The use of metformin for women with PCOS undergoing IVF treatment

Ovarian hyperstimulation syndrome: pathophysiology, staging, prediction and prevention

OBJECTIVE

To identify, appraise and summarize the current evidence regarding the pathophysiology, staging, prediction and prevention of ovarian hyperstimulation syndrome (OHSS).

METHODS

Two comprehensive systematic reviews were carried out: one examined methods of predicting either high ovarian response or OHSS and the other examined interventions aimed at reducing the occurrence of OHSS. Additionally, we describe the related pathophysiology and staging criteria.

RESULTS

Seven studies examining methods of predicting OHSS and eight more examining methods of predicting high ovarian response to controlled ovarian stimulation were included. Current evidence shows that the best methods of predicting high response are antral follicle count and anti-Müllerian hormone levels, and that a high ovarian response (examined by the number of large follicles, estradiol concentration or the number of retrieved oocytes) is the best method of predicting the occurrence of OHSS. Ninety-seven randomized controlled trials examining the effect of several interventions for reducing the occurrence of OHSS were included. There was high-quality evidence that replacing human chorionic gonadotropin by gonadotropin-releasing hormone agonists or recombinant luteinizing hormone, and moderate-quality evidence that antagonist protocols, dopamine agonists and mild stimulation, reduce the occurrence of OHSS. The evidence for the effect of the other interventions was of low/very low quality. Additionally, we identified and described 12 different staging criteria.

CONCLUSIONS

There are useful predictive tools and several preventive interventions aimed at reducing the occurrence of OHSS. Acknowledging and understanding them are of crucial importance for planning the treatment of, and, ultimately, eliminating, OHSS while maintaining high pregnancy rates.

Metformin use in patients undergoing in vitro fertilization treatment: results of a worldwide web-based survey

PURPOSE

To identify trends regarding therapeutic approaches to metformin administration in patients undergoing in vitro fertilization (IVF) treatment worldwide.

METHODS

A retrospective evaluation utilizing the results of a web-based survey, IVFWorldwide ( www.IVF-worldwide.com/ ), was performed.

RESULTS

Responses from 101 centers performing a total of 50,800 annual IVF cycles was performed. Of these cycles, 10.4% (n = 5,260) reported metformin use during IVF cycles. Indications for metformin use in IVF cycles included polycystic ovary syndrome (PCOS) patients who were habitual abortions (67%), had prior poor egg quality (61%), had high serum insulin levels (56%). Less reported was PCOS with obesity/anvoulation (29%), PCOS with multiple manifestations (23%) and glucose intolerance and insulin resistance (23%). Over half of cycles (54%) treated patients with metformin up to 3 months prior to starting IVF. A majority (82%) of IVF cycles utilized 1500-2000 mg/day of metformin. A nearly equal percentage of centers continued metformin up to a positive β-HCG test (35%) or to 12 weeks gestation (33%). 70% of IVF cycles reported increased pregnancy rates and decreased miscarriage rates due to the use of metformin. 75% reported the data in the literature is not sufficient for reaching a definitive conclusion concerning metformin treatment in patients undergoing IVF.

CONCLUSIONS

While metformin is used worldwide as an adjunct to standard IVF protocols, there is much variation in its use and the majority of centers report lack of evidence supporting its use.

Metformin treatment before and during IVF or ICSI in women with polycystic ovary syndrome

BACKGROUND

The use of insulin-sensitising agents, such as metformin, in women with polycystic ovary syndrome (PCOS) who are undergoing ovulation induction or in vitro fertilisation (IVF) cycles has been widely studied. Metformin reduces hyperinsulinaemia and suppresses the excessive ovarian production of androgens. As a consequence, it is suggested that metformin could improve assisted reproductive techniques (ART) outcomes, such as ovarian hyperstimulation syndrome (OHSS), pregnancy and live birth rates.

OBJECTIVES

To determine the effectiveness and safety of metformin as a co-treatment during IVF or intracytoplasmic sperm injection (ICSI) in achieving pregnancy or live birth in women with PCOS.

SEARCH METHODS

We searched the Cochrane Menstrual Disorders and Subfertility Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE, LILACS, the metaRegister of Controlled Trials and reference lists of articles (up to 15 October 2014).

SELECTION CRITERIA

Types of studies: randomised controlled trials (RCTs) comparing metformin treatment with placebo or no treatment in women with PCOS who underwent IVF or ICSI treatment.

TYPES OF PARTICIPANTS

women of reproductive age with anovulation due to PCOS with or without co-existing infertility factors.Types of interventions: metformin administered before and during IVF or ICSI treatment.Types of outcome measures: live birth rate, clinical pregnancy rate, miscarriage rate, incidence of ovarian hyperstimulation syndrome , incidence of participant-reported side effects, serum oestradiol level on the day of trigger, serum androgen level, and fasting insulin and glucose levels.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected the studies, extracted the data according to the protocol and assessed study quality. The overall quality of the evidence was assessed using GRADE methods.

MAIN RESULTS

We included nine randomised controlled trials involving a total of 816 women with PCOS. When metformin was compared with placebo there was no clear evidence of a difference between the groups in live birth rates (OR 1.39, 95% CI 0.81 to 2.40, five RCTs, 551 women, I(2) = 52%, low-quality evidence). Our findings suggest that for a woman with a 32 % chance of achieving a live birth using placebo or other treatment, the corresponding chance using metformin treatment would be between 28% and 53%.When metformin was compared with placebo or no treatment, clinical pregnancy rates were higher in the metformin group (OR 1.52; 95% CI 1.07 to 2.15; eight RCTs, 775 women, I(2) = 18%, moderate-quality evidence). This suggests that for a woman with a 31% chance of achieving a clinical pregnancy using placebo or no treatment, the corresponding chance using metformin treatment would be between 32% and 49%.The risk of ovarian hyperstimulation syndrome was lower in the metformin group (OR 0.29; 95% CI 0.18 to 0.49, eight RCTs, 798 women, I(2) = 11%, moderate-quality evidence). This suggests that for a woman with a 27% risk of having OHSS without metformin the corresponding chance using metformin treatment would be between 6% and 15%.Side effects (mostly gastrointestinal) were more common in the metformin group (OR 4.49, 95% CI 1.88 to 10.72, for RCTs, 431 women, I(2)=57%, low quality evidence)The overall quality of the evidence was moderate for the outcomes of clinical pregnancy, OHSS and miscarriage, and low for other outcomes. The main limitations in the evidence were imprecision and inconsistency.

