PCOS and Fertility: Understanding What's Actually Affecting Ovulation
Polycystic ovary syndrome is not one condition. Different factors — insulin resistance, inflammation, high androgens, high AMH — affect fertility through different mechanisms, and understanding which factors are involved changes the conversation about what can help. Whether you’re 25 or 40, an individualized assessment is the starting point.
Dr. Fiona McCulloch, ND
- Author, 8 Steps to Reverse Your PCOS
- Peer reviewer, 2023 International Evidence-Based PCOS Guidelines
- 25+ years clinical focus in PCOS and hormonal health
Licensed to prescribe bioidentical hormone therapy in Ontario, including progesterone used in fertility contexts.
If PCOS Is Making It Harder to Get Pregnant, You’re Not Alone — and You’re Not Out of Options
If you have PCOS and you’re trying to conceive
- You were told at diagnosis that PCOS would make it hard to get pregnant — but nobody explained why or what could be done
- Your doctor suggested Letrozole or metformin without assessing what’s actually driving your anovulation
- Ovulation predictor kits give confusing results because your LH is chronically elevated
- You’ve tried supplements recommended on social media without a clear plan or monitoring
- You feel like “just another PCOS patient” — no one has assessed your specific pattern
If you’re 35+ with PCOS and wondering about age
- You’re not sure if your difficulty conceiving is still PCOS or if it’s now age-related
- Your AMH looks high — because of PCOS — but practitioners say “everything looks fine” while you still can’t conceive
- You feel the dual pressure of a condition you’ve always had and a new biological timeline
- No one is looking at how PCOS and perimenopause interact — they’re treated as separate issues
Dr. Fiona McCulloch notes that PCOS-related fertility challenges are among the more treatable causes of difficulty conceiving. In her clinical experience, most women with PCOS can conceive, especially with treatment that addresses their specific pattern. The term “infertility” often overstates the situation — for most women with PCOS, the issue is subfertility related to ovulatory patterns that can be evaluated and often influenced.
PCOS also tends to increase egg reserve, which means there is often more time to work with than women have been told. The real question is not whether pregnancy is possible, but which specific mechanism is preventing ovulation — and that depends on an individualized assessment.
How Different Factors in PCOS Affect Fertility
Not all PCOS affects fertility the same way — and multiple factors can be involved at once. The first step in a PCOS fertility assessment at White Lotus Clinic is evaluating ovulation and metabolic markers — because insulin resistance is the most common driver of anovulation in PCOS, and its presence or absence determines the clinical pathway. If insulin resistance is significant, addressing it is often a key component of the fertility approach. If it’s not the primary factor, the assessment shifts to other hormonal patterns that may be involved.
Insulin-Resistant PCOS and Fertility
Insulin resistance is the most common metabolic driver of PCOS-related anovulation. When insulin levels are elevated, they stimulate the ovaries to produce excess androgens (testosterone). This disrupts follicular development and prevents the hormonal cascade needed for ovulation.
Because insulin also elevates LH — a hormone that triggers ovulation in a normal cycle — women with insulin-resistant PCOS often see misleadingly positive results on ovulation predictor kits without actually ovulating.
Assessment includes reviewing metabolic health history, family history of diabetes, and testing for insulin resistance, blood sugar patterns, fatty liver, cholesterol, and inflammatory markers. When insulin resistance is identified as the primary driver, addressing it is often the most impactful step in the fertility approach.
Adrenal PCOS and Fertility
Many women with PCOS have high adrenal androgens. Elevated DHEA-S levels from the adrenal glands can drive a different pattern of anovulation — one that standard insulin-focused PCOS protocols can miss entirely, because insulin markers may be normal.
This is one reason why individualized assessment matters. A woman with high adrenal androgens may not respond to the same interventions as someone whose primary driver is insulin resistance, because the mechanism contributing to her anovulation is different. Assessment includes evaluating DHEA levels, cortisol patterns, and adrenal androgen markers alongside the broader hormonal panel.
