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Taheripanah R, Kazemi SN, Taheripanah A, Fereidoonjah S. A randomized controlled trial comparing pioglitazone and metformin prior to in vitro fertilization in polycystic ovary syndrome - associated infertile women: impact on pregnancy rates. Ann Med Surg (Lond) 2024; 86:2696-2701. [PMID: 38694345 PMCID: PMC11060239 DOI: 10.1097/ms9.0000000000001816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 01/27/2024] [Indexed: 05/04/2024] Open
Abstract
Background Polycystic ovarian syndrome (PCOS) is one of the significant causes of infertility. Impaired glucose metabolism and insulin resistance add chiefly to the pathogenesis of PCOS. This study aimed to evaluate the efficacy of metformin and pioglitazone (insulin sensitizers) on the quality of the ovum and pregnancy rate in the IVF cycle. Methods In this randomized clinical trial study, 172 infertile women with PCO were enrolled and randomly assigned to receive either 15 mg pioglitazone (case group) or 1000 mg metformin (control group) twice a day for 6 weeks before IVF, and the pregnancy rate was compared across the groups. The number of ovum and embryos were also accessed and compared between the two groups. Results In the study, 172 patients participated. The mean age in the control and case groups was 32.09±3.9 years and 32.12±3.9 years, respectively, with no significant age difference. In both groups, the mean number of IVF eggs retrieved was 11.76±3.7 (control) and 11.86±3.7 (case), and the number of embryos formed was 7.43±2.8 (control) and 7.87±3.5 (case), with no significant disparities (P<0.05). Regarding positive pregnancies, 28 out of 86 (32.6%) occurred in the control group, while 42 out of 86 (48.8%) happened in the case group, demonstrating a significant difference (P=0.03). Conclusions According to the results obtained in this study, it may be concluded that pioglitazone is superior to metformin in IVF cycles in PCOS-associated infertile women leading to a higher pregnancy rate.
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Affiliation(s)
- Robabeh Taheripanah
- Department of Obstetrics and Gynecology, School of Medicine, Imam Hossein Hospital
| | | | - Anahita Taheripanah
- Department of Molecular and Cellular Sciences, Faculty of Advanced Sciences and Technology Pharmaceutical Sciences Branch, Islamic Azad University, Tehran, Iran
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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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Zeng H, Huang Y, Liu D, Xie T, Chen Z, Huang Q, Zhou X, Lai X, Liu J. Interaction between OCT1 and LPIN1 polymorphisms and response to pioglitazone-metformin tablets in patients with polycystic ovary syndrome. Chin Med J (Engl) 2023:00029330-990000000-00627. [PMID: 37232475 DOI: 10.1097/cm9.0000000000002322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Indexed: 05/27/2023] Open
Affiliation(s)
- Haixia Zeng
- Department of Endocrinology, Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, China
| | - Yanting Huang
- Department of Endocrinology, Xiangyang First People's Hospital, Xiangyang, Hubei 441099, China
| | - Dengke Liu
- Department of Endocrinology, Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, China
| | - Tianqin Xie
- Department of Endocrinology, Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, China
| | - Zheng Chen
- Department of Endocrinology, Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, China
| | - Qiulan Huang
- Department of Endocrinology, Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, China
| | - Xiaojun Zhou
- School of Public Health, Nanchang University, School of Public Health, Nanchang University, Nanchang, Jiangxi 330031, China
| | - Xiaoyang Lai
- Department of Endocrinology, Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, China
| | - Jianping Liu
- Department of Endocrinology, Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, China
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Naseri A, Sanaie S, Hamzehzadeh S, Seyedi-Sahebari S, Hosseini MS, Gholipour-Khalili E, Rezazadeh-Gavgani E, Majidazar R, Seraji P, Daneshvar S, Rezazadeh-Gavgani E. Metformin: new applications for an old drug. J Basic Clin Physiol Pharmacol 2023; 34:151-160. [PMID: 36474458 DOI: 10.1515/jbcpp-2022-0252] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 11/17/2022] [Indexed: 12/12/2022]
Abstract
