PCOS and pregnancy: a review of available therapies to improve the outcome of pregnancy in women with polycystic ovary syndrome

Comparison of dietary and physical activity behaviors in women with and without polycystic ovary syndrome: a systematic review and meta-analysis of 39 471 women

BACKGROUND

Lifestyle (dietary and/or physical activity [PA]) modification is recommended as first-line therapy to manage polycystic ovary syndrome (PCOS). Current recommendations are based on healthy lifestyle practices for the general public since evidence for unique lifestyle approaches in PCOS is limited and low quality.

OBJECTIVE AND RATIONALE

We aimed to synthesize evidence on dietary and PA behaviors between women with PCOS and those without PCOS. Primary outcomes were overall diet quality, total energy intake and total PA, and secondary outcomes included macronutrients, micronutrients, food groups, foods, glycemic indices, sedentary time and sitting levels. We conducted this work to identify any unique lifestyle behaviors in women with PCOS that could underlie the propensity of weight gain and obesity in PCOS and be targeted for precision nutrition and PA interventions. These findings could be used to inform future practice recommendations and research that more effectively address complications (weight gain, obesity, diabetes, infertility, cardiovascular disease and mental health) in this high-risk population.

SEARCH METHODS

Databases of MEDLINE, Web of Science, Scopus and CINAHL were searched until 15 February 2022 to identify observational studies documenting dietary and PA behaviors between women with PCOS and without PCOS (Controls). Studies on children, adolescents (<18 years), pregnant or menopausal-aged women (>50 years) were excluded. Data were pooled by random-effects models and expressed as (standardized) mean differences (MD) and 95% CIs. The risk of bias was assessed by the Newcastle-Ottawa scale (NOS).

OUTCOMES

Fifty-four studies (N = 39 471 participants; [n = 8736 PCOS; 30 735 Controls]) were eligible (96%; [52/54] NOS scores ≥ 7). Women with PCOS had higher cholesterol (MD: 12.78, 95% CI: 1.48 to 24.08 mg/day; P = 0.03; I2 = 19%), lower magnesium (MD: -21.46, 95% CI: -41.03 to -1.91 mg/day; P = 0.03; I2 = 76%), and a tendency for lower zinc (MD: -1.08, 95% CI: -2.19 to -0.03 mg/day; P = 0.05; I2 = 96%) intake, despite lower alcohol consumption (MD: -0.95, 95% CI: -1.67 to 0.22 g/day; P = 0.02; I2 = 0%) versus Controls. Also, women with PCOS had lower total PA (standardized mean difference: -0.38, 95% CI: -0.72 to 0.03; P = 0.03; I2 = 98%). Conversely, energy, macronutrients (carbohydrate, fat, protein, fiber), micronutrients (folic acid, iron, calcium, sodium), glycemic index and glycemic load were similar (all: P ≥ 0.06). Most eligible studies reported lower total adherence to healthy eating patterns or poorer consumption of major food groups (grains, fruits, vegetables, proteins, seeds, nuts, dairy) in women with PCOS, as described narratively since variable study methodology did not permit meta-analyses.

WIDER IMPLICATIONS

Collective evidence supports that women with PCOS have a lower overall diet quality, poorer dietary intakes (higher cholesterol, lower magnesium and zinc) and lower total PA, despite lower alcohol consumption versus those without PCOS. Considerable heterogeneity among studies reinforces the need for research to address any relative contributions of other factors (e.g. genetic, metabolic or sociodemographic) to the observed differences. These clarifications may contribute to future evidence-based guideline recommendations on monitoring and managing PCOS in the era of precision lifestyle medicine.

Polycystic ovarian syndrome and infertility: overview and insights of the putative treatments

Infertility concerns 15% of the couples. Management of female infertility requires a complete history of the patient followed by a physical, gynecological and endocrine examination. Infertility etiology will be investigated thanks to different tests including ovarian function and reserve assessment, search for uterine abnormalities and evaluation of tubal permeability. Polycystic ovarian syndrome (PCOS) is a predominant cause of infertility and a common gyne-endocrine disorder affecting 7 to 15% of women in reproductive age. Behavioral, medical and surgical treatments have been evaluated in order to improve the fertility of women with PCOS. Lifestyle modifications (stop smoking, physical exercise and weight loss when necessary) are of the utmost importance. Clomiphene citrate remains the first line of medical treatment of infertility in women with PCOS in absence of other male or female causes of infertility. Use of metformin solely for infertility is not recommended in absence of metabolic anomaly and new treatment as myoinositol is emerging. Surgical techniques aiming to enhance ovulation and pregnancy rate are an option when medical treatment failed. Ovarian drilling by laparoscopy or by transvaginal hydrolaparoscopy is taking a larger place in the treatment of infertility. In vitro maturation and fertilization remain the third-line of treatment in PCOS.