Lean PCOS and Fertility
PCOS does not require insulin resistance. Women with lean PCOS have a normal BMI but still experience anovulation, irregular cycles, and difficulty conceiving. They can have very high androgens, inflammation, or other hormonal disruptions. The challenge is that this presentation is frequently dismissed or undiagnosed — and the standard advice to “lose weight” is both irrelevant and harmful.
Because insulin resistance may not be the primary driver, lean PCOS requires a comprehensive hormonal evaluation — including testosterone, DHEA, FSH, LH, and thyroid — rather than a metabolic-focused assessment alone. Understanding which factors are preventing ovulation in lean PCOS is what makes an individualized approach different from a generic one.
Inflammatory PCOS and Fertility
Most patients with PCOS have inflammation — it is a common factor, not a separate condition. In PCOS, chronic low-grade inflammation disrupts the follicular environment. Women with a lot of inflammation in PCOS may ovulate, but the quality of egg development can be affected. There can be difficulties with implantation and early pregnancy maintenance.
This means fertility challenges may present differently: not as absent ovulation, but as compromised egg quality or luteal phase function. Assessment includes inflammatory markers as part of a comprehensive metabolic and hormonal panel, along with evaluation of gut health and environmental factors that may contribute to systemic inflammation.
PCOS Fertility After 35: What the Research — and Clinical Experience — Actually Shows
One of the most common concerns among women with PCOS in their mid-30s and beyond is that age is making their fertility picture worse. The clinical reality is more nuanced — and, for many women, more encouraging than they expect.
In Dr. Fiona McCulloch’s clinical experience, women with PCOS who are 35 and older usually have fairly good fertility. PCOS often increases egg reserve, meaning these patients tend to have a higher egg count than age-matched women without PCOS. Many women with PCOS actually become more fertile around 35, as hormonal patterns shift in ways that can improve ovulatory function. Some begin to ovulate more regularly — even naturally — and treatments aimed at supporting ovulation tend to be more effective in this age group.
This is often the opposite of what women have been told. The fear that age compounds PCOS in a purely negative way is understandable, but the clinical picture is more complex.
There are genuine considerations for the 35+ age group, however — and they tend to be metabolic rather than related to egg count. Insulin resistance tends to increase in the perimenopausal years, which can affect ovulatory function even if other aspects of the PCOS picture are improving. Higher estrogen levels — a feature of perimenopause — can also influence the hormonal environment. These factors are assessable and addressable through a comprehensive metabolic and hormonal evaluation.
This is why the assessment matters more, not less, for women with PCOS in their mid-30s and beyond. The value isn’t urgency — it’s understanding how the metabolic picture is shifting so the clinical approach reflects what’s actually happening in your body right now.
Learn more about our menopause and perimenopause program →
AMH testing in PCOS →
Cyclic Progesterone Therapy for PCOS Fertility
Progesterone is a key hormone for fertility — it supports the luteal phase, prepares the endometrial lining for implantation, and helps sustain early pregnancy. In PCOS, progesterone is often low because poor follicular development and irregular or absent ovulation mean the body doesn’t produce adequate amounts on its own.
At White Lotus Clinic, progesterone is used in PCOS fertility care as cyclic progesterone therapy — an approach based on the research of Dr. Jerilynn Prior at the Centre for Menstrual Cycle and Ovulation Research (CeMCOR) at the University of British Columbia. Cyclic progesterone has multiple effects relevant to PCOS fertility: it lowers LH and testosterone, it is anti-inflammatory, and it supports mood — addressing several of the hormonal disruptions that contribute to anovulation, not just the progesterone deficiency itself.
At White Lotus Clinic, cyclic progesterone is typically prescribed as vaginal suppositories, as this delivery method has more evidence supporting its use in fertility contexts. This approach differs from how progesterone is used in many fertility clinic settings, where it is typically prescribed in conjunction with ovulation-induction medications like letrozole or gonadotrophins. At White Lotus, cyclic progesterone therapy is used as a therapeutic intervention in its own right — not solely as luteal phase support after medicated ovulation.