AUTHORS' CONCLUSIONS

This review found no conclusive evidence that metformin treatment before or during ART cycles improved live birth rates in women with PCOS. However, the use of this insulin-sensitising agent increased clinical pregnancy rates and decreased the risk of OHSS.

The effect of metformin treatment in vivo on acute and long-term energy metabolism and progesterone production in vitro by granulosa cells from women with polycystic ovary syndrome

STUDY QUESTION

What are the consequences of polycystic ovary syndrome (PCOS) pathology and metformin-pretreatment in vivo in women with PCOS on the metabolism and steroid production of follicular phenotype- and long-term cultured-granulosa cells (GC)?

SUMMARY ANSWER

PCOS pathology significantly compromised glucose metabolism and the progesterone synthetic capacity of follicular- and long-term cultured-GCs and the metabolic impact of PCOS on GC function was alleviated by metformin-pretreatment in vivo.

WHAT IS KNOWN ALREADY

Granulosa cells from women with PCOS have been shown to have an impaired insulin-stimulated glucose uptake and lactate production in vitro. However, these results were obtained by placing GCs in unphysiological conditions in culture medium containing high glucose and insulin concentrations. Moreover, existing data on insulin-responsive steroid production in vitro by PCOS GCs vary.

STUDY DESIGN, SIZE AND DURATION

Case-control experimental research comparing glucose uptake, pyruvate and lactate production and progesterone production in vitro by GCs from three aetiological groups, all undergoing IVF; healthy control women (Control, n = 12), women with PCOS treated with metformin in vivo (Metformin, n = 8) and women with PCOS not exposed to metformin (PCOS, n = 8). The study was conducted over a period of 3 years between 2007 and 2010.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Rotterdam criteria were used for the diagnosis of PCOS; all subjects were matched for age, BMI and baseline FSH. Individual patient cultures were undertaken with cells incubated in a validated, physiological, serum-free culture medium containing doses of 0–6 mM glucose and 0–100 ng/ml insulin for 6 h and 144 h to quantify the impact of treatments on acute and long-term metabolism, respectively, and progesterone production. The metabolite content of spent media was measured using spectrophotometric plate reader assay. The progesterone content of spent media was measured by enzyme-linked immunosorbent assay. Viable GC number was quantified after 144 h of culture by the vital dye Neutral Red uptake assay.

MAIN RESULTS AND THE ROLE OF CHANCE

Granulosa cells from women with PCOS pathology revealed reduced pyruvate production and preferential lactate production in addition to their reduced glucose uptake during cultures (P < 0.05). Metformin pretreatment alleviated this metabolic lesion (P < 0.05) and enhanced cell proliferation in vitro (P < 0.05), but cells retained a significantly reduced capacity for progesterone synthesis compared with controls (P < 0.05).

LIMITATIONS, REASONS FOR CAUTION

Although significant treatment effects were detected in this small cohort, further studies are required to underpin the molecular mechanisms of the effect of metformin on GCs.

WIDER IMPLICATIONS OF THE FINDINGS

The individual patient culture strategy combined with multifactorial experimental design strengthens the biological interpretation of the data. Collectively, these results support the notion that there is an inherent impairment in progesterone biosynthetic capacity of the GCs from women with PCOS. The positive, acute metabolic effect and the negative long-term steroidogenic effect on GCs following metformin exposure in vivo may have important implications for follicular development and luteinized GC function when the drug is used in clinical practice.

STUDY FUNDING/COMPETING INTEREST(S)

No competing interests. This work was supported by the UK Medical Research Council Grant Reference number G0800250.

Optimal management of subfertility in polycystic ovary syndrome

The purpose of this paper is to provide a stepwise approach to treating the infertility/subfertility associated with polycystic ovary syndrome. Defining polycystic ovary syndrome in a patient requires first investigating other possible causes for polycystic ovary morphology, acne, hirsutism, obesity, and the metabolic derangements that often accompany polycystic ovary syndrome. Beginning with lifestyle modification and use of metformin, the progressive inclusion of more intensive therapies for induction of ovulation is described. Second-line treatments are discussed and the new findings from a large multicenter trial are discussed in the context of evidence-based treatment strategies for first-line agents. Finally, monofollicular development as a treatment goal and in vitro fertilization are discussed for those with recalcitrant disease.

Comparison of gonadotropin-releasing hormone agonist with GnRH antagonist in polycystic ovary syndrome patients undergoing in vitro fertilization cycle: Retrospective analysis from a tertiary center and review of literature

INTRODUCTION:

Polycystic ovary syndrome (PCOS) is one of the most common infertility factor for which women are enrolled in in vitro fertilization (IVF) technique. In the recent years, gonadotropin releasing hormone antagonist protocol has emerged as the protocol of choice for controlled ovarian hyperstimulation in these patients.

OBJECTIVES:

The objective of the present study is to compare conventional long agonist protocol with fixed antagonist protocol in PCOS patients undergoing IVF cycle.

MATERIALS AND METHODS:

Retrospective analysis of 4 years data of a single center from northern India. Totally 81 patients who had long agonist protocol were compared with 36 patients with similar baseline characteristics who had antagonist protocol.

RESULT:

Total dose of gonadotropin required was significantly lower (P - 0.004) in the antagonist group. There was no significant difference in pregnancy rate or incidence of ovarian hyperstimulation syndrome between two groups. Cycle cancellation due to arrest of follicular growth was significantly higher in the antagonist group (P - 0.027).

CONCLUSION:

More randomized control trials and meta-analysis are required before replacing conventional long agonist protocol with antagonist protocol in patients with polycystic ovary syndrome.

