I am on Glucophage, as I am insulin resistant and have PCOS. I have gotten my period on two perfect 28-day cycles, but I did not ovulate with either cycle. What should my next step be? I am overweight, 186 pounds at five feet four inches, but I have recently lost eight pounds. I would love to increase my chances in any way possible.

Heather

When I use metformin (Glucophage) to help someone attempt pregnancy, I increase the dose slowly up to 850mg twice daily and occasionally up to 1,000mg twice daily. Doses less than 1,500mg per day are usually not effective. While studies have shown that metformin may be effective in up to 65 percent or more of women who stay on it for six or more months, the best results are seen when metformin is combined with a diet and exercise program. My patients are advised to begin their exercise program with walking 20-30 minutes at least three times each week. In addition, I counsel them on a diet low in processed carbohydrates and saturated fats. Counseling with a PCOS-smart dietitian is often helpful. You mentioned that you already lost eight pounds. That is excellent, and a good beginning to get you back toward your ideal body weight. Your chances to conceive and regulate your cycles improve as you continue with your program of diet, exercise and weight loss.

It is not always clear how menstrual cycles can be regular if you are not ovulating. It would be important for me to know how you determined that you did not ovulate. In order to monitor the response to metformin therapy, I recommend the use of basal body temperature charting. While some physicians prefer to measure a blood progesterone level, I can't be certain when to do this blood test unless you are also monitoring your temperature. After three months of therapy I ask the patient to bring in her BBT charts for review. Free software available online simplifies the task of charting. If on review I see infrequent or absent signs of ovulation, I may choose to increase the dose of metformin, add a second insulin-sensitizing medication, or consider alternatives such as clomiphene or ovarian drilling.