCOUS CYCLE
The characteristics of PCOS mean that women can be overweight and can have insensitivity to insulin (but not always). You may recall that insulin is the hormone that helps the cells absorb glucose from our blood. When insulin resistance occurs this means that more insulin is needed to absorb the same amount of sugar, this gets into a vicious cycle that means sugar levels and insulin levels climb and climb (as does your weight and stored fat) ultimately leading to metabolic changes and an imbalance in your sex hormones such as estrogen. This stops ovulation whilst at the same time the insulin stimulates your ovaries to over produce male hormones. It’s like a double whammy and in there the extra fat you have laid down also starts to produce androgens again adding to the viscous cycle (2)
Treatment for PCOS will often focus on treating the symptom that the presenting woman is concerned about and doesn’t really tend to focus on fixing the underlying hormonal changes. When the presenting issue is infertility (why else are we here?!?) there can be a number of suggestions. Following the medical model (and there are many natural, complementary therapy alternatives out there) the first line of treatment is ovulation induction (3). The problem with this though is that women with PCOS can fail to ovulate at all and underlying mechanisms of insulin resistance is not addressed. IVF is another option though women with PCOS can be very sensitive to injectable hormones meaning that it can be difficult to find the ideal quantity that will produce a good quantity and quality of mature eggs on collection day. For example, you may be doing an IVF cycle and be prescribed 100 units of Gonal F. On day 7 when you have your first lot of bloods taken your estrogen may not really be moving, say the Gonal F gets increased to 125 units, which is still a small increase this may be over the tipping point for you and your oestrogen may have increased much more than anticipated which potentially puts the quality of the eggs in jeopardy… see the balancing act that is needed?
WHATS WITH THE NEW RESEARCH THOUGH?
Because of these reasons, and many others, attention is often, but perhaps not often enough, turned to improving precycle health. That is it is much better to try and improve your health before going into a cycle to try and level out those hormone levels, reduce the number of antral follicles that are ready to go (and muck up oestrogen levels) and ultimately get a few good quality eggs. And lets face it a few good quality eggs are much much better then the 10 plus eggs that women with PCOS can easily get sometimes. AND THAT IS WHERE THE NEW RESEARCH COMES INTO IT. I took too long to get there huh? I knew it. Legro and his colleagues completed this study to compare the effectiveness of two of the main preconceptive treatments out there for women with PCOS. That is comparing weight loss against the oral contraceptive pill (OCP).
Women with PCOS are often placed on the pill in order to suppress the ovaries, get those pesky antral follicles under control and lower the levels of androgens in the blood. Additionally, women are also often recommended to lose weight for many reasons , one being to try and improve insulin resistance and attack the vicious cycle that way. But which is better? It may come as no surprise but in this study hands down the women in the group that modified their lifestyle and lost weight had better outcomes than those that were taking the pill. And what was this outcome? LIVE BIRTH RATES! The holy grail of fertility treatments and an outcome measure that is not used anywhere near enough (researchers tend to settle for ‘ongoing pregnancy rates’ a lot of the time it seems). Although it was a small study with only 149 participants, these women were randomly categorised into one of three preconception arms for 16 weeks:
- Life style intervention with the goal of achieving 7% weight loss reduction. Interestingly, as well as implementing calorie limitation (between 1200 to 2000 calories depending on weight) and physical exercise they also implemented orlistat (generic name Alli) for women with a BMI of over 30. Whilst in a perfect world a healthy diet and physical exercise would do the trick for larger women the reasons for their increased weight can be multifactorial, insulin resistance makes it harder to lose weight, it is often more difficult for larger ladies to do physical exercise and sometimes there are also psychological reasons for putting weight on. Implementing the weightloss drug in this way stimulates weightloss and gives the ladies help to lose weight which also increase motivation and compliance to the regime. Who doesn’t get inspired to continue on the weight loss path when you can see the number on the scales actually going down?
- Oral contraceptive pill taken continuously over the 16 weeks
- Both. That is they received a lifestyle intervention AND the oral contraceptive pill
After only four cycles of timed intercourse, of the 49 women on the contraceptive pill only, five gave birth. This was in comparison to 13 out of 50 women in the lifestyle intervention and 12 out of 50 in the combination category.
What this shows is what we really deep down already know and that is that by exercising and reducing your weight by the targeted 7% its going to increase your chances of a live birth over taking the oral contraceptive pill. It is definitely easier said than done but what I liked about this study was the openness the researchers had to alternatives in helping women lose the weight. As we said, in a perfect world diet and exercise would be enough but sometimes a helping hand is needed and when the outcome is one of those take home babies then the more help the better!
- Agency for Health care Research and Quality http://www.ahrq.gov/news/newsletters/research-activities/13sep/0913RA34.html
- Chevarro, J. & Willett, W. 2009. The Fertility Diet. McGraw Hill Publishers.
- Legro, R., Dodson, W., Kris-Etherton, P., Kunselman, A., Stetter, C., Williams, N., Gnatuk, C., Estes, S., Fleming, J., Allison, K., Sarwer, D., Coutifaris, C. & Dokras, A. 2015 Randomized Controlled Trial of Preconception Interventions in Infertile Women With Polycystic Ovary Syndrome. Journal of Clinical Endocrinology and Metabolism.