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One-third or more of women with PCOS experience some degree of infertility but the incidence may be less for non-obese women. It is important to distinguish women with PCOS and women without PCOS who may have polycystic ovaries but regular ovulatory cycles, since their rates of infertility are different.

Some estimates ascribe anovulation to be the cause of infertility in 25% of couples and it is known that PCOS is the most common cause of anovulation. This would mean that PCOS could be a factor in approximately 20% of infertile couples.

Cystic Ovaries

Women with PCOS often have ovaries that contain multiple cysts (fluid filled sacs of underdeveloped follicles) that have been described as a "string of pearls". Polycystic ovaries in women diagnosed with PCOS are often 1.5 to 3 times larger than normal and usually contain at least 8-10 cysts each of which is less than 10 mm.

Often, there is also an increase of stromal tissue (connective tissue of the ovary) in the center of the ovary and around the follicles. Both the cysts and stromal tissue produce hormones that may increase the probability, and possibly the severity, of symptoms of PCOS. It is not clear if PCOS affects the quality of the eggs.

Obesity

Approximately 40% of women with PCOS are obese. Obesity is a significant risk factor in PCOS as it increases the chances for and exacerbates existing insulin resistance, which, in turn, may intensify the other factors of PCOS. The most common type of obesity in PCOS is android obesity, often described as an 'apple figure' and is measured by the waist:hip ratio.

Obesity can be described using different parameters of weight and height ratios. According to the National Women's Health Information Center, women with more than 30% body fat are considered obese. The American Obesity Association defines obesity based on body mass index (BMI) where a BMI greater than 30 indicates obesity. Others describe obesity as 120% of ideal body weight. The cause of obesity is not clear but it has a marked effect on glucose tolerance and exacerbates the hyperinsulinemia. Women with PCOS can also be significantly overweight but not obese (BMI between 25 and 30). Women who are obese are at increased risk for multiple health problems including cardiovascular problems such as heart attack and hypertension.

Hirsutism

Hirsutism is defined as inappropriate hair growth in androgen sensitive areas of the body (areas where hair growth is related to male/female hormones). These include the chin, upper lip, neck, chest, upper and lower back, upper and lower abdomen, upper arms, thighs, and perineum (area between the scrotum and the anus). The severity of hair growth is measured by the Ferriman-Gallway scoring system and hirsutism is defined as a value of 8 or more on this scale.

The presence of hirsutism is related to several factors including:

• Potency and quantity of circulating androgens
• Sensitivity of the hair follicles to androgens
• Duration of the exposure of the follicles to androgens