PCOS and Fertility: A Root-Cause Approach
If you have PCOS and you're trying to conceive, you've probably been offered two options: Clomid or IVF. Maybe Metformin. Maybe you've been told to lose weight, as if you haven't tried.
What often gets missed is the question of why. Why aren't you ovulating? Why are your androgens elevated? Why does your body respond this way?
PCOS is not one condition. It's a pattern with different drivers for different women. And until you understand what's driving yours, treatment is guesswork.
What Is PCOS?
Polycystic ovary syndrome affects 8-13% of women of reproductive age. Despite its name, the condition isn't primarily about cysts on the ovaries. Those "cysts" are actually follicles that started developing but never matured enough to ovulate.
The hallmarks of PCOS include irregular or absent ovulation, elevated androgens (testosterone and other male hormones), and polycystic-appearing ovaries on ultrasound. You don't need all three to be diagnosed, which is part of why PCOS looks so different in different women. Some have acne and excess hair growth. Some gain weight easily. Some are lean and wouldn't suspect PCOS at all.
The reason PCOS affects fertility is straightforward: if you're not ovulating regularly, you can't conceive. But even women with PCOS who do ovulate may have reduced egg quality, hormonal imbalances that affect implantation, or higher miscarriage rates.
PCOS is not a life sentence. When you address what's actually driving the condition, ovulation often returns. We've seen it happen hundreds of times, and there's good reason to believe it can happen for you too.
What Causes PCOS?
PCOS has several underlying drivers. Most women have one or two that are primary. Identifying yours changes everything about how we approach treatment.
Insulin Resistance
This is the most common driver. When your cells don't respond efficiently to insulin, your body produces more to compensate. High insulin stimulates the ovaries to produce androgens and disrupts the hormonal signaling needed for ovulation.
Research published in the Journal of Clinical Endocrinology and Metabolism confirms that approximately 70% of women with PCOS have some degree of insulin resistance, regardless of body weight.
You might recognize this pattern if you carry weight around your middle, struggle to lose weight despite real effort, have skin tags or darkened patches of skin (especially on your neck or underarms), crave sugar or carbs, feel tired after meals, or notice energy dips in the afternoon.
Insulin resistance doesn't mean you did something wrong. It often has genetic components, and it's worsened by the modern diet and chronic stress that most women are navigating. But it responds well to treatment. This is one of the most changeable aspects of PCOS.
Inflammation
Chronic low-grade inflammation can drive PCOS even without significant insulin resistance. Inflammation disrupts ovarian function, contributes to elevated androgens, and affects egg quality.
A study in the Journal of Clinical Endocrinology and Metabolism found that women with PCOS have elevated inflammatory markers even when controlling for weight, suggesting inflammation is intrinsic to the condition, not just a consequence of it.
When inflammation is the primary driver, you might notice joint pain, skin issues, digestive discomfort, headaches, or fatigue alongside your PCOS symptoms. Lab work might show elevated CRP or ferritin.
Inflammation often originates in the digestive system. Many women with PCOS have underlying digestive imbalances, food sensitivities, or intestinal permeability that create systemic inflammation. Addressing the digestive system often improves PCOS symptoms significantly.
Adrenal PCOS
In some women, elevated androgens come primarily from the adrenal glands rather than the ovaries. This pattern is often related to chronic stress. Your adrenals produce DHEA-S, which can convert to testosterone.
Women with adrenal PCOS are often lean. They don't fit the typical PCOS picture. They might have normal fasting insulin but high DHEA-S. They're usually running on stress, not sleeping well, pushing hard in their careers or lives. Their bodies are stuck in survival mode.
This pattern responds beautifully to stress reduction, nervous system regulation, and adrenal support rather than the insulin-focused interventions that help other types.
Post-Pill PCOS
Some women develop PCOS-like symptoms after stopping hormonal birth control. The pill suppresses your own hormone production, and when you stop, it can take time for your system to recalibrate. Cycles may be irregular, androgens may be temporarily elevated, and ovulation may be delayed.
This pattern usually resolves within a year, but support can speed the process. If your cycles were regular before you started the pill, this is likely what's happening, and that's actually reassuring.
Can You Get Pregnant with PCOS?
Yes. Many women with PCOS conceive, both naturally and with treatment. The key is understanding what's actually happening in your body.
The standard approach to PCOS fertility treatment is to induce ovulation with medication. Clomid or letrozole can work. But they don't address why you're not ovulating in the first place.
This matters because the underlying drivers of PCOS don't just affect ovulation. They affect egg quality, uterine lining, implantation, and miscarriage risk. You can force ovulation with medication and still struggle to conceive or maintain a pregnancy if the underlying issues aren't addressed.
We're not against medication. Sometimes it's the right tool. But it works better when the foundation is addressed first. And many women find they don't need it once the foundation is in place.
How We Treat PCOS Naturally
We start by understanding which drivers are most active in your body. This requires a thorough intake, review of your labs and history, and sometimes additional testing. We want to know not just that you have PCOS, but why.
Then we address the root causes while supporting ovulation.
Addressing Insulin Resistance
Diet is the most powerful intervention for insulin resistance. We focus on reducing sugar and refined carbohydrates, prioritizing protein at every meal, including healthy fats, and eating in a way that keeps blood sugar stable. This isn't about restriction or deprivation. It's about giving your body what it needs to regulate insulin.
Specific supplements help. Inositol (particularly myo-inositol) has strong research support for improving insulin sensitivity and restoring ovulation in PCOS. A Cochrane review found that myo-inositol improved ovulation rates and menstrual cycle regularity in women with PCOS. Berberine works similarly to Metformin but is often better tolerated. We use these strategically based on your specific situation.
