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Prevention of moderate and severe ovarian hyperstimulation syndrome: a guideline. Fertil Steril 2024; 121:230-245. [PMID: 38099867 DOI: 10.1016/j.fertnstert.2023.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 11/14/2023] [Indexed: 02/05/2024]
Abstract
Ovarian hyperstimulation syndrome is a serious complication associated with assisted reproductive technology. This systematic review aims to identify who is at high risk for developing ovarian hyperstimulation syndrome, along with evidence-based strategies to prevent it and replaces the document of the same name last published in 2016.
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2
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Palomba S, Costanzi F, Nelson SM, Caserta D, Humaidan P. Interventions to prevent or reduce the incidence and severity of ovarian hyperstimulation syndrome: a systematic umbrella review of the best clinical evidence. Reprod Biol Endocrinol 2023; 21:67. [PMID: 37480081 PMCID: PMC10360244 DOI: 10.1186/s12958-023-01113-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 06/21/2023] [Indexed: 07/23/2023] Open
Abstract
Ovarian hyperstimulation syndrome (OHSS) is a potentially life-threating iatrogenic complication of the early luteal phase and/or early pregnancy after in vitro fertilization (IVF) treatment. The aim of the current study was to identify the most effective methods for preventing of and reducing the incidence and severity of OHSS in IVF patients. A systematic review of systematic reviews of randomized controlled trials (RCTs) with meta-analysis was used to assess each potential intervention (PROSPERO website, CRD 268626) and only studies with the highest quality were included in the qualitative analysis. Primary outcomes included prevention and reduction of OHSS incidence and severity. Secondary outcomes were maternal death, incidence of hospital admission, days of hospitalization, and reproductive outcomes, such as incidence of live-births, clinical pregnancies, pregnancy rate, ongoing pregnancy, miscarriages, and oocytes retrieved. A total of specific interventions related to OHSS were analyzed in 28 systematic reviews of RCTs with meta-analyses. The quality assessment of the included studies was high, moderate, and low for 23, 2, and 3 studies, respectively. The certainty of evidence (CoE) for interventions was reported for 37 specific situations/populations and resulted high, moderate, and low-to-very low for one, 5, and 26 cases, respectively, while it was not reported in 5 cases. Considering the effective interventions without deleterious reproductive effects, GnRH-ant co-treatment (36 RCTs; OR 0.61, 95% C 0.51 to 0.72, n = 7,944; I2 = 31%) and GnRH agonist triggering (8 RCTs; OR 0.15, 95% CI 0.05 to 0.47, n = 989; I2 = 42%) emerged as the most effective interventions for preventing OHSS with a moderate CoE, even though elective embryo cryopreservation exhibited a low CoE. Furthermore, the use of mild ovarian stimulation (9 RCTs; RR 0.26, CI 0.14 to 0.49, n = 1,925; I2 = 0%), and dopaminergic agonists (10 RCTs; OR 0.32, 95% CI 0.23 to 0.44, n = 1,202; I2 = 13%) coadministration proved effective and safe with a moderate CoE. In conclusion, the current study demonstrates that only a few interventions currently can be considered effective to reduce the incidence of OHSS and its severity with high/moderate CoE despite the numerous published studies on the topic. Further well-designed RCTs are needed, particularly for GnRH-a down-regulated IVF cycles.
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Affiliation(s)
- Stefano Palomba
- Department of Surgical and Medical Sciences and Translational Medicine, Sapienza University of Rome, Sant'Andrea Hospital, via di Grottarossa, n. 1035/1039, Rome, 00189, Italy.
