Fertility Mapping: Navigating Fertility with PCOS and Insulin Resistance (Part II)

Posted by Behcet Bicakci on March 25, 2025

Fertility Mapping: Navigating Fertility with PCOS and Insulin Resistance (Part II)
By Dr. Alison McAllister

Polycystic Ovary Syndrome (PCOS) is a complex, multifactorial condition influenced by disruptions in hormone receptors, metabolism, neurotransmitter function, and nutrient balance. As a lifelong disorder, PCOS is a leading contributor to infertility, weight gain, and an increased risk for cardiometabolic issues. In this blog post, we dive deeper into laboratory testing, helping healthcare providers understand which tests are critical for women suspected of having PCOS.

Lab Testing for PCOS

PCOS is most commonly diagnosed through the Rotterdam Criteria, a diagnostic framework that considers various indicators, including clinical symptoms, lab results showing elevated testosterone levels, ovulatory dysfunction, and ultrasound findings of ovarian cysts. Not all criteria need to be met for a diagnosis of PCOS. Ultimately, it remains a clinical diagnosis, and the Rotterdam Criteria should be referred to for more detailed information (see NCBI Article).

Recommended Lab Tests for PCOS

Women with PCOS should undergo the following hormone tests:

17 OH Progesterone – to rule out congenital adrenal hyperplasia
Cortisol – to rule out Cushing's syndrome
DHEAS
Glucose
Hemoglobin A1c (Hgb A1c)
hsCRP (High-Sensitivity C-Reactive Protein)
Insulin
LH/FSH (Day 3 or 4 of the cycle) – typically, a 1:1 ratio is expected, but ratios of 2:1 or higher are common in PCOS
Lipids/Cholesterol
Prolactin – elevated prolactin can cause irregular periods and polycystic ovaries
SHBG (Sex Hormone-Binding Globulin) – useful if assessing total hormone levels
Testosterone
TSH (Thyroid Stimulating Hormone)

Testing for PCOS through saliva and bloodspot often reveals elevated levels of testosterone and DHEAS, accompanied by lower progesterone levels. Even though women with PCOS may show symptoms of estrogen dominance, their estrogen levels are rarely high.

Salivary lab tests offer a more accurate reflection of bioavailable testosterone and DHEAS levels compared to serum testing, as they can detect these elevations more clearly.

For example, one patient showed a total testosterone level at the upper end of the normal range in bloodspot testing, while their insulin levels were significantly elevated in the fasting sample—well above the optimal threshold of 10. Though not reported, this patient's hemoglobin A1c was within the optimal range.

Urine analysis may also reveal heightened levels of testosterone, androstenedione, DHEA, and DHT, suggesting PCOS. For example, a profile with a very high DHT level, along with other androgens, is indicative of this condition.

Treatment for PCOS

The primary objective in managing PCOS is to reduce insulin levels. Lowering insulin in turn helps to decrease androgen levels and promote ovulation, leading to an increase in progesterone. Women should aim for six months of health optimization before attempting pregnancy, particularly if they plan to undergo assisted reproductive technologies. However, if discontinuing oral contraceptives, conception efforts should begin as soon as possible—ideally within the first month after stopping.

Insulin Reduction

For all women with PCOS, a foundational approach should focus on reducing simple carbohydrates, increasing complex carbohydrates, and boosting dietary fiber. Medications like metformin, GLP1 agonists, and herbs such as Berberine, along with nutrients like inositol, are particularly beneficial for women with high insulin levels—even those with a normal body weight.

Inositol—also known as vitamin B8—is a sugar that supports receptor functionality in the body. It works as a secondary messenger for insulin, thus improving insulin sensitivity. Many women with PCOS experience inositol deficiencies, impairing its function in cells. Supplementing with inositol has been shown to reduce insulin resistance, improve menstrual cycles, and even enhance pregnancy rates. Additionally, inositol is present in high levels in follicular fluid, and studies have shown that higher inositol concentrations in eggs correlate with better quality.

Other beneficial therapies may include melatonin and vitamin D, which could be appropriate for many women with PCOS. Research suggests that continuing metformin and inositol during pregnancy may help optimize insulin levels and improve pregnancy outcomes.

Optimizing Fertility with PCOS

Achieving pregnancy with PCOS may require additional effort. Effectively managing insulin levels, optimizing weight, and enhancing overall health are critical factors in successfully conceiving, even when assisted reproductive technologies are necessary. By incorporating lifestyle changes into treatment plans before conception, during pregnancy, and in postpartum care, healthcare providers can ensure the healthiest possible environment for eggs, embryos, and newborns.