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The most common cause of women's infertility is PCOS, polycystic ovarian disease. Because PCOS is a disease of not just the ovaries but also of the hypothalamus and pituitary in the brain, treatment can be complicated-but sometimes simple measures work.

Most women who are infertile because of PCOS are not able to ovulate. That is, their ovaries do not release an egg for fertilization in the middle of the menstrual period. But the process of ovulation does not begin in the ovaries. The process of ovulation begins in the brain.

Deep inside the brain, the hypothalamus senses changes in a woman's estrogen levels with the progress of her menstrual cycle. It sends out pulses of a hormone called gonadotrophin releasing hormone, or GnRH for short. GnRH then circulates to the pituitary gland, which releases follicle stimulating hormone (FSH) and luteinizing hormone (LH). FSH and LH have multiple actions in reproductive health, but for ovulation, FSH tells the ovaries to create a "stalk" to carry the egg out of the ovary and LH prepares the uterus for implantation.

If anything goes wrong with any of these hormones, if they are secreted in the wrong amount or at the wrong rate or at the wrong time, ovulation may not occur. And if there is no ovulation, there can be no pregnancy without in vitro fertilization. But treating infertility can be a lot simpler than managing the functions of multiple endocrine glands. Surprisingly often, just losing weight is enough for woman with PCOS who is trying to conceive.

From 1/3 to 2/3 of women with PCOS experience changes in hormone balance that enable ovulation after losing as little as 5% of their total body weight. Taking off just 5 pounds (about 2.5 kilos) might be all the treatment that is needed. Reversing weight gain sometimes restores fertility.

Chlomiphene citrate, also known as Clomid

If diet and exercise leading to weight loss don't work, then doctors usually offer chlomiphene citrate, also known as Clomid. This is a drug that forces ovulation. Within 28 days of starting the drug about 22% of women who have PCOS get pregnant. Within 6 months, which is the maximum amount of time the drug is administered, that percentage climbs to 60%. A combination of weight loss and chlomiphene citrate may be what a woman who has PCOS may need to become pregnant. The third drug given to women trying to conceive used to be metformin, more commonly used for diabetes treatment, but now fertility specialists reserve that drug for women who have both PCOS and diabetes.

Artificial form of GnRH

Nowadays the third line of treatment is an artificial form of GnRH. Only about 20% of women who take this drug get pregnant, but 1/3 of them will have twins, triplets, or quadruplets. If drugs don't work, then there is ovarian drilling. This is a laparoscopic procedure, done through a small incision, to physically remove 1 to 12 eggs for fertilization. It works about 50% of the time.

In vitro fertilization, or IVF

Then, if all these procedures fail, the option is in vitro fertilization, or IVF as it is more commonly known. IVF is an iffy procedure that requires a considerable investment in time and money, but it may enable childbearing. IVF works about 1/3 of the time. A small number of women with PCOS will not become pregnant even if they have all of these procedures, but the overwhelming majority of women with PCOS can become pregnant with persistent treatment. Any woman with polycystic ovaries, however, should try diet and exercise first.

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