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Chen YH, Zhang XL, Li ZY, Wang XP, Wang J, Zhang ZP, Zhu PF, Wu XQ. Efficacy of Dan'e Fukang Soft Extract in Moderate Ovarian Hyperstimulation Syndrome for Concurrent Treatment of Blood and Fluid Guided by the "Triple Prevention" Principle. Int J Womens Health 2024; 16:385-394. [PMID: 38463688 PMCID: PMC10924772 DOI: 10.2147/ijwh.s436965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 02/25/2024] [Indexed: 03/12/2024] Open
Abstract
Objective This study aimed to evaluate the therapeutic efficacy and safety of Dan'e Fukang soft extracts in moderate ovarian hyperstimulation syndrome (OHSS) for the simultaneous treatment of blood and fluid, guided by the traditional Chinese medicine principle of "triple prevention". Methods This study conducted a retrospective analysis of clinical data from outpatients who underwent in vitro fertilization (IVF)/intracytoplasmic sperm injection embryo transfer (ICSI-ET). A total of 2245 cases were included and divided into a treatment group (1002 cases) and a control group (1243 cases). Patients in the treatment group were administered Dan'e Fukang soft extracts orally in addition to conventional Western medicine. Comparative assessments were made between the two groups on pelvic ascites volume, maximum ovary diameter, dysmenorrhea incidence post-oocyte retrieval, and safety indicators. Results There were no statistically significant differences between the treatment group and the control group in terms of general characteristics or the levels of follicle-stimulating hormone (FSH), luteotropic hormone (LH), estradiol (E2), or progesterone (P) at the time of gonadotropin (Gn) initiation. The groups did not differ significantly when we compared the levels of LH, E2, or P on the day of human chorionic gonadotropin (hCG) injection and during ovarian hyperstimulation protocols (P > 0.05 for all indicators). The differences in the volume of pelvic ascites, the maximum ovarian diameter, and the incidence of dysmenorrhea after oocyte retrieval were statistically significant between the treatment group and the control group (P < 0.05 in both). There were no instances of adverse reactions in either group. Conclusion Based on the traditional Chinese medicine principle of "triple prevention", the use of Dan'e Fukang soft extracts for the simultaneous treatment of blood and fluid in moderate OHSS significantly improved the absorption of pelvic ascites, promoted ovarian recovery, and reduced the incidence of dysmenorrhea after oocyte retrieval.
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Affiliation(s)
- Yan-Hua Chen
- Reproductive Medicine Center, Shanxi Maternal and Child Health Care Hospital, Taiyuan, People's Republic of China
| | - Xue-Luo Zhang
- Reproductive Medicine Center, Shanxi Maternal and Child Health Care Hospital, Taiyuan, People's Republic of China
| | - Zhong-Yun Li
- Rectum Branch, Shanxi Provincial Hospital of Traditional Chinese Medicine, Taiyuan, People's Republic of China
| | - Xian-Ping Wang
- Reproductive Medicine Center, Shanxi Maternal and Child Health Care Hospital, Taiyuan, People's Republic of China
| | - Jun Wang
- The Sixth Hospital of Shanxi Medical University (General Hospital of Tisco), Taiyuan, People's Republic of China
| | - Zhi-Ping Zhang
- Reproductive Medicine Center, Shanxi Maternal and Child Health Care Hospital, Taiyuan, People's Republic of China
| | - Peng-Fei Zhu
- Reproductive Medicine Center, Shanxi Maternal and Child Health Care Hospital, Taiyuan, People's Republic of China
| | - Xue-Qing Wu
- Reproductive Medicine Center, Shanxi Maternal and Child Health Care Hospital, Taiyuan, People's Republic of China
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Gao Y, Li J, Fan S, Chen P, Huang M, Bi H. Lipid Analysis of Follicular Fluids by UHPLC-ESI-HRMS Discovers Potential Biomarkers for Ovarian Hyperstimulation Syndrome. Front Endocrinol (Lausanne) 2022; 13:895116. [PMID: 35846297 PMCID: PMC9276923 DOI: 10.3389/fendo.2022.895116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Accepted: 05/12/2022] [Indexed: 11/29/2022] Open
Abstract
Ovarian hyperstimulation syndrome (OHSS) is a serious iatrogenic complication during ovarian stimulation. Even though the incidence of OHSS was relatively low in clinical practice, the consequence can be potentially devastating and life-threatening. Abnormal lipid metabolism may relate to the pathological development of OHSS, but there is still a research gap in the lipidomic research. So here in our study, an ultra-high-performance liquid chromatography coupled with electrospray ionization high-resolution mass spectrometry (UHPLC-ESI-HRMS) based lipidomic analysis was performed using follicular fluid samples obtained from 17 patients undergoing OHSS. The lipid profiles of OHSS patients were characterized by increased cholesterol ester (ChE) and decreased lysophosphatidylcholine (LPC), phosphatidylinositol (PI), sphingomyelin (SM), dimethylphosphatidylethanolamine (dMePE) and lysodimethylphosphatidylethanolamine (LdMePE). Totally 10 lipids including LPC(18:0), SM(d18:1/16:0), PC(18:0/18:1), PC(20:2/20:5), PC(16:0/18:1), TG(16:0/18:1/18:1), TG(16:0/18:2/18:2), TG(16:0/16:1/18:1), ChE(20:4) and TG(8:0/8:0/10:0) were selected as differential lipids. In conclusion, this study demonstrated the alteration of various lipids in OHSS patients, which suggested the key role of lipids during the development of OHSS and shed light on the further pathophysiological research of OHSS.
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Affiliation(s)
- Yue Gao
- Guangdong Provincial Key Laboratory of New Drug Design and Evaluation, School of Pharmaceutical Sciences, Sun Yat-Sen University, Guangzhou, China
| | - Jingjie Li
- Center of Reproductive Medicine, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Shicheng Fan
- Guangdong Provincial Key Laboratory of New Drug Design and Evaluation, School of Pharmaceutical Sciences, Sun Yat-Sen University, Guangzhou, China
| | - Pan Chen
- Pharmacy Department, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Min Huang
- Guangdong Provincial Key Laboratory of New Drug Design and Evaluation, School of Pharmaceutical Sciences, Sun Yat-Sen University, Guangzhou, China
| | - Huichang Bi
- Guangdong Provincial Key Laboratory of New Drug Design and Evaluation, School of Pharmaceutical Sciences, Sun Yat-Sen University, Guangzhou, China
- School of Pharmaceutical Sciences, Southern Medical University, Guangzhou, China
- *Correspondence: Huichang Bi, ;
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3
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Tang H, Mourad SM, Wang A, Zhai SD, Hart RJ. Dopamine agonists for preventing ovarian hyperstimulation syndrome. Cochrane Database Syst Rev 2021; 4:CD008605. [PMID: 33851429 PMCID: PMC8092425 DOI: 10.1002/14651858.cd008605.pub4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Ovarian hyperstimulation syndrome (OHSS) is a potentially serious complication of ovarian stimulation in assisted reproduction technology (ART). It is characterised by enlarged ovaries and an acute fluid shift from the intravascular space to the third space, resulting in bloating, increased risk of venous thromboembolism, and decreased organ perfusion. Most cases are mild, but forms of moderate or severe OHSS appear in 3% to 8% of in vitro fertilisation (IVF) cycles. Dopamine agonists were introduced as a secondary prevention intervention for OHSS in women at high risk of OHSS undergoing ART treatment. OBJECTIVES: To assess the effectiveness and safety of dopamine agonists in preventing OHSS in women at high risk of developing OHSS when undergoing ART treatment. SEARCH METHODS We searched the following databases from inception to 4 May 2020: Cochrane Gynaecology and Fertility Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL, and PsycINFO for randomised controlled trials (RCTs) assessing the effect of dopamine agonists on OHSS rates. We also handsearched reference lists and grey literature. SELECTION CRITERIA We considered RCTs for inclusion that compared dopamine agonists with placebo/no intervention or another intervention for preventing OHSS in ART. Primary outcome measures were incidence of moderate or severe OHSS and live birth rate. Secondary outcomes were rates of clinical pregnancy, multiple pregnancy, miscarriage, and adverse events. DATA COLLECTION AND ANALYSIS Two review authors independently screened titles, abstracts, and full texts of publications; selected studies; extracted data; and assessed risk of bias. We resolved disagreements by consensus. We reported pooled results as odds ratios (OR) and 95% confidence interval (CI) by the Mantel-Haenszel method. We applied GRADE criteria to judge overall quality of the evidence. MAIN RESULTS The search identified six new RCTs, resulting in 22 included RCTs involving 3171 women at high risk of OHSS for this updated review. The dopamine agonists were cabergoline, quinagolide, and bromocriptine. Dopamine agonists versus placebo or no intervention Dopamine agonists probably lowered the risk of moderate or severe OHSS compared to placebo/no intervention (OR 0.32, 95% CI 0.23 to 0.44; 10 studies, 1202 participants; moderate-quality evidence). This suggests that if the risk of moderate or severe OHSS following placebo/no intervention is assumed to be 27%, the risk following dopamine agonists would be between 8% and 14%. We are uncertain of the effect of dopamine agonists on rates of live birth (OR 0.96, 95% CI 0.60 to 1.55; 3 studies, 362 participants; low-quality evidence). We are also uncertain of the effect of dopamine agonists on clinical pregnancy, multiple pregnancy, miscarriage or adverse events (very low to low-quality evidence). Dopamine agonists plus co-intervention versus co-intervention Dopamine agonist plus co-intervention (hydroxyethyl starch, human albumin, or withholding ovarian stimulation 'coasting') may decrease the risk of moderate or severe OHSS compared to co-intervention (OR 0.48, 95% CI 0.28 to 0.84; 4 studies, 748 participants; low-quality evidence). Dopamine agonists may improve rates of live birth (OR 1.21, 95% CI 0.81 to 1.80; 2 studies, 400 participants; low-quality evidence). Dopamine agonists may improve rates of clinical pregnancy and miscarriage, but we are uncertain if they improve rates of multiple pregnancy or adverse events (very low to low-quality evidence). Dopamine agonists versus other active interventions We are uncertain if cabergoline improves the risk of moderate or severe OHSS compared to human albumin (OR 0.21, 95% CI 0.12 to 0.38; 3 studies, 296 participants; very low-quality evidence), prednisolone (OR 0.27, 95% CI 0.05 to 1.33; 1 study; 150 participants; very low-quality evidence), hydroxyethyl starch (OR 2.69, 95% CI 0.48 to 15.10; 1 study, 61 participants; very low-quality evidence), coasting (OR 0.42, 95% CI 0.18 to 0.95; 3 studies, 320 participants; very low-quality evidence), calcium infusion (OR 1.83, 95% CI 0.88 to 3.81; I² = 81%; 2 studies, 400 participants; very low-quality evidence), or diosmin (OR 2.85, 95% CI 1.35 to 6.00; 1 study, 200 participants; very low-quality evidence). We are uncertain of the effect of dopamine agonists on rates of live birth (OR 1.08, 95% CI 0.73 to 1.59; 2 studies, 430 participants; low-quality evidence). We are uncertain of the effect of dopamine agonists on clinical pregnancy, multiple pregnancy or miscarriage (low to moderate-quality evidence). There were no adverse events reported. AUTHORS' CONCLUSIONS Dopamine agonists probably reduce the incidence of moderate or severe OHSS compared to placebo/no intervention, while we are uncertain of the effect on adverse events and pregnancy outcomes (live birth, clinical pregnancy, miscarriage). Dopamine agonists plus co-intervention may decrease moderate or severe OHSS rates compared to co-intervention only, but we are uncertain whether dopamine agonists affect pregnancy outcomes. When compared to other active interventions, we are uncertain of the effects of dopamine agonists on moderate or severe OHSS and pregnancy outcomes.
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Affiliation(s)
- Huilin Tang
- Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China
| | - Selma M Mourad
- Radboud University Medical Centre, Nijmegen, Netherlands
| | - Aihua Wang
- Department of Pharmacy, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - Suo-Di Zhai
- Department of Pharmacy, Therapeutic Drug Monitoring and Clinical Toxicology Center of Peking University, Peking University Third Hospital, Beijing, China
| | - Roger J Hart
- School of Women's and Infants' Health, The University of Western Australia, King Edward Memorial Hospital and Fertility Specialists of Western Australia, Subiaco, Perth, Australia
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Shpakov AO. Improvement Effect of Metformin on Female and Male Reproduction in Endocrine Pathologies and Its Mechanisms. Pharmaceuticals (Basel) 2021; 14:ph14010042. [PMID: 33429918 PMCID: PMC7826885 DOI: 10.3390/ph14010042] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 01/02/2021] [Accepted: 01/06/2021] [Indexed: 02/07/2023] Open
Abstract
Metformin (MF), a first-line drug to treat type 2 diabetes mellitus (T2DM), alone and in combination with other drugs, restores the ovarian function in women with polycystic ovary syndrome (PCOS) and improves fetal development, pregnancy outcomes and offspring health in gestational diabetes mellitus (GDM) and T2DM. MF treatment is demonstrated to improve the efficiency of in vitro fertilization and is considered a supplementary drug in assisted reproductive technologies. MF administration shows positive effect on steroidogenesis and spermatogenesis in men with metabolic disorders, thus MF treatment indicates prospective use for improvement of male reproductive functions and fertility. MF lacks teratogenic effects and has positive health effect in newborns. The review is focused on use of MF therapy for restoration of female and male reproductive functions and improvement of pregnancy outcomes in metabolic and endocrine disorders. The mechanisms of MF action are discussed, including normalization of metabolic and hormonal status in PCOS, GDM, T2DM and metabolic syndrome and restoration of functional activity and hormonal regulation of the gonadal axis.
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Affiliation(s)
- Alexander O Shpakov
- I.M. Sechenov Institute of Evolutionary Physiology and Biochemistry of Russian Academy of Sciences, 194223 Saint Petersburg, Russia
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5
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Hussein RS, Elnashar I, Amin AF, Zhao Y, Abdelmagied AM, Abbas AM, Abdelaleem AA, Farghaly TA, Abdalmageed OS, Youssef AA, Badran E, Abou-Taleb HA. Effect of Metformin on Premature Luteinization and Pregnancy Outcomes in Intracytoplasmic Sperm Injection-Fresh Embryo Transfer Cycles: A Randomized Double-Blind Controlled Trial. INTERNATIONAL JOURNAL OF FERTILITY & STERILITY 2021; 15:108-114. [PMID: 33687163 PMCID: PMC8052800 DOI: 10.22074/ijfs.2020.134643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 09/14/2020] [Indexed: 11/08/2022]
Abstract
BACKGROUND Premature luteinization (PL) is not unusual in in vitro fertilization (IVF) and could not be wholly avoided by using either gonadotropin-releasing hormone (GnRH) agonists or GnRH antagonist regimens. The study aims to evaluate metformin's efficacy in preventing PL in fresh GnRH antagonist intracytoplasmic sperm injection (ICSI) cycles with cleavage-stage embryo transfer. MATERIALS AND METHODS This randomized, double-blind, placebo-controlled trial was conducted in a tertiary university IVF center. We recruited infertile women who were scheduled to perform their first or second ICSI trial. Eligible women were recruited and randomized in a 1:1 ratio into two groups. Metformin was administered in a dose of 1500 mg per day since the start of contraceptive pills in the cycle antecedent to stimulation cycle until the day of ovulation triggering, while women in the placebo group received a placebo for the same regimen and duration. The primary outcome was the incidence of PL, defined as serum progesterone (P) on the triggering day ≥1.5 ng/mL. Secondary outcomes comprised the live birth, ongoing pregnancy, implantation, and good-quality embryos rates. RESULTS The trial involved 320 eligible participants (n=160 in each group). Both groups had comparable stimulation days, endometrial thickness, peak estradiol levels, number of oocytes retrieved, and number of mature oocytes. Metformin group experienced lower level of serum P (P<0.001) and incidence of PL (10 vs. 23.6%, P=0.001). Moreover, lower progesterone/estradiol (P/E) ratio and progesterone to mature oocyte index (PMOI) (P=0.002 and P=0.002, respectively) were demonstrated in women receiving metformin. Metformin group generated a better rate of goodquality embryos (P=0.005) and ongoing pregnancy (43.8 vs. 31.8%, P=0.026). A similar trend, though of borderline significance, was observed in the live birth rate in favor of metformin administration (38.15 vs. 27.5%, P=0.04). CONCLUSION Metformin could be used in patients with potential PL to improve fresh cycle outcomes by preventing PL (Registration number: NCT03088631).
