PCOS & Risk of Miscarriage
Guest post by Rashmi Kudesia, MD MSc
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, 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. Kudesia is a board-certified Reproductive Endocrinology and Infertility specialist, practicing at Houston IVF in Houston, Texas. She joined Houston IVF in 2018 after practicing in New York City, where she was named a “New York Super Doctors Rising Star” in 2016 and 2017.
After completing her Baccalaureate degree in Biology & Medicine magna cum laude from Brown University, she received her M.D. with honors from the Duke University School of Medicine, where she was selected into a clinical research training program co-sponsored by the National Institutes of Health. Her residency training in Obstetrics & Gynecology at the New York Hospital-Weill Cornell Medical Center was followed by subspecialty training in Reproductive Endocrinology and Infertility (REI) at the Albert Einstein College of Medicine-Montefiore Medical Center, alongside a Masters’ of Science degree in Clinical Research Methods. She subsequently served as a Clinical Assistant Professor at the Icahn School of Medicine at Mount Sinai, as well as the Research Rotational Director for the REI fellowship, and Medical Director of the Brooklyn office of the Reproductive Medicine Associates of New York.
Dr. Kudesia is a Fellow of the American College of Obstetricians and Gynecologists, and an active member of the American Society for Reproductive Medicine (ASRM), Society for Reproductive Endocrinology and Infertility, Androgen Excess & Polycystic Ovary Syndrome Society, and American Medical Association (AMA). She has served in multiple local and national leadership roles in organized medicine, including her current positions as Secretary of the ASRM Women’s Council Executive Board and the ASRM delegate to the AMA Young Physicians’ Section.
Dr. Kudesia has also presented scientific research at national and international conferences, and has received multiple awards and grants for her work. She has published peer-reviewed articles and book chapters, including in leading journals such as Fertility & Sterility and the American Journal of Obstetrics & Gynecology, as well as editing a theme issue on reproductive medicine for the American Medical Association Journal of Ethics. Her current areas of focus include improving in vitro fertilization cycle prognosis, polycystic ovary syndrome, LGBT fertility, and fertility awareness, counseling, and access to care. She actively promotes women’s health and wellness on social media via Twitter, Facebook, and Instagram.