The use of berberine for women with polycystic ovary syndrome undergoing IVF treatment

OBJECTIVE

Previous studies have indicated that berberine is an effective insulin sensitizer with comparable activity to metformin (Diabetes 2006, 55, 2256). Reduced insulin sensitivity is reportedly a factor adversely affecting the outcome of IVF in patients with polycystic ovary syndrome (PCOS) (Human Reproduction 2006, 21, 1416). Our objective was to evaluate the clinical, metabolic and endocrine effects of berberine vs metformin in PCOS women scheduled for IVF treatment and to explore the potential benefits to the IVF process.

DESIGN

We performed a prospective study in 150 infertile women with PCOS undergoing IVF treatment. Patients were randomized to receive berberine, metformin or placebo tablets for 3 months before ovarian stimulation.

MEASUREMENTS

The clinical, endocrine, metabolic parameters and the outcome of IVF.

RESULTS

Compared with placebo, greater reductions in total testosterone, free androgen index, fasting glucose, fasting insulin and HOMA-IR, and increases in SHBG, were observed in the berberine and metformin groups. Three months of treatment with berberine or metformin before the IVF cycle increased the pregnancy rate and reduced the incidence of severe ovarian hyperstimulation syndrome. Furthermore, treatment with berberine, in comparison with metformin, was associated with decreases in BMI, lipid parameters and total FSH requirement, and an increase in live birth rate with fewer gastrointestinal adverse events.

CONCLUSIONS

Berberine and metformin treatments prior to IVF improved the pregnancy outcome by normalizing the clinical, endocrine and metabolic parameters in PCOS women. Berberine has a more pronounced therapeutic effect and achieved more live births with fewer side effects than metformin.

In PCOS patients the addition of low-dose spironolactone induces a more marked reduction of clinical and biochemical hyperandrogenism than metformin alone

BACKGROUND & AIMS

Polycystic ovary syndrome (PCOS) is characterized by ovarian dysfunction and hyperandrogenism and by insulin resistance and related metabolic alterations. Both metformin and anti-androgens, such as spironolactone, are used to ameliorate the different aspects of this disorder. We investigated whether therapy with metformin plus low-dose spironolactone is more effective than metformin alone in PCOS patients.

METHODS AND RESULTS

Fifty-six PCOS patients were randomized in two groups: group A (28 patients) was treated with metformin (1700 mg/die) and group B (28 patients) was treated with metformin (1700 mg/die) plus low-dose spironolactone (25 mg/die). Anthropometric, hormonal and metabolic parameters were evaluated at baseline and after six months of treatment. After therapy regular menses were restored in approximately 82% of group A patients (P < 0.001) and in 68% of group B patients (P < 0.001). Circulating testosterone, Δ-4-androstenedione and Hirsutism Score (HS) significantly decreased in both groups. However, dehydro-epiandrosterone sulphate significantly decreased only in group B, and HS underwent a stronger reduction in group B (P < 0.001). At baseline, 39/56 (69.6%) patients met the diagnostic criteria for metabolic syndrome, but only one patient met these criteria after treatment.

CONCLUSIONS

This study confirms the beneficial effects of metformin in PCOS patients. It also indicates that the addition of low-dose spironolactone induces a more marked reduction of clinical and biochemical hyperandrogenism as compared to metformin alone.

Diagnosis and treatment of polycystic ovary syndrome: an Endocrine Society clinical practice guideline

OBJECTIVE

The aim was to formulate practice guidelines for the diagnosis and treatment of polycystic ovary syndrome (PCOS).

PARTICIPANTS

An Endocrine Society-appointed Task Force of experts, a methodologist, and a medical writer developed the guideline.

EVIDENCE

This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system to describe both the strength of recommendations and the quality of evidence.

CONSENSUS PROCESS

One group meeting, several conference calls, and e-mail communications enabled consensus. Committees and members of The Endocrine Society and the European Society of Endocrinology reviewed and commented on preliminary drafts of these guidelines. Two systematic reviews were conducted to summarize supporting evidence.

CONCLUSIONS

We suggest using the Rotterdam criteria for diagnosing PCOS (presence of two of the following criteria: androgen excess, ovulatory dysfunction, or polycystic ovaries). Establishing a diagnosis of PCOS is problematic in adolescents and menopausal women. Hyperandrogenism is central to the presentation in adolescents, whereas there is no consistent phenotype in postmenopausal women. Evaluation of women with PCOS should exclude alternate androgen-excess disorders and risk factors for endometrial cancer, mood disorders, obstructive sleep apnea, diabetes, and cardiovascular disease. Hormonal contraceptives are the first-line management for menstrual abnormalities and hirsutism/acne in PCOS. Clomiphene is currently the first-line therapy for infertility; metformin is beneficial for metabolic/glycemic abnormalities and for improving menstrual irregularities, but it has limited or no benefit in treating hirsutism, acne, or infertility. Hormonal contraceptives and metformin are the treatment options in adolescents with PCOS. The role of weight loss in improving PCOS status per se is uncertain, but lifestyle intervention is beneficial in overweight/obese patients for other health benefits. Thiazolidinediones have an unfavorable risk-benefit ratio overall, and statins require further study.

Metformin decreases the incidence of ovarian hyperstimulation syndrome: an experimental study

Background

In assisted reproduction cycles, gonadotropins are administered to obtain a greater number of oocytes. A majority of patients do not have an adverse response; however, approximately 3-6% develop ovarian hyperstimulation syndrome (OHSS). Metformin reduces the risk of OHSS but little is known about the possible effects and mechanisms of action involved.

Objective

To evaluate whether metformin attenuates some of the ovarian adverse effects caused by OHSS and to study the mechanisms involved.

Material and methods

A rat OHSS model was used to investigate the effects of metformin administration. Ovarian histology and follicle counting were performed in ovarian sections stained with Masson trichrome. Vascular permeability was measured by the release of intravenously injected Evans Blue dye (EB). VEGF levels were measured by commercially immunosorbent assay kit. COX-2 protein expression was evaluated by western blot and NOS levels were analyses by immunohistochemistry.

