Weight loss by bariatric surgery and subsequent fertility

Ovarian kisspeptin expression is related to age and to monocyte chemoattractant protein-1

PURPOSE

The objective of this study was to test the hypothesis that ovarian kisspeptin (kiss1) and its receptor (kiss1r) expression are affected by age, obesity, and the age- and obesity-related chemokine monocyte chemoattractant protein-1 (MCP-1).

METHODS

Ovaries from reproductive-aged and older C57BL/6J mice fed normal chow (NC) or high-fat (HF) diet, ovaries from age-matched young MCP-1 knockout and young control mice on NC, and finally, cumulus and mural granulosa cells (GCs) from women who underwent in vitro fertilization (IVF) were collected. Kiss1, kiss1r, anti-Mullerian hormone (AMH), and AMH receptor (AMHR-II) messenger RNA (mRNA) expression levels were quantified using real-time polymerase chain reaction (RT-PCR).

RESULTS

In mouse ovaries, kiss1 and kiss1r mRNA levels were significantly higher in old compared to reproductive-aged mice, and diet-induced obesity did not alter kiss1 or kiss1r mRNA levels. Compared to young control mice, young MCP-1 knockout mice had significantly lower ovarian kiss1 mRNA but significantly higher AMH and AMHR-II mRNA levels. In human cumulus GCs, kiss1r mRNA levels were positively correlated with age but not with BMI. There was no expression of kiss1 mRNA in either cumulus or mural GCs.

CONCLUSION

These data suggest a possible age-related physiologic role for the kisspeptinergic system in ovarian physiology. Additionally, the inflammatory MCP-1 may be associated with kiss1 and AMH genes, which are important in ovulation and folliculogenesis, respectively.

Obesity adversely impacts the number and maturity of oocytes in conventional IVF not in minimal stimulation IVF

OBJECTIVE

The objective of this study was to assess the relationship between BMI and oocyte number and maturity in participants who underwent minimal stimulation (mini-) or conventional IVF.

METHODS

Participants who underwent their first autologous cycle of either conventional (n = 219) or mini-IVF (n = 220) were divided according to their BMI to analyze IVF outcome parameters. The main outcome measure was the number of oocytes in metaphase II (MII). Secondary outcomes included the number of total oocytes retrieved, fertilized (2PN) oocytes, cleavage and blastocyst stage embryos, clinical pregnancy (CP), and live birth (LB) rates.

RESULTS

In conventional IVF, but not in mini-IVF, the number of total oocytes retrieved (14.5  ±  0.8 versus 8.8  ±  1.3) and MII oocytes (11.2 ± 0.7 versus 7.1 ± 1.1) were significantly lower in obese compared with normal BMI women. Multivariable linear regression adjusting for age, day 3 FSH, days of stimulation, and total gonadotropin dose demonstrated that BMI was an independent predictor of the number of MII oocytes in conventional IVF (p = 0.0004). Additionally, only in conventional IVF, BMI was negatively correlated with the total number of 2PN oocytes, as well as the number of cleavage stage embryos.

CONCLUSIONS

Female adiposity might impair oocyte number and maturity in conventional IVF but not in mini-IVF. These data suggest that mild ovarian stimulation might yield healthier oocytes in obese women.

Does weight loss in overweight or obese women improve fertility treatment outcomes? A systematic review

This systematic review assessed the effect of weight loss in overweight and/or obese women undergoing assisted reproductive technology (ART) on their subsequent pregnancy outcome. Weight losses achieved by diet and lifestyle changes, very-low-energy diets, non-surgical medical interventions and bariatric surgery translated into significantly increased pregnancy rates and/or live birth in overweight and/or obese women undergoing ART in 8 of the 11 studies reviewed. In addition, regularization of the menstrual pattern, a decrease in cancellation rates, an increase in the number of embryos available for transfer, a reduction in the number of ART cycles required to achieve pregnancy and a decrease in miscarriage rates were reported. There were also a number of natural conceptions in five of the six studies that reported this outcome. Non-surgical medical weight loss procedures and bariatric surgery induced the greatest weight losses, but their use, as well as that of very-low-energy diets, for weight loss prior to ART requires careful consideration. While the overall quality of the studies included in this review was poor, these results support the clinical recommendation of advising overweight and/or obese women to lose weight prior to ART. Prospective randomized controlled trials are required to establish efficacious evidence-based guidelines for weight loss interventions in overweight and/or obese women prior to ART treatment.