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Affiliation(s)
- Reda S. Hussein
- Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt,Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA,Department of Obstetrics and GynecologyFaculty of
MedicineAssiut UniversityAssiutEgypt
| | - Ihab Elnashar
- Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Ahmed F Amin
- Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Yulian Zhao
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ahmed M. Abdelmagied
- Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt,Department of Obstetrics and Gynecology, Taibah University, Medina, KSA
| | - Ahmed M. Abbas
- Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Ahmed A. Abdelaleem
- Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Tarek A. Farghaly
- Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Osama S Abdalmageed
- Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Ahmed A. Youssef
- Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Esraa Badran
- Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Hisham A. Abou-Taleb
- Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt
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6
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Wu Y, Tu M, Huang Y, Liu Y, Zhang D. Association of Metformin With Pregnancy Outcomes in Women With Polycystic Ovarian Syndrome Undergoing In Vitro Fertilization: A Systematic Review and Meta-analysis. JAMA Netw Open 2020; 3:e2011995. [PMID: 32744629 PMCID: PMC7399751 DOI: 10.1001/jamanetworkopen.2020.11995] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
IMPORTANCE Metformin is widely used among women with polycystic ovary syndrome (PCOS). However, its associations with outcomes of in vitro fertilization or intracytoplasmic sperm injection and embryo transfer (IVF/ICSI-ET) in women with PCOS remain controversial. OBJECTIVE To assess whether metformin is associated with improved outcomes of IVF/ICSI-ET in women with PCOS. DATA SOURCES PubMed, Embase, and Cochrane were searched from database inception to January 31, 2020. STUDY SELECTION Only randomized clinical trials (RCTs) were included. Eligible studies enrolled women with PCOS undergoing infertility treatment with IVF/ICSI-ET and reported at least 1 outcome of IVF/ICSI-ET. DATA EXTRACTION AND SYNTHESIS This study followed the Preferred Reporting Items for Systematic Reviews and Meta analyses guidelines. Two authors independently extracted the data. Study quality was evaluated using the GRADE system. Treatment effect was quantified using odds ratios (ORs) with 95% CIs using random-effect models with the Mantel-Haenszel method. MAIN OUTCOMES AND MEASURES Ovarian hyperstimulation syndrome (OHSS), clinical pregnancy rate, and live birth rate. RESULTS A total of 12 RCTs, which collectively included 1123 women with PCOS undergoing infertility treatment with IVF/ICSI-ET, were identified. The risk of OHSS in women randomized to metformin was lower than in women not randomized to metformin (OR, 0.43; 95% CI, 0.24-0.78), although this difference was not significant for women with PCOS with a body mass index of less than 26 (OR, 0.67; 95% CI, 0.30-1.51). There was no significant difference in clinical pregnancy rate (OR, 1.24; 95% CI, 0.82-1.86) or live birth rate (OR, 1.23; 95% CI, 0.74-2.04) in the total population studied. However, in a post hoc analysis among women with a body mass index of 26 or greater, metformin treatment was associated with increased clinical pregnancy rates (OR, 1.71; 95% CI, 1.12-2.60). CONCLUSIONS AND RELEVANCE In this study, metformin treatment was associated with a decreased risk of OHSS but had no association with the overall clinical pregnancy rate or live birth rate among women with PCOS undergoing IVF/ICSI-ET. Metformin treatment should be carefully considered for women with PCOS undergoing IVF/ICSI-ET and may be more preferred for women with a body mass index greater than 26.
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Affiliation(s)
- Yiqing Wu
- Women’s Reproductive Health Research Key Laboratory of Zhejiang Province, Women’s Hospital, Department of Reproductive Endocrinology, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Mixue Tu
- Key Laboratory of Reproductive Genetics, Zhejiang University, Ministry of Education, Hangzhou, Zhejiang, China
| | - Yun Huang
- Women’s Reproductive Health Research Key Laboratory of Zhejiang Province, Women’s Hospital, Department of Reproductive Endocrinology, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Yifeng Liu
- Women’s Reproductive Health Research Key Laboratory of Zhejiang Province, Women’s Hospital, Department of Reproductive Endocrinology, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Dan Zhang
- Women’s Reproductive Health Research Key Laboratory of Zhejiang Province, Women’s Hospital, Department of Reproductive Endocrinology, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
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7
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Schirmer DA, Kulkarni AD, Zhang Y, Kawwass JF, Boulet SL, Kissin DM. Ovarian hyperstimulation syndrome after assisted reproductive technologies: trends, predictors, and pregnancy outcomes. Fertil Steril 2020; 114:567-578. [PMID: 32680613 DOI: 10.1016/j.fertnstert.2020.04.004] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Revised: 04/01/2020] [Accepted: 04/02/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To assess trends, predictors, and perinatal outcomes of ovarian hyperstimulation syndrome (OHSS) associated with in vitro fertilization (IVF) cycles in the United States. DESIGN Retrospective cohort study using National Assisted Reproductive Technology Surveillance System (NASS) data. SETTING Not applicable. PATIENT(S) Fresh autologous and embryo-banking cycles performed from 2000 to 2015. INTERVENTIONS(S) None. MAIN OUTCOME MEASURE(S) OHSS, first-trimester loss, second-trimester loss, stillbirth, low birth weight, and preterm delivery. RESULT(S) The proportion of IVF cycles complicated by OHSS increased from 10.0 to 14.3 cases per 1,000 from 2000 to 2006, and decreased to 5.3 per 1,000 from 2006 to 2015. The risk of OHSS was highest for cycles with more than 30 oocytes retrieved (adjusted risk ratio [aRR] 3.85). OHSS was associated with a diagnosis of ovulatory disorder (aRR 2.61), tubal factor (aRR 1.14), uterine factor (aRR 1.17) and cycles resulting in pregnancy (aRR 3.12). In singleton pregnancies, OHSS was associated with increased risk of low birth weight (aRR 1.29) and preterm delivery (aRR 1.32). In twin pregnancies, OHSS was associated with an increased risk of second-trimester loss (aRR 1.81), low birth weight (aRR 1.06), and preterm delivery (aRR 1.16). CONCLUSION(S) Modifiable predictive factors for OHSS include number of oocytes retrieved, pregnancy following fresh embryo transfer, and the type of medication used for pituitary suppression during controlled ovarian hyperstimulation. Patients affected by OHSS had a higher risk of preterm delivery and low birth weight. Clinicians should take measures to reduce the risk of OHSS whenever possible.
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Affiliation(s)
- David A Schirmer
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia; Department of Gynecology and Obstetrics, School of Medicine, Emory University, Atlanta, Georgia.
| | - Aniket D Kulkarni
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Yujia Zhang
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jennifer F Kawwass
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia; Department of Gynecology and Obstetrics, School of Medicine, Emory University, Atlanta, Georgia
| | - Sheree L Boulet
- Department of Gynecology and Obstetrics, School of Medicine, Emory University, Atlanta, Georgia
| | - Dmitry M Kissin
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia; Department of Gynecology and Obstetrics, School of Medicine, Emory University, Atlanta, Georgia
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8
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Nayak G, Salian SR, Agarwal P, Suresh Poojary P, Rao A, Kumari S, Kalthur SG, Shreya AB, Mutalik S, Adiga SK, Kalthur G. Antidiabetic drug metformin affects the developmental competence of cleavage-stage embryos. J Assist Reprod Genet 2020; 37:1227-1238. [PMID: 32335799 PMCID: PMC7244706 DOI: 10.1007/s10815-020-01709-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 01/30/2020] [Indexed: 12/22/2022] Open
Abstract
PURPOSE Metformin is the most commonly prescribed drug in the management of metabolic disorders such as polycystic ovarian syndrome (PCOS) and gestational diabetes in women of reproductive age. Insulin-sensitizing effect of metformin helps in improving from PCOS features such as hyperandrogenism, anovulation, and infertility. However, its ability to cross placental barrier raises concern about safety of the drug on early embryonic development. In this study, we evaluated the effect of metformin on the ovarian function and embryo development. METHODS Adult Swiss albino female mice were administered with metformin (0, 50, 100, and 200 mg/kg body weight) for 4 weeks and assessed for reproductive function and preimplantation embryo development. Further, effect of metformin (0, 10, 25, 50, 100, 250, and 500 μg/mL) exposure to 2-cell-stage embryos was tested under in vitro conditions. RESULTS Metformin did not alter the body weight, blood glucose, ovarian weight, and follicular reserve. However, the early embryo development was significantly affected in mice treated with metformin in vivo at highest dose. Moreover, embryos which were exposed to metformin in vitro showed dose-dependent decline in blastocyst rate and hatching rate. Furthermore, at highest concentration of metformin (500 μg/mL), all the embryos were arrested at compaction stage. CONCLUSION The study revealed that metformin affects the early embryonic development and raises concern about its use during conception.
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Affiliation(s)
- Guruprasad Nayak
- Department of Clinical Embryology, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
| | - Sujith Raj Salian
- Department of Clinical Embryology, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
| | - Pooja Agarwal
- Department of Clinical Embryology, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
| | - Pooja Suresh Poojary
- Department of Clinical Embryology, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
| | - Arpitha Rao
- Department of Clinical Embryology, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
| | - Sandhya Kumari
- Department of Clinical Embryology, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
| | - Sneha Guruprasad Kalthur
- Department of Anatomy, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
| | - Ajjappla B Shreya
- Department of Pharmaceutics, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
| | - Srinivas Mutalik
- Department of Pharmaceutics, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
| | - Satish Kumar Adiga
- Department of Clinical Embryology, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
| | - Guruprasad Kalthur
- Department of Clinical Embryology, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India.
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Bosch E, Broer S, Griesinger G, Grynberg M, Humaidan P, Kolibianakis E, Kunicki M, La Marca A, Lainas G, Le Clef N, Massin N, Mastenbroek S, Polyzos N, Sunkara SK, Timeva T, Töyli M, Urbancsek J, Vermeulen N, Broekmans F. ESHRE guideline: ovarian stimulation for IVF/ICSI †. Hum Reprod Open 2020; 2020:hoaa009. [PMID: 32395637 PMCID: PMC7203749 DOI: 10.1093/hropen/hoaa009] [Citation(s) in RCA: 166] [Impact Index Per Article: 41.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 12/05/2019] [Indexed: 12/29/2022] Open
Abstract
STUDY QUESTION What is the recommended management of ovarian stimulation, based on the best available evidence in the literature? SUMMARY ANSWER The guideline development group formulated 84 recommendations answering 18 key questions on ovarian stimulation. WHAT IS KNOWN ALREADY Ovarian stimulation for IVF/ICSI has been discussed briefly in the National Institute for Health and Care Excellence guideline on fertility problems, and the Royal Australian and New Zealand College of Obstetricians and Gynaecologist has published a statement on ovarian stimulation in assisted reproduction. There are, to our knowledge, no evidence-based guidelines dedicated to the process of ovarian stimulation. STUDY DESIGN SIZE DURATION The guideline was developed according to the structured methodology for development of ESHRE guidelines. After formulation of key questions by a group of experts, literature searches and assessments were performed. Papers published up to 8 November 2018 and written in English were included. The critical outcomes for this guideline were efficacy in terms of cumulative live birth rate per started cycle or live birth rate per started cycle, as well as safety in terms of the rate of occurrence of moderate and/or severe ovarian hyperstimulation syndrome (OHSS). PARTICIPANTS/MATERIALS SETTING METHODS Based on the collected evidence, recommendations were formulated and discussed until consensus was reached within the guideline group. A stakeholder review was organized after finalization of the draft. The final version was approved by the guideline group and the ESHRE Executive Committee. MAIN RESULTS AND THE ROLE OF CHANCE The guideline provides 84 recommendations: 7 recommendations on pre-stimulation management, 40 recommendations on LH suppression and gonadotrophin stimulation, 11 recommendations on monitoring during ovarian stimulation, 18 recommendations on triggering of final oocyte maturation and luteal support and 8 recommendations on the prevention of OHSS. These include 61 evidence-based recommendations-of which only 21 were formulated as strong recommendations-and 19 good practice points and 4 research-only recommendations. The guideline includes a strong recommendation for the use of either antral follicle count or anti-Müllerian hormone (instead of other ovarian reserve tests) to predict high and poor response to ovarian stimulation. The guideline also includes a strong recommendation for the use of the GnRH antagonist protocol over the GnRH agonist protocols in the general IVF/ICSI population, based on the comparable efficacy and higher safety. For predicted poor responders, GnRH antagonists and GnRH agonists are equally recommended. With regards to hormone pre-treatment and other adjuvant treatments (metformin, growth hormone (GH), testosterone, dehydroepiandrosterone, aspirin and sildenafil), the guideline group concluded that none are recommended for increasing efficacy or safety. LIMITATIONS REASON FOR CAUTION Several newer interventions are not well studied yet. For most of these interventions, a recommendation against the intervention or a research-only recommendation was formulated based on insufficient evidence. Future studies may require these recommendations to be revised. WIDER IMPLICATIONS OF THE FINDINGS The guideline provides clinicians with clear advice on best practice in ovarian stimulation, based on the best evidence available. In addition, a list of research recommendations is provided to promote further studies in ovarian stimulation. STUDY FUNDING/COMPETING INTERESTS The guideline was developed and funded by ESHRE, covering expenses associated with the guideline meetings, with the literature searches and with the dissemination of the guideline. The guideline group members did not receive payment. F.B. reports research grant from Ferring and consulting fees from Merck, Ferring, Gedeon Richter and speaker's fees from Merck. N.P. reports research grants from Ferring, MSD, Roche Diagnositics, Theramex and Besins Healthcare; consulting fees from MSD, Ferring and IBSA; and speaker's fees from Ferring, MSD, Merck Serono, IBSA, Theramex, Besins Healthcare, Gedeon Richter and Roche Diagnostics. A.L.M reports research grants from Ferring, MSD, IBSA, Merck Serono, Gedeon Richter and TEVA and consulting fees from Roche, Beckman-Coulter. G.G. reports consulting fees from MSD, Ferring, Merck Serono, IBSA, Finox, Theramex, Gedeon-Richter, Glycotope, Abbott, Vitrolife, Biosilu, ReprodWissen, Obseva and PregLem and speaker's fees from MSD, Ferring, Merck Serono, IBSA, Finox, TEVA, Gedeon Richter, Glycotope, Abbott, Vitrolife and Biosilu. E.B. reports research grants from Gedeon Richter; consulting and speaker's fees from MSD, Ferring, Abbot, Gedeon Richter, Merck Serono, Roche Diagnostics and IBSA; and ownership interest from IVI-RMS Valencia. P.H. reports research grants from Gedeon Richter, Merck, IBSA and Ferring and speaker's fees from MSD, IBSA, Merck and Gedeon Richter. J.U. reports speaker's fees from IBSA and Ferring. N.M. reports research grants from MSD, Merck and IBSA; consulting fees from MSD, Merck, IBSA and Ferring and speaker's fees from MSD, Merck, IBSA, Gedeon Richter and Theramex. M.G. reports speaker's fees from Merck Serono, Ferring, Gedeon Richter and MSD. S.K.S. reports speaker's fees from Merck, MSD, Ferring and Pharmasure. E.K. reports speaker's fees from Merck Serono, Angellini Pharma and MSD. M.K. reports speaker's fees from Ferring. T.T. reports speaker's fees from Merck, MSD and MLD. The other authors report no conflicts of interest. DISCLAIMER This guideline represents the views of ESHRE, which were achieved after careful consideration of the scientific evidence available at the time of preparation. In the absence of scientific evidence on certain aspects, a consensus between the relevant ESHRE stakeholders has been obtained. Adherence to these clinical practice guidelines does not guarantee a successful or specific outcome, nor does it establish a standard of care. Clinical practice guidelines do not replace the need for application of clinical judgment to each individual presentation, nor variations based on locality and facility type. ESHRE makes no warranty, express or implied, regarding the clinical practice guidelines and specifically excludes any warranties of merchantability and fitness for a particular use or purpose. (Full disclaimer available at www.eshre.eu/guidelines.) †ESHRE Pages content is not externally peer reviewed. The manuscript has been approved by the Executive Committee of ESHRE.