Results

Animals of the OHSS group showed similar physiopathology characteristics to the human syndrome: increased body weight, elevated progesterone and estradiol levels (P<0.001), increased number of corpora lutea (P<0.001), higher ovarian VEGF levels and vascular permeability (P<0.001 and P<0.01); and treatment with metformin prevented this effect (OHSS+M group; P<0.05). The vasoactive factors: COX-2 and NOS were increased in the ovaries of the OHSS group (P<0.05 and P<0.01) and metformin normalized their expression (P<0.05); suggesting that metformin has a role preventing the increased in vascular permeability caused by the syndrome.

Conclusion

Metformin has a beneficial effect preventing OHSS by reducing the increase in: body weight, circulating progesterone and estradiol and vascular permeability. These effects of metformin are mediated by inhibiting the increased of the vasoactive molecules: VEGF, COX-2 and partially NOS. Molecules that are increased in OHSS and are responsible for a variety of the symptoms related to OHSS.

Diverse roles of metformin during peri-implantation development: revisiting novel molecular mechanisms underlying clinical implications

Metformin is not only a widely used oral antidiabetic drug, which acts as an insulin sensitizer and suppressor of hepatic gluconeogenesis, but it also exhibits antitumor properties. Besides, it has been utilized in the treatment of polycystic ovary syndrome (PCOS) for infertile women with glucose intolerance and as a component of combination therapy to reduce early (first trimester) pregnancy loss or spontaneous abortion (SAB). Based on recent studies demonstrating its beneficial effects on mothers and the fetus, metformin is even recommended for later stages of pregnancy. Probing into the mechanism of action revealed that it can activate a stress modulatory pathway, none other than the AMP-activated protein kinase (AMPK) via LKB 1. It is well accepted that AMPK signaling plays a crucial role during implantation by combating stress in multiple ways. Stress factors commonly encountered during pregnancy are malnutrition, diabetes, and hypoxia, which may result in SABs or other complications. For instance, the elevated levels of insulin, which are a typical characteristic of hyperinsulinemic, obese, or PCOS patients, can impair the development of the blastocyst and the preimplantation embryo. Further, a severe hypoxic environment prompts early and untimely differentiation of the embryonic cells leading to abnormal growth and development. Therefore, the modulation of stress-related pathways could be pivotal in ameliorating such stress responses during implantation. Here we hypothesize a putative noncanonical pathway underpinning the role of metformin in high-risk pregnancies to counteract stress by recreating an in vitro replica of human implantation, engaging embryonic stem cells, trophoblast stem cells, and endometrial stromal cells in a three-dimensional scaffold.

Assisted reproduction in polycystic ovarian disease: A multicentric trial in India

AIM:

The aim of this study is to compare ovarian response, oocyte, embryo quality, ovarian hyperstimulation syndrome incidence, and pregnancy rates in polycystic ovary syndrome (PCOS) and non-PCOS group.

MATERIALS AND METHODS:

This was a prospective observational study on PCOS carried out in seven assisted reproduction centers in India between August 2008 and July 2010, as part of trial under the Indian Society of Assisted Reproduction. A total of 192 women (77 in the PCOS group and 115 in the non- PCOS group) undergoing in vitro fertilization/intracytoplasmic sperm injection were included. All women had long protocol and recombinant follicle-stimulating hormone stimulation.

ANALYSIS:

The mean number of follicles and oocytes was higher in PCOS group compared with non-PCOS, being 27.2 (±8.8) and 13.6 (±5.3); 15.9 (±6.3) and 10.9 (±6.2), respectively. The recovery rates of oocytes and mature oocytes per follicle were less in the PCOS group which was 64% and 61.1%, respectively as opposed to 80.3% and 74.5%, respectively in non-PCOS group. The total numbers of top-quality embryos were less in the PCOS group.

CONCLUSION:

In PCOS women though the number of follicles was more, recovery of mature oocytes, top-quality embryos was less. Pregnancy rates were comparable in both groups.

Ovulation induction in the management of anovulatory polycystic ovary syndrome

The aim of this brief review is to describe the management of anovulatory infertility in the polycystic ovary syndrome (PCOS). This has traditionally involved the use of clomiphene citrate (CC), and then gonadotropin therapy or laparoscopic ovarian surgery, in those who are clomiphene resistant (The Thessaloniki ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group, 2008). Recently developed therapeutic approaches include aromatase inhibitors and the potential use of in vitro maturation (IVM) of oocytes collected from unstimulated (or minimally stimulated) polycystic ovaries. Unfortunately the early promise of the insulin sensitizing drugs has not been translated into significant improvement in outcomes and therefore are not prescribed unless the patient has an impairment of glucose tolerance (The Thessaloniki ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group, 2008). There has been an unfortunate shift away from Mono-follicular ovulation induction remains the first line approach for the management of anovulatory PCOS, and in vitro fertilization treatment (IVF) should be reserved for those who fail to respond or who have additional infertility factors (The Thessaloniki ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group, 2008). Superovulation for IVF presents significant risks for women with polycystic ovaries, namely the potentially life-threatening complication of ovarian hyperstimulation syndrome (OHSS). Carefully conducted and monitored ovulation induction can achieve good cumulative conception rates and furthermore, multiple pregnancy rates can be minimized with strict adherence to criteria that limit the number of follicles that are permitted to ovulate.

A case of ovarian hyperstimulation syndrome following a spontaneous complete hydatidiform molar pregnancy

INTRODUCTION

To present a rare case of ovarian hyperstimulation syndrome (OHSS) following a spontaneous complete hydatidiform molar (CHM) pregnancy.

CASE

A 38-year-old woman underwent vacuum curettage for a CHM pregnancy. Seven days later, she was admitted to our hospital with the symptoms of OHSS. Transvaginal ultrasonography demonstrated enlarged multicystic ovaries, marked ascites and large pleural effusions that required abdominocentesis and thoracocentesis, respectively. She was treated with intravenous fluid, exogenous colloid supplementation, prophylaxis for deep vein thrombosis, and drainage of the ascites and bilateral pleural effusions. She recovered by day 14 of admission.

CONCLUSION

OHSS may develop in older women who undergo treatment for CHM pregnancies. Serious complications may develop rapidly and therefore the prompt diagnosis of OHSS is very important.