Acupuncture improves insulin sensitivity. Research published in the American Journal of Physiology has demonstrated this directly in women with PCOS.
Reducing Inflammation
We identify and address inflammatory triggers. This often involves dietary changes, particularly reducing inflammatory foods and sometimes eliminating gluten or dairy on a trial basis. We support digestive health, which is frequently compromised in women with PCOS. We use anti-inflammatory herbs and nutrients.
Many women notice improvements not just in their cycles but in their energy, skin, digestion, and overall health when inflammation is addressed.
Regulating the Nervous System
Chronic stress affects every aspect of PCOS. The HPA axis (your stress response system) and the HPO axis (your reproductive hormone system) are deeply interconnected. When you're running on stress, your body deprioritizes reproduction.
For women with adrenal PCOS, this is the primary intervention. But even for women with insulin-driven or inflammatory PCOS, nervous system regulation matters. Acupuncture is one of the most effective tools we have for shifting the body out of chronic stress response. Many women tell us their acupuncture sessions are the first time they've felt truly relaxed in years.
Supporting Ovulation
Acupuncture can directly support ovulation. A study published in the American Journal of Physiology found that electroacupuncture improved menstrual frequency and reduced testosterone levels in women with PCOS. Research in Evidence-Based Complementary and Alternative Medicine showed that acupuncture combined with lifestyle intervention improved ovulation rates more than lifestyle changes alone.
Chinese herbs can also support ovulation when prescribed based on your specific pattern. We often see women begin ovulating within two to three months of consistent treatment.
Best Diet for PCOS Fertility
What you eat profoundly affects PCOS. The specifics depend on your drivers, but some principles apply broadly.
Reduce sugar and refined carbohydrates. These spike insulin and worsen the hormonal cascade. This doesn't mean eliminating all carbohydrates. It means choosing complex carbs like vegetables, legumes, and whole grains, and always pairing them with protein and fat.
Prioritize protein. Aim for 20-30 grams at each meal. Protein stabilizes blood sugar, supports hormone production, and helps you feel satisfied.
Include healthy fats. Omega-3s reduce inflammation. Good sources include fatty fish, flaxseeds, chia seeds, and walnuts. Avoid inflammatory oils like corn, soy, and canola.
Eat plenty of vegetables. Fiber supports digestive health and helps clear excess hormones. Cruciferous vegetables like broccoli, cauliflower, and Brussels sprouts support estrogen metabolism.
Consider eliminating dairy and gluten. These are inflammatory for some women with PCOS. A three-week elimination trial can reveal whether they're contributing to your symptoms. Many women are surprised by how much better they feel.
Best Supplements for PCOS
Several supplements have research support. Dosages below reflect what has been used in studies. This is not medical advice, and you should consult with a healthcare provider before starting any protocol.
Inositol improves insulin sensitivity and ovarian function. Myo-inositol has been shown to restore ovulation and improve egg quality. Research has used 2-4 grams daily.
Berberine improves insulin sensitivity and has anti-inflammatory effects. Studies have used 500mg two to three times daily. Don't combine with Metformin without guidance.
Vitamin D deficiency is common in PCOS and associated with worse outcomes. Test your levels and supplement to reach 40-60 ng/mL. Most people need 2,000-5,000 IU daily.
Omega-3 fatty acids reduce inflammation and improve metabolic markers. Studies have used 2-3 grams of combined EPA and DHA daily.
What This Looks Like in Practice
A woman came to us at 31 after two years of trying to conceive. She'd been diagnosed with PCOS at 25 when she came off birth control and her periods never regulated. She had maybe four or five periods a year, never predictable.
Her doctor had prescribed Clomid. She'd done six cycles with monitoring. She ovulated on the medication, but didn't conceive. Her doctor was recommending IVF.
When we talked, a clearer picture emerged. She'd gained about twenty pounds since her diagnosis, mostly around her middle. She was exhausted, with energy that crashed hard in the afternoons. She'd been living with constant bloating, to the point where she'd stopped wearing fitted clothes. Her skin had gotten worse, not just the hormonal acne she expected, but eczema on her arms that had appeared in the last year. She was stressed, not sleeping well, running on coffee. She felt like her body was working against her.
Her previous workup had focused on her reproductive hormones. No one had looked at her fasting insulin, her inflammatory markers, or her digestive health.
We started with diet changes focused on blood sugar stability. More protein, fewer refined carbs, regular meals instead of the skipping and snacking she'd been doing. We added inositol and berberine. We started weekly acupuncture.
The first thing she noticed was her energy. Within three weeks, the afternoon crashes were gone. Her bloating improved significantly within a month. The eczema started clearing.
After two months, she got a period on her own, the first spontaneous period she'd had in over a year. After three months, another one.
We added Chinese herbs to support ovulation. We continued working on her digestive health, which had been a bigger factor than anyone had recognized.
She conceived naturally in her fifth month of working with us. Her pregnancy was uncomplicated.
What changed? We addressed why she wasn't ovulating, not just whether she was ovulating. Her body knew how to do this. It just needed the obstacles removed.
This doesn't happen for every woman with PCOS. Some do need medication. Some do need IVF. But many don't, and even those who do need intervention respond better when the underlying drivers are addressed.
Read stories from women we've worked with →
Your Next Step
If you have PCOS and you're trying to conceive, there's more available to you than Clomid and IVF. Understanding what's driving your PCOS changes what's possible.
We've worked with hundreds of women with PCOS over the past two decades. We know this condition, and we know it responds to treatment.
Learn more about our Fertility & Health path or contact us at 212.432.1110 or info@fafwellness.com.