White Lotus practitioners are licensed to prescribe bioidentical progesterone in Ontario. This distinguishes our approach from supplement-based naturopathic care, where hormonal prescriptions are not available.
How cyclic progesterone therapy works →
PCOS Fertility Treatment: Conventional and Naturopathic Approaches
PCOS fertility treatment is not one thing — it’s a landscape of options, and the right approach depends on what’s driving the anovulation and where you are in the process.
Conventional approaches
Letrozole is currently the first-line medication for ovulation induction in PCOS. It works by temporarily lowering estrogen, which prompts the brain to increase FSH production and stimulate follicle development. Injectable gonadotrophins (FSH injections such as Gonal-F or Menopur) are considered when oral medications are unsuccessful. In vitro fertilization (IVF) is typically recommended when other approaches have not been effective.
Naturopathic assessment and treatment
A naturopathic PCOS fertility assessment evaluates ovulatory function, insulin and metabolic markers, and hormonal patterns — with treatment planned based on the specific factors involved in your PCOS. This may include cyclic progesterone therapy, metabolic optimization, nutritional and botanical support, and ovulatory pattern monitoring. Naturopathic care can serve as a primary approach or work alongside conventional fertility treatment.
Working with both
Many patients work with both a naturopathic doctor and a fertility clinic. Naturopathic assessment focuses on identifying and addressing modifiable factors — metabolic, hormonal, nutritional — that may support ovulatory function. When assisted reproductive technology is the most appropriate path, we support that decision and coordinate care with the fertility team.
Botanical and Nutritional Support for PCOS Fertility
Black cohosh
Black cohosh (Cimicifuga racemosa) is a phytoestrogen that may help support ovulatory function. In a randomized controlled trial of 100 women with PCOS, black cohosh extract was found to support ovulation induction [1]. Black cohosh can help modulate estrogen levels, which may contribute to a more balanced hormonal environment for follicular development.
Other botanicals
White peony, licorice, and saw palmetto are commonly used in clinical practice to address elevated androgen levels in PCOS. Each has a different mechanism — white peony influences ovarian hormone production, licorice affects androgen metabolism, and saw palmetto acts as an androgen receptor blocker. These are used as part of an individualized plan, not as standalone treatments.
Acupuncture
Electro-acupuncture has been studied for its effects on ovulation in PCOS. In one study, women with PCOS who received electro-acupuncture over three months showed improved ovulation rates, lower testosterone levels, and improved metabolic markers [4].
Diet and lifestyle
For women with insulin-resistant PCOS, dietary changes that support healthy glucose and insulin levels can be one of the most impactful interventions. High insulin levels drive ovarian testosterone production, which can prevent ovulation. Moderate- to high-intensity interval training has also been shown to improve insulin sensitivity.
What to Expect at a PCOS Fertility Consultation
1
Initial Consultation — Ovulation and Metabolic Assessment
Your first visit begins with a detailed review of your PCOS history, ovulatory patterns, and any prior testing or treatment. Dr. Fiona evaluates metabolic markers — including your metabolic health history, family history of diabetes, and any existing bloodwork — because insulin resistance is the most common driver of anovulation in PCOS. We build on what’s already been done. You don’t start from scratch.
Duration: 60–90 minutes
2
Comprehensive Testing — Identifying Your Pattern
Based on your initial assessment, targeted testing is ordered. A comprehensive PCOS fertility panel may include insulin resistance markers, blood sugar, fatty liver indicators, cholesterol, inflammatory markers, testosterone, DHEA, FSH, LH, and thyroid function. The key clinical question is whether insulin resistance is a significant factor — because its presence or absence determines the treatment pathway.
3
Individualized Treatment Plan
Once results are reviewed, Dr. Fiona identifies the primary mechanism affecting your fertility and determines which factors are modifiable. Your treatment plan is based on your assessment results — not a generic PCOS protocol. This may include cyclic progesterone therapy, metabolic support, nutritional and botanical interventions, and ovulatory cycle monitoring. If your assessment suggests that assisted reproductive technology is the most appropriate path, we discuss that honestly.