Endocrinological insights into different in vitro fertilization treatment aspects

The science of reproductive endocrinology/in vitro fertilization (IVF) has moved forward considerably since the first IVF baby was born in 1978. IVF was originally indicated for women with tubal factor infertility, but it has now become the treatment for couples with unexplained subfertility, male subfertility, cervical factor, failed ovulation induction, endometriosis or unilateral tubal pathology. IVF was initially performed with the single dominant ovarian follicle produced during a spontaneous menstrual cycle. This was very inefficient and pregnancy rates were dismal. Consequently, superovulation protocols using parenteral gonadotrophins to induce maturation of multiple follicles were soon adopted worldwide. In addition, any supernumerary embryos remaining after embryo transfer may be cryopreserved for future embryo transfers without the need for another fresh IVF cycle. A greater understanding of IVF endocrinology has led to improved IVF pregnancy outcomes and satisfaction for the anxious parents. However, with the greater success of IVF treatment, new complications associated with the treatment arise, namely the ovarian hyperstimulation syndrome. Ovarian hyperstimulation can be associated with severe morbidity and may be even fatal. Ovarian hyperstimulation syndrome is an iatrogenic condition secondary to medical stimulation of the ovary, and was virtually unknown until IVF treatment was initiated. This article will discuss the recent developments in IVF treatment endocrinology and protocols, as well as prevention/treatment of its complications.

Is metformin indicated as primary ovulation induction agent in women with PCOS? A systematic review and meta-analysis

BACKGROUND

A recent meta-analysis has proven that metformin (M) is highly effective for ovulation induction in the clomiphene citrate (CC)-resistant patient. There is uncertainty whether M should be introduced as a primary ovulation induction agent in polycystic ovarian syndrome (PCOS).

METHODS

We conducted a systematic review and meta-analysis to establish if M is better when given alone or in combination with CC (CC+M) when compared with CC alone. This systematic review studied live birth delivery rate as the primary outcome.

RESULTS

We identified 14 prospective trials. Analysis of these results showed a reduction in the live birth rate in the group of patients treated only with M when compared with CC alone (OR = 0.48, 95% CI 0.31-0.73, p = 0.0006). An increase in ovulation (OR = 1.6, 95% CI 1.2-2.1, p = 0.0009) and pregnancy rate (OR = 1.3, 95% CI 1.0-1.6, p = 0.05) with CC+M when compared with CC alone was reported, but no difference was found when live birth rate was analyzed (OR = 1.1, 95% CI 0.8-1.5, p = 0.61).

CONCLUSION

CC alone is superior to M alone regarding live birth rate and ovulation. The combination (CC+M) is superior to CC alone as a primary method for ovulation induction and to achieve pregnancy in PCOS. However, when addressing live birth rate, no statistically significant difference could be demonstrated. Because of the side effects profile and contraindications of M, we believe M should not be indicated as a primary ovulation induction agent in women with PCOS.

Metformin administration in patients with polycystic ovary syndrome who receive gonadotropins for in vitro fertilization cycles: 10-year experience in a large infertile population

The study aim was to evaluate our personal experience regarding the use and the reproductive effect of metformin administration in a large population of infertile patients with polycystic ovary syndrome (PCOS) undergoing gonadotropins ovarian stimulation for in vitro fertilization (IVF). Infertile patients with PCOS undergoing gonadotropins ovarian stimulation with (metformin group, n = 191) or without (control group, n = 187) metformin and IVF were evaluated. Treatment characteristics, patients' data and reproductive outcomes were evaluated. In all cases, metformin with an immediate-release formulation was administered, and in most of cases it was given as pre- and co-treatment (74.9%) and at a dosage of 1700 mg/day (59.7%). Stimulation length and gonadotropins doses were significantly (p < 0.05) higher in metformin group than in control group. The number of dominant follicles on day of ovarian maturation triggering and peak oestradiol levels were significantly (p < 0.05) lower in metformin group than in control group. Cycle cancellation rate under metformin resulted significantly influenced by interaction with body mass index (BMI), age and basal follicle-stimulating hormone (FSH) levels. Notwithstanding, metformin use in infertile PCOS patients who receive gonadotropins for IVF is not standardized, it seems to modulate the ovarian response to stimulation. This effect may benefit or harm on the basis of ovarian reserve and patients' characteristics.

Comparison of Endocrine Profile and In Vitro Fertilization Outcome in Patients with PCOS, Ovulatory PCO, or Normal Ovaries

Aim. To compare the basic endocrine profile and outcomes of in vitro fertilization (IVF) in women with polycystic ovary syndrome (PCOS), ovulatory polycystic ovaries (PCO), or normal ovaries (NO). Methods. The basic clinical features and in vitro fertilization and embryo transfer outcome in patients receiving IVF or intracytoplasmic sperm injection (ICSI) were retrospectively analyzed. Results. The body mass index, basal luteinizing hormone, and testosterone levels were significantly lower in patients with ovulatory PCO compared to those in patients with PCOS. The PCOS patients exhibited the shortest duration of ovarian stimulation and lowest dose of gonadotropin, followed by the ovulatory PCO and NO patients. The ovulatory PCO and PCOS patients showed similar levels of E2 on the human chorionic gonadotropin treatment day and numbers of oocytes, which were both significantly higher than those of the NO patients. The fertilization rate of the PCOS patients was significantly lower than the other two groups. Compared to NO patients, the cleavage rate was lower in both PCOS and ovulatory PCO patients, however, the number of available embryos was significantly more in these two groups. The incidence of the moderate to severe ovarian hyperstimulation syndrome (OHSS) was markedly higher in the PCOS and ovulatory PCO patients. Conclusion. Ovulatory PCO patients do not express similar endocrine abnormalities as PCOS patients. Although the fertilization rate and cleavage rate were relatively low in PCOS patients, ultimately, all the three groups showed similar transferred embryo numbers, clinical pregnancy rates, and implantation rates. Since the incidence of OHSS was much higher in the PCOS and ovulatory PCO patients, we should take more care of these patients and try to prevent severe OHSS.