| | - Flavia Costanzi
- Department of Surgical and Medical Sciences and Translational Medicine, Sapienza University of Rome, Sant'Andrea Hospital, via di Grottarossa, n. 1035/1039, Rome, 00189, Italy
| | - Scott M Nelson
- School of Medicine, University of Glasgow, Glasgow, UK
- NIHR Bristol Biomedical Research Centre, University of Bristol, Oakfield House, Oakfield Grove, Bristol, UK
- TFP, Oxford Fertility, Institute of Reproductive Sciences, Oxford, UK
| | - Donatella Caserta
- Department of Surgical and Medical Sciences and Translational Medicine, Sapienza University of Rome, Sant'Andrea Hospital, via di Grottarossa, n. 1035/1039, Rome, 00189, Italy
| | - Peter Humaidan
- The Fertility Clinic, Faculty of Health, Skive Regional Hospital, Aarhus University, Aarhus C, Denmark
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3
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Song Y, Wang H, Zhu Z, Huang H. Effects of Metformin and Exercise in Polycystic Ovary Syndrome: Systematic Review and Meta-Analysis. Horm Metab Res 2021; 53:738-745. [PMID: 34740275 DOI: 10.1055/a-1666-8979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Polycystic ovary syndrome (PCOS) is a common endocrine disorder in women of reproductive age. Metformin is introduced for treatment of women with PCOS, and the beneficial effects of exercise in women with PCOS are found for a range of outcomes. Our aim is to compare the effects of metformin plus exercise with exercise intervention in PCOS on clinical, anthropometric, metabolic, and psychological parameters. MEDLINE, EMBASE, Web of Science and China National Knowledge Infrastructure were searched for studies. Nine studies were considered eligible for inclusion. The meta-analysis reveals that metformin offers additive benefits to exercise, leading to modest improvements in menstrual cycles, hyperandrogenism, and abdominal fat.
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Affiliation(s)
- Yu Song
- Department of Obstetrics and Gynecology, The Third Hospital of Wuhan, HuBei, China
| | - Huimin Wang
- Department of Obstetrics and Gynecology, The Third Hospital of Wuhan, HuBei, China
| | - Zhengyan Zhu
- Department of Obstetrics and Gynecology, The Third Hospital of Wuhan, HuBei, China
| | - Hongli Huang
- Department of Obstetrics and Gynecology, The Third Hospital of Wuhan, HuBei, China
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4
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Levi-Setti PE, Di Segni N, Gargasole C, Ronchetti C, Cirillo F. Ovarian Hyperstimulation: Diagnosis, Prevention, and Management. Semin Reprod Med 2021; 39:170-179. [PMID: 34644798 DOI: 10.1055/s-0041-1736492] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Ovarian hyperstimulation syndrome (OHSS) is a severe complication of controlled ovarian stimulation (COS). Pathogenesis of the disease is based on massive transudation of protein-rich fluid from the vascular compartment into the peritoneal, pleural and pericardial spaces, with a variable picture of clinical manifestations depending on its severity. Nowadays OHSS can easily be avoided by several prevention methods, ranging from identification of high-risk patients, choice of a correct protocol stimulation, trigger with gonadotropin-releasing hormone (GnRH) agonists or, finally, the freeze-all strategy. When OHSS occurs, it can usually be managed as outpatient care. Only if severe/critical cases are diagnosed hospitalization is necessary for appropriate rehydration, monitoring of fluid balance and eventual drainage of ascitic fluid. One of the most dangerous complications of OHSS is venous thromboembolism (VTE). Thromboprophylaxis has shown to be cost effective and widely used, while there are controversies regarding the usage of low dose aspirin (LDA) as a preventive measure.
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Affiliation(s)
- Paolo Emanuele Levi-Setti
- IRCCS Humanitas Research Hospital, Department of Gynecology, Division of Gynecology and Reproductive Medicine, Fertility Center, Milan, Italy
| | - Noemi Di Segni
- IRCCS Humanitas Research Hospital, Department of Gynecology, Division of Gynecology and Reproductive Medicine, Fertility Center, Milan, Italy.,Humanitas University, Department of Biomedical Sciences, Milan, Italy
| | - Clara Gargasole
- IRCCS Humanitas Research Hospital, Department of Gynecology, Division of Gynecology and Reproductive Medicine, Fertility Center, Milan, Italy.,Humanitas University, Department of Biomedical Sciences, Milan, Italy
| | - Camilla Ronchetti
- IRCCS Humanitas Research Hospital, Department of Gynecology, Division of Gynecology and Reproductive Medicine, Fertility Center, Milan, Italy.,Humanitas University, Department of Biomedical Sciences, Milan, Italy
| | - Federico Cirillo
- IRCCS Humanitas Research Hospital, Department of Gynecology, Division of Gynecology and Reproductive Medicine, Fertility Center, Milan, Italy
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5
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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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6
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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 2019; 13:257-270. [PMID: 31710185 PMCID: PMC6875858 DOI: 10.22074/ijfs.2020.5608] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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 reproductive-
