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IVF Therapy for Women With PCOS

Zoie Davis, Megan Kidd, Ava LaGamba, Jennifer Reebel, Andreanna Tocicki

Centofanti School of Nursing, Youngstown State University

NURS 3749: Nursing Research

Dr. Danielle Class

April 9, 2023
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Introduction

Polycystic ovary syndrome (PCOS) is a condition that causes chronic anovulation often

as a result of reproductive hormonal imbalance. Anovulation occurs when the ovum abstains

from releasing from the egg during the menstrual period. This results in women experiencing

ovarian dysfunction. Along with ovarian dysfunction, women with PCOS produce abnormally

high androgen levels. Increased androgen levels contribute to ovulation failure, missed menstrual

periods, and the inability to become pregnant. Women with PCOS encounter high infertility rates

and often resort to alternative methods to become pregnant. This literary review aims to provide

a description of PCOS and educate on the prevalence of infertility in women with the condition.

Furthermore, PCOS is often diagnosed in either the late teenage years or early adulthood,

especially if there are complications when attempting to become pregnant. Studies have also

found that 20-40 percent of first female relatives of women with PCOS also have the syndrome

(Jahan & Wing, 2021). Some methods of diagnosing the condition include evaluating hormonal

production levels, a non-invasive ultrasound scan, or a transvaginal ultrasound (TVUS)

(Bekhatroh & Adel, 2019). When evaluating hormonal levels, an endocrine panel is performed to

assess for elevated serum LH, testosterone, and aldosterone, while accompanied by normal or

lower serum FSH and abnormal E2 production. The endocrine panel is performed to compare the

lab values of the patient to those of a patient without PCOS present. Another diagnostic method

would include the non-invasive ultrasound and the TVUS. The non-invasive ultrasound assesses

the total ovarian volume and the morphology for indications of ovarian dysfunction. While the

TVUS is performed to assess for follicles on the ovaries that indicate the presence of cysts above

or on the ovaries. The TVUS also assesses for an increased serum anti-mullerian hormone

(AMH), which is present in women with PCOS. Lastly, upon utilizing the previously mentioned
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diagnostic methods, an official diagnosis is made when an ultrasound confirms polycystic

ovaries and one symptom of PCOS is present within the patient.

Moreover, women with PCOS can face several symptoms or be completely asymptomatic

of the condition. Common symptoms that are faced with the condition include irregular

menstrual periods, weight gain, acne, excessive facial or body hair, and ovarian cysts (Jahan &

Wing, 2021). The prevalence and appearance of symptoms vary for each patient. Also, the

expression of the condition can be completely silent or brought on by other factors. Fortunately,

some of these symptoms can be minimized or resolved with adequate treatment. It is highly

recommended that women with PCOS actively exercise as it aids in response to therapies geared

towards sub-fertility or other abnormalities associated with the condition. However, weight loss

will not normalize the condition, it has been found to improve the other symptoms faced.

PCOS can cause several complications and contribute to multiple conditions. Within

research, it has been found that PCOS affects 7% to 15% of women in their reproductive age and

is the most common endocrine disorder in this population (Yadav & Malhotra, 2022). Though

the primary complication of PCOS is infertility, as many women with the condition severely

struggle to become pregnant. Infertility in women with PCOS is primarily caused by

anovulation, thus the egg is unable to become fertilized by sperm. This inhibits pregnancy from

occurring and results in infertility, leaving many women with the inability to become pregnant.

As a result, many women have to resort to alternative methods to gain the ability to conceive.

The most common method utilized is known as in vitro fertilization (IVF), which allows the

woman to provide mature eggs so that they can be fertilized by sperm outside of the uterus. All

in all, methods to improve infertility outcomes are continuing to advance and help those facing

infertility, especially women with PCOS.

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Search Strategy

An initial search was made using the terms “IVF”, or “in vitro fertilization”, and

“PCOS”, or “polycystic ovary syndrome”, on both the Cumulative Index to Nursing and Allied

Health Literature (CINAHL) and Medline. All searches were published between 2018-2023,

written in English, peer-reviewed, and published in academic journals. Our initial Medline

search, including previously mentioned filters, showed 5,743 results on CINAHL and 642 on

Medline. Each researcher narrowed their search to meet the criteria for their specific subtopic.

Fertility in Women with PCOS

Women with polycystic ovary syndrome (PCOS) face many challenges daily due to a

lack of reproductive hormones. These can range from increased body hair, hormone imbalances,

irregular menstrual cycles, and many more. The effects of PCOS can be seen during the time of

childbearing age, this can cause problems with conception, miscarriages, and complications

during pregnancy. Multiple studies have been performed to try to combat the growing concern

about the effects of PCOS on a woman's ability to become pregnant and carry a child to term. In

vitro fertilization (IVF) is an intervention widely used when conception cannot be obtained

through traditional measures. This literature review aims to show the impact of intervention

using IVF in women impacted by PCOS.