Follicular fluid soluble receptor for advanced glycation end-products (sRAGE): a potential indicator of ovarian reserve

CONTEXT

The interaction of advanced glycation end-products (AGEs) with their cellular receptor (RAGE) is implicated in the pathogenesis of abnormal ovarian follicular growth. RAGE has a circulating secretory receptor form, soluble RAGE (sRAGE), which neutralizes the action of AGEs and might exert a protective role on the follicular environment.

OBJECTIVE

The objective of the study was to investigate whether serum or follicular fluid (FF) sRAGE levels are associated with markers of ovarian reserve.

DESIGN, SETTING, AND PARTICIPANTS

Serum anti-Mullerian hormone (AMH) and sRAGE protein levels were correlated in 31 reproductive-aged women. An additional 33 women who underwent oocyte retrieval for in vitro fertilization were enrolled. AMH and its receptor (AMHR-II) mRNA levels were quantified in cumulus granulosa cells and FF sRAGE and AMH protein levels were measured.

MAIN OUTCOME MEASURES

Granulosa cell AMH and AMHR-II gene expression, serum and FF AMH and sRAGE protein concentration, and number of oocytes retrieved were measured.

RESULTS

In the serum, sRAGE levels were negatively correlated with body mass index (BMI) (r = -0.5, P < .001) but not with age or serum AMH. The higher the FF sRAGE, the lower the number of international units of gonadotropin needed per cycle independent of age, BMI, or day 3 FSH level (r = -0.4, P = .04). After adjusting for age, BMI, day 3 FSH, and the total dose of gonadotropins, FF sRAGE predicted the number of oocytes retrieved (R(2) = 0.27, P = .045). FF sRAGE positively correlated with FF AMH levels (r = 0.5, P = .0085). RT-PCR results showed no correlation between the FF sRAGE and AMH or AMHR-II mRNA levels.

CONCLUSION

These data support a relationship between FF sRAGE and measures of ovarian reserve. The pathological significance of the harmful inflammatory AGEs in follicular health clearly requires further investigation. Targeting AGEs might offer potential therapeutic options for the treatment of diminished ovarian response.

Advanced glycation end products and their relevance in female reproduction

STUDY QUESTION

Do advanced glycation end products (AGEs) and their receptors play a role in female reproduction?

SUMMARY ANSWER

AGEs might contribute to the etiology of polycystic ovary syndrome (PCOS) and infertility.

WHAT IS KNOWN ALREADY

The endogenous AGEs are produced in the body by chemical reactions. Exogenous sources of AGEs are diet and smoking. AGEs have been proposed to be among the main intermediaries involved in several diseases, such as metabolic syndrome, type 2 diabetes mellitus, cardiovascular disease, ovarian aging, inflammation, neurodegenerative disorders and PCOS.

STUDY DESIGN, SIZE, DURATION

A systematic review was performed for all available basic science and clinical peer-reviewed articles published in PubMed from 1987 to date. Abstracts of annual meetings of the Endocrine Society and American Society for Reproductive Medicine were also reviewed.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A total of 275 publications and scientific abstracts were identified from the initial search. Sixty-two papers and four published scientific abstracts were selected for full review. The main outcomes were the regulatory effects of AGEs on: (i) granulosa cells, adipocyte physiology, obesity and insulin resistance in women with PCOS and in polycystic ovary animal models and (ii) infertility and measures of ovarian reserve.

MAIN RESULTS AND THE ROLE OF CHANCE

There is an intricate relationship between the AGE-RAGE (receptor for AGEs) system and some aspects of PCOS, such as granulosa cell dysfunction, adipocyte pathophysiology, obesity and insulin resistance. Additionally, irregular ovarian AGE signaling might in part explain the abnormal ovarian histology observed in women with PCOS. The ovarian dysfunction due to AGEs in women without PCOS suggests a role for the AGE-RAGE system in the ovarian follicular environment, and might relate to assisted reproduction technology outcome and measures of ovarian reserve.

LIMITATIONS, REASONS FOR CAUTION

The body of literature currently available limits these findings. The results obtained from granulosa cell lines and animal models may not fully extrapolate to humans.

WIDER IMPLICATIONS OF THE FINDINGS

This review underscores a critical need to unveil the exact mechanistic actions of AGEs in reproductive physiology and more specifically the hypothalamic-pituitary-ovarian axis. AGE inhibitors might present an emerging therapeutic approach with significant applications in the context of PCOS and infertility.