aged 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 undergo-
ing in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI), the addition of metformin to gonadotro-
phins 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 popula-
tions 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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7
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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: 54] [Impact Index Per Article: 10.8] [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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Bellver J, Rodríguez-Tabernero L, Robles A, Muñoz E, Martínez F, Landeras J, García-Velasco J, Fontes J, Álvarez M, Álvarez C, Acevedo B. Polycystic ovary syndrome throughout a woman's life. J Assist Reprod Genet 2018; 35:25-39. [PMID: 28951977 PMCID: PMC5758469 DOI: 10.1007/s10815-017-1047-7] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 09/12/2017] [Indexed: 01/22/2023] Open
Abstract
Polycystic ovary syndrome (PCOS) is the most common endocrine disorder among reproductive-aged women and the main cause of infertility due to anovulation. However, this syndrome spans the lives of women affecting them from in-utero life until death, leading to several health risks that can impair quality of life and increase morbidity and mortality rates. Fetal programming may represent the beginning of the condition characterized by hyperandrogenism and insulin resistance which leads to a series of medical consequences in adolescence, adulthood, and old age. Menstrual and fertility problems evolve into metabolic complications as age advances. An early and precise diagnosis is important for an adequate management of PCOS, especially at the extreme ends of the reproductive lifespan. However, many different phenotypes are included under the same condition, being important to look at these different phenotypes separately, as they may require different treatments and have different consequences. In this way, PCOS exhibits a great metabolic complexity and its diagnosis needs to be revised once again and adapted to recent data obtained by new technologies. According to the current medical literature, lifestyle therapy constitutes the first step in the management, especially when excess body weight is associated. Pharmacotherapy is frequently used to treat the most predominant manifestations in each age group, such as irregular menses and hirsutism in adolescence, fertility problems in adulthood, and metabolic problems and risk of cancer in old age. Close surveillance is mandatory in each stage of life to avoid health risks which may also affect the offspring, since fetal and post-natal complications seem to be increased in PCOS women.
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Affiliation(s)
- José Bellver
- IVI-Valencia, University of Valencia, Valencia, Spain.
| | | | | | | | | | | | | | - Juan Fontes
- Hospital Virgen de las Nieves, Granada, Spain
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9
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Wu Y, Li P, Zhang D, Sun Y. Metformin and pioglitazone combination therapy ameliorate polycystic ovary syndrome through AMPK/PI3K/JNK pathway. Exp Ther Med 2017; 15:2120-2127. [PMID: 29434814 DOI: 10.3892/etm.2017.5650] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Accepted: 02/07/2017] [Indexed: 11/06/2022] Open
Abstract
Polycystic ovary syndrome (PCOS) is a common gynecological endocrine disorder, which results in health problems such as menstrual disorders, hyperandrogenism and persistent anovulation. Hyperandrogenism and insulin resistance are the basic characteristics of PCOS. To investigate the combined effect of metformin and pioglitazone on POCS and the potential mechanisms, a rat model of PCOS was established by intramuscular injection of estradiol valerate (EV). The effect of metformin and pioglitazone monotherapy or combination therapy in control rats and PCOS rats was evaluated, involving the testosterone level, follicular development and insulin resistance. The potential mechanism for the therapeutic effect of metformin and pioglitazone on POCS was explored through using three inhibitors of the 5'adenosine monophosphate-activated protein kinase (AMPK)/phosphoinositide-3 kinase (PI3K)/c-Jun N-terminal kinase (JNK) pathway (Compound C, Wortmannin and SP600125). The results showed that EV-induced PCOS rats demonstrated hyperandrogenemia, hyperinsulinemia and follicular dysplasia. Metformin or pioglitazone monotherapy significantly suppressed the high level of testosterone, reduced the raised percentage of cystic follicles and primary follicles, promoted the number of early antral follicles, and markedly decreased the high concentration of fasting insulin and homeostatic model assessment for insulin resistance index in PCOS rats. In addition, metformin and pioglitazone combination therapy demonstrated greater efficacy than its individual components. Furthermore, individual or joint treatment with metformin and pioglitazone affected the phosphorylation level of JNK in PCOS rats. Compound C and Wortmannin eliminated the effect of metformin and pioglitazone combination therapy on improving the follicular growth in PCOS rats, whereas SP600125 treatment enhanced this combination therapy effect. These data suggested that metformin and pioglitazone combination therapy demonstrated great efficacy in ameliorating PCOS through regulating the AMPK/PI3K/JNK pathway.