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Affiliation(s)
| | | | - Simone Broer
- Department of Reproductive Medicine and Gynecology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Georg Griesinger
- Department of Gynecological Endocrinology and Reproductive Medicine, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Michael Grynberg
- Department of Reproductive Medicine & Fertility Preservation, Hopital Antoine Béclère, Clamart, France
| | - Peter Humaidan
- The Fertility Clinic, Skive Regional Hospital, Faculty of Health, Aarhus University, Skive, Denmark
| | - Estratios Kolibianakis
- Unit for Human Reproduction, 1 Dept of ObGyn, Medical School, Aristotle University, Thessaloniki, Greece
| | - Michal Kunicki
- INVICTA Fertility and Reproductive Centre, Department of Gynaecological Endocrinology, Medical University of Warsaw, Warsaw, Poland
| | - Antonio La Marca
- Department of Obstetrics and Gynaecology, University of Modena Reggio Emilia and Clinica Eugin, Modena, Italy
| | | | - Nathalie Le Clef
- European Society of Human Reproduction and Embryology, Grimbergen, Belgium
| | - Nathalie Massin
- Department of Obstetrics, Gynaecology and Reproduction, University Paris-Est Créteil, Centre Hospitalier Intercommunal Créteil, Créteil, France
| | - Sebastiaan Mastenbroek
- Amsterdam Reproduction & Development, Center for Reproductive Medicine, University Medical Center Amsterdam, Amsterdam, The Netherlands
| | - Nikolaos Polyzos
- Department of Reproductive Medicine, Dexeus University Hospital, Barcelona, Spain
| | - Sesh Kamal Sunkara
- Department of Women and Children’s Health, King’s College London, London, UK
| | | | - Mira Töyli
- Kanta-Häme Central Hospital, Hämeenlinna, Mehiläinen Clinics, Helsinki, Finland
| | - Janos Urbancsek
- Department of Obstetrics and Gynaecology, Semmelweis University Faculty of Medicine, Budapest, Hungary
| | - Nathalie Vermeulen
- European Society of Human Reproduction and Embryology, Grimbergen, Belgium
| | - Frank Broekmans
- Department of Reproductive Medicine and Gynecology, University Medical Center Utrecht, Utrecht, The Netherlands
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10
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Romualdi D, Versace V, Lanzone A. What is new in the landscape of insulin-sensitizing agents for polycystic ovary syndrome treatment. Ther Adv Reprod Health 2020; 14:2633494120908709. [PMID: 32435760 PMCID: PMC7236839 DOI: 10.1177/2633494120908709] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 01/11/2020] [Indexed: 12/19/2022] Open
Abstract
Polycystic ovary syndrome, the most common gynecological endocrinopathy, is burdened with a state of hyperinsulinemia and insulin resistance in 50-80% of affected women. Wherever the origin of these metabolic abnormalities lies, their pathogenetic role in determining, perpetuating, and worsening the clinical traits of the syndrome is ascertained. Many studies have already highlighted possible mechanisms: hyperinsulinemia and insulin resistance may contribute to hyperandrogenemia, chronic anovulation, and other comorbidities of the syndrome by differentially affecting the endocrine glands (ovaries, adrenals, and pituitary) and peripheral tissues (fat mass and skeletal muscle). Based on these evidences, in the past years, thorough research has been focused on the possible role of insulin-sensitizing agents in the treatment of polycystic ovary syndrome. Many compounds were tested to verify their efficacy against polycystic ovary syndrome-related metabolic dysfunction, both relying on previous acquired experiences in the field of diabetes mellitus and experimenting new agents, in particular, those belonging to the class of nutraceuticals. We sought to summarize the most relevant aspects of insulin-sensitizing treatments in polycystic ovary syndrome, by reporting the relevant literature on this topic and by keeping an attentive eye on the newly published international guidelines on polycystic ovary syndrome 2018. This overview encompasses metformin, thiazolidinediones, inositols, alpha-lipoic acid, and GLP1-R analogues. Starting from the analysis of the mechanisms of action, we anchored to the state of the art of the use of these drugs in polycystic ovary syndrome, to the most recent evidences for clinical practice and to the remaining open questions around indications, dose, treatment schedules, and side effects.
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Affiliation(s)
- Daniela Romualdi
- Department of Woman, Child Health and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
- Department Of Woman And Child Health, Division of Obstetrics and Gynecology, Azienda Ospedaliera “Cardinale Panico”, Tricase, Italy
| | - Valeria Versace
- Department of Woman, Child Health and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Antonio Lanzone
- Department of Woman, Child Health and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
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11
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Gadalla MA, Norman RJ, Tay CT, Hiam DS, Melder A, Pundir J, Thangaratinam S, Teede HJ, Mol BWJ, Moran LJ. Medical and Surgical Treatment of Reproductive Outcomes in Polycystic Ovary Syndrome: An Overview of Systematic Reviews. INTERNATIONAL JOURNAL OF FERTILITY & STERILITY 2020; 13:257-270. [PMID: 31710185 PMCID: PMC6875858 DOI: 10.22074/ijfs.2020.5608] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 03/10/2019] [Indexed: 12/28/2022]
Abstract
Polycystic ovary syndrome (PCOS) is a common, complex condition that affects up to 18% of reproductiveaged women, causing reproductive, metabolic and psychological dysfunctions. We performed an overview and appraisal of methodological quality of systematic reviews that assessed medical and surgical treatments for reproductive outcomes in women with PCOS. Databases (MEDLINE, EMBASE, CINAHL PLUS and PROSPERO) were searched on the 15th of September 2017. We included any systematic review that assessed the effect of medical or surgical management of PCOS on reproductive, pregnancy and neonatal outcomes. Eligibility assessment, data extraction and quality assessment by the Assessing the Methodological Quality of Systematic Reviews (AMSTAR) tool were performed in duplicate. We identified 53 reviews comprising 44 reviews included in this overview; the majority were moderate to high quality. In unselected women with PCOS, letrozole was associated with a higher live birth rate than clomiphene citrate (CC), while CC was better than metformin or placebo. In women with CC-resistant PCOS, gonadotrophins were associated with a higher live birth rate than CC plus metformin, which was better than laparoscopic ovarian drilling (LOD). LOD was associated with lower multiple pregnancy rates than other medical treatments. In women with PCOS undergoing in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI), the addition of metformin to gonadotrophins resulted in less ovarian hyperstimulation syndrome (OHSS), and higher pregnancy and live birth rates than gonadotrophins alone. Gonadotrophin releasing hormone (GnRH) antagonist was associated with less OHSS, gonadotrophin units and shorter stimulation length than GnRH agonist. Letrozole appears to be a good first line treatment and gonadotrophins, as a second line treatment, for anovulatory women with PCOS. LOD results in lower multiple pregnancy rates. However, due to the heterogeneous nature of the included populations of women with PCOS, further larger scale trials are needed with more precise assessment of treatments according to heterogeneous variants of PCOS.
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Affiliation(s)
- Moustafa A Gadalla
- Women's Health Hospital, Department of Obstetrics and Gynaecology, Assiut University, Assiut, Egypt.Elevtronic Address:
- Robinson Research Institute, Discipline of Obstetrics and Gynaecology, University of Adelaide, Adelaide, Australia
| | - Robert J Norman
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Victoria, Melbourne, Australia
- Monash Diabetes and Endocrinology Units, Monash Health, Victoria, Melbourne, Australia
| | | | - Danielle S Hiam
- Institute of Sport, Exercise and Active Living, Victoria University, Melbourne, Australia
| | - Angela Melder
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Victoria, Melbourne, Australia
| | - Jyotsna Pundir
- Centre of Reproductive Medicine, St Bartholomew's Hospital, London, United Kingdom
| | - Shakila Thangaratinam
- Women's Health Research Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University London, London, United Kingdom
| | - Helena J Teede
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Victoria, Melbourne, Australia
- Monash Diabetes and Endocrinology Units, Monash Health, Victoria, Melbourne, Australia
| | - Ben W J Mol
- Robinson Research Institute, Discipline of Obstetrics and Gynaecology, University of Adelaide, Adelaide, Australia
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Melbourne, Australia
| | - Lisa J Moran
- Robinson Research Institute, Discipline of Obstetrics and Gynaecology, University of Adelaide, Adelaide, Australia
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Victoria, Melbourne, Australia
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12
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Sawant S, Bhide P. Fertility Treatment Options for Women With Polycystic Ovary Syndrome. CLINICAL MEDICINE INSIGHTS. REPRODUCTIVE HEALTH 2019; 13:1179558119890867. [PMID: 31908561 PMCID: PMC6935873 DOI: 10.1177/1179558119890867] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 10/29/2019] [Indexed: 01/08/2023]
Abstract
Polycystic ovary syndrome is the most common endocrinological disorder in women of reproductive age. It is commonly associated with anovulatory subfertility, for which there are a range of treatment options available to help them conceive. These options are given in a step-wise manner with an appropriate selection of patients to maximise success rates with minimal complications. This review discusses the importance and involvement of multidisciplinary care when offering treatment to women with subfertility. Multidisciplinary care gives an excellent opportunity to identify, assess risk, and potentially prevent future morbidities and complications while treating women for fertility issues. We have also summarised the various options available for fertility treatment: pharmacological treatments, nonpharmacological intervention, and assisted reproductive technology.
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Affiliation(s)
- Shital Sawant
- Homerton Fertility Centre, Homerton University Hospital, London, UK
| | - Priya Bhide
- Homerton Fertility Centre, Homerton University Hospital, London, UK.,Queen Mary University of London, UK
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13
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Sharpe A, Morley LC, Tang T, Norman RJ, Balen AH. Metformin for ovulation induction (excluding gonadotrophins) in women with polycystic ovary syndrome. Cochrane Database Syst Rev 2019; 12:CD013505. [PMID: 31845767 PMCID: PMC6915832 DOI: 10.1002/14651858.cd013505] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Polycystic ovary syndrome (PCOS) is characterised by infrequent or absent ovulation, and high levels of androgens and insulin (hyperinsulinaemia). Hyperinsulinaemia occurs secondary to insulin resistance and is associated with an increased biochemical risk profile for cardiovascular disease and an increased prevalence of diabetes mellitus. Insulin-sensitising agents such as metformin may be effective in treating PCOS-related anovulation. This is an update of Morley 2017 and only includes studies on metformin. OBJECTIVES To evaluate the effectiveness and safety of metformin in combination with or in comparison to clomiphene citrate (CC), letrozole and laparoscopic ovarian drilling (LOD) in improving reproductive outcomes and associated gastrointestinal side effects for women with PCOS undergoing ovulation induction. SEARCH METHODS We searched the following databases from inception to December 2018: Cochrane Gynaecology and Fertility Group Specialised Register, CENTRAL, MEDLINE, Embase, PsycINFO and CINAHL. We searched registers of ongoing trials and reference lists from relevant studies. SELECTION CRITERIA We included randomised controlled trials of metformin compared with placebo, no treatment, or in combination with or compared with CC, letrozole and LOD for women with PCOS subfertility. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for eligibility and bias. Primary outcomes were live birth rate and gastrointestinal adverse effects. Secondary outcomes included other pregnancy outcomes and ovulation. We combined data to calculate pooled odds ratios (ORs) and 95% confidence intervals (CIs). We assessed statistical heterogeneity using the I2 statistic and reported quality of the evidence for primary outcomes and reproductive outcomes using GRADE methodology. MAIN RESULTS We included 41 studies (4552 women). Evidence quality ranged from very low to moderate based on GRADE assessment. Limitations were risk of bias (poor reporting of methodology and incomplete outcome data), imprecision and inconsistency. Metformin versus placebo or no treatment The evidence suggests that metformin may improve live birth rates compared with placebo (OR 1.59, 95% CI 1.00 to 2.51; I2 = 0%; 4 studies, 435 women; low-quality evidence). For a live birth rate of 19% following placebo, the live birth rate following metformin would be between 19% and 37%. The metformin group probably experiences more gastrointestinal side effects (OR 4.00, 95% CI 2.63 to 6.09; I2 = 39%; 7 studies, 713 women; moderate-quality evidence). With placebo, the risk of gastrointestinal side effects is 10% whereas with metformin this risk is between 22% and 40%. There are probably higher rates of clinical pregnancy (OR 1.98, 95% CI 1.47 to 2.65; I2 = 30%; 11 studies, 1213 women; moderate-quality evidence). There may be higher rates of ovulation with metformin (OR 2.64, 95% CI 1.85 to 3.75; I2 = 61%; 13 studies, 684 women; low-quality evidence). We are uncertain about the effect on miscarriage rates (OR 1.08, 95% CI 0.50 to 2.35; I2 = 0%; 4 studies, 748 women; low-quality evidence). Metformin plus CC versus CC alone We are uncertain if metformin plus CC improves live birth rates compared to CC alone (OR 1.27, 95% CI 0.98 to 1.65; I2 = 28%; 10 studies, 1219 women; low-quality evidence), but gastrointestinal side effects are probably more common with combined therapy (OR 4.26, 95% CI 2.83 to 6.40; I2 = 8%; 6 studies, 852 women; moderate quality evidence). The live birth rate with CC alone is 24%, which may change to between 23% to 34% with combined therapy. With CC alone, the risk of gastrointestinal side effects is 9%, which increases to between 21% to 37% with combined therapy. The combined therapy group probably has higher rates of clinical pregnancy (OR 1.62, 95% CI 1.32 to 1.99; I2 = 31%; 19 studies, 1790 women; moderate-quality evidence). The combined group may have higher rates of ovulation (OR 1.65, 95% CI 1.35 to 2.03; I2 = 63%;21 studies, 1568 women; low-quality evidence). There was no clear evidence of an effect on miscarriage (OR 1.35, 95% CI 0.91 to 2.00; I2 = 0%; 10 studies, 1206 women; low-quality evidence). Metformin versus CC When all studies were combined, findings for live birth were inconclusive and inconsistent (OR 0.71, 95% CI 0.49 to 1.01; I2 = 86%; 5 studies, 741 women; very low-quality evidence). In subgroup analysis by obesity status, obese women had a lower birth rate in the metformin group (OR 0.30, 95% CI 0.17 to 0.52; 2 studies, 500 women), while the non-obese group showed a possible benefit from metformin, with high heterogeneity (OR 1.71, 95% CI 1.00 to 2.94; I2 = 78%, 3 studies, 241 women; very low-quality evidence). However, due to the very low quality of the evidence we cannot draw any conclusions. Among obese women taking metformin there may be lower rates of clinical pregnancy (OR 0.34, 95% CI 0.21 to 0.55; I2 = 0%; 2 studies, 500 women; low-quality evidence) and ovulation (OR 0.29, 95% CI 0.20 to 0.43; I2 = 0%; 2 studies, 500 women; low-quality evidence) while among non-obese women, the metformin group may have more pregnancies (OR 1.56, 95% CI 1.06 to 2.29; I2 = 26%; 6 studies, 530 women; low-quality evidence) and no clear difference in ovulation rates (OR 0.80, 95% CI 0.52 to 1.25; I2 = 0%; 5 studies, 352 women; low-quality evidence). We are uncertain whether there is a difference in miscarriage rates between the groups (overall: OR 0.92, 95% CI 0.51 to 1.66; I2 = 36%; 6 studies, 781 women; low-quality evidence) and no studies reported gastrointestinal side effects. AUTHORS' CONCLUSIONS Our updated review suggests that metformin may be beneficial over placebo for live birth however, more women probably experience gastrointestinal side effects. We are uncertain if metformin plus CC improves live birth rates compared to CC alone, but gastrointestinal side effects are probably increased with combined therapy. When metformin was compared with CC, data for live birth were inconclusive, and the findings were limited by lack of evidence. Results differed by body mass index (BMI), emphasising the importance of stratifying results by BMI. No studies reported gastrointestinal side effects in this comparison. Due to the low quality of the evidence, we are uncertain of the effect of metformin on miscarriage in all three comparisons.
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Affiliation(s)
| | - Lara C Morley
- The General Infirmary of LeedsDepartment of Obstetrics and GynaecologyUnited Leeds Teaching Hospitals NHS TrustBelmont GroveLeedsUKLS2 9NS
| | - Thomas Tang
- Royal Jubilee Maternity ServiceRegional Fertility CentreGrosvenor RoadBelfastUKBT12 6BA
| | - Robert J Norman
- University of AdelaideObstetrics & Gynaecology, Robinson InstituteAdelaide South Australia 5005AdelaideSouth AustraliaAustralia
- University of AdelaideReproductive Medicine Unit, Department of Obstetrics and GynaecologyLevel 6, Medical School North Frome RoadAdelaideSouth AustraliaAustralia5005
- Fertility SAAdelaideAustralia
| | - Adam H Balen
- The Leeds Centre for Reproductive Medicine, Seacroft HospitalReproductive Medicine and SurgeryYork RoadLeedsUKLS14 6UH
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14
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Costello MF, Garad RM, Hart R, Homer H, Johnson L, Jordan C, Mocanu E, Qiao J, Rombauts L, Teede HJ, Vanky E, Venetis CA, Ledger WL. A Review of Second- and Third-line Infertility Treatments and Supporting Evidence in Women with Polycystic Ovary Syndrome. Med Sci (Basel) 2019; 7:E75. [PMID: 31247909 PMCID: PMC6681353 DOI: 10.3390/medsci7070075] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 06/13/2019] [Accepted: 06/20/2019] [Indexed: 12/04/2022] Open
Abstract
In clomiphene-citrate-resistant anovulatory women with polycystic ovary syndrome (PCOS) and no other infertility factors, either metformin combined with clomiphene citrate or gonadotrophins could be used as a second-line pharmacological therapy, although gonadotrophins are more effective. Gonadotrophins could also be used as a second-line pharmacological therapy in anovulatory women with PCOS and clomiphene-citrate-failure. Laparoscopic ovarian surgery can also be used as a second-line therapy for ovulation induction in anovulatory women with clomiphene-citrate-resistant PCOS and no other infertility factors. The usefulness of letrozole as a second-line pharmacological treatment for ovulation induction in clomiphene-citrate-resistant women with PCOS requires further research. In terms of improving fertility, both pharmacological anti-obesity agents and bariatric surgery should be considered an experimental therapy in anovulatory women with PCOS and no other infertility factors. Where first- or second-line ovulation induction therapies have failed, in vitro fertilization (IVF)/ intracytoplasmic sperm injection (ICSI) could be offered as a third-line therapy in women with PCOS in the absence of an absolute indication for IVF/ICSI. For women with PCOS undergoing IVF/ICSI treatment, the gonadotropin-releasing hormone (GnRH) antagonist protocol is preferred and an elective frozen embryo transfer strategy could be considered. In assisted conception units with sufficient expertise, in-vitro maturation (IVM) of oocytes could be offered to women with PCOS.