Metformin is a biguanide, evolved as one of the most widely used medicines. The applications of this component include but are not limited to reducing blood glucose, weight loss, and polycystic ovary syndrome. Studies about other probable indications have emerged, indicating that this agent can also be utilized for other purposes. In this review, applications of metformin are noticed based on the current evidence. Metformin commonly is used as an off-label drug in non-alcoholic fatty liver disease (NAFLD), but it worsens inflammation and should not be used for this purpose, according to the latest research. Metformin decreased the risk of death in patients with liver cirrhosis. It is an effective agent in the prevention and improvement of survival in patients suffering hepatocellular carcinoma. There is evidence of the beneficial effects of metformin in colorectal cancer, early-stage prostate cancer, breast cancer, urothelial cancer, blood cancer, melanoma, and bone cancer, suggesting metformin as a potent anti-tumor agent. Metformin shows neuroprotective effects and provides a potential therapeutic benefit for mild cognitive impairment and Alzheimer's disease (AD). It also has been shown to improve mental function and reduce the incidence of dementia. Another condition that metformin has been shown to slow the progression of is Duchenne muscular dystrophy. Regarding infectious diseases, tuberculosis (TB) and coronavirus disease (COVID-19) are among the conditions suggested to be affected by metformin. The beneficial effects of metformin in cardiovascular diseases were also reported in the literature. Concerning renal function, studies showed that daily oral administration of metformin could ameliorate kidney fibrosis and normalize kidney structure and function. This study reviewed the clinical and preclinical evidence about the possible benefits of metformin based on recent studies. Numerous questions like whether these probable indications of metformin can be observed in non-diabetics, need to be described by future basic experiments and clinical studies.
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Affiliation(s)
- Amirreza Naseri
- Research Center for Evidence-Based Medicine, Iranian EBM Centre: A Joanna Briggs Institute (JBI) Center of Excellence, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Sarvin Sanaie
- Research Center for Integrative Medicine in Aging, Aging Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Sina Hamzehzadeh
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | | | | | - Ehsan Rezazadeh-Gavgani
- Research Center for Evidence-Based Medicine, Iranian EBM Centre: A Joanna Briggs Institute (JBI) Center of Excellence, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Reza Majidazar
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Parya Seraji
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Sara Daneshvar
- Research Center for Evidence-Based Medicine, Iranian EBM Centre: A Joanna Briggs Institute (JBI) Center of Excellence, Tabriz University of Medical Sciences, Tabriz, Iran
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5
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Fiorentino G, Cimadomo D, Innocenti F, Soscia D, Vaiarelli A, Ubaldi FM, Gennarelli G, Garagna S, Rienzi L, Zuccotti M. Biomechanical forces and signals operating in the ovary during folliculogenesis and their dysregulation: implications for fertility. Hum Reprod Update 2023; 29:1-23. [PMID: 35856663 DOI: 10.1093/humupd/dmac031] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 05/12/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Folliculogenesis occurs in the highly dynamic environment of the ovary. Follicle cyclic recruitment, neo-angiogenesis, spatial displacement, follicle atresia and ovulation stand out as major events resulting from the interplay between mechanical forces and molecular signals. Morphological and functional changes to the growing follicle and to the surrounding tissue are required to produce oocytes capable of supporting preimplantation development to the blastocyst stage. OBJECTIVE AND RATIONALE This review will summarize the ovarian morphological and functional context that contributes to follicle recruitment, growth and ovulation, as well as to the acquisition of oocyte developmental competence. We will describe the changes occurring during folliculogenesis to the ovarian extracellular matrix (ECM) and to the vasculature, their influence on the mechanical properties of the ovarian tissue, and, in turn, their influence on the regulation of signal transduction. Also, we will