Women with PCOS who have been working through fertility support are usually laser focused on the difficulties they have ovulating. PCOS by definition results in many anovulatory (no ovulation) cycles a year, which accounts for long cycles (sometimes 35-70 days) and other hormone imbalances like acne and unwanted hair growth.
But the lack of ovulation isn’t the only thing getting in the way of fertility in women with PCOS. Even if we successfully get you to ovulate (which we can), and successfully get a positive pregnancy test (which we can), there is still another threat standing in the way of carrying to term: miscarriage.
If you have PCOS, we recommend screening for risk of miscarriage as part of your pre-conception plan. An couple of simple blood tests can save a thousand tears.
Miscarriages happen for many reasons. Sometimes the egg and sperm themselves are not healthy, and as they start to grow, these problems prevent the embryo from developing. Interestingly, women with PCOS are very successful egg donors. It’s not the eggs that are the problem; it’s the micro-environment the eggs are trying to grow in causing infertility. Take the eggs out, and give them a new environment, and they develop perfectly.
So what explains the increase in miscarriage in POCS women if their eggs are fine? The problem is occurring slightly farther downstream – at implantation.
Implantation is an amazingly choreographed event that involves the immune system, hormones, and blood vessel development. As women with PCOS age, their lifetime risk of cardiovascular disease is a problem. They have high levels of cholesterol, vascular inflammation and elevated homocysteine (a marker of vascular inflammation) and as a result, have a future risk of cardiovascular disease, similar to what we would expect in a diabetic patient.
At implantation, as blood vessels attempt to grow to create a healthy and functional placenta, inflammation and homocysteine gets in the way, preventing an adequate connection from forming between the embryo and the uterus. This is what causes the significant increase in risk of miscarriage we see in women with PCOS(1). Homocysteine is both a marker of a problem (low B12, folate, or genetic challenges with these nutrients that are essential for fertility), and a problem itself. It prevents vessels from forming properly, and may stimulate the uterus to contract during this important window of time (2–4).
Blood tests can be done to help us understand how to reduce miscarriage rates in women with PCOS, such as homocysteine, insulin and vitamin D. If you have been taking a B vitamin or prenatal your homocysteine levels should be normal. However, some women need more targeted treatment to lower their homocysteine, or even blood thinners to not miscarry in the future. Testing homocysteine also helps predict other challenges you may face in your pregnancy such as pre-eclampsia and premature labour (5).
Additional supports such as vaginal progesterone (6,7) and dietary changes (8,9) can lower the risk of miscarriage even further in at-risk women by lowering homocysteine, and increasing blood flow during implantation (to overcome the difficulties created by PCOS).
Vitamin D is concentrated in the uterine lining(10), and plays a role in supporting implantation. Women with PCOS have lower vitamin D status than women without, and restoring this nutritional deficiency is an important part of holistic fertility care.
Naturopathic Doctors with a prescribing licence can provide women undergoing fertility care with progesterone suppositories to support their pregnancy and reduce their risk of miscarriage. Over 75% of fertility clinics worldwide use progesterone in every fertility case to improve blood flow, and establish a strong implantation during the first few weeks of pregnancy. Contact the clinic to learn more about the options for managing fertility with a Naturopathic Doctor.
- Palomba S, Russo T, Falbo A, Di Cello A, Amendola G, Mazza R, et al. Decidual Endovascular Trophoblast Invasion in Women with Polycystic Ovary Syndrome: An Experimental Case-Control Study. J Clin Endocrinol Metab. 2012 Jul 1;97(7):2441–9.
- Murphy MM, Fernandez-Ballart JD, Molloy AM, Canals J. Moderately elevated maternal homocysteine at preconception is inversely associated with cognitive performance in children 4 months and 6 years after birth. Matern Child Nutr. 2016 Jan 27;
- Murphy MM. Homocysteine: biomarker or cause of adverse pregnancy outcome? Biomark Med. 2007 Jun;1(1):145–57.
- Ayar A, Celik H, Ozcelik O, Kelestimur H. Homocysteine-induced enhancement of spontaneous contractions of myometrium isolated from pregnant women. Acta Obstet Gynecol Scand. 2003 Sep;82(9):789–93.
- de la Calle M, Usandizaga R, Sancha M, Magdaleno F, Herranz A, Cabrillo E. Homocysteine, folic acid and B-group vitamins in obstetrics and gynaecology. Eur J Obstet Gynecol Reprod Biol. 2003 Apr 25;107(2):125–34.
- Arck PC, Rücke M, Rose M, Szekeres-Bartho J, Douglas AJ, Pritsch M, et al. Early risk factors for miscarriage: a prospective cohort study in pregnant women. Reprod Biomed Online. 2008 Jul;17(1):101–13.
- Ismail AM, Abbas AM, Ali MK, Amin AF. Peri-conceptional progesterone treatment in women with unexplained recurrent miscarriage: a randomized double-blind placebo-controlled trial. J Matern-Fetal Neonatal Med Off J Eur Assoc Perinat Med Fed Asia Ocean Perinat Soc Int Soc Perinat Obstet. 2017 Feb 15;1–7.
- Brouwer IA, Verhoef P, Urgert R. Betaine Supplementation and Plasma Homocysteine in Healthy Volunteers. Arch Intern Med. 2000 Sep 11;160(16):2546–2546.
- Atkinson W, Elmslie J, Lever M, Chambers ST, George PM. Dietary and supplementary betaine: acute effects on plasma betaine and homocysteine concentrations under standard and postmethionine load conditions in healthy male subjects. Am J Clin Nutr. 2008 Mar 1;87(3):577–85.
- Asadi M, Matin N, Frootan M, Mohamadpour J, Qorbani M, Tanha FD. Vitamin D improves endometrial thickness in PCOS women who need intrauterine insemination: a randomized double-blind placebo-controlled trial. Arch Gynecol Obstet. 2014 Apr 1;289(4):865–70.