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Affiliation(s)
- Michael F Costello
- University of New South Wales, High St. Kensington, Sydney, NSW 2052, Australia.
| | - Rhonda M Garad
- Monash Centre for Health Research and Implementation, Monash Public Health and Preventive Medicine, Monash University and Monash Health, Melbourne, VIC 3168, Australia.
| | - Roger Hart
- Division of Obstetrics and Gynaecology, The University of Western Australia, University of Western Australia, Crawley, WA 6008, Australia.
| | - Hayden Homer
- Christopher Chen Oocyte Biology Research Laboratory, UQ Centre for Clinical Research, The University of Queensland, Brisbane, QLD 4029, Australia.
| | - Louise Johnson
- Victorian Assisted Reproductive Treatment Authority, Melbourne, VIC 3000, Australia.
| | | | - Edgar Mocanu
- Royal College of Surgeons, Rotunda Hospital, D02 YN77 Dublin, Ireland.
| | - Jie Qiao
- Department of Obstetrics and Gynaecology, Medical Center for Human Reproduction, Peking University Third Hospital, Beijing 100191, China.
| | - Luk Rombauts
- Department of Obstetrics and Gynaecology, Monash University, Melbourne 3168, Australia.
| | - Helena J Teede
- Monash Centre for Health Research and Implementation, Monash Public Health and Preventive Medicine, Monash University and Monash Health, Melbourne, VIC 3168, Australia.
- National Health and Medical Research Council Centre for Research Excellence in PCOS, Monash University, Melbourne 3168, VIC, Australia.
- National Health and Medical Research Council Centre for Research Excellence in PCOS, University of Adelaide, Adelaide 5006, SA, Australia.
- University of New South Wales, Sydney 2033, NSW, Australia.
| | - Eszter Vanky
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, 1517 Trondheim, Norway.
| | - Christos A Venetis
- University of New South Wales, High St. Kensington, Sydney, NSW 2052, Australia.
| | - William L Ledger
- University of New South Wales, High St. Kensington, Sydney, NSW 2052, Australia.
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15
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Sha T, Wang X, Cheng W, Yan Y. A meta-analysis of pregnancy-related outcomes and complications in women with polycystic ovary syndrome undergoing IVF. Reprod Biomed Online 2019; 39:281-293. [PMID: 31255606 DOI: 10.1016/j.rbmo.2019.03.203] [Citation(s) in RCA: 93] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 02/13/2019] [Accepted: 03/08/2019] [Indexed: 12/24/2022]
Abstract
This meta-analysis aimed to study whether pregnancy-related outcomes and complications differed between patients with polycystic ovary syndrome (PCOS) and those with other causes of infertility who had undergone IVF. A systematic search of PubMed, Embase, the Cochrane Library and Chinese databases was carried out to identify relevant studies published before July 2018. Outcomes were expressed as odds ratios (OR) and 95% confidence intervals (CI). Subgroup analyses and sensitivity analyses were also conducted. Twenty-nine studies were identified for inclusion. Women with PCOS had higher risks of miscarriage (OR 1.41, 95% CI 1.04-1.91), ovarian hyperstimulation syndrome (OR 4.96, 95% CI 3.73-6.60), gestational diabetes mellitus (OR 2.67, 95% CI 1.43-4.98), pregnancy-induced hypertension (OR 2.06, 95% CI 1.45-2.91), preterm birth (OR 1.60, 95% CI 1.25-2.04) and large-for-gestational-age babies (OR 2.10, 95% CI 1.01-4.37). Women with PCOS showed similar rates of clinical pregnancy, multiple pregnancy, ectopic pregnancy, small for gestational age and congenital malformations, and a higher live birth rate, compared with women without PCOS. This study provides an update on and comprehensive evidence to support the observation that despite the fact that PCOS patients achieve a better live birth rate, physicians should continue to consider them to be at high risk of adverse pregnancy-related outcomes.
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Affiliation(s)
- Tingting Sha
- Department of Epidemiology and Medical Statistics, Xiangya School of Public Health, Central South University, Changsha Hunan, China
| | - Xiaojuan Wang
- Reproductive and Genetic Hospital of CITIC-Xiangya, Changsha Hunan, China
| | - Wenwei Cheng
- Third Xiangya Hospital of Central South University, Changsha Hunan, China
| | - Yan Yan
- Department of Epidemiology and Medical Statistics, Xiangya School of Public Health, Central South University, Changsha Hunan, China.
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Costello MF, Misso ML, Balen A, Boyle J, Devoto L, Garad RM, Hart R, Johnson L, Jordan C, Legro RS, Norman RJ, Mocanu E, Qiao J, Rodgers RJ, Rombauts L, Tassone EC, Thangaratinam S, Vanky E, Teede HJ. Evidence summaries and recommendations from the international evidence-based guideline for the assessment and management of polycystic ovary syndrome: assessment and treatment of infertility. Hum Reprod Open 2019; 2019:hoy021. [PMID: 31486807 PMCID: PMC6396642 DOI: 10.1093/hropen/hoy021] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Accepted: 12/13/2018] [Indexed: 12/12/2022] Open
Abstract
STUDY QUESTION What is the recommended assessment and management of infertile women with polycystic ovary syndrome (PCOS), based on the best available evidence, clinical expertize and consumer preference? SUMMARY ANSWER International evidence-based guidelines, including 44 recommendations and practice points, addressed prioritized questions to promote consistent, evidence-based care and improve the experience and health outcomes of infertile women with PCOS. WHAT IS KNOWN ALREADY Previous guidelines on PCOS lacked rigorous evidence-based processes, failed to engage consumer and multidisciplinary perspectives or were outdated. The assessment and management of infertile women with PCOS are inconsistent. The needs of women with PCOS are not being adequately met and evidence practice gaps persist. PARTICIPANTS/MATERIALS, SETTING, METHODS Governance included a six continent international advisory and a project board, a multidisciplinary international guideline development group (GDG), consumer and translation committees. Extensive health professional and consumer engagement informed the guideline scope and priorities. The engaged international society-nominated panel included endocrinology, gynaecology, reproductive endocrinology, obstetrics, public health and other experts, alongside consumers, project management, evidence synthesis and translation experts. Thirty-seven societies and organizations covering 71 countries engaged in the process. Extensive online communication and two face-to-face meetings over 15 months addressed 19 prioritized clinical questions involving nine evidence-based reviews and 10 narrative reviews. Evidence-based recommendations (EBRs) were formulated prior to consensus voting within the guideline panel. STUDY DESIGN, SIZE, DURATION International evidence-based guideline development engaged professional societies and consumer organizations with multidisciplinary experts and women with PCOS directly involved at all stages. A (AGREE) II-compliant processes were followed, with extensive evidence synthesis. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework was applied across evidence quality, desirable and undesirable consequences, feasibility, acceptability, cost, implementation and ultimately recommendation strength. The guideline was peer-reviewed by special interest groups across our partner and collaborating societies and consumer organizations, was independently assessed against AGREE II criteria and underwent methodological review. This guideline was approved by all members of the GDG and has been approved by the NHMRC. MAIN RESULTS AND THE ROLE OF CHANCE The quality of evidence (QOE) for the EBRs in the assessment and management of infertility in PCOS included very low (n = 1), low (n = 9) and moderate (n = 4) quality with no EBRs based on high-quality evidence. The guideline provides 14 EBRs, 10 clinical consensus recommendations (CCRs) and 20 clinical practice points on the assessment and management of infertility in PCOS. Key changes in this guideline include emphasizing evidence-based fertility therapy, including cheaper and safer fertility management. LIMITATIONS, REASONS FOR CAUTION Overall evidence is generally of low to moderate quality, requiring significantly greater research in this neglected, yet common condition. Regional health systems vary and a process for adaptation of this guideline is provided. WIDER IMPLICATIONS OF THE FINDINGS The international guideline for the assessment and management of infertility in PCOS provides clinicians with clear advice on best practice based on the best available evidence, expert multidisciplinary input and consumer preferences. Research recommendations have been generated and a comprehensive multifaceted dissemination and translation program supports the guideline with an integrated evaluation program. STUDY FUNDING/COMPETING INTEREST(S) The guideline was primarily funded by the Australian National Health and Medical Research Council of Australia (NHMRC) supported by a partnership with ESHRE and the American Society for Reproductive Medicine (ASRM). GDG members did not receive payment. Travel expenses were covered by the sponsoring organizations. Disclosures of conflicts of interest were declared at the outset and updated throughout the guideline process, aligned with NHMRC guideline processes. Dr Costello has declared shares in Virtus Health and past sponsorship from Merck Serono for conference presentations. Prof. Norman has declared a minor shareholder interest in the IVF unit Fertility SA, travel support from Merck and grants from Ferring. Prof. Norman also has scientific advisory board duties for Ferring. The remaining authors have no conflicts of interest to declare. This article was not externally peer-reviewed by Human Reproduction Open.
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Affiliation(s)
- M F Costello
- School of Women's and Children's Health, University of New South Wales, High St, Kensington, Sydney, New South Wales, Australia
| | - M L Misso
- Monash Centre for Health Research and Implementation, Monash Public Health and Preventive Medicine, Monash University, Clayton, Victoria, Australia.,Monash Health, Clayton, Melbourne, Australia
| | - A Balen
- Reproductive Medicine and Surgery, Leeds Centre for Reproductive Medicine, Leeds Teaching Hospitals, Leeds, UK
| | - J Boyle
- Monash Centre for Health Research and Implementation, Monash Public Health and Preventive Medicine, Monash University, Clayton, Victoria, Australia.,Monash Health, Clayton, Melbourne, Australia
| | - L Devoto
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Chile, Santiago, Chile
| | - R M Garad
- Monash Health, Clayton, Melbourne, Australia.,National Health and Medical Research Council Centre for Research Excellence in PCOS, Monash Centre for Health Research and Implementation, Monash Public Health and Preventive Medicine, Monash University, Victoria, Australia
| | - R Hart
- Division of Obstetrics and Gynaecology, University of Western Australia, Crawley, WA, Australia
| | - L Johnson
- Victorian Assisted Reproductive Treatment Authority, Victoria, Australia
| | - C Jordan
- Victorian Assisted Reproductive Treatment Authority, Victoria, Australia.,Genea Hollywood Fertility, 190 Cambridge St, Wembley WA, Australia
| | - R S Legro
- Department of Obstetrics and Gynecology, Penn State University College of Medicine, USA
| | - R J Norman
- National Health and Medical Research Council Centre for Research Excellence in PCOS, Monash University, Melbourne, Victoria, Australia.,Adelaide University, Adelaide, South Australia, Australia
| | - E Mocanu
- Royal College of Surgeons, Rotunda Hospital, 123 St Stephen's Green, Dublin, Ireland
| | - J Qiao
- Peking University Third Hospital, Haidian Qu, Beijing Shi, China
| | - R J Rodgers
- Robinson Research Institute, University of Adelaide and Fertility SA, Adelaide, South Australia, Australia
| | - L Rombauts
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Melbourne, Victoria 3168, Australia
| | - E C Tassone
- Monash Centre for Health Research and Implementation, Monash Public Health and Preventive Medicine, Monash University, Clayton, Victoria, Australia.,Monash Health, Clayton, Melbourne, Australia
| | - S Thangaratinam
- Barts Research Centre for Women's Health (BARC), Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - E Vanky
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - H J Teede
- Monash Health, Clayton, Melbourne, Australia.,National Health and Medical Research Council Centre for Research Excellence in PCOS, Monash Centre for Health Research and Implementation, Monash Public Health and Preventive Medicine, Monash University, Victoria, Australia
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Faure M, Bertoldo MJ, Khoueiry R, Bongrani A, Brion F, Giulivi C, Dupont J, Froment P. Metformin in Reproductive Biology. Front Endocrinol (Lausanne) 2018; 9:675. [PMID: 30524372 PMCID: PMC6262031 DOI: 10.3389/fendo.2018.00675] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 10/29/2018] [Indexed: 12/19/2022] Open
Abstract
Initially produced in Europe in 1958, metformin is still one of the most widely prescribed drugs to treat type II diabetes and other comorbidities associated with insulin resistance. Metformin has been shown to improve fertility outcomes in females with insulin resistance associated with polycystic ovary syndrome (PCOS) and in obese males with reduced fertility. Metformin treatment reinstates menstrual cyclicity, decreases the incidence of cesareans, and limits the number of premature births. Notably, metformin reduces steroid levels in conditions associated with hyperandrogenism (e.g., PCOS and precocious puberty) in females and improves fertility of adult men with metabolic syndrome through increased testosterone production. While the therapeutical use of metformin is considered to be safe, in the last 10 years some epidemiological studies have described phenotypic differences after prenatal exposure to metformin. The goals of this review are to briefly summarize the current knowledge on metformin focusing on its effects on the female and male reproductive organs, safety concerns, including the potential for modulating fetal imprinting via epigenetics.
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Affiliation(s)
- Melanie Faure
- Unité de Physiologie de la Reproduction et des Comportements, Centre Val de Loire, Institut National de la Recherche Agronomique, UMR85, Nouzilly, France
| | - Michael J Bertoldo
- Discipline of Obstetrics and Gynaecology, School of Women's and Children's Health, University of New South Wales, Sydney, NSW, Australia
| | - Rita Khoueiry
- Department of Development and Regeneration, Stem Cell Institute, KU Leuven, Leuven, Belgium
| | - Alice Bongrani
- Unité de Physiologie de la Reproduction et des Comportements, Centre Val de Loire, Institut National de la Recherche Agronomique, UMR85, Nouzilly, France
| | - François Brion
- INERIS, Direction des Risques Chroniques, Pole VIVA, Unite d'ecotoxicologie in vitro et in vivo, BP2, Verneuil-en-Halatte, France
| | - Cecilia Giulivi
- Department of Molecular Biosciences, School of Veterinary Medicine, University of California, Davis, Davis, CA, United States
- Medical Investigations of Neurodevelopmental Disorders Institute, University of California, Davis, Davis, CA, United States
| | - Joelle Dupont
- Unité de Physiologie de la Reproduction et des Comportements, Centre Val de Loire, Institut National de la Recherche Agronomique, UMR85, Nouzilly, France
| | - Pascal Froment
- Unité de Physiologie de la Reproduction et des Comportements, Centre Val de Loire, Institut National de la Recherche Agronomique, UMR85, Nouzilly, France
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D'Amato G, Caringella AM, Stanziano A, Cantatore C, Palini S, Caroppo E. Mild ovarian stimulation with letrozole plus fixed dose human menopausal gonadotropin prior to IVF/ICSI for infertile non-obese women with polycystic ovarian syndrome being pre-treated with metformin: a pilot study. Reprod Biol Endocrinol 2018; 16:89. [PMID: 30217209 PMCID: PMC6137735 DOI: 10.1186/s12958-018-0405-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 08/28/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Letrozole is widely employed as ovulation induction agent in women with PCOS, but its use in mild stimulation (MS) protocols for IVF is limited. Aim of the present study was to evaluate the feasibility of a MS protocol with letrozole plus hMG in non-obese PCOS women undergoing IVF after a metformin pre-treatment. METHODS We retrospectively evaluated the data of 125 non-obese PCOS undergoing MS with letrozole plus hMG, 150 IU as starting dose, (group 1, N = 80) compared to those undergoing a conventional IVF stimulation protocols (CS) (group 2, N = 45) prior to IVF. All patients had received metformin extended release 1200-2000 mg daily for three to six months before IVF. GnRH antagonist was administered in both groups when the leading follicles reached 14 mm. RESULTS Both groups were comparable for age, BMI and ovarian reserve markers. Both groups showed lower than expected AFC and AMH values as a consequence of metformin pre-treatment. Letrozole-treated patients required a significantly lower amount of gonadotropins units (p < 0.0001), and showed significantly lower day 5, day 8 and hCG day E2 levels compared to patients undergoing the CS protocol (p < 0.0001, p < 0.0001 and p = 0.001 respectively). The oocyte yield, in terms of total (6, IQR 3, vs 6, IQR 4 respectively,) and MII oocytes (5, IQR 3, vs 5, IQR 3, respectively) number, did not differ among groups; the number of total (3, IQR 2, vs 3, IQR 1 respectively) and good quality embryos (2, IQR1 vs 2, IQR 1,5 respectively) obtained was comparable as well in the two groups. The number of fresh transfers was significantly higher in group 1 compared to group 2 (80% vs 60%, p = 0.016). A trend for higher cumulative clinical pregnancy rate was found in women undergoing MS compared to CS (42.5%vs 24,4%, p = 0.044), but the study was not powered to detect this difference. CONCLUSIONS The present study suggests that the use of letrozole as adjuvant treatment to MS protocols for IVF may be an effective alternative to CS protocols for non-obese PCOS patients pre-treated with metformin, as it provides comparable IVF outcome without requiring high FSH dose, and avoiding supraphysiological estradiol levels.