outline how their dysregulation might be associated with pathologies such as polycystic ovary syndrome (PCOS), endometriosis or premature ovarian insufficiency (POI). Finally, for each of these three pathologies, we will highlight therapeutic strategies attempting to correct the altered biomechanical context in order to restore fertility. SEARCH METHODS For each area discussed, a systematic bibliographical search was performed, without temporal limits, using PubMed Central, Web of Science and Scopus search engines employing the keywords extracellular matrix, mechanobiology, biomechanics, vasculature, angiogenesis or signalling pathway in combination with: ovary, oogenesis, oocyte, folliculogenesis, ovarian follicle, theca, granulosa, cumulus, follicular fluid, corpus luteum, meiosis, oocyte developmental competence, preimplantation, polycystic ovary syndrome, premature ovarian insufficiency or endometriosis. OUTCOMES Through search engines queries, we yielded a total of 37 368 papers that were further selected based on our focus on mammals and, specifically, on rodents, bovine, equine, ovine, primates and human, and also were trimmed around each specific topic of the review. After the elimination of duplicates, this selection process resulted in 628 papers, of which 287 were cited in the manuscript. Among these, 89.2% were published in the past 22 years, while the remaining 8.0%, 2.4% or 0.3% were published during the 1990s, 1980s or before, respectively. During folliculogenesis, changes occur to the ovarian ECM composition and organization that, together with vasculature modelling around the growing follicle, are aimed to sustain its recruitment and growth, and the maturation of the enclosed oocyte. These events define the scenario in which mechanical forces are key to the regulation of cascades of molecular signals. Alterations to this context determine impaired folliculogenesis and decreased oocyte developmental potential, as observed in pathological conditions which are causes of infertility, such as PCOS, endometriosis or POI. WIDER IMPLICATIONS The knowledge of these mechanisms and the rules that govern them lay a sound basis to explain how follicles recruitment and growth are modulated, and stimulate insights to develop, in clinical practice, strategies to improve follicular recruitment and oocyte competence, particularly for pathologies like PCOS, endometriosis and POI.
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Affiliation(s)
- Giulia Fiorentino
- Laboratory of Developmental Biology, Department of Biology and Biotechnology "Lazzaro Spallanzani", University of Pavia, Pavia, Italy.,Center for Health Technologies, University of Pavia, Pavia, Italy
| | | | | | - Daria Soscia
- Clinica Valle Giulia, GeneraLife IVF, Rome, Italy
| | | | | | - Gianluca Gennarelli
- Obstetrics and Gynecology, Physiopathology of Reproduction and IVF Unit, Department of Surgical Sciences, Sant'Anna Hospital, University of Torino, Turin, Italy.,Livet, GeneraLife IVF, Turin, Italy
| | - Silvia Garagna
- Laboratory of Developmental Biology, Department of Biology and Biotechnology "Lazzaro Spallanzani", University of Pavia, Pavia, Italy.,Center for Health Technologies, University of Pavia, Pavia, Italy
| | - Laura Rienzi
- Clinica Valle Giulia, GeneraLife IVF, Rome, Italy.,Department of Biomolecular Sciences, University of Urbino "Carlo Bo", Urbino, Italy
| | - Maurizio Zuccotti
- Laboratory of Developmental Biology, Department of Biology and Biotechnology "Lazzaro Spallanzani", University of Pavia, Pavia, Italy.,Center for Health Technologies, University of Pavia, Pavia, Italy
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Xu B, Dai W, Liu L, Han H, Zhang J, Du X, Pei X, Fu X. Metformin ameliorates polycystic ovary syndrome in a rat model by decreasing excessive autophagy in ovarian granulosa cells via the PI3K/AKT/mTOR pathway. Endocr J 2022; 69:863-875. [PMID: 35228471 DOI: 10.1507/endocrj.ej21-0480] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Polycystic ovary syndrome (PCOS) is a common gynecological disease accompanied by a variety of clinical features, including anovulation, hyperandrogenism, and ovarian abnormalities, resulting in infertility. PCOS affects approximately 6%-15% of all reproductive-age women worldwide. Metformin, a popular drug used to treat PCOS in patients, has beneficial effects in reducing hyperandrogenism and inducing ovulation; however, the mechanisms by which metformin ameliorates PCOS are not clear. Hence, we