4
Ongoing Monitoring and Coordination
Follow-up visits track ovulatory patterns, lab marker changes, and treatment response. Plans are adjusted as needed. If you’re also working with a fertility clinic, we coordinate care — naturopathic and conventional fertility treatment can work together.
Follow-up visits: 30–45 minute
For women whose fertility concerns are primarily PCOS-related, our PCOS practice provides comprehensive individualized assessment. For women 35+ whose PCOS patterns may be compounding with perimenopause-related metabolic changes, our menopause and perimenopause program includes this evaluation as part of a broader hormonal assessment.
Ready to discuss your PCOS fertility questions? Request a consultation →
Common Questions About PCOS and Fertility
Can you get pregnant with PCOS?
In Dr. Fiona McCulloch’s clinical experience, most women with PCOS can conceive, especially with treatment that addresses their specific pattern. PCOS is one of the more treatable causes of fertility challenges — though many women are told at diagnosis that they will struggle to conceive, which causes significant anxiety that often doesn’t reflect the clinical reality.
For most women with PCOS, the issue is subfertility — meaning ovulatory patterns that can be evaluated and often influenced — rather than permanent infertility. PCOS also tends to increase egg reserve, which means women with PCOS often have more time to work with than they’ve been told. The key is understanding which mechanism is preventing ovulation, because different factors involve different mechanisms.
Of course, this varies from person to person. A thorough assessment is the best way to understand your specific situation.
Do different factors in PCOS affect fertility differently?
Yes. Different factors involved in PCOS can affect fertility through different mechanisms, including insulin resistance, inflammation, high androgens, and high anti-müllerian hormone. These factors often overlap — a woman may have more than one contributing to her fertility challenges.
For example, insulin resistance is the most common metabolic driver of anovulation, but a woman with normal insulin markers may still have high adrenal androgens or significant inflammation affecting egg quality. This is why an individualized assessment matters — the first step is identifying which factors are involved in your specific pattern.
How does age affect PCOS fertility?
Women with PCOS who are 35 and older usually have fairly good fertility. PCOS often increases egg reserve — meaning a higher egg count than age-matched women without PCOS. In Dr. Fiona McCulloch’s clinical experience, many women with PCOS actually become more fertile around 35, as hormonal patterns shift in ways that can improve ovulatory function. Some begin to ovulate more regularly, and treatments tend to be more effective in this age group.
The real considerations for women 35+ with PCOS are metabolic rather than related to egg count. Insulin resistance tends to increase in the perimenopausal years, and estrogen levels can rise — both of which are assessable through comprehensive testing. This is why our menopause and perimenopause program includes PCOS fertility assessment for women in this age group.
Is progesterone safe to use while trying to conceive?
Bioidentical progesterone has a well-established safety profile in fertility contexts and is widely used in both conventional and naturopathic fertility medicine. At White Lotus Clinic, cyclic progesterone therapy is prescribed based on research from CeMCOR at the University of British Columbia, using vaginal suppositories — a delivery method with strong evidence supporting its use in fertility.
Cyclic progesterone in PCOS doesn’t only support the luteal phase — it also lowers LH and testosterone, reduces inflammation, and supports mood. Your progesterone protocol is prescribed and monitored as part of a clinical treatment plan. For broader context on bioidentical hormone safety, see our page on bioidentical hormone therapy.
What happens at the first PCOS fertility consultation?
Your first visit is a conversation — not a treatment commitment. Dr. Fiona reviews your PCOS history, ovulatory patterns, prior testing, and any treatments you’ve already tried. She evaluates metabolic markers, including family history of diabetes and prior insulin resistance testing, because the presence or absence of insulin resistance determines the clinical pathway.
Based on this initial assessment, she may order targeted testing: a comprehensive panel that can include insulin markers, testosterone, DHEA, FSH, LH, thyroid, and inflammatory markers. The goal of the first visit is to understand your specific PCOS pattern and develop a clear assessment plan — not to start treatment.
Can naturopathic doctors prescribe hormones for fertility?