STUDY FUNDING/COMPETING INTEREST(S)

American Society for Reproductive Medicine New Investigator Award and University of Vermont College of Medicine Internal Funds. No competing interests.

Determining an anti-Mullerian hormone cutoff level to predict clinical pregnancy following in vitro fertilization in women with severely diminished ovarian reserve

PURPOSE

Serum anti-Mullerian hormone (AMH) levels estimate ovarian reserve. The purpose of this study was to identify a minimum serum AMH level that correlates with acceptable clinical pregnancy rate (CPR) in women with severe diminished ovarian reserve (DOR) undergoing in vitro fertilization (IVF).

METHODS(S)

A historical cohort of severe DOR participants (age ≥35) with day 3 FSH of >10 ng/mL were included (n = 120). Participants were categorized into 3 groups: AMH <0.2 (Group 1, n = 38), AMH = 0.2-0.79 (Group 2, n = 57) and AMH ≥ 0.8 (Group 3, n = 25) ng/mL. The main outcome was CPR. The number of retrieved and mature oocytes, transferred embryos, spontaneous abortion (SAB) and live birth (LB) rates were also evaluated.

RESULT(S)

Among the three groups, there was no difference in day 3 FSH and estradiol, total gonadotropins dose used per cycle, or LB. Participants in Group 1 were two years older than those in Group 2 and had significantly higher BMI than those in Groups 2 and 3. The three groups significantly differed in AFC (Group 1< Group 2< Group 3; p = 0.001) and cycle cancellation rate (Group 1> Group 2> Group 3; p = 0.006), and had a trend toward significance in SAB rate (Group 1> Group 2> Group 3; p = 0.06). Group 3 had significantly more retrieved and mature oocytes than Groups 1 or 2. Group 2 and 3 had significantly higher CPR per cycle start compared to Group 1. Although Group 2 had significantly fewer oocytes retrieved and mature oocytes than Group 3, CPR per cycle start for both groups was not different. ROC curve indicated that the point of maximal inflection between lower and higher CPR represents an AMH value of 0.2 ng/mL.

CONCLUSION(S)

AMH of 0.2 ng/mL appears to be a meaningful threshold for predicting CPR in women with severe DOR at our practice. This information can be crucial during the pre-cycle counseling of these women.

Bariatric surgery: impact on pregnancy outcomes

The dramatic increase in the prevalence of obesity in women of reproductive age has resulted in approximately 1 in 5 women being obese when they conceive. Bariatric surgery has been shown to be the most effective long-term weight loss strategy in obese women in this age group. Clinicians should be aware of the effects of bariatric surgery on fertility and future pregnancies. Regarding certain complications, pregnancy after bariatric surgery appears to be safer than pregnancy in the obese. In patients where nutrition is properly maintained and monitored, the risks for obesity-related obstetric complications, such as gestational diabetes mellitus and hypertension, are significantly reduced, but possibly at the expense of an increase in neonates born small-for-gestational-age. At the present, definitive conclusions cannot be drawn concerning the risk for Caesarian delivery, differences in type of bariatric procedure, or the optimal surgery-to-conception interval.

Pregnancy after bariatric surgery: a current view of maternal, obstetrical and perinatal challenges

With the increase in the number of bariatric surgeries being performed in women of childbearing age, physicians must have concerns regarding the safety of pregnancy after bariatric surgery. The aim of this review is to summarize the literature reporting on maternal, obstetrical and perinatal implications of pregnancy following BS.

METHODS

English, Spanish and Portuguese-language articles were identified in a PUBMED search from 2005 to February 2011 using the keywords for pregnancy and bariatric surgery or gastric bypass or gastric banding.

RESULTS

The studies show improved fertility and a reduced risk of gestational diabetes, pregnancy-induced hypertension and pre-eclampsia, macrosomia in pregnant women after bariatric surgery. The incidence of intrauterine growth restriction and small for gestational age are increased. No conclusions can be drawn concerning the risk for cesarean delivery and the best surgery-to-conception interval. Deficiencies in iron, vitamin A, vitamin B12, vitamin K, folate and calcium can result in maternal and fetal complications.