aimed to explore the mechanisms of metformin in treating PCOS. In the present study, we first treated a letrozole-induced PCOS rat model with metformin, detected the pathological recovery of PCOS, and then assessed the effects of metformin on H2O2-induced autophagy in ovarian granulosa cells (GCs) by detecting the level of oxidative stress and the expression of autophagy-associated proteins and key proteins in the PI3K/AKT/mTOR pathway. We demonstrated that metformin ameliorated PCOS in a rat model by downregulating autophagy in GCs, and metformin decreased the levels of oxidative stress and autophagy in H2O2-induced GCs and affected the PI3K/AKT/mTOR signaling pathway. Taken together, our results indicate that metformin ameliorates PCOS in a rat model by decreasing excessive autophagy in GCs via the PI3K/AKT/mTOR pathway, and this study provides evidence for targeted reduction of excessive autophagy of ovarian granulosa cells and improvement of PCOS.
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Affiliation(s)
- Bo Xu
- Key Laboratory of Fertility Preservation and Maintenance of Ministry of Education, School of Basic Medical Sciences, Ningxia Medical University, Yinchuan 750004, China
| | - Wenjie Dai
- Key Laboratory of Fertility Preservation and Maintenance of Ministry of Education, School of Basic Medical Sciences, Ningxia Medical University, Yinchuan 750004, China
| | - Ling Liu
- Key Laboratory of Fertility Preservation and Maintenance of Ministry of Education, School of Basic Medical Sciences, Ningxia Medical University, Yinchuan 750004, China
| | - Hang Han
- Key Laboratory of Fertility Preservation and Maintenance of Ministry of Education, School of Basic Medical Sciences, Ningxia Medical University, Yinchuan 750004, China
| | - Jingjing Zhang
- Key Laboratory of Fertility Preservation and Maintenance of Ministry of Education, School of Basic Medical Sciences, Ningxia Medical University, Yinchuan 750004, China
| | - Xing Du
- Key Laboratory of Fertility Preservation and Maintenance of Ministry of Education, School of Basic Medical Sciences, Ningxia Medical University, Yinchuan 750004, China
| | - Xiuying Pei
- Key Laboratory of Fertility Preservation and Maintenance of Ministry of Education, School of Basic Medical Sciences, Ningxia Medical University, Yinchuan 750004, China
| | - Xufeng Fu
- Key Laboratory of Fertility Preservation and Maintenance of Ministry of Education, School of Basic Medical Sciences, Ningxia Medical University, Yinchuan 750004, China
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Rehman R, Alam F, Abidi SH, Farooqi N, Jehan F. Oxidative stress and metformin: An in-vitro study on serum and primary human granulosa cell cultures. ELECTRONIC JOURNAL OF GENERAL MEDICINE 2022. [DOI: 10.29333/ejgm/12037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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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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9
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Liu MM, Chen XH, Lu XM, Wang FF, Wang C, Liu Y, Li PL, Du BT, Liang S, Gong PD, Wang YX. Variations in the Profiles of Vascular-Related Factors Among Different Sub-Types of Polycystic Ovarian Syndrome in Northern China. Front Endocrinol (Lausanne) 2021; 11:527592. [PMID: 33716949 PMCID: PMC7953058 DOI: 10.3389/fendo.2020.527592] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 12/04/2020] [Indexed: 11/13/2022] Open
Abstract
Recently, a growing body of evidence has suggested that abnormal ovarian angiogenesis, secondary to the imbalance between various angiogenic markers, is involved in the pathogenesis of PCOS, and this has led to the use of various interventions (such as Diane-35) to restore the normal ovarian angiogenesis. Therefore, we conducted the current investigation to determine the role of such markers (endothelial growth factor (VEGF), endostatin (ES), and thrombospondin-1 (TSP-1)) in the pathogenesis of PCOS along with the associated changes in ovarian blood flow in patients with PCOS compared to healthy controls, both before and after a course of oral contraception. A total of 381 patients with PCOS and 98 healthy females of childbearing age were recruited from July 2014 to June 2017 at the Reproductive Center of the Second Affiliated Hospital of Harbin Medical University. The serum levels of VEGF, ES, and TSP-1 were determined by enzyme-linked immunosorbent assay, while ovarian perfusion was measured by the pulsatility index (PI) and resistance index (RI) by using transvaginal color Doppler ultrasound. Repeated analyses were carried out after 3 months of Diane-35 treatment. Post-treatment serum levels of luteinizing hormone (LH)/follicle stimulating hormone (FSH) ratio of patients with PCOS decreased significantly (P <0.05). The RI values of most PCOS patients increased after treatment (P<0.05), while PI was significantly increased in all patients (P<0.05). However, variable changes in the serum levels of TSP-1, VEGF, and ES after treatment were observed. Serum VEGF levels showed a negative correlation with serum LH/FSH ratio, T concentration, and ES (P <0.05), while ES levels were negatively correlated with serum T concentrations only (P<0.05). The markers of angiogenesis (VEGF, ES, and TSP-1) were expressed differently among PCOS patients, who also responded differently to the same course of Diane-35 treatment. This field still warrants further investigation to reach a more definitive conclusion.
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Affiliation(s)
- Mei-mei Liu
- Department of Gynaecology and Obstetrics, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
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10
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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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11
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Palomba S, Piltonen TT, Giudice LC. Endometrial function in women with polycystic ovary syndrome: a comprehensive review. Hum Reprod Update 2020; 27:584-618. [PMID: 33302299 DOI: 10.1093/humupd/dmaa051] [Citation(s) in RCA: 137] [Impact Index Per Article: 34.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 09/29/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Polycystic ovary syndrome (PCOS) is the most common cause of anovulatory infertility. An endometrial component has been suggested to contribute to subfertility and poor reproductive outcomes in affected women. OBJECTIVE AND RATIONALE The aim of this review was to determine whether there is sufficient evidence to support that endometrial function is altered in women with PCOS, whether clinical features of PCOS affect the endometrium, and whether there are evidence-based interventions to improve endometrial dysfunction in PCOS women. SEARCH METHODS An extensive literature search was performed from 1970 up to July 2020 using PubMed and Web of Science without language restriction. The search included all titles and abstracts assessing a relationship between PCOS and endometrial function, the role played by clinical and biochemical/hormonal factors related to PCOS and endometrial function, and the potential interventions aimed to improve endometrial function in women with PCOS. All published papers were included if considered relevant. Studies having a specific topic/hypothesis regarding endometrial cancer/hyperplasia in women with PCOS were excluded from the analysis. OUTCOMES Experimental and clinical data suggest that the endometrium differs in women with PCOS when compared to healthy controls. Clinical characteristics related to the syndrome, alone and/or in combination, may contribute to dysregulation of endometrial expression of sex hormone receptors and co-receptors, increase endometrial insulin-resistance with impaired glucose transport and utilization, and result in chronic low-grade inflammation, immune dysfunction, altered uterine vascularity, abnormal endometrial gene expression and cellular abnormalities in women with PCOS. Among several interventions to improve endometrial function in women with PCOS, to date, only lifestyle modification, metformin and bariatric surgery have the highest scientific evidence for clinical benefit. WIDER IMPLICATIONS Endometrial dysfunction and abnormal trophoblast invasion and placentation in PCOS women can predispose to miscarriage and pregnancy complications. Thus, patients and their health care providers should advise about these risks. Although currently no intervention can be universally recommended to reverse endometrial dysfunction in PCOS women, lifestyle modifications and metformin may improve underlying endometrial dysfunction and pregnancy outcomes in obese and/or insulin resistant patients. Bariatric surgery has shown its efficacy in severely obese PCOS patients, but a careful evaluation of the benefit/risk ratio is warranted. Large scale randomized controlled clinical trials should address these possibilities.