In Ontario, naturopathic doctors with appropriate training are licensed to prescribe bioidentical hormones, including progesterone used in fertility contexts. This is part of their regulated scope of practice under the College of Naturopaths of Ontario (CONO).
This distinguishes naturopathic doctors with prescribing authority — like the practitioners at White Lotus Clinic — from supplement-based practitioners who cannot prescribe hormonal medications. Prescriptions at White Lotus are issued as part of a clinical treatment plan with ongoing monitoring, not as standalone supplements.
What if Letrozole or other fertility treatments haven’t worked?
Prior treatment experience is clinically valuable information. If Letrozole hasn’t produced consistent ovulation, it may mean that ovulation induction alone isn’t addressing the primary mechanism driving your anovulation. Letrozole works through one pathway — if the main driver is insulin resistance, adrenal androgen excess, or inflammatory disruption, a different or additional approach may be worth evaluating.
An individualized assessment looks at the factors that may not have been addressed in a standard protocol: metabolic patterns, hormonal balance, inflammatory markers, and ovulatory cycle detail. This information can inform next steps — whether that’s naturopathic treatment, a revised conventional approach, or both.
If assisted reproductive technology is the most appropriate path, we support that decision and can coordinate care with your fertility team.
Fees, Insurance, and Booking
PCOS fertility consultations are available with Dr. Fiona McCulloch ND and Dr. Alex Triandall ND. Each practitioner has a different fee schedule reflecting their experience and specialization.
For current consultation fees, appointment durations, and online booking, see the booking section on our PCOS practice page:
Insurance Coverage
Many Ontario extended health insurance plans include naturopathic coverage. We provide receipts for insurance submission. Lab testing may also be partially covered depending on your plan. Check with your insurance provider for your specific coverage details.
Prescribing Authority
White Lotus practitioners are licensed to prescribe bioidentical hormone therapy in Ontario, including progesterone support used in fertility contexts. Prescriptions are issued as part of a clinical treatment plan with ongoing monitoring — not as standalone supplements. This is part of the regulated scope of practice for naturopathic doctors in Ontario.
What Women with PCOS Most Often Want from Fertility Care
Understanding your pattern
Knowing which factors in your PCOS are affecting fertility, why ovulation isn’t happening, and what’s addressable — so you can make informed decisions rather than guessing.
Having a specific plan
A treatment approach based on your assessment results, not a generic protocol — something you can follow, track, and adjust with your practitioner over time.
Feeling understood
Working with a practitioner who knows PCOS at a level where your pattern, your history, and your specific concerns are the starting point — not an afterthought.
Feeling hopeful but not pressured
Having realistic expectations about what’s possible, based on clinical evidence rather than fear — without false promises and without being told to just relax.aHaving realistic expectations about what’s possible, based on clinical evidence rather than fear — without false promises and without being told to just relax.
Feeling proactive
Being able to tell your partner, your family, and yourself that you are taking informed, meaningful action — not just waiting and hoping.
Individual experiences vary. These reflect common priorities expressed by patients exploring PCOS fertility care. We cannot guarantee specific outcomes.
Why Understanding Your PCOS Pattern Matters
Ovulatory pattern assessment provides a clinical baseline that helps guide treatment decisions. Having this information earlier in the fertility process is generally more useful than having it later — not because of urgency, but because it gives you and your practitioner more data to work with.
For women with PCOS who are also in their mid-30s and beyond, metabolic factors like insulin resistance tend to shift during the perimenopausal years. Understanding how these factors are changing — and whether they’re affecting ovulatory function — can inform the clinical approach. This is assessment, not alarm.
Hormonal patterns contributing to anovulation may be influenced by modifiable factors. The purpose of a thorough assessment is to identify these factors — and to give you a clear picture of what’s addressable and what isn’t.