Different expression and localization of aquaporin 7 and aquaporin 9 in granulosa cells, oocytes, and embryos of patients with polycystic ovary syndrome and the negatively correlated relationship with insulin regulation

OBJECTIVE

To investigate the expression of aquaporin 7 (AQP7) and aquaporin 9 (AQP9) in the granulosa cells of patients with polycystic ovary syndrome (PCOS) and healthy women and detect their localization in oocytes at the germinal vesicle (GV), metaphase I (MI), MII, embryo, and blastocyst stages and the in vitro response to insulin stimulation.

DESIGN

Randomized, assessor-blinded study.

SETTING

Reproductive medical center.

PATIENT(S)

A total of 40 women (aged 20-38 years) comprising 29 cases of primary infertility and 11 cases of secondary infertility, of whom 17 had an initial diagnosis of PCOS and three received a PCOS diagnosis after an infertility examination.

INTERVENTION(S)

Controlling different concentrations of insulin and different treatment times in cultures of normal human granulosa cells in vitro.

MAIN OUTCOME MEASURE(S)

Expression of AQP7 and AQP9 genes and proteins in granulosa cells detected by real-time quantitative polymerase chain reaction, and localization in oocytes at the GV, MI, MII, embryo, and blastocyst stages by Western blot, immunohistochemical, and immunofluorescence assays, and concentrations of insulin in follicular fluid by enzyme-linked immunosorbent assay.

RESULT(S)

The expression levels of the AQP7 mRNA and protein in the granulosa cells of patients with PCOS were higher than found in healthy controls. We found AQP7 protein expressed in human oocytes at GV, MI, MII, embryo, and blastocyst stages; it was mainly located in the nucleoplasm. In the PCOS group, the expression level of AQP9 mRNA and protein in granulosa cells was lower, and AQP9 protein was expressed in oocytes at the GV, MI, MII, embryo, and blastocyst stages; it was localized on the nuclear membrane. Compared with healthy women, the insulin expression in patients with PCOS was higher. In cultures of normal human granulosa cells in vitro, the expression of AQP7 and AQP9 mRNA and protein decreased with the increase in insulin concentration; expression statistically significantly decreased when the insulin concentration was 100 nmol/L, and after 6 to 24 hours of exposure the lowest expression levels were found at 12 hours.

CONCLUSION(S)

The different localization and expression of AQP7 and AQP9 between the two groups suggests that they might be involved in oocyte maturation and embryonic development through different regulatory pathways. The expression levels of AQP7 and AQP9 were negatively correlated with insulin regulation, suggesting that insulin might affect the maturation of PCOS follicles by changing AQP7 and AQP9 expression.

Histomorphometric and immunohistochemical changes in interstitial cells and ovarian follicles of rats with polycystic ovaries treated with clomiphene citrate

OBJECTIVE

To evaluate the histomorphometric and immunohistochemical changes in interstitial cells and ovarian follicles of rats treated with clomiphene citrate during and after induction of permanent estrus.

METHODS

Twenty four adult-female rats with regular estrous cycle were equally divided into three groups: (1) GCtrl-at estrous phase. (2) GPCOS-at permanent-estrous phase. (3) GCC-PCOS rats, which remained exposed to 60 days of continuous illumination and treated with Clomiphene Citrate. After that, the animals were euthanized, and the ovaries were removed and processed for paraffin embedding. Sections were stained with H.E. for histomorphometry or subjected to immunohistochemistry for Ki-67 and cleaved caspase-3 detections.

RESULTS

The GPCOS showed lack of corpus luteum and several ovarian cysts, as well as interstitial-like cells. The presence of corpus luteum and a significant increase in primary and antral follicles were observed in GCC, which also showed a decrease in the number of ovarian cysts and in the area occupied by interstitial-like cells, as well as a decrease in nuclear volume of interstitial cells. The percentage of cell proliferation was significantly higher in granulosa cells of the GCC. On the other hand, the percentage of apoptosis was significantly higher in the granulosa cells of GPCOS than the GCC.

CONCLUSION

The ovaries of rats treated with clomiphene citrate showed a decrease in the number of cysts, an increase in the number of ovarian follicles, the presence of corpus luteum along with a decrease in the nuclear volume in the area occupied by interstitial cells.