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Affiliation(s)
- Yuanyuan Wu
- Reproductive Medicine Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China.,Reproductive Medicine Center, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450014, P.R. China
| | - Pengfen Li
- Reproductive Medicine Center, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450014, P.R. China
| | - Dan Zhang
- Reproductive Medicine Center, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450014, P.R. China
| | - Yingpu Sun
- Reproductive Medicine Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
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10
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Tal R, Seifer DB. Ovarian reserve testing: a user's guide. Am J Obstet Gynecol 2017; 217:129-140. [PMID: 28235465 DOI: 10.1016/j.ajog.2017.02.027] [Citation(s) in RCA: 230] [Impact Index Per Article: 32.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Revised: 02/08/2017] [Accepted: 02/14/2017] [Indexed: 10/20/2022]
Abstract
Ovarian reserve is a complex clinical phenomenon influenced by age, genetics, and environmental variables. Although it is challenging to predict the rate of an individual's ovarian reserve decline, clinicians are often asked for advice about fertility potential and/or recommendations regarding the pursuit of fertility treatment options. The purpose of this review is to summarize the state-of-the-art of ovarian reserve testing, providing a guide for the obstetrician/gynecologist generalist and reproductive endocrinologist. The ideal ovarian reserve test should be convenient, be reproducible, display little if any intracycle and intercycle variability, and demonstrate high specificity to minimize the risk of wrongly diagnosing women as having diminished ovarian reserve and accurately identify those at greatest risk of developing ovarian hyperstimulation prior to fertility treatment. Evaluation of ovarian reserve can help to identify patients who will have poor response or hyperresponse to ovarian stimulation for assisted reproductive technology. Ovarian reserve testing should allow individualization of treatment protocols to achieve optimal response while minimizing safety risks. Ovarian reserve testing may inform patients regarding their reproductive lifespan and menopausal timing as well as aid in the counselling and selection of treatment for female cancer patients of reproductive age who receive gonadotoxic therapy. In addition, it may aid in establishing the diagnosis of polycystic ovary syndrome and provide insight into its severity. While there is currently no perfect ovarian reserve test, both antral follicular count and antimüllerian hormone have good predictive value and are superior to day-3 follicle-stimulating hormone. The convenience of untimed sampling, age-specific values, availability of an automated platform, and potential standardization of antimüllerian hormone assay make this test the preferred biomarker for the evaluation of ovarian reserve in women.
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11
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Kalem MN, Kalem Z, Gurgan T. Effect of metformin and oral contraceptives on polycystic ovary syndrome and IVF cycles. J Endocrinol Invest 2017; 40:745-752. [PMID: 28244019 DOI: 10.1007/s40618-017-0634-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 02/01/2017] [Indexed: 12/30/2022]
Abstract
AIM The aim of this study is to investigate the effect of metformin and/or OC added to the treatment of PCOS patients at our clinic on IVF outcome. MATERIALS AND METHODS This study is a retrospective study that assesses the data of PCOS patients who received IVF between 2005 and 2015 at a private IVF center. The study included 496 PCOS cases aged between 24 and 40. Participants diagnosed with PCOS were divided into 4 groups according to the use of metformin and OC prior to the IVF cycle: 11.1% were in the metformin group, 31.3% in the OC group, 14.9% in the Metformin + OC group, and 42.7% in the control group. RESULTS No difference was found in the total gonadotropin dose and duration of stimulation between the groups. Clinical pregnancy rates and implantation rates were similar in all groups, although the numbers of oocytes, mature oocytes, fertilized oocytes, and transferred embryos were lower in the treatment groups received metformin compared to the OC group and control group. There was no significant difference in the presence of OHSS and the singleton and multiple pregnancies between the four groups. CONCLUSION The present study established no positive role of metformin and OC use in increasing the treatment success in IVF/ICSI cycles in PCOS patients. It would be appropriate to limit the use of these agents with special indications such as decreasing insulin resistance or synchronizing follicular cohort.