Assessing the risk of ovarian hyperstimulation syndrome in egg donation: implications for human embryonic stem cell research

Stem cell research has important implications for medicine. The source of stem cells influences their therapeutic potential, with stem cells derived from early-stage embryos remaining the most versatile. Somatic cell nuclear transfer (SCNT), a source of embryonic stem cells, allows for understandings about disease development and, more importantly, the ability to yield embryonic stem cell lines that are genetically matched to the somatic cell donor. However, SCNT requires women to donate eggs, which involves injection of ovulation-inducing hormones and egg retrieval through laparoscopy or transvaginal needle aspiration. Risks from this procedure are fiercely debated, most notably risk of ovarian hyperstimulation syndrome (OHSS). This review examines risk of OHSS resulting from oocyte donation. We conclude that risk posed by OHSS in egg donation is not significant enough to warrant undue concern, and much of this can be eliminated when proper precautions are taken. This bears relevance to the future of stem cell research policymaking.

Use of metformin before and during assisted reproductive technology in non-obese young infertile women with polycystic ovary syndrome: a prospective, randomized, double-blind, multi-centre study

BACKGROUND

To study the effect of metformin before and during assisted reproductive technology (ART) on the clinical pregnancy rate (CPR) in non-obese women with polycystic ovary syndrome (PCOS).

METHODS

A multi-centre, prospective, randomized, double-blind study was conducted in eight IVF clinics in four Nordic countries. We enrolled 150 PCOS women with a body mass index <28 kg/m(2), and treated them with 2000 mg/day metformin or identical placebo tablets for ≥ 12 weeks prior to and during long protocol IVF or ICSI and until the day of pregnancy testing. The primary outcome measure was CPR. Secondary outcome measures included spontaneous pregnancy rates during the pretreatment period, and the live birth rate (LBR).

RESULTS

Among IVF treated women (n = 112), biochemical pregnancy rates were identical in both groups (42.9%), and there were no significant differences in the metformin versus the placebo group in CPR [39.3 versus 30.4%; 95% confidence interval (CI): -8.6 to 26.5]. The LBR was 37.5 versus 28.6% (95% CI: -8.4 to 26.3). However, prior to IVF there were 15 (20.3%) spontaneous pregnancies in the metformin group and eight (10.7%) in the placebo group (95% CI: -1.9 to 21.1; P = 0.1047). According to intention to treat analyses (n = 149); significantly higher overall CPR were observed in the metformin versus placebo group (50.0 versus 33.3%; 95% CI: -1.1 to 32.3; P = 0.0391). LBR was also significantly higher with use of metformin versus placebo (48.6 versus 32.0; 95% CI: 1.1 to 32.2; P = 0.0383). No major unexpected safety issues or multiple births were reported. More gastrointestinal side effects occurred in the metformin group (41 versus 12%; 95% CI: 0.15 to 0.42; P < 0.001).

CONCLUSIONS

Metformin treatment for 12 weeks before and during IVF or ICSI in non-obese women with PCOS significantly increases pregnancy and LBRs compared with placebo. However, there was no effect on the outcome of ART per se.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT00159575.

Treatment options for polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in women. The clinical manifestation of PCOS varies from a mild menstrual disorder to severe disturbance of reproductive and metabolic functions. Management of women with PCOS depends on the symptoms. These could be ovulatory dysfunction-related infertility, menstrual disorders, or androgen-related symptoms. Weight loss improves the endocrine profile and increases the likelihood of ovulation and pregnancy. Normalization of menstrual cycles and ovulation could occur with modest weight loss as little as 5% of the initial weight. The treatment of obesity includes modifications in lifestyle (diet and exercise) and medical and surgical treatment. In PCOS, anovulation relates to low follicle-stimulating hormone concentrations and the arrest of antral follicle growth in the final stages of maturation. This can be treated with medications such as clomiphene citrate, tamoxifen, aromatase inhibitors, metformin, glucocorticoids, or gonadotropins or surgically by laparoscopic ovarian drilling. In vitro fertilization will remain the last option to achieve pregnancy when others fail. Chronic anovulation over a long period of time is also associated with an increased risk of endometrial hyperplasia and carcinoma, which should be seriously investigated and treated. There are androgenic symptoms that will vary from patient to patient, such as hirsutism, acne, and/or alopecia. These are troublesome presentations to the patients and require adequate treatment. Alternative medicine has been emerging as one of the commonly practiced medicines for different health problems, including PCOS. This review underlines the contribution to the treatment of different symptoms.

Insulin and hyperandrogenism in women with polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a very common endocrine disorder characterized by chronic anovulation, clinical and/or biochemical hyperandrogenism, and/or polycystic ovaries. But most experts consider that hyperandrogenism is the main characteristic of PCOS. Several theories propose different mechanisms to explain PCOS manifestations: (1) a primary enzymatic default in the ovarian and/or adrenal steroidogenesis; (2) an impairment in gonadotropin releasing hormone (GnRH) secretion that promotes luteal hormone (LH) secretion; or (3) alterations in insulin actions that lead to insulin resistance with compensatory hyperinsulinemia. However, in the past 20 years there has been growing evidence supporting that defects in insulin actions or in the insulin signalling pathways are central in the pathogenesis of the syndrome. Indeed, most women with PCOS are metabolically insulin resistant, in part due to genetic predisposition and in part secondary to obesity. But some women with typical PCOS do not display insulin resistance, which supports the hypothesis of a genetic predisposition specific to PCOS that would be revealed by the development of insulin resistance and compensatory hyperinsulinemia in most, but not all, women with PCOS. However, these hypotheses are not yet appropriately confirmed, and more research is still needed to unravel the true pathogenesis underlying this syndrome. The present review thus aims at discussing new concepts and findings regarding insulin actions in PCOS women and how it is related to hyperandrogenemia.