CONCLUSIONS

Pregnancy outcome of women who delivered after BS, as compared to obese populations, is better and safer and comparable to the general population. Close supervision before, during and after pregnancy following bariatric surgery and nutrient supplementation adapted to the patient's individual requirements can prevent nutrition-related complications and improve maternal and fetal health.

Pregnancy after bariatric surgery

The incidence of obesity is increasing rapidly, and it affects a greater proportion of women than men. Unfortunately, obesity has a negative impact on women's reproductive health, including increased adverse perinatal outcomes. Weight loss surgery, also known as bariatric surgery, is performed in many hospitals, and can allow for significant weight loss and improvement in medical comorbidities such as diabetes and hypertension. A woman who becomes pregnant after bariatric surgery usually has an uncomplicated pregnancy but requires special attention to some complications that can occur after these procedures. This article reviews the perinatal outcomes and provides recommendations for care regarding the unique issues that arise during a pregnancy after bariatric surgery.

Obesity and female fertility: a primary care perspective

Infertility affects approximately one in six couples during their lifetime. Obesity affects approximately half of the general population and is thus a common problem among the fertile population. Obese women have a higher prevalence of infertility compared with their lean counterparts. The majority of women with an ovulatory disorder contributing to their infertility have polycystic ovary syndrome (PCOS) and a significant proportion of women with PCOS are obese. Ovulation disorders and obesity-associated infertility represent a group of infertile couples that are relatively simple to treat. Maternal morbidity, mortality and fetal anomalies are increased with obesity and the success of assisted reproductive technology (ART) treatments is significantly reduced for obese women. Body mass index (BMI) treatment limits for ART throughout the UK vary. The mainstay for treatment is weight loss, which improves both natural fertility and conception rates with ART. The most cost-effective treatment strategy for obese infertile women is weight reduction with a hypo-caloric diet. Assisted reproduction is preferable in women with a BMI of 30 kg/m(2) or less and weight loss strategies should be employed within primary care to achieve that goal prior to referral.

The adverse effects of obesity on conception and implantation

Whilst many multiparous women are obese (body mass index >30 kg/m(2)), obesity has been associated with impaired fecundity; however, the mechanism which links obesity to reduced fertility remains to be fully elucidated. Obese women, particularly those with central obesity, are less likely to conceive per cycle. Obese women suffer perturbations to the hypothalamic-pituitary-ovarian axis, menstrual cycle disturbance and are up to three times more likely to suffer oligo-/anovulation. A fine hormonal balance regulates follicular development and oocyte maturation, and it has been observed that obesity can alter the hormonal milieu. Leptin, a hormone produced by adipocytes, is elevated in obese women, and raised leptin has been associated with impaired fecundity. Obesity impairs ovulation but has also been observed to detrimentally affect endometrial development and implantation. The expression of polycystic ovary syndrome (PCOS) is regulated, in part, by weight, and so obese women with PCOS often have a more severe phenotype and experience more subfertility. Obesity also impairs the response of women to assisted conception treatments. Weight loss through lifestyle modification or bariatric surgery has been demonstrated to restore menstrual cyclicity and ovulation and improve the likelihood of conception. In this article, we will discuss the effect of obesity upon key reproductive mechanisms and its relation to fertility treatments.

Infertility treatment outcome in sub groups of obese population

BACKGROUND

Obesity is a common disorder with a negative impact on IVF treatment outcome. It is not clear whether morbidly obese women (BMI >= 35 kg/m2) respond to treatment differently as compared to obese women (BMI = 30-34.9 kg/m2) in IVF. Our aim was to compare the outcome of IVF or ICSI treatments in obese patients to that in morbidly obese patients.

METHODS

This retrospective cohort study was conducted in a tertiary care centre. Patients inclusion criteria were as follows; BMI >or= 30, age 20-40 years old, first cycle IVF/ICSI treatment with primary infertility and long follicular pituitary down regulation protocol.

RESULTS

A total of 406 obese patients (group A) and 141 morbidly obese patients (group B) satisfied the inclusion criteria. Average BMI was 32.1 +/- 1.38 kg/m2 for group A versus 37.7 +/- 2.99 kg/m2 for group B. Patient age, cause of infertility, duration of stimulation, fertilization rate, and number of transferred embryos were similar in both groups. Compared to group A, group B had fewer medium size and mature follicles (14 vs. 16), fewer oocytes collected (7 vs. 9) and required higher doses of HMG (46.2 vs. 38.5 amps). There was also a higher cancellation rate in group B (28.3% vs. 19%) and lower clinical pregnancy rate per started cycle (19.9% vs. 28.6%).