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Affiliation(s)
- M N Kalem
- Department of Obstetrics and Gynecology, Liv Hospital, Ankara, Turkey.
| | - Z Kalem
- IVF Department, Gurgan Clinic, Ankara, Turkey
| | - T Gurgan
- IVF Department, Gurgan Clinic, Ankara, Turkey
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12
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Comparative effectiveness of 9 ovulation-induction therapies in patients with clomiphene citrate-resistant polycystic ovary syndrome: a network meta-analysis. Sci Rep 2017. [PMID: 28630466 PMCID: PMC5476620 DOI: 10.1038/s41598-017-03803-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
The comparative efficacies of ovulation-induction treatments in patients with clomiphene citrate-resistant (CCR) polycystic ovary syndrome (PCOS) are not well known. Therefore, we conducted a network meta-analysis to rank the reproductive efficacies of these treatments. We ultimately included 26 randomized clinical trials with 2722 participants and 9 types of therapies: clomiphene citrate (CC), metformin, letrozole, follicle stimulating hormone (FSH), human menopausal gonadotropin (hMG), unilateral laparoscopic ovarian drilling (ULOD), bilateral laparoscopic ovarian drilling (BLOD), the combination of metformin with letrozole (metformin+letrozole), and the combination of metformin with CC (metformin+CC). The network meta-analysis demonstrates that hMG therapy result in higher pregnancy rates than BLOD, ULOD and CC therapies. Pregnancy, live birth and ovulation rates are significantly higher in metformin+letrozole and FSH groups than CC group. The abortion rate in the metformin+letrozole group is significantly lower than that in the metformin+CC group. Ranking probabilities show that, apart from gonadotropin (FSH and hMG), metformin+letrozole is also potentially more effective in improving reproductive outcomes than other therapies. In conclusion, owing to the low quality of evidence and the wide confidence intervals, no recommendation could be made for the treatment of ovulation-induction in patients with CCR PCOS.
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13
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Kahyaoglu S, Yumuşak OH, Ozyer S, Pekcan MK, Erel M, Cicek MN, Erkaya S, Tasci Y. Clomiphene Citrate Treatment Cycle Outcomes of Polycystic Ovary Syndrome Patients Based on Basal High Sensitive C-Reactive Protein Levels: A Cross-Sectional Study. INTERNATIONAL JOURNAL OF FERTILITY & STERILITY 2017; 10:320-326. [PMID: 28042411 PMCID: PMC5134747 DOI: 10.22074/ijfs.2016.4849] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 07/07/2016] [Indexed: 12/03/2022]
Abstract
Background Polycystic ovary syndrome (PCOS) is highly associated with an ovulatory
infertility, features of the metabolic syndrome, including obesity, insulin resistance and
dyslipidemia. Serum concentrations of high sensitive C-reactive protein (hs-CRP) were
significantly higher in obese than in non-obese PCOS patients at baseline, suggesting a
relationship between elevated hs-CRP levels and obesity. The aim of this study was to
evaluate whether cycle day 3 hs-CRP levels before clomiphene citrate (CC) treatment
would predict cycle outcomes in women with PCOS. Materials and Methods This cross-sectional study was conducted among 84 infertile
women with PCOS who were treated with CC at Zekai Tahir Burak Women’s Health
Education and Research Hospital, Ankara, Turkey, between January 2014 and January
2015. Based on the exclusion criteria, cycle outcomes of remaining 66 infertile women
with PCOS treated with CC were analyzed. The hs-CRP levels and insulin resistance indexes
were evaluated on day 3 of the CC treatment cycle. The primary outcome measures
were number of preovulatory follicles measuring≥17 mm and pregnancy rates. Results The mean ± SD age of the patients was 24.0 ± 3.8 years (range 18-36). The mean
± SD body mass index (BMI) of the patients was 25.7 ± 4.9 (range 17-43). Fifty patients
developed dominant follicle (75%) and 5 patients established clinical pregnancy during
the study (clinical pregnancy rate: 7%). The mean ± SD baseline hs-CRP, fasting insulin
and Homeostasis Model Assessment-Insulin Resistance (HOMA-IR) values of the
patients with and without dominant follicle generation during treatment cycle were 6.42 ±
7.05 and 4.41 ± 2.95 (P=0.27), 11.61 ± 6.94 and 10.95 ± 5.65 (P=0.73), 2.68 ± 1.79 and
2.41 ± 1.30 (P=0.58), respectively. The mean ± SD baseline hs-CRP, fasting insulin and
HOMA-IR values of the patients with and without clinical pregnancy establishment
following treatment cycle were 6.30 ± 2.56 and 5.90 ± 6.57 (P=0.89), 11.60 ± 7.54 and 11.44
± 6.61 (P=0.95), 2.42 ± 1.51 and 2.63 ± 1.70 (P=0.79), respectively. Conclusion In this study, we did not observe a predictive value of cycle day 3 hs-CRP
levels on preovulatory follicle development and pregnancy rates among infertile PCOS
patients treated with CC. Also, no relationship between HOMA-IR values and dominant
follicle generation or clinical pregnancy establishment was demonstrated in our study,
confirming the previous studies emphasizing the neutral effect of metformin utilization
before and/or during ovulation induction to pregnancy rates.