Association between amino acid turnover and chromosome aneuploidy during human preimplantation embryo development in vitro

This study investigated the relationship between human preimplantation embryo metabolism and aneuploidy rates during development in vitro. One hundred and eighty-eight fresh and cryopreserved embryos from 59 patients (33.9 +/- 0.6 years) were cultured for 2-5 days. The turnover of 18 amino acids was measured in spent media by high-performance liquid chromatography. Embryos were either fixed for interphase fluorescent in situ hybridization analysis of chromosomes 13, 18, 19, 21, X or Y, or were assayed for mitochondrial activity. Amino acid turnover was different (P < 0.05) between stage-matched fresh and cryopreserved embryos due to blastomere loss following warming. The proportion of embryos with aneuploid cells increased as cell division progressed from pronucleate- (23%) to late cleavage stages (50-70%). Asparagine, glycine and valine turnover was significantly different between uniformly genetically normal and uniformly abnormal embryos on Days 2-3 of culture. By Days 3-4, the profiles of serine, leucine and lysine differed between uniformly euploid versus aneuploid embryos. Gender significantly (P < 0.05) affected the metabolism of tryptophan, leucine and asparagine by cleavage-stage embryos. Pronucleate zygotes had a significantly higher proportion of active:inactive mitochondria compared with cleavage-stage embryos. Furthermore, mitochondrial activity was correlated (P < 0.05) with altered aspartate and glutamine turnover. These results demonstrate the association between the metabolism, cytogenetic composition and health of human embryos in vitro.

Metabolism and karyotype analysis of oocytes from patients with polycystic ovary syndrome

BACKGROUND

Polycystic ovary syndrome (PCOS) is associated with metabolic disturbances which include impaired insulin signalling and glucose metabolism in ovarian follicles. The oocyte is metabolically dependent upon its follicle environment during development, but it is unclear whether PCOS or polycystic ovarian (PCO) morphology alone affect oocyte metabolism and energy-demanding processes such as meiosis.

METHODS

Immature human oocytes were donated by PCOS (n = 14), PCO (n = 14) and control (n = 46) patients attending the assisted conception programme at Leeds Teaching Hospitals NHS Trust. Oocytes were cultured individually and carbohydrate metabolism was assessed during overnight in vitro maturation (IVM). Meiotic status was assessed and oocyte intracellular nicotinamide adenine dinucleotide phosphate (NAD(P)H) content and mitochondria activity were measured prior to karyotype analysis by multifluor in situ hybridization.

RESULTS

Patient aetiology had no significant effect on oocyte maturation potential or incidence of numerical chromosome abnormalities (44%), although PCOS and PCO oocytes were more likely to suffer predivision. Group G chromosomes were most likely to be involved in non-disjunction and predivision. PCOS was associated with increased glucose consumption (2.06 +/- 0.43 and 0.54 +/- 0.12 pmol/h for PCOS and control oocytes, respectively) and increased pyruvate consumption (18.4 +/- 1.2 and 13.9 +/- 0.9 pmol/h for PCOS and control oocytes, respectively) during IVM. Prior prescription of metformin significantly attenuated pyruvate consumption by maturing oocytes (8.5 +/- 1.8 pmol/h) from PCOS patients. Oocytes from PCO patients had intermediate metabolism profiles. Higher pyruvate turnover was associated with abnormal oocyte karyotypes (13.4 +/- 1.9 and 19.9 +/- 2.1 pmol/h for normal versus abnormal oocytes, respectively). Similarly, oocyte NAD(P)H content was 1.35-fold higher in abnormal oocytes.

CONCLUSIONS

The chromosomal constitution of in vitro matured oocytes from PCOS is similar to that of controls, but aspects of oocyte metabolism are perturbed by PCOS. Elevated pyruvate consumption was associated with abnormal oocyte karyotype.

IVF outcome in women with PCOS, PCO and normal ovarian morphology

OBJECTIVE

To examine the outcome of IVF in women who have normal ovaries, ovulatory PCO or PCOS.

STUDY DESIGN

Analysis of a prospectively collected database in an assisted conception unit in a university teaching hospital including 290 women <37 years of age undergoing their first IVF cycle. The main outcome measure was severe OHSS requiring hospitalization.

RESULTS

Severe OHSS rates were significantly higher in women with PCO (12.6%) and PCOS (15.4%) compared to those with normal ovaries (2.7%). Coasting was used significantly more often. Live birth rates per cycle started are similar among women with PCO (38%), PCOS (37%) and normal ovaries (40%).

CONCLUSION

Women with ovaries of polycystic morphology are at increased risk of developing severe OHSS and of requiring avoidance techniques such as coasting, regardless of ovulatory status. However, live birth rates per cycle are similar to women with normal ovaries.

Economic consequences of overweight and obesity in infertility: a framework for evaluating the costs and outcomes of fertility care

BACKGROUND

Overweight and obesity are an epidemic in Western society, and have a strong impact on fertility. We studied the consequences of overweight and obesity with respect to fecundity, costs of fertility treatment and pregnancy outcome in subfertile women.

METHODS

We searched the literature for systematic reviews and large studies reporting on the effect of weight on both fecundity and pregnancy outcome in subfertile women. We collected data on costs of treatment with ovulation induction, intrauterine insemination and in vitro fertilization, as well as costs of pregnancy complications. We calculated, for ovulatory and anovulatory women separately, the number of expected pregnancies, complications and costs in a hypothetical cohort of 1000 normal weight, overweight and obese women each.

RESULTS

In our hypothetical cohort of 1000 women, compared with women with normal weight, live birth was decreased by 14 and 15% (from 806 live births to 692 and 687 live births) in overweight and obese anovulatory women, respectively, for ovulatory women it was decreased by 22 and 24% (from 698 live births to 546 and 531 live births), respectively. These outcomes were associated with an increase in the number of complications and associated costs leading to cost per live birth in anovulatory overweight and obese women were 54 and 100% higher than their normal weight counterparts, for ovulatory women they were 44 and 70% higher, respectively.

CONCLUSIONS

Overweight and obese subfertile women have a reduced probability of successful fertility treatment and their pregnancies are associated with more complications and higher costs.

