Unexplained Infertility / PCOS

Part of my wife Molly’s and my challenges with trying to conceive are suspected to be due to some level of female primary infertility. Before we started the trying-to-conceive process, Molly had no particular reason to suspect she would have fertility problems; she had been on a contraceptive for about 10 years, not to prevent pregnancy but to stabilize her estrogen and progesterone levels, which in turn stabilized mood. Her cycles while on the contraceptive drugs were normal ~30 day cycles.

She first discontinued the contraception drugs in January 2009 in preparation for basal body temperature and ovulation tracking. After six months of normal 30-32 day cycles, she began to have irregular cycles – one was ~60 days, one was more than 80 days. The reproductive endocrinologist began speculating that perhaps she hadn’t been ovulating during every cycle.

A subsequent baseline ultrasound showed that Molly’s ovaries are polycystic in appearance, meaning there were more than a normal number of cysts along the outside of the ovary. It’s important to note that simply having polycystic-appearing ovaries is not necessarily diagnostic for Polycystic Ovarian Syndrome (PCOS) as the ovaries of normal women can also be polycystic-appearing.

According to Rotterdam Consensus1, the diagnosis of PCOS is made when at least two of the three following conditions occur simultaneously:

  1. Polycystic-appearing ovaries on ultrasound or direct inspection
  2. Clinical or biochemical signs of hyperandrogenism (high androgens such as testosterone)
  3. Oligoovulation (infrequent, irregular ovulation) or anovulation (lack of ovulation)

Most people associate PCOS with the first two criteria – polycystic-appearing ovaries with high levels of androgens. All of Molly’s bloodwork, including androgens, glucose, insulin, and thyroid hormone levels, were all normal. Therefore, a diagnosis of Unexplained Infertility was made after six intrauterine inseminations failed to produce a pregnancy. However, even though her hormone levels are normal, because Molly had polycystic-appearing ovaries as well as infrequent/irregular menstruation, she technically meets the diagnostic criteria for PCOS. These findings led us to pursue more advanced reproductive technologies faster than someone who has no other reason to believe they may have fertility problems.

1 The Rotterdam ESHRE/ASRM-sponsored PCOS consensus workshop group. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome (PCOS). Hum Reprod (2004) 19(1):41-47.

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