How can I effectively counsel a patient with PCOS regarding fertility options and the impact of the condition on reproductive health?

Counselling a patient with polycystic ovary syndrome (PCOS) regarding fertility options and reproductive health impact involves several key points:

• Explain the impact of PCOS on fertility: PCOS is a common cause of ovulatory dysfunction (WHO Group 2 ovulation disorder), leading to anovulatory infertility due to hormonal imbalances and insulin resistance ².
• Emphasize lifestyle modification: Encourage a healthy lifestyle including weight management, healthy eating, and regular physical activity, as weight loss of as little as 5% can improve insulin resistance, reduce androgen levels, restore spontaneous ovulation, and improve response to ovulation induction treatments ¹.
• Discuss first-line pharmacological treatments: For women with PCOS-related anovulatory infertility, first-line ovulation induction options include clomifene citrate, metformin, or a combination, with choice tailored to the woman’s BMI, preferences, and side effect profiles ².
• Inform about treatment monitoring and duration: Clomifene citrate treatment should be monitored by ultrasound during the first cycle to minimize multiple pregnancy risk and should not be continued beyond 6 months ².
• Address second-line treatments if resistant to clomifene: Options include laparoscopic ovarian drilling, combined clomifene and metformin, or gonadotrophins, depending on clinical circumstances and patient preference ².
• Highlight the importance of managing menstrual irregularities and hyperandrogenism: Combined oral contraceptives (COCs) are recommended to manage hyperandrogenism and irregular cycles when pregnancy is not planned, but are not fertility treatments ¹.
• Discuss the risks and benefits of ovulation induction: Inform patients that ovulation induction and ovarian stimulation have not been associated with increased cancer risk in the short to medium term, but long-term data are awaited; use the lowest effective doses and durations ².
• Refer to fertility specialists as needed: For complex cases or if initial treatments fail, referral to secondary or tertiary fertility services is appropriate ².
• Provide information on long-term reproductive health: PCOS increases risks of type 2 diabetes and cardiovascular disease, so ongoing management and screening are important to optimize overall health and fertility outcomes ¹.
• Offer sources of support and information: Direct patients to reputable resources such as the Royal College of Obstetricians and Gynaecologists, NHS, and PCOS support groups ¹.