A link between PCOS and early loss of pregnancy was first described in the late 1980s and yet, despite this, in the past 30 years very little progress has been made. We are still not sure why women with PCOS are at greater risk of miscarrying and, perhaps more importantly for those affected, we are no closer to finding a solution. It almost goes without saying that this is an area of research that desperately needs more attention and resources. Here we explore the limited data available, discuss why the need for answers is getting greater, and suggest what you can do to maximise your chances of falling pregnant and staying pregnant.
What does the available data suggest?
Women with PCOS often struggle to conceive; in fact, the condition is considered to be one of the leading causes of infertility in females. The problem is that once pregnant, those women with PCOS are also at increased risk of going through the trauma of one, or even multiple, miscarriages.
Women with PCOS are three times more likely to miscarry than those without PCOS. There is some evidence that women who suffer recurrent miscarriages are more likely to have polycystic ovaries, but no proof that this abnormal ovarian morphology is causing pregnancy loss. There is also very little data to support the idea that increased levels of luteinising hormone or testosterone are implicated in miscarriage.
One of the biggest issues with the work that has been completed to date is that many of the studies rely on retrospective evidence. The accuracy and reproducibility of the results is dependent on participant recollection. As a result, many of the large scale reviews have deemed the evidence that is currently available to be of low quality and inconclusive. Also, the variation in the criteria used to define PCOS before the Rotterdam criteria became the gold standard in 2003, led to some inconsistencies in the association between PCOS and miscarriages.
Why does it urgently require further work?
PCOS is a medical condition that is not going to disappear any time soon. In fact, the percentage of women affected by it is likely to increase over the coming years. PCOS is strongly associated with obesity and insulin resistance; and, whilst these two conditions are increasing in prevalence across the developed world, an unfortunate consequence of this will be that more women will find themselves facing the realities of a PCOS diagnosis.
We know that women with PCOS who do conceive are at risk of further pregnancy complications, including gestational diabetes, preeclampsia and premature delivery. This is financially costly, placing an increasing burden on healthcare systems across the world; but it is also emotionally draining for those couples who have to go through it.
Experiencing a miscarriage can be a devastating experience. There can never be a right or wrong way of coping with and managing your loss. However, for many women, closure, or acceptance, is possible once they understand why something has happened. We need to improve our knowledge on PCOS and pregnancy; we need to better understand why PCOS increases the risk of miscarriage; and, perhaps above all, we need to give those women who have experienced a loss, answers.
What can you do to manage your risk and increase your chances of a healthy pregnancy?
As already discussed, there is significant work to be done in this field. Some reports have suggested that ovulation induction agents, such as clomiphene citrate and metformin, might improve live birth rates. In fact, metformin is not strictly an ovulation inducer, it is used to treat insulin resistance, and has, therefore, been used ‘off-label’ to manage some of the symptoms of PCOS. There is limited evidence that it improves ovulation rates. There is no solid evidence that either of these drugs reduce the risk of miscarriage and the data across different studies remains conflicting.
Whilst this may all be sounding a little depressing, there is one key thing that should be remembered; many of the symptoms of PCOS can be alleviated by making healthy lifestyle decisions. Losing weight, exercising more, making considered choices with regards to your diet, these are all things that can help to improve menstrual cycle regularity. This in turn, increases your chances of getting, and staying, pregnant.
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- Cocksedge Karen, et al., “How common is polycystic ovary syndrome in recurrent miscarriage?” Reproductive Biomedicine Online, 2009 Oct;19(4):572-6. doi: 10.1016/j.rbmo.2009.06.003. PMID: 19909600.
- “Does PCOS Affect Pregnancy?” Eunice Kennedy Shriver National Institute of Child Health and Human Development, U.S. Department of Health and Human Services, www.nichd.nih.gov/health/topics/pcos/more_information/FAQs/pregnancy.
- Kaur, R and Gupta, K. “Endocrine Dysfunction and Recurrent Spontaneous Abortion: An Overview.” International Journal of Applied and Basic Medical Research, vol. 6, no. 2, 2016, pp. 79–83., doi:10.4103/2229-516x.179024.
- Legro, Richard S., et al. “Clomiphene, Metformin, or Both for Infertility in the Polycystic Ovary Syndrome.” New England Journal of Medicine, vol. 356, no. 6, 8 Feb. 2007, pp. 551–566., doi:10.1056/nejmoa063971.
- Mills, Ginevra, et al. “Associations between Polycystic Ovary Syndrome and Adverse Obstetric and Neonatal Outcomes: a Population Study of 9.1 Million Births.” Human Reproduction, vol. 35, no. 8, 9 July 2020, pp. 1914–1921., doi:10.1093/humrep/deaa144.
- Rai, Raj, et al. “Polycystic Ovaries and Recurrent Miscarriage—a Reappraisal.” Human Reproduction, vol. 15, no. 3, 1 Mar. 2000, pp. 612–615., doi:10.1093/humrep/15.3.612.
- Sagle, M., et al. “Recurrent Early Miscarriage and Polycystic Ovaries.” Bmj, vol. 297, no. 6655, 22 Oct. 1988, pp. 1027–1028., doi:10.1136/bmj.297.6655.1027.
- Sharpe, Abigail, et al. “Metformin for Ovulation Induction (Excluding Gonadotrophins) in Women with Polycystic Ovary Syndrome.” Cochrane Database of Systematic Reviews, 17 Dec. 2019, doi:10.1002/14651858.cd013505.