Guest post by Rashmi Kudesia, MD MSc
Reproductive Endocrinologist and Infertility Specialist, RMA of New York
Women with polycystic ovary syndrome (PCOS) often experience a number of struggles in conceiving – sometimes including optimizing their health and weight before conception and most frequently inducing ovulation to allow for a chance at conception. Once a pregnancy is finally established, however, we often hope that the PCOS-related difficulties are over with! Nonetheless, many women wonder whether they are at an elevated risk for miscarriage. And, as with many issues related to PCOS, the question arises – if we do find a link, is it associated to the PCOS diagnosis itself, or could it be a result of fertility treatments, multiple pregnancies resulting from fertility treatment, weight in the overweight or obese range, or insulin resistance? The scientific data is actually a bit complex, so let’s evaluate the evidence we have so far.
In 2006, Heijnen and colleagues undertook a meta-analysis to evaluate all prior studies addressing outcomes for PCOS women undergoing in-vitro fertilization (IVF). This type of study uses exhaustive search techniques to sift through previous data relating to the question of interest, and compiles it to make one summary conclusion. This analysis, including 9 studies and 793 PCOS women, showed no significant difference in the miscarriage rate.
In 2012, a large consensus meeting was held to comprehensively review evidence related to PCOS management. With regard to miscarriage, they concluded the following as Level A evidence (the highest grade given to scientific research-based summaries): “Miscarriage rates are not increased in natural conceptions in women with PCOS, independent of obesity. Miscarriage rates after induction of ovulation mirror those found in other infertile populations”. In other words, though we do know that body mass indices (BMI) in the overweight/obese levels and infertility generally speaking are associated with a higher miscarriage rate, the PCOS diagnosis was not felt by this expert committee to have an additional impact.
Indeed, subsequent studies since then have seemed to confirm this conclusion. A 2014 Australian study comparing PCOS women to control women in the general community showed a higher miscarriage rate in the PCOS women; however, when they controlled for other variables, the PCOS diagnosis did not have a significant independent effect. Other factors that were independently associated with a higher miscarriage rate included: increasing BMI, BMI in the overweight or obese category, use of fertility treatment, increasing age, gestational or Type 2 diabetes, gestational hypertension or smoking.
Thus, when we look through our social circles or at support group forums for women with PCOS, it often appears that anecdotally, the miscarriage rate is higher than women without PCOS. The good news, though, is that the bulk of data suggests that it is not the diagnosis itself, but the associated health conditions that are the true risk factor. Therefore, the critical takeaway is that, particularly for young women, taking 3-6 months (or however long is needed!) to truly evaluate and optimize one’s health status – by getting the weight into a healthier range, improving diet & exercise habits, considering bariatric surgery evaluation if you meet criteria (BMI above 40, or above 35 with signs of diabetes, heart disease, blood pressure or other health conditions), testing for insulin resistance and hypertensive disorders, and smoking cessation – is the best first step to ensuring a healthy pregnancy. Furthermore, picking a fertility clinic that truly explains all your options, including starting with letrozole and timed intercourse or intrauterine insemination to aim for a healthy singleton pregnancy, avoiding the risk of multiple pregnancy associated with injectable medications in the non-IVF context, or emphasizing a single embryo transfer for those women undergoing IVF, is paramount. So, as we head into the holiday season, now is the time to make sure that your lifestyle and PCOS care team are reflecting your personal and fertility goals as closely as can be!
Dr. Rashmi Kudesia is a reproductive endocrinologist and infertility specialist who leads RMA of New York’s Brooklyn office. Dr. Kudesia specializes in treating couples who are trying to build their families.
Dr. Kudesia earned her medical degree from Duke University. She completed her residency in obstetrics and gynecology at New York Presbyterian Hospital/Weill Cornell Medical College. She completed her fellowship training in Reproductive Endocrinology and Infertility as well as a Masters of Science in Clinical Research Methods at Albert Einstein College of Medicine.
Dr. Kudesia has received numerous grants and awards for her academic accomplishments and medical research. She was awarded a Global Women’s Health certificate by Mount Sinai School of Medicine in 2011, and was nominated into the Duke Engel Society, which recognizes intellectual development, service and clinical excellence. Dr. Kudesia is the recipient of the Joan F. Giambalvo Scholarship Research Grant from the AMA Foundation in 2013, as well as multiple in-training research grants. Dr. Kudesia served as a Theme Issue Editor for the American Medical Association’s Journal of Ethics’ issue on Innovation in Reproductive Care, and has held multiple regional and national leadership positions within organized medicine.
Dr. Kudesia is an accomplished lecturer and author and has written numerous scientific research articles and manuscripts in leading medical journals. She has presented many of her research findings at national meetings, including the American Society for Reproductive Medicine (ASRM).