Fertility is one thing that can be impaired when talking about women with polycystic

ovary syndrome. According to research, fertility in women with PCOS is greatly impacted by

multiple intra and extra-ovarian factors causing an anovulatory cycle that subsequently leads to

sub-fertility (Bekhatroh & Adel, 2019). In women, fertility is compromised due to ovulatory

dysfunction, lower-quality embryos, and a higher incidence of miscarriages. These effects can

cause subfertility to emerge, approximately 75% of anovulatory infertility has PCOS as the
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culprit (Bekhatroh & Adel, 2019). These occur in various body parts including the

hypothalamus, pituitary, and ovaries.

Not only is fertility affected, but the days leading up to the day of birth can be altered as

well. Conditions such as preeclampsia, gestational diabetes, preterm birth, and spontaneous

miscarriage may occur. Preeclampsia causes increased blood pressure while pregnant and can

lead to death for the mother and the fetus. Women with PCOS also have an increased risk of

obesity, increasing their chances of having gestational diabetes. This can result in complications

such as birth trauma and stillbirths. Preterm birth can result from PCOS, causing long-term

complications and even death of the infant. Another detrimental side effect of PCOS in pregnant

women can also be spontaneous miscarriages which is the loss of the fetus during pregnancy. A

spontaneous miscarriage can be related to factors such as infection, increased age of the mother,

and endocrine disorders (Mirza et al., 2022). Unfortunately, in women with PCOS, these

complications are increased which causes a very stressful pregnancy.

PCOS predisposes women to an increased body mass index (BMI), causing the risk of

gestational diabetes to elevate. With this incidence of a higher BMI, the risk for hypertension is

greater than in women without PCOS leading to preeclampsia. An increase in a woman's BMI

also puts her at risk of having a preterm birth, causing complications that can last throughout the

infant's lifespan. Spontaneous miscarriages are also related to an elevated BMI, the degree of risk

is undetermined and prevention strategies have proven to be challenging (Mirza et al., 2022).

These complications make conception and pregnancy uncertain and traumatic for these women

of childbearing age with PCOS.

With PCOS, women face problems concerning conception and the uncertainty of how the

pregnancy will progress. PCOS impacts as high as 25% of women in some populations but is
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difficult to determine (Bekhatroh & Adel, 2019). Extensive research has been performed but with

a condition like PCOS, there is still much to learn about the effects on not only the mother but

the child as well. Significant studies have shown improvement in the success rates of PCOS

women who utilize IVF therapies for conception and to decrease the percentage of genetic

complications. Unfortunately, the struggle does not stop here as the risks and complications still

vary, especially in women with PCOS.

What is IVF?

In vitro fertilization begins with assessing both the follicular reserve in the female and the

sperm count and quality of a male partner. It is then decided whether donated sperm or oocytes is

necessary (Chloe & Shanks, 2022). Then overstimulation of the ovaries is initiated using a

variety of daily hormone medications to encourage the maturation of multiple follicles in one

menstrual cycle. Follicular growth is measured using transvaginal ultrasonography and hormone

levels in the blood. Mature follicles, now considered oocytes, are then injected with human

chorionic gonadotropin hormone (hCG) 34-36 hours before retrieval to finalize the maturation

process. Once the oocytes are ready for retrieval, the woman is sedated and the eggs are

aspirated using ultrasound-guided suction (Chloe & Shanks, 2022).

Oocytes are then fertilized either in a petri dish over 12-18 hours or in cases of male

infertility, by intracytoplasmic sperm injection (ICSI). Fertilized embryos can either be

transferred on day 3 or 5 after insemination or frozen for later use. The protocol depends on the

age, embryo quality, and health of each individual candidate. When it is time for transfer,

embryos are inserted directly into the uterus via catheter under ultrasound guidance. This process

can be repeated many times until a live birth is successful (Chloe & Shanks, 2022).
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New interventions are being implemented into in vitro fertilization therapy to maximize

the outcome of live births in subfertile women. A Chinese study published in The New England

Journal of Medicine tested the effectiveness of preimplantation genetic testing for aneuploidy

(Yan et al., 2021). It had previously been tested multiple times on women over 35, but no known

statistical data showing effectiveness in younger, infertile women with promising prognoses. The

randomized experiment consisted of 1212 infertile women between the ages of 20-37, across 14

different reproductive centers in China. Separated into two equal groups, half of these women

had done genetic testing to ensure the quality of blastocysts before transplantation, and the other

half followed standard IVF protocol. After one year, 77.2% of the genetic testing group and

81.8% of the control group were successful in having live births. The results were too

insignificant to show that preimplantation testing is a worthwhile intervention at this time (Yan et

al., 2021).