CONCLUSION

In a homogenous infertile and obese patient population stratified according to their BMI, morbid obesity is associated with unfavorable IVF/ICSI cycle outcome as evidenced by lower pregnancy rates. It is recommended that morbidly obese patients undergo appropriate counseling before the initiation of this expensive and invasive therapy.

Clomiphene citrate, metformin or both as first-step approach in treating anovulatory infertility in patients with polycystic ovary syndrome (PCOS): a systematic review of head-to-head randomized controlled studies and meta-analysis

BACKGROUND

To date, no systematic review or meta-analysis has been published of direct head-to-head studies comparing clomiphene citrate (CC) vs. metformin, or the combination of both drugs as first-line therapy in anovulatory polycystic ovary syndrome (PCOS) patients seeking pregnancy. The aim of the current paper was to define, if possible, the best evidence-based recommendations regarding the use of CC and/or metformin as the initial treatment of PCOS women with anovulatory infertility.

DESIGN

Systematic review and meta-analysis of the head-to-head randomized controlled trials (RCTs) available in the literature.

METHODS

A bibliographic search was performed using the following bibliographic databases: Medline, EMBASE, Biological Abstracts, Cochrane Controlled Trials Register and Cochrane Database of Systematic Reviews. Reference lists of included studies, other relevant review articles and textbooks were checked for additional citations of interest.

RESULTS

Four head-to-head RCTs were identified and qualified for inclusion in the analysis. No difference in fertility improvement was observed comparing CC with metformin (OR = 1.22, 95% CI 0.23-6.55, P = 0.815), whereas a significant (P < 0.0001) heterogeneity was observed. Homogeneous data showed no difference in fertility improvement between the combination treatment and CC monotherapy (OR = 0.99, 95% CI 0.70-1.40, P = 0.982), but a significant difference in comparison with metformin monotherapy (OR = 0.23, 95% CI 0.14-0.37, P < 0.0001).

CONCLUSIONS

In PCOS patients with anovulatory infertility and not previously treated, the administration of metformin plus CC is not better than monotherapy (metformin alone or CC alone), whereas to date no specific recommendation can be given regarding the use of CC or metformin as first-step drug.

Evidence-based and potential benefits of metformin in the polycystic ovary syndrome: a comprehensive review

Metformin is an insulin sensitizer widely used for the treatment of patients affected by type 2 diabetes mellitus. Because many women with polycystic ovary syndrome (PCOS) are insulin resistant, metformin was introduced in clinical practice to treat these patients also. Moreover, metformin's effect has other targets beside its insulin-sensitizing action. The present review was aimed at describing all evidence-based and potential uses of metformin in PCOS patients. In particular, we will analyze the uses of metformin not only for the treatment of all PCOS-related disturbances such as menstrual disorders, anovulatory infertility, increased abortion, or complicated pregnancy risk, hyperandrogenism, endometrial, metabolic and cardiovascular abnormalities, but also for the prevention of the syndrome.

Morbid obesity is associated with lower clinical pregnancy rates after in vitro fertilization in women with polycystic ovary syndrome

OBJECTIVE

To determine whether morbid obesity is associated with decreased pregnancy and live birth rates after IVF in women with polycystic ovary syndrome (PCOS).

DESIGN

Retrospective cohort study.

SETTING

University-based fertility center.

PATIENT(S)

Seventy-two women with PCOS who completed their first IVF cycle between 2001 and 2006.

INTERVENTION(S)

Outcomes of IVF were compared between women with a body mass index (BMI) of <40 kg/m(2) vs. those with a BMI of > or =40 kg/m(2).

MAIN OUTCOME MEASURE(S)

Clinical pregnancy rate, live birth rate.

RESULT(S)

Morbidly obese women with PCOS (n = 19) had significantly lower clinical pregnancy rates after IVF than patients with PCOS who were not morbidly obese (n = 53) (32% vs. 72%, relative risk 0.44, 95% confidence interval 0.22-0.87). Their live birth rates were lower too, although this difference was not statistically significant (32% vs. 60%, relative risk 0.52, 95% confidence interval 0.26-1.05).

CONCLUSION(S)

Morbid obesity is associated with lower pregnancy rates in women with PCOS after IVF, raising the question of whether weight loss may improve IVF success rates for morbidly obese PCOS patients.