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Affiliation(s)
- Giuseppe D'Amato
- Asl Bari, Department of Maternal and Child Health, Reproductive and IVF Unit, Conversano, BA, Italy
| | - Anna Maria Caringella
- Asl Bari, Department of Maternal and Child Health, Reproductive and IVF Unit, Conversano, BA, Italy
| | - Antonio Stanziano
- Asl Bari, Department of Maternal and Child Health, Reproductive and IVF Unit, Conversano, BA, Italy
| | - Clementina Cantatore
- Asl Bari, Department of Maternal and Child Health, Reproductive and IVF Unit, Conversano, BA, Italy
| | - Simone Palini
- Asl Bari, Department of Maternal and Child Health, Reproductive and IVF Unit, Conversano, BA, Italy
| | - Ettore Caroppo
- Asl Bari, Department of Maternal and Child Health, Reproductive and IVF Unit, Conversano, BA, Italy.
- ASL Bari, PTA "F Jaia", Fisiopatologia della Riproduzione Umana e P.M.A, via de Amicis 30, 70014, Conversano, BA, Italy.
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19
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Abstract
BACKGROUND As many as one in six couples will encounter problems with fertility, defined as failure to achieve a clinical pregnancy after regular intercourse for 12 months. Increasingly, couples are turning to assisted reproductive technology (ART) for help with conceiving and ultimately giving birth to a healthy live baby of their own. Fertility treatments are complex, and each ART cycle consists of several steps. If one of these steps is incorrectly applied, the stakes are high as conception may not occur. With this in mind, it is important that each step of the ART cycle is supported by good evidence from well-designed studies. OBJECTIVES To summarise the evidence from Cochrane systematic reviews on procedures and treatment options available to couples with subfertility undergoing assisted reproductive technology (ART) procedures. METHODS Published Cochrane systematic reviews of couples undergoing ART procedures (in vitro fertilisation or intracytoplasmic sperm injection) were eligible for inclusion in the overview. We also identified Cochrane reviews in preparation, for future inclusion.The primary outcome of the overview was live birth or the composite outcome live birth or ongoing pregnancy, as reported by the included reviews. Our secondary outcomes were clinical pregnancy, multiple pregnancy, miscarriage, and ovarian hyperstimulation syndrome. We excluded studies of intrauterine insemination and ovulation induction.We undertook selection of systematic reviews, data extraction, and quality assessment in duplicate. We assessed review quality by using the AMSTAR tool. We organised reviews by their relevance to specific stages in the ART cycle. We summarised their findings in the text and reported data for each outcome in 'Additional tables'. MAIN RESULTS We included 68 systematic reviews published in the Cochrane Library up to May 2018. All were of high quality. These reviews identified 38 interventions that were effective (n = 23) or promising (n = 15), and they identified 19 interventions that were ineffective (n = 2) or possibly ineffective (n = 17). For 15 interventions, review authors were unable to draw conclusions owing to lack of evidence.We identified an additional 11 protocols and four titles for future inclusion in this overview. AUTHORS' CONCLUSIONS This overview provides the most up-to-date evidence on ART cycles from systematic reviews of randomised controlled trials. Fertility treatments are costly, and the stakes are high. Using the best available evidence to optimise outcomes is best practice. Evidence from this overview could be used to develop clinical practice guidelines and protocols that can be applied in daily clinical practice to improve live birth rates and reduce rates of multiple pregnancy, cycle cancellation, and ovarian hyperstimulation syndrome.
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Affiliation(s)
- Cindy Farquhar
- University of AucklandDepartment of Obstetrics and GynaecologyFMHS Park RoadGraftonAucklandNew Zealand1003
| | - Jane Marjoribanks
- University of AucklandDepartment of Obstetrics and GynaecologyFMHS Park RoadGraftonAucklandNew Zealand1003
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20
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Julania S, Walls ML, Hart R. The Place of In Vitro Maturation in PCO/PCOS. Int J Endocrinol 2018; 2018:5750298. [PMID: 30154841 PMCID: PMC6091445 DOI: 10.1155/2018/5750298] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 02/13/2018] [Accepted: 07/03/2018] [Indexed: 11/29/2022] Open
Abstract
In vitro maturation (IVM) of human oocytes is an emerging treatment option for women with polycystic ovary/polycystic ovary syndrome (PCO/PCOS) in addition to the standard in vitro fertilization (IVF) treatment. There has been significant improvements in pregnancy rates with IVM over the last two decades. This article reviews the place of IVM for women with PCO/PCOS, placing an emphasis on the predictors of successful pregnancy, optimization of culture media, IVM protocols, pregnancy rates, and neonatal outcomes following IVM treatment.
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Affiliation(s)
- Shital Julania
- King Edward Memorial Hospital, 374 Bagot Road, Subiaco, WA 6008, Australia
| | - Melanie L. Walls
- Fertility North, Suite 213, Specialist Medical Centre, Joondalup Health Campus, Shenton Avenue, Joondalup, WA 6027, Australia
- Fertility Specialists of Western Australia, Bethesda Hospital, 25 Queenslea Drive, Claremont, Perth, WA 6010, Australia
| | - Roger Hart
- Fertility Specialists of Western Australia, Bethesda Hospital, 25 Queenslea Drive, Claremont, Perth, WA 6010, Australia
- Division of Obstetrics and Gynaecology, University of Western Australia, King Edward Memorial Hospital, 374 Bagot Road, Subiaco, Perth, WA 6008, Australia
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21
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Morley LC, Tang T, Yasmin E, Norman RJ, Balen AH. Insulin-sensitising drugs (metformin, rosiglitazone, pioglitazone, D-chiro-inositol) for women with polycystic ovary syndrome, oligo amenorrhoea and subfertility. Cochrane Database Syst Rev 2017; 11:CD003053. [PMID: 29183107 PMCID: PMC6486196 DOI: 10.1002/14651858.cd003053.pub6] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Polycystic ovary syndrome (PCOS) is characterised by infrequent or absent ovulation, and high levels of androgens and insulin (hyperinsulinaemia). Hyperinsulinaemia occurs secondary to insulin resistance and is associated with increased risk of cardiovascular disease and diabetes mellitus. Insulin-sensitising agents such as metformin may be effective in treating PCOS-related anovulation. OBJECTIVES To evaluate the effectiveness and safety of insulin-sensitising drugs in improving reproductive and metabolic outcomes for women with PCOS undergoing ovulation induction. SEARCH METHODS We searched the following databases from inception to January 2017: Cochrane Gynaecology and Fertility Group Specialised Register, CENTRAL, MEDLINE, Embase, PsycINFO and CINAHL. We searched registers of ongoing trials and reference lists from relevant studies. SELECTION CRITERIA We included randomised controlled trials of insulin-sensitising drugs compared with placebo, no treatment, or an ovulation-induction agent for women with oligo and anovulatory PCOS. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for eligibility and bias. Primary outcomes were live birth rate and gastrointestinal adverse effects. Secondary outcomes included other pregnancy outcomes, menstrual frequency and metabolic effects. We combined data to calculate pooled odds ratios (ORs) and 95% confidence intervals (CIs). We assessed statistical heterogeneity using the I2 statistic and reported quality of the evidence for primary outcomes using GRADE methodology. MAIN RESULTS We assessed the interventions metformin, clomiphene citrate, metformin plus clomiphene citrate, D-chiro-inositol, rosiglitazone and pioglitazone. We compared these with each other, placebo or no treatment. We included 48 studies (4451 women), 42 of which investigated metformin (4024 women). Evidence quality ranged from very low to moderate. Limitations were risk of bias (poor reporting of methodology and incomplete outcome data), imprecision and inconsistency. Metformin versus placebo or no treatmentThe evidence suggests that metformin may improve live birth rates compared with placebo (OR 1.59, 95% CI 1.00 to 2.51, 4 studies, 435 women, I2 = 0%, low-quality evidence). The metformin group experienced more gastrointestinal side effects (OR 4.76, 95% CI 3.06 to 7.41, 7 studies, 670 women, I2 = 61%, moderate-quality evidence) but had higher rates of clinical pregnancy (OR 1.93, 95% CI 1.42 to 2.64, 9 studies, 1027 women, I2 = 43%, moderate-quality evidence), ovulation (OR 2.55, 95% CI 1.81 to 3.59, 14 studies, 701 women, I2 = 58%, moderate-quality evidence) and menstrual frequency (OR 1.72, 95% CI 1.14 to 2.61, 7 studies, 427 women, I2 = 54%, low-quality evidence). There was no clear evidence of a difference in miscarriage rates (OR 1.08, 95% CI 0.50 to 2.35, 4 studies, 748 women, I2 = 0%, low-quality evidence). Metformin plus clomiphene citrate versus clomiphene citrate alone There was no conclusive evidence of a difference between the groups in live birth rates (OR 1.21, 95% CI 0.92 to 1.59, 9 studies, 1079 women, I2 = 20%, low-quality evidence), but gastrointestinal side effects were more common with combined therapy (OR 3.97, 95% CI 2.59 to 6.08, 3 studies, 591 women, I2 = 47%, moderate-quality evidence). However, the combined therapy group had higher rates of clinical pregnancy (OR 1.59, 95% CI 1.27 to 1.99, 16 studies, 1529 women, I2 = 33%, moderate-quality evidence) and ovulation (OR 1.57, 95% CI 1.28 to 1.92, 21 studies, 1624 women, I2 = 64%, moderate-quality evidence). There was a statistically significant difference in miscarriage rate per woman, with higher rates in the combined therapy group (OR 1.59, 95% CI 1.03 to 2.46, 9 studies, 1096 women, I2 = 0%, low-quality evidence) but this is of uncertain clinical significance due to low-quality evidence, and no clear difference between groups when we analysed miscarriage per pregnancy (OR 1.30, 95% CI 0.80 to 2.12, 8 studies; 400 pregnancies, I2 = 0%, low-quality evidence). Metformin versus clomiphene citrateWhen all studies were combined, findings for live birth were inconclusive and inconsistent (OR 0.71, 95% CI 0.49 to 1.01, 5 studies, 741 women, I2 = 86%, very low-quality evidence). In subgroup analysis by obesity status, obese women had a lower birth rate in the metformin group (OR 0.30, 95% CI 0.17 to 0.52, 2 studies, 500 women, I2 = 0%, very low-quality evidence), while data from the non-obese group showed a possible benefit from metformin, with high heterogeneity (OR 1.71, 95% CI 1.00 to 2.94, 3 studies, 241 women, I2 = 78%, very low-quality evidence). Similarly, among obese women taking metformin there were lower rates of clinical pregnancy (OR 0.34, 95% CI 0.21 to 0.55, 2 studies, 500 women, I2 = 0%, very low-quality evidence) and ovulation (OR 0.29, 95% CI 0.20 to 0.43 2 studies, 500 women, I2 = 0%, low-quality evidence) while among non-obese women, the metformin group had more pregnancies (OR 1.56, 95% CI 1.05 to 2.33, 5 studies, 490 women, I2 = 41%, very low-quality evidence) and no clear difference in ovulation rates (OR 0.81, 95% CI 0.51 to 1.28, 4 studies, 312 women, low-quality evidence, I2=0%). There was no clear evidence of a difference in miscarriage rates (overall: OR 0.92, 95% CI 0.50 to 1.67, 5 studies, 741 women, I2 = 52%, very low-quality evidence). D-chiro-inositol (2 studies), rosiglitazone (1 study) or pioglitazone (1 study) versus placebo or no treatmentWe were unable to draw conclusions regarding other insulin-sensitising drugs as no studies reported primary outcomes. AUTHORS' CONCLUSIONS Our updated review suggests that metformin alone may be beneficial over placebo for live birth, although the evidence quality was low. When metformin was compared with clomiphene citrate, data for live birth were inconclusive, and our findings were limited by lack of evidence. Results differed by body mass index (BMI), emphasising the importance of stratifying results by BMI. An improvement in clinical pregnancy and ovulation suggests that clomiphene citrate remains preferable to metformin for ovulation induction in obese women with PCOS.An improved clinical pregnancy and ovulation rate with metformin and clomiphene citrate versus clomiphene citrate alone suggests that combined therapy may be useful although we do not know whether this translates into increased live births. Women taking metformin alone or with combined therapy should be advised that there is no evidence of increased miscarriages, but gastrointestinal side effects are more likely.
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Affiliation(s)
- Lara C Morley
- The General Infirmary of LeedsDepartment of Obstetrics and GynaecologyUnited Leeds Teaching Hospitals NHS TrustBelmont GroveLeedsUKLS2 9NS
| | - Thomas Tang
- Royal Jubilee Maternity ServiceRegional Fertility CentreGrosvenor RoadBelfastUKBT12 6BA
| | - Ephia Yasmin
- University College Hospital2nd floor North, 250 Euston RoadLondonUKNW1 2PG
| | - Robert J Norman
- University of AdelaideObstetrics & Gynaecology, Robinson InstituteAdelaideSouth AustraliaAustralia5005
| | - Adam H Balen
- The Leeds Centre for Reproductive Medicine, Seacroft HospitalReproductive Medicine and SurgeryYork RoadLeedsUKLS14 6UH
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Al-Ruthia YS, Al-Mandeel H, AlSanawi H, Balkhi B, Mansy W, AlGasem R, AlMutairi L. The effect of metformin use on pregnancy rates among polycystic ovary syndrome patients undergoing in vitro fertilization: A retrospective-cohort study. Saudi Pharm J 2017; 25:906-910. [PMID: 28951677 PMCID: PMC5605958 DOI: 10.1016/j.jsps.2017.02.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2016] [Accepted: 02/12/2017] [Indexed: 11/26/2022] Open
Abstract
Background Metformin is widely used with gonadotropins by women with polycystic ovary syndrome (PCOS) during in vitro fertilization (IVF) to increase their chances of pregnancy. The aim of this study was to evaluate the efficacy of metformin in improving the rates of clinical pregnancy among women with PCOS undergoing IVF. Methods This was a retrospective cohort study of women with PCOS, aged 18–40 years, undergoing IVF during 2006–2012 at a University Hospital in Riyadh, Saudi Arabia. Baseline patient data including menstrual frequency, biochemical parameters such as fasting serum insulin (FSI) concentration, comorbidities, and the rates of ovulation and pregnancy were collected. Pregnancy rates were compared between the metformin and non-metformin groups. Results A total of 210 women with PCOS met the inclusion criteria and were included in the study. Of the 210 women with PCOS, 109 of them received metformin in addition to gonadotropins. Patients who received metformin were 16% less likely to be pregnant in comparison with those who did not receive metformin (OR = 0.840; 95% CI = 0.710–0.993; P = 0.0415), when controlled for baseline prolactin level, testosterone level, lipid panel, FSI concentration, fasting plasma glucose (FPG) concentration, comorbidities, duration of infertility, daily metformin dosage, and the previous use of clomiphene and/or leuprolide. Conclusions Metformin co-treatment during IVF may negatively affect pregnancy rates. Further well-designed, randomized, double-blind placebo-control clinical trials are needed to confirm the findings of this study.
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Affiliation(s)
- Yazed Sulaiman Al-Ruthia
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Hazem Al-Mandeel
- Department of Obstetrics and Gynecology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Hisham AlSanawi
- Department of Orthopedic Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Bander Balkhi
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Wael Mansy
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Reem AlGasem
- Prince Muhammad Bin Abdulaziz Hospital, Riyadh, Saudi Arabia
| | - Lama AlMutairi
- King Abdulaziz University Hospital, Riyadh, Saudi Arabia
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Management of ovarian stimulation for IVF: narrative review of evidence provided for World Health Organization guidance. Reprod Biomed Online 2017; 35:3-16. [PMID: 28501428 DOI: 10.1016/j.rbmo.2017.03.024] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Revised: 03/24/2017] [Accepted: 03/30/2017] [Indexed: 01/08/2023]
Abstract
In this paper, a review of evidence provided to the World Health Organization (WHO) guideline development, who prepare global guidance on the management of ovarian stimulation for women undergoing IVF, is presented. The purpose of ovarian stimulation is to facilitate retrieval of multiple oocytes during a single IVF cycle. Availability of multiple oocytes compensates for inefficiencies in subsequent stages of the cycle, which include oocyte maturation, IVF, embryo culture, embryo transfer, and implantation. Multiple embryos can be transferred in most women, and spare embryos can be frozen to allow for future chances of pregnancy without the need for repeated ovarian stimulation and oocyte retrieval. Our evidence synthesis team addressed 10 clinical questions on management of ovarian stimulation for IVF, prepared a narrative review of the evidence and drafted recommendations to be considered through WHO guideline development processes. Our main outcome measures were live birth, clinical pregnancy, and ovarian hyperstimulation syndrome.
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Kahyaoğlu S, Yılmaz B, Işık AZ. Pharmacokinetic, pharmacodynamic, and clinical aspects of ovulation induction agents: A review of the literature. J Turk Ger Gynecol Assoc 2017; 18:48-55. [PMID: 28506951 PMCID: PMC5450211 DOI: 10.4274/jtgga.2016.0107] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Controlled ovarian hyperstimulation is a key step for successful outcomes of assisted reproductive technique cycle outcomes. Many medications are available, which are commonly useed solely or in combination to achieve multiple follicular development. Pharmacokinetic, pharmacodynamic, and clinical information of ovulation induction drugs deserve to be elucidated for every individual patient before commencing infertility treatment. New concepts and new treatment protocols are introduced as ovulation physiology is understood by infertility specialists. Increasing treatment success by minimizing aderse effects is a milestone of all ovarian stimulation protocols that use these novel interventions. Achievement of a satisfactory cycle outcome includes retrieval of sufficient oocytes, a single clinical pregnancy, and avoidance of ovarian hyperstimulation syndrome. In this review, we evaluate the current literature to determine the most reliable and relevant information about the most used ovulation induction drugs.