Understanding Your PCOS Fertility Options
| Approach | Typical Provider | Focus | Considerations |
|---|---|---|---|
| Conventional fertility treatment (Letrozole, gonadotrophins, IVF) | Reproductive endocrinologist / fertility clinic | Ovulation induction, assisted reproduction | First-line for many women with PCOS; may not assess underlying PCOS type or metabolic factors |
| GP-managed PCOS care | Family physician | Metformin, lifestyle guidance, specialist referral | Accessible; limited time for individualized PCOS assessment or hormonal evaluation |
| Naturopathic PCOS assessment (individualized) | Naturopathic doctor with PCOS focus + prescribing authority | Individualized evaluation, hormonal support, metabolic optimization | Assesses modifiable factors; can complement conventional care or serve as primary approach |
| Supplement-based naturopathic care | Naturopathic doctor (general practice) | Supplement protocols, dietary guidance | May lack prescribing authority for hormonal support like progesterone |
| Online PCOS programs / self-directed | Various | General education, supplement recommendations | Accessible and affordable; not individualized to your specific PCOS pattern |
All approaches have value depending on your situation. Our goal is to help you understand your specific PCOS pattern so you can make informed decisions about your care — whether that care is with us, with a fertility clinic, or both.
8 Steps to Reverse Your PCOS
Dr. Fiona McCulloch’s published guide to PCOS management covers the individualized approach used in clinical practice — including the metabolic, hormonal, and inflammatory factors that affect fertility differently depending on your specific PCOS pattern.
2023 International PCOS Guidelines
Dr. Fiona was invited to serve as a peer reviewer for the 2023 International Evidence-Based Guidelines for the Assessment and Management of Polycystic Ovary Syndrome — the global clinical standard for PCOS care. This role is independently verifiable and reflects recognized clinical expertise in PCOS assessment.
25+ Years Clinical Focus
Dr. Fiona McCulloch completed the Fellowship of the American Board of Naturopathic Endocrinology exam and served on the board of directors of the Endocrinology Association of Naturopathic Physicians for eight years. She has maintained a clinical focus in PCOS and hormonal health since 2001. Dr. Alex Triandall ND brings approximately 15 years of complementary clinical experience.
Your Next Step — When You’re Ready
PCOS Fertility Consultation
For women whose fertility concerns are primarily PCOS-related — at any age.
Your first visit is exploratory — a conversation about your history, your PCOS pattern, and your questions.
Menopause Program Consultation
For women 35+ whose PCOS may be compounding with perimenopause-related metabolic changes.
Our menopause program includes PCOS fertility assessment as part of a comprehensive hormonal and metabolic evaluation.
Not ready to book? Here are other ways to learn more:
Consultations are exploratory — not a commitment to treatment. We respect your decision-making timeline. There is no pressure to proceed with any recommendation.
Consultations are exploratory — not a commitment to treatment. We respect your decision-making timeline. There is no pressure to proceed with any recommendation.
Written by Dr. Fiona McCulloch ND with over 25 years of clinical focus in PCOS and hormonal health. Last reviewed March 2026.
References
- Kamel, H. H. (2013). Role of phyto-oestrogens in ovulation induction in women with polycystic ovarian syndrome. European Journal of Obstetrics & Gynecology and Reproductive Biology, 168(1), 60–63. doi:10.1016/j.ejogrb.2012.12.025
- Nidhi, R., Padmalatha, V., Nagarathna, R., & Ram, A. (2012). Effect of a yoga program on glucose metabolism and blood lipid levels in adolescent girls with polycystic ovary syndrome. International Journal of Gynecology & Obstetrics, 118(1), 37–41. doi:10.1016/j.ijgo.2012.01.027
- Stefanaki, C., Bacopoulou, F., & Livadas, S. (2015). Impact of a mindfulness stress management program on stress, anxiety, depression and quality of life in women with polycystic ovary syndrome. Stress, 18(1), 57–66. doi:10.3109/10253890.2014.974030
- Stener-Victorin, E., Waldenström, U., Tägnfors, U., et al. (2000). Effects of electro-acupuncture on anovulation in women with polycystic ovary syndrome. Acta Obstetricia et Gynecologica Scandinavica, 79(3), 180–188. PubMed
Additional citations pending: Semcor/UBC cyclic progesterone research and 2023 International PCOS Guidelines.