In Search of New Therapeutics-Molecular Aspects of the PCOS Pathophysiology: Genetics, Hormones, Metabolism and Beyond

In a healthy female reproductive system, a subtle hormonal and metabolic dance leads to repetitive cyclic changes in the ovaries and uterus, which make an effective ovulation and potential implantation of an embryo possible. However, that is not so in the case of polycystic ovary syndrome (PCOS), in which case the central mechanism responsible for entraining hormonal and metabolic rhythms during the menstrual cycle is notably disrupted. In this review we provide a detailed description of the possible scenario of PCOS pathogenesis. We begin from the analysis of how a set of genetic disorders related to PCOS leads to particular malfunctions at a molecular level (e.g., increased enzyme activities of cytochrome P450 (CYP) type 17A1 (17α-hydroxylase), 3β-HSD type II and CYP type 11A1 (side-chain cleavage enzyme) in theca cells, or changes in the expression of aquaporins in granulosa cells) and discuss further cellular- and tissue-level consequences (e.g., anovulation, elevated levels of the advanced glycation end products in ovaries), which in turn lead to the observed subsequent systemic symptoms. Since gene-editing therapy is currently out of reach, herein special emphasis is placed on discussing what kinds of drug targets and which potentially active substances seem promising for an effective medication, acting on the primary causes of PCOS on a molecular level.

Fertility and Pregnancy Outcomes in Women with Polycystic Ovary Syndrome Following Bariatric Surgery

CONTEXT

Restoration of ovulation is quite common in women with polycystic ovary syndrome (PCOS) after surgically induced weight loss. Whether or not this results in an improvement of PCOS-associated infertility is uncertain.

OBJECTIVE

To study fertility and gestational outcomes in women with PCOS after bariatric surgery.

DESIGN

Unicenter cohort study.

SETTING

Academic hospital.

PATIENTS

Two hundred and sixteen premenopausal women were screened for PCOS before bariatric surgery. Women were followed-up after the intervention until mid-2019 regardless of having or not PCOS.

INTERVENTIONS

All participants underwent bariatric surgery from 2005 to 2015.

MAIN OUTCOME MEASURES

Pregnancy and live birth rates in the PCOS and control groups.

RESULTS

In women seeking fertility, pregnancy rates were 95.2% in PCOS and 76.9% in controls (P = 0.096) and live birth rates were 81.0% and 69.2%, respectively (P = 0.403). The time to achieve the first pregnancy after surgery was 34 ± 28 months in women with PCOS and 32 ± 25 months in controls. Albeit the mean birth weight was lower (P = 0.040) in newborns from women with PCOS (2763 ± 618 g) compared with those from controls (3155 ± 586 g), the number of newborns with low birth weight was similar in both groups (3 in the PCOS group and 1 in the controls, P = 0.137). Maternal (17.6% in PCOS and 22.2% in controls, P = 0.843) and neonatal (23.5% in PCOS and 14.8% in controls, P = 0.466) complications were rare, showing no differences between groups.

CONCLUSIONS

Pregnancy and fertility rates in very obese women with PCOS after bariatric surgery were high, with few maternal and neonatal complications.

Is it worth reducing twins to singletons after IVF-ET? A retrospective cohort study using propensity score matching

INTRODUCTION

Many studies have shown that multifetal reduction of high-order multiple pregnancies results in improved pregnancy outcomes. However, whether conducting elective fetal reduction from dichorionic twins after in vitro fertilization (IVF) is worthwhile remains controversial. This study aimed to determine whether elective fetal reduction of dichorionic twins after IVF and embryo transfer (IVF-ET) is associated with increased take-home baby rate.

MATERIAL AND METHODS

This was a retrospective cohort study of 3600 dichorionic twin pregnancies after IVF-ET. The reduced group included 71 women with transvaginal elective fetal reduction between 7 and 8 weeks of gestation. The control group (n = 3529) comprised women who were managed expectantly. Propensity score matching was conducted before pregnancy outcomes were compared.

RESULTS

The take-home baby rate was significantly lower in the reduced group (83.1% vs 92.8%, P = 0.004). The total miscarriage rate was significantly higher in the reduced group (12.7% vs 6.2%, P = 0.04). Although preterm delivery rate was lower in the reduced group (P < 0.001), over 90% were over 32 weeks, whereas the proportions were equal in the reduced group.

CONCLUSIONS

In dichorionic twin pregnancies after IVF-ET, elective fetal reduction to singleton significantly decreased the chance of taking home live babies.