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Affiliation(s)
- Serkan Kahyaoğlu
- Department of Obstetrics and Gynecology, Zekai Tahir Burak Women's Health Training and Research Hospital, Ankara, Turkey
| | - Bülent Yılmaz
- Department of Obstetrics and Gynecology, İzmir Katip Çelebi University Faculty of Medicine, Tepecik Training and Research Hospital, IVF Unit, İzmir, Turkey
| | - Ahmet Zeki Işık
- Assisted Reproductive Technologies Unit, Medical Park Hospital, İzmir, Turkey
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Abstract
This review attempts to summarize the known literature on high responders to ovarian stimulation during assisted reproductive techniques (ART). Response to gonadotrophins is subject to significant interindividual and intercycle variation, thus carrying a risk of high response or poor response to ovarian stimulation regimens. The main risk for high responders is the development of ovarian hyperstimulation syndrome (OHSS) which is associated with significant morbidity. Hence, the definition of high responders in the literature has primarily focussed on risk factors for OHSS. Strategies to reduce OHSS including tailoring of the ovarian stimulation regimens and adjusting gonadotrophin doses according to patient characteristics and findings during the cycle of stimulation. In addition, modifying the type of ovulation trigger used and adjuvant therapies, such as metformin, intravenous colloids and vascular endothelial growth factor blockers, have also been studied as options to reduce OHSS. Apart from the risk of OHSS, high response also appears to have an adverse impact on the oocyte and endometrium, though there is a paucity of data regarding the extent and mechanisms behind this impact.
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Affiliation(s)
- Mariano Mascarenhas
- a Seacroft Hospital , Leeds Centre for Reproductive Medicine , Leeds , United Kingdom
| | - Adam H Balen
- a Seacroft Hospital , Leeds Centre for Reproductive Medicine , Leeds , United Kingdom
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Freis A, Renke T, Kämmerer U, Jauckus J, Strowitzki T, Germeyer A. Effects of a hyperandrogenaemic state on the proliferation and decidualization potential in human endometrial stromal cells. Arch Gynecol Obstet 2017; 295:1005-1013. [PMID: 28168653 DOI: 10.1007/s00404-017-4295-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 01/10/2017] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in women, involving hyperandrogenaemia and insulin resistance. Treatment options include dexamethasone, as well as the off-label use of metformin. To evaluate the impact of those drugs on cyclic changes in endometrial development, we tested possible effects of metformin and dexamethasone on endometrial stromal cells decidualisation, proliferation, and gene regulation in a hyperandrogenaemic microenvironment in vitro. METHODS/DESIGN Ten endometrial biopsies (of which five were decidualized in vitro) were used from regularly cycling women. Cells were treated with testosterone, dexamethasone, and metformin in different concentrations. Thereafter, cells were assessed for proliferation and decidualization capacity, as well as mTor and MMP-2 gene regulation. RESULTS Metformin showed a dose-dependent negative effect on prolactin secretion, a known decidualization marker. This effect was stronger in a hyperandrogenaemic condition and could not be compensated by dexamethasone. Testosterone had a dose dependent negative effect on proliferation in decidualized endometrial stromal cells. Dexamethasone slightly compensated the negative proliferative effect only in low-dose testosterone. High-dose metformin also showed a dose-dependent reduction in endometrial stromal cell proliferation without a major impact by testosterone or dexamethasone in decidualized and non-decidualized cells. High-dose metformin significantly reduced the expression of matrix metalloproteinase-2 (MMP-2) and mechanistic Target of Rapamycin (mTor), regardless of the concentration of dexamethasone and testosterone. The strongest effect could be observed for the combination with high-dose dexamethasone. CONCLUSION When therapies, such as metformin and dexamethasone, are used to normalize peripheral androgen levels in patients with PCOS, their effect on the endometrial microenvironment should be taken into consideration as well, especially metformin has to be used with caution because of its dose dependent, possibly inhibiting effect at the endometrial proliferation.
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Affiliation(s)
- Alexander Freis
- Department of Gynaecological Endocrinology and Fertility Disorders, University Hospital Heidelberg, Heidelberg, Germany.
| | - Tobias Renke
- Department of Gynaecological Endocrinology and Fertility Disorders, University Hospital Heidelberg, Heidelberg, Germany
| | - Ulrike Kämmerer
- Department of Gynecology and Obstetrics, University Hospital Würzburg, Würzburg, Germany
| | - Julia Jauckus
- Department of Gynaecological Endocrinology and Fertility Disorders, University Hospital Heidelberg, Heidelberg, Germany
| | - Thomas Strowitzki
- Department of Gynaecological Endocrinology and Fertility Disorders, University Hospital Heidelberg, Heidelberg, Germany
| | - Ariane Germeyer
- Department of Gynaecological Endocrinology and Fertility Disorders, University Hospital Heidelberg, Heidelberg, Germany
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Mourad S, Brown J, Farquhar C. Interventions for the prevention of OHSS in ART cycles: an overview of Cochrane reviews. Cochrane Database Syst Rev 2017; 1:CD012103. [PMID: 28111738 PMCID: PMC6469542 DOI: 10.1002/14651858.cd012103.pub2] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Ovarian hyperstimulation syndrome (OHSS) in assisted reproductive technology (ART) cycles is a treatment-induced disease that has an estimated prevalence of 20% to 33% in its mild form and 3% to 8% in its moderate or severe form. These numbers might even be higher for high-risk women such as those with polycystic ovaries or a high oocyte yield from ovum pickup. OBJECTIVES The objective of this overview is to identify and summarise all evidence from Cochrane systematic reviews on interventions for prevention or treatment of moderate, severe and overall OHSS in couples with subfertility who are undergoing ART cycles. METHODS Published Cochrane systematic reviews reporting on moderate, severe or overall OHSS as an outcome in ART cycles were eligible for inclusion in this overview. We also identified Cochrane submitted protocols and title registrations for future inclusion in the overview. The evidence is current to 12 December 2016. We identified reviews, protocols and titles by searching the Cochrane Gynaecology and Fertility Group Database of Systematic Reviews and Archie (the Cochrane information management system) in July 2016 on the effectiveness of interventions for outcomes of moderate, severe and overall OHSS. We undertook in duplicate selection of systematic reviews, data extraction and quality assessment. We used the AMSTAR (Assessing the Methodological Quality of Systematic Reviews) tool to assess the quality of included reviews, and we used GRADE methods to assess the quality of the evidence for each outcome. We summarised the characteristics of included reviews in the text and in additional tables. MAIN RESULTS We included a total of 27 reviews in this overview. The reviews were generally of high quality according to AMSTAR ratings, and included studies provided evidence that ranged from very low to high in quality. Ten reviews had not been updated in the past three years. Seven reviews described interventions that provided a beneficial effect in reducing OHSS rates, and we categorised one additional review as 'promising'. Of the effective interventions, all except one had no detrimental effect on pregnancy outcomes. Evidence of at least moderate quality indicates that clinicians should consider the following interventions in ART cycles to reduce OHSS rates.• Metformin treatment before and during an ART cycle for women with PCOS (moderate-quality evidence).• Gonadotrophin-releasing hormone (GnRH) antagonist protocol in ART cycles (moderate-quality evidence).• GnRH agonist (GnRHa) trigger in donor oocyte or 'freeze-all' programmes (moderate-quality evidence). Evidence of low or very low quality suggests that clinicians should consider the following interventions in ART cycles to reduce OHSS rates.• Clomiphene citrate for controlled ovarian stimulation in ART cycles (low-quality evidence).• Cabergoline around the time of human chorionic gonadotrophin (hCG) administration or oocyte pickup in ART cycles (low-quality evidence).• Intravenous fluids (plasma expanders) around the time of hCG administration or oocyte pickup in ART cycles (very low-quality evidence).• Progesterone for luteal phase support in ART cycles (low-quality evidence).• Coasting (withholding gonadotrophins) - a promising intervention that needs to be researched further for reduction of OHSS.On the basis of this overview, we must conclude that evidence is currently insufficient to support the widespread practice of embryo cryopreservation. AUTHORS' CONCLUSIONS Currently, 27 reviews in the Cochrane Library were conducted to report on or to try to report on OHSS in ART cycles. We identified four review protocols but no new registered titles that can potentially be included in this overview in the future. This overview provides the most up-to-date evidence on prevention of OHSS in ART cycles from all currently published Cochrane reviews on ART. Clinicians can use the evidence summarised in this overview to choose the best treatment regimen for individual patients - a regimen that not only reduces the chance of developing OHSS but does not compromise other outcomes such as pregnancy or live birth rate. Review results, however, are limited by the lack of recent primary studies or updated reviews. Furthermore, this overview can be used by policymakers in developing local and regional protocols or guidelines and can reveal knowledge gaps for future research.
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Affiliation(s)
- Selma Mourad
- Radboud University Medical CentreNijmegenNetherlands
| | - Julie Brown
- The University of AucklandLiggins InstitutePark RdGraftonAucklandNew Zealand1142
| | - Cindy Farquhar
- University of AucklandDepartment of Obstetrics and GynaecologyFMHS Park RoadGraftonAucklandNew Zealand1003
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Alviggi C, Conforti A, De Rosa P, Strina I, Palomba S, Vallone R, Gizzo S, Borrelli R, Andersen CY, De Placido G, Guerriero S. The Distribution of Stroma and Antral Follicles Differs between Insulin-Resistance and Hyperandrogenism-Related Polycystic Ovarian Syndrome. Front Endocrinol (Lausanne) 2017; 8:117. [PMID: 28620353 PMCID: PMC5449504 DOI: 10.3389/fendo.2017.00117] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 05/12/2017] [Indexed: 02/02/2023] Open
Abstract
INTRODUCTION Although insulin resistance plays an important pathogenetic role in polycystic ovary syndrome (PCOS), no correlation between ultrasound PCOS pattern and insulin resistance has yet been reported. The aim of this retrospective observational study was to assess whether the ovarian ultrasonographic parameter differed between PCOS women with insulin resistance and those with a hyperandrogenic profile. MATERIALS AND METHODS Women who fulfilled the Rotterdam criteria for PCOS were retrospectively studied. Anthropometric, biochemical, and clinical data were recorded. Women were divided into two groups based on specific transvaginal ultrasound parameters: subjects with more than half of the follicles measuring between 5 and 9 mm in diameter, an ultrasonographic determined stroma/total area (S/A) > 0.34 and a "necklace" sign of antral follicles (Group A); and subjects with more than half of the antral follicles measuring between 2 and 4 mm in diameter, an S/A ≤ 0.34; no "necklace" sign but ubiquitously distributed follicles determined by ultrasound (Group B). The association between these ultrasound patterns and the presence of insulin resistance was also evaluated. RESULTS Seventy-eight patients were enrolled: 33 with ultrasound sound pattern A and 45 with pattern B. The latter pattern had a sensitivity of 88% and a specificity of 78% in predicting PCOS women with insulin resistance. There were no differences in age, Ferriman-Gallwey score, and serum gonadotropin or androgen levels between the two groups. Body mass index, the waist-to-hip ratio, and homeostasis model assessment were significantly higher in group B than in group A (p < 0.05). Conversely, sex hormone binding globulin levels and ovarian volume were significantly higher in group A (p < 0.05). Insulin resistance was more frequent in group B than in group A (36/41, 87.8% versus 7/32, 21.8%; p < 0.05). CONCLUSION These results suggest that insulin resistance could be associated with a specific ultrasound pattern in PCOS patients.
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Affiliation(s)
- Carlo Alviggi
- Department of Neuroscience, Reproductive Medicine, Odontostomatology, University of Naples Federico II, Naples, Italy
- *Correspondence: Carlo Alviggi,
| | - Alessandro Conforti
- Department of Neuroscience, Reproductive Medicine, Odontostomatology, University of Naples Federico II, Naples, Italy
| | - Pasquale De Rosa
- Department of Neuroscience, Reproductive Medicine, Odontostomatology, University of Naples Federico II, Naples, Italy
| | - Ida Strina
- Department of Neuroscience, Reproductive Medicine, Odontostomatology, University of Naples Federico II, Naples, Italy
| | - Stefano Palomba
- Department of Neuroscience, Reproductive Medicine, Odontostomatology, University of Naples Federico II, Naples, Italy
| | - Roberta Vallone
- Department of Neuroscience, Reproductive Medicine, Odontostomatology, University of Naples Federico II, Naples, Italy
| | - Salvatore Gizzo
- Department of Woman and Child Health, University of Padua, Padua, Italy
| | - Rosaria Borrelli
- Department of Neuroscience, Reproductive Medicine, Odontostomatology, University of Naples Federico II, Naples, Italy
| | - Claus Yding Andersen
- Laboratory of Reproductive Biology, Faculty of Health and Medical Sciences, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Giuseppe De Placido
- Department of Neuroscience, Reproductive Medicine, Odontostomatology, University of Naples Federico II, Naples, Italy
| | - Stefano Guerriero
- Department of Obstetrics and Gynecology, Policlinico Universitario Duilio Casula, University of Cagliari, Cagliari, Italy
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Kollmann M, Martins WP, Lima MLS, Craciunas L, Nastri CO, Richardson A, Raine-Fenning N. Strategies for improving outcome of assisted reproduction in women with polycystic ovary syndrome: systematic review and meta-analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 48:709-718. [PMID: 26924636 DOI: 10.1002/uog.15898] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 02/22/2016] [Accepted: 02/22/2016] [Indexed: 06/05/2023]
Abstract
OBJECTIVES To identify, appraise and summarize the current evidence regarding the efficacy of strategies aimed at improving assisted reproductive techniques in women with polycystic ovary syndrome (PCOS). METHODS A comprehensive literature search of the standard medical databases was performed. The last electronic search was run in July 2015. The primary outcome measures were live birth/ongoing pregnancy and ovarian hyperstimulation syndrome (OHSS). The secondary outcome measures were clinical pregnancy and miscarriage. RESULTS We screened 1021 records and completely assessed 173, finally including 66 studies in the quantitative analysis. Many different interventions were assessed, however the overall quality of the studies was low. We observed moderate-quality evidence that there is no clinically relevant difference in live birth/ongoing pregnancy rates (relative risk (RR), 0.95 (95% CI, 0.84-1.08)), or clinical pregnancy (RR, 1.02 (95% CI, 0.91-1.15)) when comparing antagonist and agonist protocols for ovarian stimulation. Additionally, we found low-quality evidence that metformin improves live birth/ongoing pregnancy (RR, 1.28 (95% CI, 1.01-1.63)) and clinical pregnancy rates (RR, 1.26 (95% CI, 1.04-1.53)) when compared with placebo or no intervention. We further found low-quality evidence that there is no clinically relevant difference in live birth/ongoing pregnancy rates (RR, 1.03 (95% CI, 0.80-1.34)) and clinical pregnancy rates (RR, 0.99 (95% CI, 0.81-1.22)) when comparing human menopausal gonadotropin for inducing ovulation and artificial preparation with estradiol valerate for endometrial preparation for frozen embryo transfer (FET). Low-quality evidence suggests that mannitol compared with no intervention (RR, 0.54 (95% CI, 0.39-0.77)) and antagonist protocols compared with agonist protocols (RR, 0.63 (95% CI, 0.49-0.80)) reduce rates of OHSS. CONCLUSION There is low- to moderate-quality evidence suggesting that antagonist protocols are preferable to agonist ones, because they reduce the incidence of OHSS without interfering with clinical pregnancy and live birth for women with PCOS. Additionally there is low-quality evidence pointing to a benefit of metformin supplementation on clinical pregnancy and live birth; and that ovulation induction and administration of estradiol seem to be equally effective for endometrial preparation before FET for women with PCOS. For all other interventions, the evidence is of very low quality, not allowing any meaningful conclusions to be drawn. Estrategias para mejorar el resultado de la reproducción asistida en mujeres con síndrome de ovario poliquístico: revisión sistemática y metaanálisis RESUMEN OBJETIVOS: Identificar, evaluar y resumir la evidencia actual sobre la eficacia de las estrategias para mejorar las técnicas de reproducción asistida en mujeres con síndrome de ovario poliquístico (SOP). MÉTODOS: Se realizó una búsqueda exhaustiva de literatura en las bases de datos médicas estándar. La última búsqueda electrónica se realizó en julio de 2015. Las medidas de resultado primarias fueron los nacimientos vivos/embarazos en curso y el síndrome de hiperestimulación ovárica (SHO). Las medidas de resultado secundarias fueron el embarazo confirmado ecográficamente y el aborto. RESULTADOS Se cribaron 1021 registros, de los que se evaluaron por completo 173, para finalmente incluir 66 estudios en el análisis cuantitativo. Aunque se evaluaron muchas intervenciones diferentes, en general la calidad de los estudios fue baja. Se observó evidencia de calidad moderada de que no hay diferencias relevantes clínicamente en las tasas de nacimientos vivos/embarazos en curso (riesgo relativo (RR): 0,95 (IC 95%, 0,84-1,08)), o de embarazos confirmados ecográficamente (RR: 1,02 (IC 95%, 0,91-1,15)), cuando se comparan los protocolos de antagonistas y agonistas para la estimulación ovárica. Además, se encontró evidencia de baja calidad en que la metformina mejora las tasas de nacimientos vivos/embarazos en curso (RR: 1,28 (IC 95%, 1,01-1,63)) y de embarazos confirmados ecográficamente (RR: 1,26 (IC 95%, 1,04-1,53)) en comparación con un placebo o la no intervención. Se encontró también evidencia de baja calidad en que no hay diferencias relevantes clínicamente en las tasas de nacimientos vivos/embarazos en curso (RR: 1,03 (IC 95%, 0,80-1,34)) y las tasas de embarazos confirmados ecográficamente (RR: 0,99 (IC 95%, 0.81-1,22)) al comparar la gonadotropina menopáusica humana para la inducción de la ovulación y la preparación artificial con el valerato de estradiol para preparar el endometrio para la transferencia de embriones congelados (TEC). La baja calidad de la evidencia sugiere que el manitol, en comparación con la no intervención (RR: 0,54 (IC 95%, 0,39-0,77)), y los protocolos de antagonistas, en comparación con los protocolos de agonistas (RR: 0,63 (IC 95%, 0,49-0,80)), reducen las tasas de SHO. CONCLUSIÓN: Hay evidencia de calidad baja a moderada que sugiere que los protocolos de antagonistas son preferibles a los de agonistas, ya que reducen la tasa de SHO sin interferir con el embarazo confirmado ecográficamente y los nacimientos vivos en las mujeres con SOP. Además, existe evidencia de baja calidad que indica un beneficio del uso de metformina como aporte suplementario en embarazos confirmados ecográficamente y en nacimientos vivos; y que la inducción de la ovulación y la administración de estradiol parecen ser igualmente eficaces para la preparación del endometrio antes de la TEC en mujeres con SOP. Para el resto de procedimientos, la evidencia es de muy baja calidad, y por ello no permite extraer conclusiones importantes.