Another highly controlled experiment conducted by Simon et al, (2020) monitored the

pregnancy rate and live birth outcomes between personalized embryo transfer, frozen embryo

transfer, and fresh embryo transfers after one year of therapy. Personalized embryo transfer is

where a biopsy is taken of the endometrial lining and is tested to see when the optimal window

for transplantation would be for that specific individual (Simon et al., 2020). 458 randomly

selected healthy participants at or under the age of 37 were treated amongst 16 different

reproductive clinics across the United States, Europe, and Asia.

At the end of the 5-year study, initial pregnancy rates for women undergoing personalized

embryo transfer were significantly higher than fresh or frozen transfers. Live births were also

more likely to occur with PET viruses frozen and fresh transfers, whose success rates showed

little difference from each other in both the pregnancy and live birth categories (Simon et al.,
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2020). It is important to remember that all the women in this study were relatively young and had

a healthy follicular reserve. In practice, each woman is accommodated according to their

personal bodily needs. Meaning different protocols may be necessary depending on the patient's

age, health status, and follicular reserve.

Effects of IVF on the Mother

In vitro fertilization (IVF) is often used by women with PCOS that experience infertility.

There were found to be complications associated with the use of IVF. Two articles that were

related to this topic were examined. The article “Infertility treatment and postpartum mental

illness: a population-based cohort study” discusses the incidence of postpartum mental illness in

women undergoing different fertility treatments. Another study titled “Clinical and neonatal

outcomes of intrauterine insemination with frozen donor sperm” was also used to examine the

possible effects of two different fertility treatments. Both articles displayed that there are

possible side effects associated with the use of IVF therapy on women trying to conceive.

In “Clinical and neonatal outcomes of intrauterine insemination with frozen donor

sperm”, the effects and success rates of artificial insemination by a husband (AIH) and artificial

insemination by a donor (AID) were examined. The study looked at the success rate of

pregnancy and noted complications that occurred. There were found to be very slight differences

in the occurrence of complications with AIH and AID. More fetal defects such as low birth

weight were found in the AIH treatment group (Chen et al., 2018). There were no significant

complications such as ectopic pregnancies, preeclampsia, or any other after-effects that impacted

the mother in either of the groups.

Although there were found to be no physical complications associated with the mother in

the first article, the second article titled “Infertility treatment and postpartum mental illness: a
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population-based cohort study” yielded results that suggest there may be other illnesses the

mothers may experience post- IVF therapy. The study compared women who underwent invasive

fertility treatments versus women who underwent non-invasive fertility treatments and examined

the incidence of postpartum mental illnesses.

The data that was collected throughout the study was obtained through observation of a

population of women in Ontario. Data was collected based on the incidence of one ER visit or

hospital admission, or the incidence of two or more outpatient visits attended within 365 days

after the woman was discharged from the hospital after giving birth (Dayan et al., 2022). These

visits are associated with some sort of psychological problem that brought them in. It was found

that the incidence of mood disorders is higher for women undergoing fertility treatments with

PCOS (Dayan et al., 2022). The study also found that women who underwent non-invasive

fertility treatments experienced a higher incidence of postpartum illnesses such as mood or

anxiety disorders than women who underwent invasive fertility treatments and no fertility

treatments.

It was found that there were no significant physical complications that the mothers

experienced after undergoing IVF therapy. Low birth weight and other fetal defects were found

more in women who received artificial insemination using their husband’s sperm compared to

women who used donor sperm. There were, however, complications associated with mental

illness found after women underwent fertility treatments with no prior history of mental illnesses.

The mental illnesses found were mood and anxiety disorders. Women with PCOS were found to

be more susceptible to mood disorders after undergoing fertility treatments.

IVF Outcomes for Women With and Without PCOS

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While in-vitro fertilization therapy dramatically increases the conception rate in women

with PCOS, questions may arise regarding whether IVF therapy can enhance any woman’s

ability to get pregnant. As health care becomes more and more advanced, it is now common for

women who do not have the disorder to use IVF therapy as well to increase their chances of a

successful conception. With the therapy being easily attainable to any woman and proven to have

benefits that outweigh the costs, various trials have determined that IVF is a very effective

treatment for infertility. While studies have shown it is less used in females without PCOS, IVF

therapy is still an option for all women who may have difficulty getting pregnant. Some of the

reasons why a woman may not be able to reproduce include conditions or disorders such as

endometriosis, malformed uterus or fallopian tubes, their male partner’s infertility, or a buildup

of scar tissue in the woman’s sexual organs.