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Affiliation(s)
- Stefano Palomba
- Unit of Obstetrics and Gynecology, Grande Ospedale Metropolitano of Reggio Calabria, Reggio Calabria, Italy
| | - Terhi T Piltonen
- Department of Obstetrics and Gynecology, PEDEGO Research Unit, Medical Research Center, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Linda C Giudice
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, CA, USA
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12
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The efficacy of different insulin-sensitizing agents on treatment outcomes in patients with polycystic ovary syndrome who underwent in-vitro fertilization: A retrospective, record-based, comparative study. J Gynecol Obstet Hum Reprod 2020; 50:102006. [PMID: 33242676 DOI: 10.1016/j.jogoh.2020.102006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 10/28/2020] [Accepted: 11/21/2020] [Indexed: 11/24/2022]
Abstract
INTRODUCTION It is not clear which metformin or inositol is more effective on IVF results. The aim of this study was to compare the effects of Metformin and Inositol co-treatments on IVF outcomes in Polycystic ovary syndrome patients. METHODS A retrospective examination was made of the demographic characteristics and the follicular-embryonic development results of PCOS patients applied with an antagonist protocol of ovarian hyperstimulation in the first cycle of IVF with co-treatment of Metformin at 2000 mg/day regularly for 3 months (Metformin co-treatment group, n:35) or Inositol at 4000 mg/day myo-inositol for 3 months (Inositol co-treatment group, n:34) and those not using any co-treatment (FSH only group [control group], n:40). RESULTS No significant difference was determined between the groups in respect of demographic characteristics. The HOMA-IR scores and hCG day E2 level were significantly higher in the control group than in both co-treatment groups (p = 0.021, p = 0.018, respectively). The M1 oocyte count was significantly lower in the Metformin group than in the Inositol and control groups (p = 0.001). The GVDJ oocyte count was significantly lower in both co-treatment groups than in the control group (p = 0.042). No statistically significant difference was determined between the groups in respect of other follicular and embryological development parameters, implantation, clinical pregnancy, live births and abortus rates. CONCLUSION Insulin-sensitizing agents may have positive effects on follicular development in PCOS patients applied with IVF.
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Wu Y, Tu M, Huang Y, Liu Y, Zhang D. Association of Metformin With Pregnancy Outcomes in Women With Polycystic Ovarian Syndrome Undergoing In Vitro Fertilization: A Systematic Review and Meta-analysis. JAMA Netw Open 2020; 3:e2011995. [PMID: 32744629 PMCID: PMC7399751 DOI: 10.1001/jamanetworkopen.2020.11995] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
IMPORTANCE Metformin is widely used among women with polycystic ovary syndrome (PCOS). However, its associations with outcomes of in vitro fertilization or intracytoplasmic sperm injection and embryo transfer (IVF/ICSI-ET) in women with PCOS remain controversial. OBJECTIVE To assess whether metformin is associated with improved outcomes of IVF/ICSI-ET in women with PCOS. DATA SOURCES PubMed, Embase, and Cochrane were searched from database inception to January 31, 2020. STUDY SELECTION Only randomized clinical trials (RCTs) were included. Eligible studies enrolled women with PCOS undergoing infertility treatment with IVF/ICSI-ET and reported at least 1 outcome of IVF/ICSI-ET. DATA EXTRACTION AND SYNTHESIS This study followed the Preferred Reporting Items for Systematic Reviews and Meta analyses guidelines. Two authors independently extracted the data. Study quality was evaluated using the GRADE system. Treatment effect was quantified using odds ratios (ORs) with 95% CIs using random-effect models with the Mantel-Haenszel method. MAIN OUTCOMES AND MEASURES Ovarian hyperstimulation syndrome (OHSS), clinical pregnancy rate, and live birth rate. RESULTS A total of 12 RCTs, which collectively included 1123 women with PCOS