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Affiliation(s)
- M Kollmann
- Division of Obstetrics and Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Medical University of Graz, Graz, Austria
- Division of Child Health, Obstetrics & Gynaecology, School of Medicine, University of Nottingham, Nottingham, UK
| | - W P Martins
- Department of Obstetrics and Gynecology, Medical School of Ribeirao Preto, University of Sao Paulo, Ribeirao Preto, Brazil
| | - M L S Lima
- Department of Obstetrics and Gynecology, Medical School of Ribeirao Preto, University of Sao Paulo, Ribeirao Preto, Brazil
| | - L Craciunas
- Division of Child Health, Obstetrics & Gynaecology, School of Medicine, University of Nottingham, Nottingham, UK
- Clinical Academic Office, Medical School, Newcastle University, Newcastle, UK
| | - C O Nastri
- Department of Obstetrics and Gynecology, Medical School of Ribeirao Preto, University of Sao Paulo, Ribeirao Preto, Brazil
| | - A Richardson
- Division of Child Health, Obstetrics & Gynaecology, School of Medicine, University of Nottingham, Nottingham, UK
- Nurture Fertility, The East Midlands Fertility Centre, Nottingham, UK
| | - N Raine-Fenning
- Division of Child Health, Obstetrics & Gynaecology, School of Medicine, University of Nottingham, Nottingham, UK
- Nurture Fertility, The East Midlands Fertility Centre, Nottingham, UK
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Abstract
BACKGROUND Ovarian hyperstimulation syndrome (OHSS) is a potentially serious complication of ovarian stimulation in assisted reproduction technology (ART). It is characterised by enlarged ovaries and an acute fluid shift from the intravascular space to the third space, resulting in bloating, increased risk of venous thromboembolism and decreased organ perfusion. Most cases are mild, but forms of moderate or severe OHSS appear in 3% to 8% of in vitro fertilisation (IVF) cycles. The dopamine agonist cabergoline was introduced as a secondary prevention intervention for OHSS in women at high risk of OHSS undergoing ART treatment. As cabergoline seemed to be effective in preventing OHSS, other types of dopamine agonists, such as quinagolide and bromocriptine, have since been studied in ART to prevent OHSS. OBJECTIVES To assess the effectiveness and safety of dopamine agonists in preventing OHSS in high-risk women undergoing ART treatment. SEARCH METHODS We searched several databases from inception to August 2016 (Cochrane Gynaecology and Fertility Specialised Register of trials, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, PsycINFO, Clinicaltrials.gov and the World Health Organization International Trials Registry Platform (ICTRP)) for randomised controlled trials (RCTs) assessing the effect of dopamine agonist in preventing OHSS. We handsearched the reference lists of relevant studies. SELECTION CRITERIA We considered RCTs which compared dopamine agonists with placebo/no intervention or another intervention for preventing OHSS in high-risk women for inclusion. Primary outcome measures were incidence of moderate or severe OHSS and live birth rate. Secondary endpoints were clinical pregnancy rate, multiple pregnancy rate, miscarriage rate and any other adverse effects of the treatment. DATA COLLECTION AND ANALYSIS Two authors independently screened titles, abstracts and full texts of publications, selected studies, extracted data and assessed risk of bias. We resolved any disagreements by consensus. We reported pooled results as odds ratios (OR) and 95% confidence interval (95% CI) by the Mantel-Haenszel method. In addition, we graded the overall quality of the evidence using GRADE criteria. MAIN RESULTS The search identified 14 new RCTs since the last published version of this review, resulting in 16 included RCTs involving 2091 high-risk women for this updated review. They evaluated three types of dopamine agonists: cabergoline, quinagolide and bromocriptine.When compared with placebo or no intervention, dopamine agonists seemed effective in the prevention of moderate or severe OHSS (OR 0.27, 95% CI 0.19 to 0.39; 1022 participants; 8 studies; I2 = 0%; moderate quality evidence). This suggests that if 29% of women undergoing ART experience moderate or severe OHSS, the use of dopamine agonists will lower this to 7% to 14% of women. There was no evidence of a difference in live birth rate, clinical pregnancy rate, multiple pregnancy rate or miscarriage rate (very low to moderate quality evidence). However, taking dopamine agonists (especially quinagolide) may increase the incidence of adverse events such as gastrointestinal adverse effects (OR 4.54, 95% CI 1.49 to 13.84; 264 participants; 2 studies; I2 = 49%, very low quality evidence).When we compared dopamine agonist plus co-intervention with co-intervention, there was no evidence of a difference in the outcomes of moderate or severe OHSS, live birth rate, clinical pregnancy rate, miscarriage rate or adverse events. The co-interventions were hydroxyethyl starch (two RCTs) and albumin (one RCT).Cabergoline was associated with a lower risk of moderate or severe OHSS compared with human albumin (OR 0.21, 95% CI 0.12 to 0.38; 296 participants; 3 studies; I2 = 72%). However, there was no evidence of a difference between cabergoline and hydroxyethyl starch, coasting (withholding any more ovarian stimulation for a few days) or prednisolone. There was an increased clinical pregnancy rate in the cabergoline group when cabergoline was compared with coasting (OR 2.65, 95% CI 1.13 to 6.21; 120 participants; 2 studies; I2 = 0%). In other respects, there was no evidence of a difference in clinical pregnancy rate, multiple pregnancy rate or miscarriage rate between cabergoline and other active interventions.The quality of the evidence between dopamine agonist and placebo or no intervention ranged from very low to moderate, mainly due to poor reporting of study methods (mostly a lack of details on randomisation or blinding) and serious imprecision for some comparisons. AUTHORS' CONCLUSIONS Dopamine agonists appear to reduce the incidence of moderate or severe OHSS in women at high risk of OHSS (moderate quality evidence). If a fresh embryo transfer is performed, the use of dopamine agonists does not affect the pregnancy outcome (live birth rate, clinical pregnancy rate and miscarriage rate) (very low to moderate quality evidence). However, dopamine agonists might increase the risk of adverse events, such as gastrointestinal symptoms. Further research should focus on dose-finding, comparisons with other effective treatments and consideration of combination treatments. Therefore, large, well-designed and well-executed RCTs that involve more clinical endpoints (e.g., live birth rate) are necessary to further evaluate the role of dopamine agonists in OHSS prevention.
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Affiliation(s)
- Huilin Tang
- Peking University Third HospitalDepartment of Pharmacy49 North Garden RdHaidian DistrictBeijingChina100191
| | - Selma Mourad
- Radboud University Medical CentreNijmegenNetherlands
| | - Suo‐Di Zhai
- Peking University Third HospitalDepartment of Pharmacy, Therapeutic Drug Monitoring and Clinical Toxicology Center of Peking University49 North Garden RdHaidian DistrictBeijingChina100191
| | - Roger J Hart
- The University of Western Australia, King Edward Memorial Hospital and Fertility Specialists of Western AustraliaSchool of Women's and Infants' Health374 Bagot RoadSubiaco, PerthAustralia6008
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Hormonal Changes After Laparoscopic Ovarian Diathermy in Patients with Polycystic Ovarian Syndrome. J Obstet Gynaecol India 2016; 66:528-33. [PMID: 27651657 DOI: 10.1007/s13224-016-0882-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Accepted: 03/19/2016] [Indexed: 12/30/2022] Open
Abstract
AIM OF THE PRESENT STUDY To assess the changes in hormonal profile (serum FSH, LH, prolactin and total testosterone) following laparoscopic ovarian drilling (LOD) in patients with polycystic ovarian syndrome. MATERIALS AND METHODS Fifty patients with PCOS have been included in this study. Serum prolactin, total testosterone, follicular-stimulating hormone (FSH) and luteinizing hormone (LH) levels have been used as biochemical markers, before and after procedures. RESULTS Laparoscopic ovarian drilling was successfully employed without any surgical complications and on an average follow-up time of 24 weeks after the procedure. During the follow-up serum values for prolactin, total testosterone and LH have decreased significantly and FSH levels remained unchanged after the procedure. CONCLUSIONS The LOD in patients with PCOS may avoid or reduce the risk of OHSS and the multiple pregnancy rate induced by gonadotropin therapy. The high pregnancy rate and the economic aspect of the procedure offer an attractive management for patients with PCOS. However, LOD can be considered as second-line treatment after clomiphene citrate treatment failure and/or resistance.
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Griesinger G, Verweij PJM, Gates D, Devroey P, Gordon K, Stegmann BJ, Tarlatzis BC. Prediction of Ovarian Hyperstimulation Syndrome in Patients Treated with Corifollitropin alfa or rFSH in a GnRH Antagonist Protocol. PLoS One 2016; 11:e0149615. [PMID: 26950065 PMCID: PMC4780699 DOI: 10.1371/journal.pone.0149615] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Accepted: 02/03/2016] [Indexed: 11/18/2022] Open
Abstract
Study Question What is the threshold for the prediction of moderate to severe or severe ovarian hyperstimulation syndrome (OHSS) based on the number of growing follicles ≥ 11 mm and/or estradiol (E2) levels? Summary Answer The optimal threshold of follicles ≥11 mm on the day of hCG to identify those at risk was 19 for both moderate to severe OHSS and for severe OHSS. Estradiol (E2) levels were less prognostic of OHSS than the number of follicles ≥ 11 mm. What Is Known Already In comparison to long gonadotropin-releasing hormone (GnRH) agonist protocols, the risk of severe OHSS is reduced by approximately 50% in a GnRH antagonist protocol for ovarian stimulation prior to in vitro fertilisation (IVF), while the two protocols provide equal chances of pregnancy per initiated cycle. Nevertheless, moderate to severe OHSS may still occur in GnRH antagonist protocols if human chorionic gonadotropin (hCG) is administered to trigger final oocyte maturation, especially in high responder patients. Severe OHSS following hCG trigger may occur with an incidence of 1–2% in a relatively young (aged 18 to 36 years) IVF population treated in a GnRH-antagonist protocol. Study Design, Size, Duration From the Engage, Ensure and Trust trials, in total, 2,433 women who received hCG for oocyte maturation and for whom the number of follicles ≥ 11 mm and the level of E2 on the day of hCG administration were known were included in the analyses. Participants/Materials, Setting, Methods The threshold for OHSS prediction of moderate and severe OHSS was assessed in women treated with corifollitropin alfa or daily recombinant follicle stimulation hormone (rFSH) in a gonadotropin-releasing hormone (GnRH)-antagonist protocol. Receiver operating characteristics curve analyses for moderate to severe OHSS and severe OHSS were performed on the combined dataset and the sensitivity and specificity for the optimal threshold of number of follicles ≥ 11 mm, E2 levels on the day of (hCG), and a combination of both, were determined. Main Results and the Role of Chance The optimal threshold of follicles ≥ 11 mm on the day of hCG to identify those at risk of moderate to severe OHSS was 19 (sensitivity and specificity 62.3% and 75.6%, respectively) and for severe OHSS was also 19 (sensitivity and specificity 74.3% and 75.3%, respectively). The positive and negative predictive values were 6.9% and 98.6%, respectively, for moderate to severe OHSS, and 4.2% and 99.5% for severe OHSS. Limitations, Reasons for Caution This was a retrospective analysis of combined data from three trials following ovarian stimulation with two different gonadotropins. Wider Implications of the Findings For patients with 19 follicles or more ≥11 mm on the day of hCG, measures to prevent the development of OHSS should be considered. Secondary preventive measures include cycle cancellation or coasting, use of a GnRH agonist to trigger final oocyte maturation in place of hCG and a freeze all strategy. Trial Registration ClinicalTrials.gov NCT00702845 NCT00696800 NCT00696878
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Affiliation(s)
- Georg Griesinger
- Department of Reproductive Medicine and Gynecological Endocrinology, University Hospital of Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
- * E-mail:
| | | | - Davis Gates
- Merck & Co., Inc., Kenilworth, NJ, United States of America
| | - Paul Devroey
- Center for Reproductive Medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Keith Gordon
- Merck & Co., Inc., Kenilworth, NJ, United States of America
| | | | - Basil C. Tarlatzis
- 1st Department of Obstetrics and Gynecology, Papageorgiou Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Guo JL, Zhang DD, Zhao Y, Zhang D, Zhang XM, Zhou CQ, Yao SZ. Pharmacologic Interventions in Preventing Ovarian Hyperstimulation Syndrome: A Systematic Review and Network Meta-Analysis. Sci Rep 2016; 6:19093. [PMID: 26752241 PMCID: PMC4707491 DOI: 10.1038/srep19093] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Accepted: 12/04/2015] [Indexed: 01/20/2023] Open
Abstract
Ovarian hyperstimulation syndrome (OHSS) is a severe iatrogenic complication of controlled ovarian stimulation. Randomised controlled trials (RCTs) have proven several pharmacologic interventions to be effective in OHSS prevention, but these trials have seldom compared multiple drugs. We identified randomised controlled trials (RCTs) through June 2015 by searching databases and compared 11 intervention strategies in preventing OHSS (primary outcome) and their influence on pregnancy rate (secondary outcome). A network meta-analysis was used to evaluate the relative effectiveness among treatments and to create a rank probability table. Thirty-one RCTs were identified, including 7181 participants. Five pharmacologic interventions were superior to placebo in decreasing OHSS incidence: aspirin [relative risk (RR) 0.07, 95% credible interval (CrI) 0.01-0.30, p < 0.05], intravenous (IV) calcium [RR 0.11, 95% CrI 0.02-0.54, p < 0.05], cabergoline [RR 0.17, 95% CrI 0.06-0.43, p < 0.05], metformin [RR 0.20, 95% CrI 0.07-0.59, p < 0.05] and IV hydroxyethyl starch (HES) [RR 0.26, 95% CrI 0.05-0.99, p < 0.05]. The rank probability demonstrated aspirin (Rank 1: 36%) and IV calcium (Rank 1: 35%) to be the most efficacious. Additionally, albumin might decrease the pregnancy rate when compared with placebo [RR 0.85, 95% CI 0.74-0.97, p < 0.05]. This conclusion provides a relative standard and objective reference for choosing an OHSS prophylactic agent.