In the cohort research study article “IVF outcome with a high level of AMH: a focus on

PCOS versus non-PCOS” by R. Muharam, Yohanes Danang Prasetyo, Kevin Ardito Prabowo,

Yuannita Ika Putri, Mila Maidarti and Andon Hestiantoro, the effectiveness of IVF was examined

in two parties which consisted of women with PCOS and those without, which equaled 238

subjects in total. Both parties went through an IVF cycle, comparing their anti-Müllerian

hormone levels before and oocytes received after treatment as their units of measurement to

evaluate the therapy’s effectiveness. AMH hormone is used to measure a woman’s egg count, as

well as be a way to determine the ovary’s response to stimulation from sperm, reflecting their

level of fertility. Average AMH levels in women free from reproductive impairments or disorders

range from 1.0-4.0 ng/ml. If a woman has polycystic ovary syndrome, the AMH levels are much

higher than normal, resulting in a less desirable fertility percentage rate. Oocytes are cells that

develop into eggs that can ultimately be fertilized by sperm.

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At the end of the study, the number of oocytes retrieved from the PCOS group was 17 as

opposed to 14 in the non-PCOS one (R. Muharam et al., 2022). Utilizing this data, it can be

determined that IVF therapy creates more of a desirable response in women who have PCOS

than those who do not. Even though the AMH levels were higher in the PCOS group, after one

IVF cycle, it was determined that they were able to produce more oocytes than the group without

the disorder. The AMH levels were the only statistical difference between the two parties before

treatment. Taking into consideration that high levels of AMH decrease the probability of

fertilization, both parties had a more successful rate of producing viable eggs. Even though they

both show an improvement, it is more of a significant one in women with the disorder, proving to

be a more effective therapy choice for women with PCOS than opposed to those without.

Another examination of the contrast between the effectiveness of IVF therapy in women

with and without PCOS is in the article, ”In vitro fertilization outcomes in women with

polycystic ovary syndrome: A meta-analysis” by Kefu Tang, Lei Wu, Ying Luo, Bo Gong. This

article looks at multiple previous research studies and compiles all the data from each into one

cumulative statistical analysis. It specifically looks at GnRh administration as the intervention

and oocyte production as a result. Throughout the results of the studies, a common characteristic

was that the women in the PCOS group did not need as much gonadotropin-releasing hormone as

the non-PCOS group did. This, in turn, led to the PCOS group releasing more oocytes (Tang et

al., 2021). Gonadotropin-releasing hormone, also referred to as GnRh, releases a

follicle-stimulating hormone that starts the development of eggs in women. This is important to

take this into consideration when comparing IVF therapy success rates because this means that

women in the PCOS group are more sensitive and reactive to the therapy. Looking at these

results, it can be determined that IVF therapy has more of an effect on women with PCOS as
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opposed to those without. Women without the disorder still showed an improvement in oocyte

production after GnRh administration, but it was not as pronounced as the group with PCOS.

PCOS is an endocrine disorder that causes difficulty and inconsistencies for a woman

with the syndrome to conceive. As technology has advanced with time, illnesses and

impairments can now be treated in many different ways as opposed to the years before. Not only

are there now more drugs to treat various diseases and disorders, more medical procedures are

recently becoming available to the public for utilization. Infertility due to illness has been a

problem for women regardless of the era. With in-vitro fertilization, researchers are seeing that

even with reproductive organ ailments, women still have the capability to reproduce. IVF therapy

is used to assist a woman’s own ability to reproduce. With having benefits that outweigh the

risks, studies are repeatedly proving that IVF therapy is a favorable option for women with

PCOS to conceive.
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References

Bekhatroh, R. A., & Adel, I. N. (2019). How polycystic ovary syndrome (PCOS) affects the

fertility potential of reproductive age women? International Journal of Caring Sciences,

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Chen, L., Zhu, L., Cai, C., Yan, G., & Sun, H. (2018). Clinical and neonatal outcomes of

intrauterine insemination with frozen donor sperm. Systems Biology in Reproductive

Medicine, 64(4), 240–245.

https://doi-org.eps.cc.ysu.edu/10.1080/19396368.2018.1453563

Chloe, J., and Shanks, A. L. (2022, September 5). In vitro fertilization. National Library of

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Dayan, N., Velez, M. P., Vigod, S., Pudwell, J., Djerboua, M., Fell, D. B., Basso, O., Nguyen, T.

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Muharam, R., Prasetyo, Y. D., Prabowo, K. A., Putri, Y. I., Maidarti, M., & Hestiantoro, A.

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