Planning Pregnancy with PCOS: A Step-by-Step Guide for Women Trying to Conceive

Polycystic Ovary Syndrome (PCOS) affects a large number of women of their reproductive age. One of the biggest challenges it brings is difficulty in ovulation, which often leads to infertility. In my experience, most women with PCOS struggle because they don’t ovulate regularly—what we call “chronic anovulation.” 

But here’s the truth I tell every patient:

✅ PCOS does not mean you can’t get pregnant.

✅ With the right diagnosis and the right protocol, many women with PCOS go on to conceive naturally or with minimal fertility help.

If you’re planning a pregnancy with PCOS, here’s a checklist that I always share with my patients:

✅ Ensure your fallopian tubes are open and normal

✅ Get your AMH (Anti-Müllerian Hormone) tested

✅ Rule out other causes of ovulation issues like:

• • Thyroid disorders
    
  • High prolactin levels (hyperprolactinemia)
    

✅ Get your partner’s semen analysis done to rule out male factor issues

These are basic but crucial. If all these parameters are in check, we can move to the treatment part.

If you have PCOS and irregular periods, the standard treatment is ovulation induction—simply put, we help your ovaries ovulate regularly using medications.

The most trusted and effective drug for this is Letrozole. And despite all the myths floating around, letrozole is

• Completely safe
  
• Well-researched
  
• Standard first-line treatment for PCOS-related infertility

There are multiple effective protocols that revolve around the usage of letrozole. We try to use this drug based on the patient’s body weight.

So this is how it works exactly

Letrozole Protocol: Step-by-Step

Here’s how we typically structure an ovulation induction cycle with Letrozole:

1. Cycle Day 1 or 2: You come to the clinic, OR we induce your period.

2. Baseline Ultrasound: We check your AFC (Antral Follicle Count).

3. Letrozole Dosage:

• • 2.5 mg once daily if you’re less than 60 kg
  • 2.5 mg twice daily if you’re more than 60 kg

This is predominantly only for patients who are attempting to make a pregnancy naturally.

4. Letrozole Days: Usually taken from Day 2/3 to Day 6/7 of the cycle.

5. Follicle Monitoring: Done on Day 10 or 11 to check follicle growth.

6. Trigger Shot (HCG 10,000 IU) if needed to help with ovulation

7. Timed Intercourse: For the next 4–5 days, your fertile window

8. Luteal Support: For hormonal support, medications are given for the next 14 days.

Realistic Pregnancy Chances with Letrozole

On average, a natural pregnancy rate of 10–12% per cycle is expected if protocols are followed correctly. As a referral center for PCOS treatment across India, we’ve observed that most treatment failures occur due to a lack of personalized dosing.

We spend time micromanaging doses for each woman depending on:

• Weight
• Hormone levels
• Response to medication

What we commonly observe is that a significant number of PCOS patients across the country fail to conceive simply due to inaccurate dosing protocols. Many of these patients achieve success once we carefully micro-manage and personalize their medication regimen.

For those who do not respond to the standard Letrozole cycle, we often consider alternative ovulation induction strategies, such as the Extended Letrozole Protocol. In this approach, the dosage is continued for an additional 2–3 days, particularly in patients who haven’t conceived in previous cycles or have developed Letrozole resistance.

We often switch to an Extended Letrozole Protocol where:

• Letrozole is continued for more than 5 days
• This helps women who didn’t ovulate with the standard cycle

Especially useful for those who’ve developed Letrozole resistance

Sometimes, Letrozole isn’t enough on its own. That’s when we consider adding HMG (Human Menopausal Gonadotropins).

We typically add this:

• In older women with PCOS
• Women who have tried multiple cycles without success

Given for 7–8 days in the early part of the cycle

Proper ovulation induction needs regular monitoring. It should always be closely monitored by a skilled fertility specialist, not just through ultrasound, but by correlating follicular growth with hormonal levels. This ensures precise, personalized dose adjustments throughout the cycle.

At our clinic, which serves as a referral center for PCOS and fertility care across India, we routinely manage protocols for patients who never even visit us physically.

Through remote monitoring, we guide women across the country, cycle by cycle. By closely tracking progress and fine-tuning medications, most of them successfully conceive within 6 to 8 months, provided they remain committed and patient.

IVF is not always the first step. We only recommend it when:

• • Multiple ovulation induction cycles have failed
  • 6–7 IUIs (Intrauterine Inseminations) haven’t worked

One of the most important considerations for PCOS patients undergoing IVF is the use of a freeze-all (deferred embryo transfer) protocol. This is primarily because:

• PCOS patients are at high risk for Ovarian Hyperstimulation Syndrome (OHSS).

• To prevent OHSS, the trigger injection is usually given using a GnRH agonist, which can adversely affect endometrial receptivity.

• This mismatch between the embryo and endometrial lining can reduce the chances of successful implantation.

Therefore, instead of opting for a fresh embryo transfer, it’s advisable to freeze all blastocyst-stage embryos and plan the embryo transfer in a later cycle, when the endometrial environment is optimal and OHSS (ovarian hyperstimulation syndrome) risk is eliminated.

Unfortunately, in India, due to the growing commercialization of the IVF industry, many women with severe PCOS are wrongly advised to undergo IVF. In our experience, only about 20% of these cases truly require in vitro fertilization (IVF).

At our center, Shree IVF Clinic in Mumbai, we see countless women who were advised to get IVF elsewhere but didn’t actually need it.

For many of them, a simple laparoscopic ovarian drilling using a micro-bipolar technique is all that’s needed. After this minimally invasive procedure, most of these women begin ovulating naturally and conceive without IVF.

This is why it’s critical to seek honest, expert evaluation before starting IVF. Not every PCOS case needs aggressive treatment—individualized care can often restore natural fertility.

When managing fertility in women with PCOS, medications must be carefully chosen and personalized. 

Metformin: One of the safest and most commonly prescribed medications for PCOS is metformin. It improves insulin resistance and helps regulate blood sugar levels, factors that can significantly support natural ovulation and fertility.

Most patients benefit from Metformin, and it’s often continued even during pregnancy, as it’s considered safe for both mother and baby.

Many women with PCOS are prescribed various nutraceuticals and supplements, especially combinations of multivitamins and micronutrients. While these products are widely available and heavily marketed, most of them have limited or no proven clinical benefit in managing PCOS.

For example, myo-inositol and D-chiro-inositol are among the most commonly recommended supplements.

Although they’re widely promoted, especially by manufacturers, the scientific evidence supporting their effectiveness remains inconclusive. This marketing often plays on patient anxiety, and it’s important to make informed choices rather than relying on hype.

In select cases, doctors may prescribe low-dose steroids to support ovulation induction. However, the role and effectiveness of steroids in PCOS management are still not clearly established.

As a patient, the best approach is to work with a fertility specialist who can tailor treatment based on your symptoms, test results, and ovulatory response, not just general trends or commercially driven prescriptions.

The key to successful treatment lies in micromanaging ovulation induction protocols. What works for one patient may not work for another. In our experience, when fertility protocols are tailored correctly, many PCOS patients conceive naturally without needing IVF.

Women with PCOS who become pregnant may face a higher risk of:

• Gestational diabetes
• Preterm labor

Hence, the entire pregnancy should be monitored in a fetal medicine unit under expert care. Metformin can often be safely continued during pregnancy. And yes, with the right support, a healthy conception and normal delivery are absolutely possible.