Pregnancy after bariatric surgery: a comprehensive review

BACKGROUND

Obesity continues to be a global epidemic, and strong evidence exists linking it with gestational complications such as macrosomia, hypertensive disorders of pregnancy, gestational diabetes, and cesarean section. Bariatric surgery, a highly effective treatment for obesity, may prevent such complications in subsequent pregnancies.

OBJECTIVE

This review seeks to describe the risks and benefits of post-bariatric procedure pregnancies, in comparison to both community and obese cohorts.

RESULTS

A thorough review of the literature suggests that post-surgery women are not at increased risk for poor perinatal outcomes, and moreover their risks for many obesity-related gestational complications are reduced after bariatric surgery. Data regarding fertility after bariatric surgery are quite ambiguous, however, and studies exist demonstrating both positive and negative associations between weight loss procedures and fertility.

CONCLUSIONS

Clinicians should be aware that data collected on this subject were often gathered from post-op pregnant women provided with good prenatal care and screening for nutritional deficiencies. Although pregnancy after bariatric surgery appears to be safe, providers should take extra care to properly monitor their post-op pregnant patients for appropriate weight gain and nourishment.

Bariatric surgery and adolescent gynecology

PURPOSE OF REVIEW

This review summarizes the impact of bariatric surgery on gynecologic complications in the context of the extremely obese adolescent and reviews contraceptive considerations before and after adolescent bariatric surgery.

RECENT FINDINGS

Eighteen percent of children and adolescents have a body mass index greater than the 95th percentile, with 4% of adolescents being greater than the 99th percentile. Gynecologic morbidities identified in obese adolescents include anovulatory complications such as acute menorrhagia, polycystic ovary syndrome and endometrial hyperplasia, and cancer. When conventional dietary and behavioral therapy fail to result in weight loss, specific criteria have been identified to justify bariatric surgery in extremely obese adolescents. Bariatric surgery in adult women often results in resumption of ovulatory menses, resolution of clinical and laboratory evidence of hyperandrogenism, and return of fertility. Adolescents are at risk for unintended pregnancies, and there are special concerns regarding pregnancy in bariatric patients. Specific contraceptive methods have particular potential risks, benefits, and drawbacks for use in obese adolescents.

SUMMARY

Clinicians who provide care for extremely obese adolescents must be aware of the potential for gynecologic morbidities including polycystic ovary syndrome, dysfunctional bleeding and endometrial hyperplasia, expected gynecologic and fertility outcomes of weight loss surgery for teens, as well as the implications on contraceptive options.

Clomiphene citrate versus metformin as first-line approach for the treatment of anovulation in infertile patients with polycystic ovary syndrome

CONTEXT

Clomiphene citrate (CC) and metformin are two effective drugs used to induce ovulation in patients with polycystic ovary syndrome (PCOS), even if it is still unclear which compound between them should be initially administered.

OBJECTIVE

The aim of the study was to compare in a clinical setting the efficacy of CC and metformin as first-line approaches for treating anovulation in infertile PCOS patients.

DESIGN

This study was a multicenter, nonrandomized, prospective, controlled study.

SETTING

The study was conducted at the Department of Obstetrics and Gynecology, Universities "Magna Graecia" of Catanzaro and "Federico II" of Naples, Italy.

PATIENTS

Patients included 80 infertile anovulatory patients with PCOS allocated in two body mass index- and age-matched groups (experimental and control groups).

INTERVENTIONS

Six months of 1700 mg/d metformin treatment (experimental group) or CC was administered using a traditional incremental-dose protocol (control group). In both groups, patients who ovulated under treatment continued the therapy for a total of 6 months.

MAIN OUTCOME MEASURES

Reproductive outcomes were measured.

RESULTS

Experimental and control groups were studied for a total of 204 and 169 cycles, respectively. No difference between the two groups was observed in ovulation (55.4 vs. 59.8%, respectively; P = 0.396), pregnancy (10.8 vs. 11.2%, respectively; P = 0.888), and abortion (19.5 vs. 26.3%, respectively; P = 0.530) rates. The cumulative pregnancy rate was not different between groups (62.9 vs. 48.6%, respectively; P = 0.225).

CONCLUSION

A 6-month course of 1700 mg/d metformin treatment and CC administered in an escalation protocol are two effective first-line approaches for improving fertility in anovulatory PCOS women.