Metformin in the treatment of clomiphene citrate-resistant women with polycystic ovary syndrome undergoing in vitro fertilisation treatment: a randomised controlled trial

This study was conducted to determine the efficacy of metformin vs placebo in women with polycystic ovary syndrome (PCOS) undergoing IVF treatment. A total of 66 CC-resistant patients were studied prospectively. The women were randomly assigned to receive 850 mg of metformin (n = 34) or placebo (n = 32) twice daily that started 1 month before commencing the IVF treatment and continued to the day of the pregnancy test. Compared with the metformin-treated group, women who received a placebo had a significant increase in terms of days of stimulation with HMG, number of HMG ampoules, number of follicles >14 mm, number of oocytes retrieved, number of mature eggs, fertilisation rate and oestradiol level on the day of hCG administration. Similarly, women in the placebo group showed a significant increase in poor quality embryos, cancellation rate and the rate of ovarian hyperstimulation syndrome, as compared with the metformin-treated group. On the other hand, women who received metformin showed a significantly higher number of good quality embryos and implantation rate when compared with the placebo controls. Despite the transfer of a similar number of embryos, an insignificant increased in the pregnancy rate along with significant reduction in the abortion rate was observed in the metformin-treated group as compared with the placebo controls. No fetal abnormalities were encountered in the babies born in the metformin-treated group. It is concluded that metformin affects positively the quality of both oocytes and embryos without a significant increase in the pregnancy rate. It decreases significantly the rates of abortion and ovarian hyperstimulation syndrome.

Insulin resistance and free androgen index correlate with the outcome of controlled ovarian hyperstimulation in non-PCOS women undergoing IVF

BACKGROUND

The dual effects of insulin and androgen on the ovary act to promote early folliculogenesis. In the context of polycystic ovarian syndrome (PCOS), the presence of hyperinsulinaemia, resulting from increased insulin resistance (IR), and hyperandrogenaemia lead to the appearance of multiple antral follicles and frequently a multi-follicular response to gonadotrophin stimulation for assisted reproductive treatments (ARTs). The effect of IR and androgen status in women without PCOS on the follicular outcome of controlled ovarian hyperstimulation (COH) is not known.

METHODS

We assessed the IR [using the homeostasis model assessment (HOMA)] and androgen status of 49 women without PCOS undergoing an ART cycle. This was then related to the treatment cycle outcome.

RESULTS

We found a significant positive correlation between HOMA and BMI, and free androgen index (FAI) and testosterone. The FAI significantly positively correlated with total follicle count after COH. The total follicle count was significantly higher in those with a HOMA >2.5, and HOMA positively correlated with total follicle count in this group of IR women (HOMA > 2.5).

CONCLUSIONS

Our results suggest a positive correlation of HOMA-IR levels above a threshold level of 2.5 and a continuous positive correlation of free androgen (FAI) to total ovarian follicle count following COH in the non-PCOS patient.

A woman with polycystic ovary syndrome treated for infertility by in vitro fertilization

BACKGROUND

A 25-year-old South Asian woman presented at an infertility unit with a 2-year history of anovulatory infertility. She had experienced irregular and infrequent periods for over a decade.

INVESTIGATIONS

Endocrine profile (follicle-stimulating hormone, luteinizing hormone, thyroid-function test, prolactin, testosterone), oral glucose tolerance test and pelvic ultrasonography were performed.

DIAGNOSIS

Polycystic ovary syndrome, in accordance with the recent Rotterdam consensus (2004) criteria.

MANAGEMENT

The patient failed to conceive by conventional ovulation-induction therapies with clomifene and gonadotropins. She subsequently underwent an in vitro fertilization cycle, to which she over-responded and developed a severe form of ovarian hyperstimulation syndrome. The diagnosis of ovarian hyperstimulation syndrome was based on clinical and ultrasonographic features. She was hospitalized and needed extensive supportive care, including insertion of chest and abdominal drains.

Review of the evidence base of strategies to prevent ovarian hyperstimulation syndrome

The English-language literature was reviewed to examine the evidence base for strategies that have been used to prevent ovarian hyperstimulation syndrome (OHSS). Prediction of OHSS by pretreatment patient characteristics and ovarian response parameters is unreliable, with a significant number of OHSS cases occurring in patients not thought to be high risk, while the majority of 'high-risk' cycles do not result in OHSS. Alternatives to ovarian stimulation should always be considered, depending on the clinical situation. Monofollicular ovulation induction with a cautious step-up regime carries a lower risk of overstimulation than step-down regimes. In in vitro fertilization (IVF) cycles, a low starting dose of follicle-stimulating hormone (FSH) and the use of 5000 iu human chorionic gonadotrophin (hCG) for final follicular maturation may benefit patients at high risk of OHSS. The role of GnRH antagonists is unclear. In women with polycystic ovaries, who are undergoing ovarian stimulation for IVF, metformin co-treatment may reduce the risk of OHSS. Coasting of cycles with over-response is associated with a reduced risk of OHSS, although precise criteria for initiating and ending coasting are not definable at present. Elective cryopreservation of all embryos prevents late OHSS, but its value has been poorly researched. The literature does not support a role for intravenous albumin, administered around the time of oocyte retrieval, in preventing OHSS. Evidence is insufficient regarding a possible role for hexa-ethyl starch. hCG should not be used for luteal support, as it is associated with a higher risk of OHSS, and equivalent pregnancy rates are obtained with the use of progesterone.

Current trends in the treatment of polycystic ovary syndrome with desire for children

Polycystic ovary syndrome (PCOS), one of the most frequent endocrine diseases, affects approximately 5%–10% of women of childbearing age and constitutes the most common cause of female sterility regardless of the need or not for treatment, a change in lifestyle is essential for the treatment to work and ovulation to be restored. Obesity is the principal reason for modifying lifestyle since its reduction improves ovulation and the capacity for pregnancy and lowers the risk of miscarriage and later complications that may occur during pregnancy (gestational diabetes, pre-eclampsia, etc). When lifestyle modification is not sufficient, the first step in ovulation induction is clomiphene citrate. The second-step recommendation is either exogenous gonadotrophins or laparoscopic ovarian surgery. Recommended third-line treatment is in vitro fertilization. Metformin use in PCOS should be restricted to women with glucose intolerance.