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Affiliation(s)
- Jun-Liang Guo
- Department of Obstetrics & Gynaecology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou City, 510080, P.R. China
- Zhong-shan School of Medicine, Sun Yat-sen University, Guangzhou City, 510082, P.R. China
| | - Duo-Duo Zhang
- Department of Obstetrics & Gynaecology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou City, 510080, P.R. China
- Zhong-shan School of Medicine, Sun Yat-sen University, Guangzhou City, 510082, P.R. China
| | - Yue Zhao
- Zhong-shan School of Medicine, Sun Yat-sen University, Guangzhou City, 510082, P.R. China
| | - Dan Zhang
- Department of Obstetrics & Gynaecology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou City, 510080, P.R. China
| | - Xi-Meng Zhang
- Zhong-shan School of Medicine, Sun Yat-sen University, Guangzhou City, 510082, P.R. China
| | - Can-Quan Zhou
- Department of Obstetrics & Gynaecology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou City, 510080, P.R. China
| | - Shu-Zhong Yao
- Department of Obstetrics & Gynaecology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou City, 510080, P.R. China
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Krishna D, Dhoble S, Praneesh G, Rathore S, Upadhaya A, Rao K. Gonadotropin-releasing hormone agonist trigger is a better alternative than human chorionic gonadotropin in PCOS undergoing IVF cycles for an OHSS Free Clinic: A Randomized control trial. J Hum Reprod Sci 2016; 9:164-172. [PMID: 27803584 PMCID: PMC5070398 DOI: 10.4103/0974-1208.192056] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE: The objective of this study is to evaluate if gonadotropin-releasing hormone agonist (GnRHa) trigger is a better alternative to human chorionic gonadotropin (hCG) in polycystic ovary syndrome (PCOS) of Indian origin undergoing in vitro fertilization (IVF) cycles with GnRH antagonist for the prevention of ovarian hyperstimulation syndrome (OHSS). DESIGN: Prospective randomized control trial. SETTING: Tertiary care center. MATERIALS AND METHODS: A total of 227 patients diagnosed with PCOS, undergoing IVF in an antagonist protocol were recruited and randomly assigned into two groups: Group A (study group): GnRHa trigger 0.2 mg (n = 92) and Group B (control group): 250 μg of recombinant hCG as trigger (n = 101) 35 h before oocyte retrieval. We chose segmentation strategy, freezing all embryos in both the groups. STATISTICAL ANALYSIS: Continuous variables were expressed as mean ± standard deviation independent sample t-test and Kolmogorov-Smirnov test were used for continuous variables which were normally distributed and Mann-Whitney U-test for data not normally distributed. MAIN OUTCOME MEASURES: Primary outcome: OHSS (mild, moderate, and severe) rates. Secondary outcomes: Maturity rate of the oocytes, fertilization rate, availability of top quality embryos on day 3 (Grade 1 and Grade 2). RESULTS The incidence of moderate to severe OHSS in the hCG group was 37.6% and 0% in the GnRHa group with P < 0.001. The GnRHa group had significantly more mature oocytes retrieved (19.1 ± 11.7 vs. 14.1 ± 4.3), more fertilized oocytes (15.6 ± 5.6 vs. 11.7 ± 3.6), and a higher number of top quality cleavage embryos on day 3 (12.9 ± 4.7 vs. 7.5 ± 4.3) than the hCG group. CONCLUSIONS: The most effective strategy which significantly eliminates the occurrence of OHSS in PCOS following ovarian stimulation in antagonist IVF cycles is the use of GnRHa trigger yielding more mature oocytes and good quality embryos when compared with hCG trigger.
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Affiliation(s)
- Deepika Krishna
- Department of Reproductive Medicine, Milann - The Fertility Center, Bengaluru, Karnataka, India
| | - Snehal Dhoble
- Department of Reproductive Medicine, Milann - The Fertility Center, Bengaluru, Karnataka, India
| | - Gautham Praneesh
- Department of Reproductive Medicine, Milann - The Fertility Center, Bengaluru, Karnataka, India
| | - Suvarna Rathore
- Department of Reproductive Medicine, Milann - The Fertility Center, Bengaluru, Karnataka, India
| | - Amit Upadhaya
- Department of Reproductive Medicine, Milann - The Fertility Center, Bengaluru, Karnataka, India
| | - Kamini Rao
- Department of Reproductive Medicine, Milann - The Fertility Center, Bengaluru, Karnataka, India
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Turan GA, Eskicioglu F, Sivrikoz ON, Cengiz H, Adakan S, Gur EB, Tatar S, Sahin N, Yilmaz O. Myo-inositol is a promising treatment for the prevention of ovarian hyperstimulation syndrome (OHSS): an animal study. Arch Gynecol Obstet 2015; 292:1163-71. [PMID: 25990477 PMCID: PMC4723627 DOI: 10.1007/s00404-015-3747-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 05/07/2015] [Indexed: 02/08/2023]
Abstract
PURPOSE To evaluate the efficacy of myo-inositol (MI) pretreatment in OHSS. METHODS In this experimental OHSS rat model, 42 immature Wistar albino female rats were divided into 6 groups: (1) the control group, (2) the ovarian stimulation group, (3) the OHSS group, (4) the OHSS + Metformin group, (5) OHSS + MI group, (6) OHSS + Metformin + MI group. OHSS was established after treatment with metformin and myo-inositol for 14 days, in the meanwhile the treatment of metformin and myo-inositol was also continued. All animals were killed 48 h after hCG administration and were compared in terms of vascular permeability, ovarian weight and diameter, ovarian VEGF, COX-2 and PEDF expression (immunohistochemistry), serum PEDF and estradiol (E2) levels. RESULTS Vascular permeability, VEGF and COX-2 expressions were reduced in animals treated with MI and/or metformin. While PEDF expression was increased in the groups taking metformin, there was no difference in PEDF expression in the group taking MI and OHSS group. There was no significant difference in serum PEDF levels between groups. Blood E2 levels were decreased in groups treated with MI or metformin compared to the OHSS group. CONCLUSIONS Our data demonstrate that myo-inositol is effective in preventing OHSS, similar to metformin. Although the two drugs are thought to act through distinct mechanisms, there is no apparent benefit to co-treatment with both drugs in an animal model of OHSS. Administration of myo-inositol prior to IVF treatment may favor the control of ovulation induction. Further studies are necessary to elucidate the mechanism of action and further support our findings.
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Affiliation(s)
- Guluzar Arzu Turan
- Department of Obstetrics and Gynecology, Medical School, Sifa University, Sanayi cad no:7, 35100, Bornova, Izmir, Turkey.
| | - Fatma Eskicioglu
- Department of Obstetrics and Gynecology, Medical School, Celal Bayar University, 45030, Manisa, Turkey
| | - Oya Nermin Sivrikoz
- Department of Pathology, Medical School, Sifa University, Sanayi cad no:7, 35100, Bornova, Izmir, Turkey
| | - Hakan Cengiz
- Biostatistics and Medical Informatics, Medical School, Sifa University, Ankara Cad. No:45, 35100, Bayrakli, Izmir, Turkey
- Molecular Medicine, Institute of Health Science, Dokuz Eylül University, Mithatpasa cad. No:1606 inciraltı yerleskesi, 35340, Balcova, Izmir, Turkey
| | - Saban Adakan
- Department of Obstetrics and Gynecology, Medical School, Sifa University, Sanayi cad no:7, 35100, Bornova, Izmir, Turkey
| | - Esra Bahar Gur
- Department of Obstetrics and Gynecology, Medical School, Sifa University, Sanayi cad no:7, 35100, Bornova, Izmir, Turkey
| | - Sumeyra Tatar
- Department of Obstetrics and Gynecology, Medical School, Sifa University, Sanayi cad no:7, 35100, Bornova, Izmir, Turkey
| | - Nur Sahin
- Department of Obstetrics and Gynecology, Medical School, Sifa University, Sanayi cad no:7, 35100, Bornova, Izmir, Turkey
| | - Osman Yilmaz
- Department of Laboratory Animal Science, Medical School, Dokuz Eylul University, Mithatpasa cad. No:1606 inciraltı yerleskesi, 35340, Balcova, Izmir, Turkey
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Twenty years of ovulation induction with metformin for PCOS; what is the best available evidence? Reprod Biomed Online 2015; 32:44-53. [PMID: 26656973 DOI: 10.1016/j.rbmo.2015.09.015] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 09/21/2015] [Accepted: 09/22/2015] [Indexed: 12/18/2022]
Abstract
The potential reproductive benefits of metformin, a drug endowed with the capacity to ameliorate insulin resistance in polycystic ovary syndrome (PCOS), has garnered much interest over the past 2 decades. In this review, randomized-controlled trials (RCT) and meta-analyses of RCT comparing metformin are critically appraised and summarized. PubMed and CENTRAL databases were consulted. Evidence is insufficient to favour the use of metformin or metformin plus clomiphene citrate instead of clomiphene citrate for ovulation induction in women with newly diagnosed PCOS. Evidence is also insufficient to recommend metformin as a primary treatment for non-obese women with PCOS. Metformin plus clomiphene citrate should be considered as an effective option in clomiphene citrate-resistant PCOS. In women with PCOS undergoing gonadotrophin ovulation induction, metformin significantly increased pregnancy and live birth rates (P < 0.0001 and P = 0.020, respectively) with reduced risk of cancelled cycles. A beneficial effect of metformin co-treatment in increasing clinical pregnancy rates and reducing the risk of OHSS in PCOS patients undergoing assisted reproduction techniques has been shown. No evidence was found of reduced risk of spontaneous abortion or increased risk of major anomalies in women with PCOS taking metformin during the first trimester.
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Farquhar C, Rishworth JR, Brown J, Nelen WLDM, Marjoribanks J. Assisted reproductive technology: an overview of Cochrane Reviews. Cochrane Database Syst Rev 2015:CD010537. [PMID: 26174592 DOI: 10.1002/14651858.cd010537.pub4] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND As many as one in six couples will encounter problems with fertility, defined as failure to achieve a clinical pregnancy after regular intercourse for 12 months. Increasingly, couples are turning to assisted reproductive technology (ART) for help with conceiving and ultimately giving birth to a healthy live baby of their own. Fertility treatments are complex, and each ART cycle consists of several steps. If one of the steps is incorrectly applied, the stakes are high as conception may not occur. With this in mind, it is important that each step of the ART cycle is supported by good evidence from well-designed studies. OBJECTIVES To summarise the evidence from Cochrane systematic reviews on procedures and treatment options available to couples with subfertility undergoing assisted reproductive technology (ART). METHODS Published Cochrane systematic reviews of couples undergoing ART (in vitro fertilisation or intracytoplasmic sperm injection) were eligible for inclusion in the overview. We also identified Cochrane reviews in preparation, for future inclusion.The outcomes of the overview were live birth (primary outcome), clinical pregnancy, multiple pregnancy, miscarriage and ovarian hyperstimulation syndrome (secondary outcomes). Studies of intrauterine insemination and ovulation induction were excluded.Selection of systematic reviews, data extraction and quality assessment were undertaken in duplicate. Review quality was assessed by using the AMSTAR tool. Reviews were organised by their relevance to specific stages in the ART cycle. Their findings were summarised in the text and data for each outcome were reported in 'Additional tables'. MAIN RESULTS Fifty-nine systematic reviews published in The Cochrane Library up to July 2015 were included. All were high quality. Thirty-two reviews identified interventions that were effective (n = 19) or promising (n = 13), 14 reviews identified interventions that were either ineffective (n = 2) or possibly ineffective (n = 12), and 13 reviews were unable to draw conclusions due to lack of evidence.An additional 11 protocols and five titles were identified for future inclusion in this overview. AUTHORS' CONCLUSIONS This overview provides the most up to date evidence on ART cycles from systematic reviews of randomised controlled trials. Fertility treatments are costly and the stakes are high. Using the best available evidence to optimise outcomes is best practice. The evidence from this overview could be used to develop clinical practice guidelines and protocols for use in daily clinical practice, in order to improve live birth rates and reduce rates of multiple pregnancy, cycle cancellation and ovarian hyperstimulation syndrome.
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Affiliation(s)
- Cindy Farquhar
- Department of Obstetrics and Gynaecology, University of Auckland, FMHS Park Road, Grafton, Auckland, New Zealand, 1003
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Smith V, Osianlis T, Vollenhoven B. Prevention of Ovarian Hyperstimulation Syndrome: A Review. Obstet Gynecol Int 2015; 2015:514159. [PMID: 26074966 PMCID: PMC4446511 DOI: 10.1155/2015/514159] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Accepted: 04/29/2015] [Indexed: 01/01/2023] Open
Abstract
The following review aims to examine the available evidence to guide best practice in preventing ovarian hyperstimulation syndrome (OHSS). As it stands, there is no single method to completely prevent OHSS. There seems to be a benefit, however, in categorizing women based on their risk of OHSS and individualizing treatments to curtail their chances of developing the syndrome. At present, both Anti-Müllerian Hormone and the antral follicle count seem to be promising in this regard. Both available and upcoming therapies are also reviewed to give a broad perspective to clinicians with regard to management options. At present, we recommend the use of a "step-up" regimen for ovulation induction, adjunct metformin utilization, utilizing a GnRH agonist as an ovulation trigger, and cabergoline usage. A summary of recommendations is also made available for ease of clinical application. In addition, areas for potential research are also identified where relevant.
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Affiliation(s)
- Vinayak Smith
- Alice Springs Hospital, Department of Obstetrics and Gynaecology, Alice Springs, NT 0870, Australia
| | - Tiki Osianlis
- Monash IVF, 252 Clayton Road, Clayton, VIC 3168, Australia
| | - Beverley Vollenhoven
- Monash IVF, 252 Clayton Road, Clayton, VIC 3168, Australia
- Monash Health, Women's and Children's Program, Monash Medical Centre, Clayton Road, Clayton, VIC 3168, Australia
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC 3168, Australia
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Jungheim ES, Meyer MF, Broughton DE. Best practices for controlled ovarian stimulation in in vitro fertilization. Semin Reprod Med 2015; 33:77-82. [PMID: 25734345 DOI: 10.1055/s-0035-1546424] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
As applications for IVF have expanded over the years, so too have approaches to controlled ovarian stimulation (COS) for IVF. With this expansion and improved knowledge of basic reproductive biology, there is increasing interest in how COS practice influences IVF outcomes, and whether or not specific treatment scenarios call for personalized approaches to COS. For the majority of women undergoing COS and their treating physicians, the goal is to achieve a healthy live birth through IVF in a fresh cycle. Opinions on how COS strategy best leads to this common goal varies among centers as many clinicians base COS strategy not on evidence obtained through prospective randomized trials, but rather through observational studies and experience. Overall, when it comes to COS most clinicians recognize the approach should not be "one size fits all," but rather a patient-centered approach that takes the existing evidence into consideration. We outline the existing evidence for best practices in COS for IVF, highlighting how these practices may be incorporated into a patient-centered approach.
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Affiliation(s)
- Emily S Jungheim
- Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, Missouri
| | - Melissa F Meyer
- Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, Missouri
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Metformin use in patients undergoing in vitro fertilization treatment: results of a worldwide web-based survey. J Assist Reprod Genet 2015; 32:401-6. [PMID: 25634039 DOI: 10.1007/s10815-014-0414-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2014] [Accepted: 12/18/2014] [Indexed: 10/24/2022] Open
Abstract
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.
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Farquhar C, Rishworth JR, Brown J, Nelen WLDM, Marjoribanks J. Assisted reproductive technology: an overview of Cochrane reviews. Cochrane Database Syst Rev 2014:CD010537. [PMID: 25532533 DOI: 10.1002/14651858.cd010537.pub3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND As many as one in six couples will encounter problems with fertility, defined as failure to achieve a clinical pregnancy after regular intercourse for 12 months. Increasingly, couples are turning to assisted reproductive technology (ART) for help with conceiving and ultimately giving birth to a healthy live baby of their own. Fertility treatments are complex, and each ART cycle consists of several steps. If one of the steps is incorrectly applied, the stakes are high as conception may not occur. With this in mind, it is important that each step of the ART cycle is supported by good evidence from well-designed studies. OBJECTIVES To summarise the evidence from Cochrane systematic reviews on procedures and treatment options available to couples with subfertility undergoing assisted reproductive technology (ART). METHODS Published Cochrane systematic reviews of couples undergoing ART (in vitro fertilisation or intracytoplasmic sperm injection) were eligible for inclusion in the overview. We also identified Cochrane reviews in preparation, for future inclusion.The outcomes of the overview were live birth (primary outcome), clinical pregnancy, multiple pregnancy, miscarriage and ovarian hyperstimulation syndrome (secondary outcomes). Studies of intrauterine insemination and ovulation induction were excluded.Selection of systematic reviews, data extraction and quality assessment were undertaken in duplicate. Review quality was assessed by using the AMSTAR tool. Reviews were organised by their relevance to specific stages in the ART cycle. Their findings were summarised in the text and data for each outcome were reported in 'Additional tables'. MAIN RESULTS Fifty-eight systematic reviews published in The Cochrane Library were included. All were high quality. Thirty-two reviews identified interventions that were effective (n = 19) or promising (n = 13), 14 reviews identified interventions that were either ineffective (n = 3) or possibly ineffective (n=11), and 12 reviews were unable to draw conclusions due to lack of evidence.An additional 11 protocols and one title were identified for future inclusion in this overview. AUTHORS' CONCLUSIONS This overview provides the most up to date evidence on ART cycles from systematic reviews of randomised controlled trials. Fertility treatments are costly and the stakes are high. Using the best available evidence to optimise outcomes is best practice. The evidence from this overview could be used to develop clinical practice guidelines and protocols for use in daily clinical practice, in order to improve live birth rates and reduce rates of multiple pregnancy, cycle cancellation and ovarian hyperstimulation syndrome.
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Affiliation(s)
- Cindy Farquhar
- Department of Obstetrics and Gynaecology, University of Auckland ,Auckland, NewZealand
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