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Affiliation(s)
- Serkan Kahyaoglu
- Department of Obstetrics and Gynecology, Zekai Tahir Burak Women's Health Education and Research Hospital, Ankara, Turkey
| | - Omer Hamid Yumuşak
- Department of Obstetrics and Gynecology, Zekai Tahir Burak Women's Health Education and Research Hospital, Ankara, Turkey
| | - Sebnem Ozyer
- Department of Obstetrics and Gynecology, Zekai Tahir Burak Women's Health Education and Research Hospital, Ankara, Turkey
| | - Meryem Kuru Pekcan
- Department of Obstetrics and Gynecology, Zekai Tahir Burak Women's Health Education and Research Hospital, Ankara, Turkey
| | - Merve Erel
- Department of Obstetrics and Gynecology, Zekai Tahir Burak Women's Health Education and Research Hospital, Ankara, Turkey
| | - Mahmut Nedim Cicek
- Department of Obstetrics and Gynecology, Zekai Tahir Burak Women's Health Education and Research Hospital, Ankara, Turkey
| | - Salim Erkaya
- Department of Obstetrics and Gynecology, Zekai Tahir Burak Women's Health Education and Research Hospital, Ankara, Turkey
| | - Yasemin Tasci
- Department of Obstetrics and Gynecology, Zekai Tahir Burak Women's Health Education and Research Hospital, Ankara, Turkey
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14
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Prevention and treatment of moderate and severe ovarian hyperstimulation syndrome: a guideline. Fertil Steril 2016; 106:1634-1647. [PMID: 27678032 DOI: 10.1016/j.fertnstert.2016.08.048] [Citation(s) in RCA: 216] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 08/25/2016] [Indexed: 11/15/2022]
Abstract
Ovarian hyperstimulation syndrome (OHSS) is an uncommon but serious complication associated with assisted reproductive technology (ART). This systematic review aims to identify who is at high risk, how to prevent OHSS, and the treatment for existing OHSS.
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15
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Xiao Q, Cui YY, Lu J, Zhang GZ, Zeng FL. Risk for Gestational Diabetes Mellitus and Adverse Birth Outcomes in Chinese Women with Polycystic Ovary Syndrome. Int J Endocrinol 2016; 2016:5787104. [PMID: 27066074 PMCID: PMC4808671 DOI: 10.1155/2016/5787104] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Revised: 02/18/2016] [Accepted: 02/21/2016] [Indexed: 12/18/2022] Open
Abstract
Objective. To examine the association of polycystic ovary syndrome (PCOS) in early pregnancy with gestational diabetes mellitus (GDM) and adverse birth outcomes. Methods. In this retrospective cohort study including 2389 pregnant women, the medical records of 352 women diagnosed with PCOS were evaluated. Outcomes included GDM, preterm birth, low birth weight, macrosomia, and being small and large for gestational age. Multivariable logistic regression models were used to examine the association of the risk for GDM and adverse birth outcomes with PCOS after adjusting for confounders. Results. Women previously diagnosed with PCOS had a higher risk of GDM (adjusted odds ratio [OR] 1.55, 95% confidence interval [CI]: 1.14-2.09). A strong association was seen between PCOS and preterm birth (adjusted OR 1.69, 95% CI: 1.08-2.67). On stratified analysis, the adjusted OR for GDM among women with PCOS undergoing assisted reproductive technology was 1.44 (95% CI: 1.03-1.92) and among women with PCOS who conceived spontaneously was 1.60 (1.18-2.15). No increased risk for other adverse birth outcomes was observed. Conclusions. Women with PCOS were more likely to experience GDM and preterm birth.
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Affiliation(s)
- Qing Xiao
- Department of Obstetrics and Gynecology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou 510623, China
| | - Yong-Yi Cui
- Department of Obstetrics and Gynecology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou 510623, China
| | - Jine Lu
- Department of Obstetrics and Gynecology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou 510623, China
| | - Guo-Zheng Zhang
- Department of Obstetrics and Gynecology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou 510623, China
| | - Fang-Ling Zeng
- Department of Obstetrics and Gynecology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou 510623, China
- *Fang-Ling Zeng:
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