undergoing infertility treatment with IVF/ICSI-ET, were identified. The risk of OHSS in women randomized to metformin was lower than in women not randomized to metformin (OR, 0.43; 95% CI, 0.24-0.78), although this difference was not significant for women with PCOS with a body mass index of less than 26 (OR, 0.67; 95% CI, 0.30-1.51). There was no significant difference in clinical pregnancy rate (OR, 1.24; 95% CI, 0.82-1.86) or live birth rate (OR, 1.23; 95% CI, 0.74-2.04) in the total population studied. However, in a post hoc analysis among women with a body mass index of 26 or greater, metformin treatment was associated with increased clinical pregnancy rates (OR, 1.71; 95% CI, 1.12-2.60). CONCLUSIONS AND RELEVANCE In this study, metformin treatment was associated with a decreased risk of OHSS but had no association with the overall clinical pregnancy rate or live birth rate among women with PCOS undergoing IVF/ICSI-ET. Metformin treatment should be carefully considered for women with PCOS undergoing IVF/ICSI-ET and may be more preferred for women with a body mass index greater than 26.
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Affiliation(s)
- Yiqing Wu
- Women’s Reproductive Health Research Key Laboratory of Zhejiang Province, Women’s Hospital, Department of Reproductive Endocrinology, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Mixue Tu
- Key Laboratory of Reproductive Genetics, Zhejiang University, Ministry of Education, Hangzhou, Zhejiang, China
| | - Yun Huang
- Women’s Reproductive Health Research Key Laboratory of Zhejiang Province, Women’s Hospital, Department of Reproductive Endocrinology, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Yifeng Liu
- Women’s Reproductive Health Research Key Laboratory of Zhejiang Province, Women’s Hospital, Department of Reproductive Endocrinology, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Dan Zhang
- Women’s Reproductive Health Research Key Laboratory of Zhejiang Province, Women’s Hospital, Department of Reproductive Endocrinology, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
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14
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Facchinetti F, Appetecchia M, Aragona C, Bevilacqua A, Bezerra Espinola MS, Bizzarri M, D'Anna R, Dewailly D, Diamanti-Kandarakis E, Hernández Marín I, Kamenov ZA, Kandaraki E, Laganà AS, Monastra G, Montanino Oliva M, Nestler JE, Orio F, Ozay AC, Papalou O, Pkhaladze L, Porcaro G, Prapas N, Soulage CO, Stringaro A, Wdowiak A, Unfer V. Experts' opinion on inositols in treating polycystic ovary syndrome and non-insulin dependent diabetes mellitus: a further help for human reproduction and beyond. Expert Opin Drug Metab Toxicol 2020; 16:255-274. [PMID: 32129111 DOI: 10.1080/17425255.2020.1737675] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Introduction: This Experts' opinion provides an updated scientific support to gynecologists, obstetricians, endocrinologists, nutritionists, neurologists and general practitioners on the use of Inositols in the therapy of Polycystic Ovary Syndrome (PCOS) and non-insulin dependent (type 2) diabetes mellitus (NIDDM).Areas covered: This paper summarizes the physiology of Myo-Inositol (MI) and D-Chiro-Inositol (DCI), two important molecules present in human organisms, and their therapeutic role, also for treating infertility. Some deep differences between the physiological functions of MI and DCI, as well as their safety and intestinal absorption are discussed. Updates include new evidence on the efficacy exerted in PCOS by the 40:1 MI/DCI ratio, and the innovative approach based on alpha-lactalbumin to overcome the decreased therapeutic efficacy of Inositols in some patients.Expert opinion: The evidence suggests that MI, alone or with DCI in the 40:1 ratio, offers a promising treatment for PCOS and NIDDM. However, additional studies need to evaluate some still unresolved issues, such as the best MI/DCI ratio for treating NIDDM, the potential cost-effectiveness of reduced gonadotropins administration in IVF due to MI treatment, or the benefit of MI supplementation in ovulation induction with clomiphene citrate in PCOS patients.