Acupuncture in improving endometrial receptivity: a systematic review and meta-analysis

Background

This systematic review aimed at summarizing and evaluating the evidence of randomized controlled trials (RCTs) using acupuncture to improve endometrial receptivity (ER).

Methods

We searched 12 databases electronically through August 2018 without language restrictions. We included RCTs of women of infertility due to low ER, and excluded infertility caused by other reasons or non-RCTs. Two independent reviewers extracted the characteristics of studies and resolved the differences through consensus. Data were pooled and expressed as standard mean difference (SMD) or mean difference (MD) for continuous outcomes and risk ratio (RR) for dichotomous outcomes, with 95% confidence interval (CI).

Results

We found very low to moderate level of evidence that acupuncture may improve pregnancy rate (RR = 1.23 95%CI[1.13, 1.34] P < 0.00001) and embryo transfer rate (RR = 2.04 95%CI[1.13, 3.70] P = 0.02), increase trilinear endometrium (RR = 1.47 95%CI [1.27, 1.70] P < 0.00001), thicken endometrium (SMD = 0.41 95% CI [0.11, 0.72] P = 0.008), reduce resistive index (RI) (MD = -0.08 95% CI [− 0.15, − 0.02] P = 0.01), pulse index (PI) (SMD = -2.39 95% CI [− 3.85, − 0.93] P = 0.001) and peak systolic velocity/ end-diastolic blood velocity (S/D) (SMD = -0.60 95% CI [− 0.89, − 0.30] P < 0.0001), compared with medication, sham acupuncture or physiotherapy. Acupuncture was statistically significant as a treatment approach.

Conclusion

The efficacy and safety of acupuncture on key outcomes in women with low ER is statistically significant, but the level of most evidence was very low or low. More large-scale, long-term RCTs with rigorous methodologies are needed.

Fertility concerns and related information needs and preferences of women with PCOS

STUDY QUESTION

What are the fertility and childbearing concerns and related information needs and preferences of women with polycystic ovary syndrome (PCOS)?

SUMMARY ANSWER

Women with PCOS have concerns about fertility and childbearing mainly because they believe that it will be difficult for them to conceive, and identify a need for evidence-based information and preconception care so that they can make informed decisions about having children and achieve their reproductive goals.

WHAT IS KNOWN ALREADY

Women with chronic conditions seek reproductive health information from a range of sources, including their healthcare provider, the internet, other women with the condition, patient associations and support groups, and scientific publications. Little is known about the fertility concerns and information needs of women with PCOS or their preferences for how and when to receive information about the effect of their condition and its treatment on fertility and childbearing.

STUDY DESIGN SIZE DURATION

A qualitative study of 13 women of reproductive age with self-reported PCOS living in Australia participated in an online discussion group conducted from May to June 2018. Women were recruited via targeted advertisements on social media.

PARTICIPANTS/MATERIALS SETTING METHODS

In a closed-group moderated discussion, participants responded to questions about fertility concerns and the related information needs and preferences of women with PCOS. Non-identifiable demographic information was sought via a separate online anonymous survey. The discussion transcript was analysed thematically.

MAIN RESULTS AND THE ROLE OF CHANCE

Women identified a number of concerns about childbearing including whether they could become pregnant, how to prepare for pregnancy and what they should do before trying to conceive given their PCOS. Women reported seeking information about fertility and PCOS from a range of sources, and views about the most useful types and sources of fertility information for women with PCOS varied.

LIMITATIONS REASONS FOR CAUTION

Due to the small sample size and recruitment of participants via advertisements on Facebook, women who participated in the study may not be representative of women with PCOS in the general population. Women currently contemplating childbearing or who have recently had children or fertility difficulties may also have been more likely to participate in the study. Women in this study self-reported PCOS, and this may not necessarily reflect a confirmed diagnosis of PCOS. No formal diagnostic criteria were used to confirm their PCOS status.

WIDER IMPLICATIONS OF THE FINDINGS

Women with PCOS would benefit from evidence-based information in a range of formats to help them make informed decisions about childbearing and achieving their reproductive goals. Preconception care, including counselling and information about appropriate interventions and self-management strategies to optimise health and improve chances of conception, may be of particular assistance to women with PCOS.

STUDY FUNDING/COMPETING INTERESTS

The Victorian Assisted Reproductive Treatment Authority (VARTA) commissioned researchers at Monash University to generate evidence to guide the development of resources to assist women with PCOS make informed fertility and childbearing decisions and achieve their reproductive goals. The authors have no conflict of interests to declare.

TRIAL REGISTRATION NUMBER

Not applicable.