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Affiliation(s)
- Fabio Facchinetti
- Department of Obstetrics and Gynecology and Pediatrics, University of Modena and Reggio Emilia, Modena, Italy
| | - Marialuisa Appetecchia
- Oncological Endocrinology Unit, Regina Elena National Cancer Institute - IRCCS, Rome, Italy
| | - Cesare Aragona
- Systems Biology Group Lab, Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Arturo Bevilacqua
- Department of Dynamic and Clinical Psychology, Sapienza University of Rome, Rome, Italy
| | | | - Mariano Bizzarri
- Systems Biology Group Lab, Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Rosario D'Anna
- Unit of Gynecology and Obstetrics, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University of Messina, Messina, Italy
| | - Didier Dewailly
- Faculty of Medicine, University of Lille, Lille, France.,INSERM, Laboratory of Development and Plasticity of the Neuroendocrine Brain, Jean-Pierre Aubert Research Centre, Lille, France
| | | | - Imelda Hernández Marín
- Human Reproduction Department, Hospital Juárez de México, México City Mexico.,Facultad de Medicina, Universidad Nacional Autónoma De México (UNAM), México City, México
| | - Zdravko A Kamenov
- Department of Internal Medicine, Medical University of Sofia, Sofia, Bulgaria
| | - Eleni Kandaraki
- Department of Endocrinology & Diabetes, HYGEIA Hospital, Marousi, Athens, Greece
| | - Antonio Simone Laganà
- Department of Obstetrics and Gynecology, "Filippo Del Ponte" Hospital, University of Insubria, Varese, Italy
| | - Giovanni Monastra
- Systems Biology Group Lab, Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | | | - John E Nestler
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Francesco Orio
- Department of Endocrinology, "Parthenope" University of Naples, Italy
| | - Ali Cenk Ozay
- Faculty of Medicine, Department of Obstetrics and Gynecology, Near East University, Nicosia Cyprus.,Near East University, Research Center of Experimental Health Sciences, Nicosia, Cyprus
| | - Olga Papalou
- Department of Endocrinology & Diabetes, HYGEIA Hospital, Marousi, Athens, Greece
| | - Lali Pkhaladze
- Department of Gynecological Endocrinology, Ioseb Zhordania Institute of Reproductology, Tbilisi, Georgia
| | | | - Nikos Prapas
- 3rd Department of OB-GYNAE, Aristotle University of Thessaloniki, Thessaloniki Greece.,IVF Laboratory, IAKENTRO Fertility Centre, Thessaloniki, Greece
| | | | - Annarita Stringaro
- National Center for Drug Research and Evaluation - Italian National Institute of Health, Rome, Italy
| | - Artur Wdowiak
- Diagnostic Techniques Unit, Medical University of Lublin, Poland
| | - Vittorio Unfer
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
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15
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Di Pietro M, Velazquez C, Matzkin ME, Frungieri MB, Peña MG, de Zúñiga I, Pascuali N, Irusta G, Bianchi MS, Parborell F, Abramovich D. Metformin has a direct effect on ovarian cells that is dependent on organic cation transporters. Mol Cell Endocrinol 2020; 499:110591. [PMID: 31546019 DOI: 10.1016/j.mce.2019.110591] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 09/19/2019] [Accepted: 09/20/2019] [Indexed: 12/13/2022]
Abstract
Metformin (MET) is the most widely prescribed hypoglycemic drug in type 2 diabetes and Polycystic Ovary Syndrome. Besides its effects on glucose metabolism, MET exerts beneficial effects on these patients' fertility. However, the exact mechanisms of action of MET on female fertility are still unclear. In this work, we analyzed a possible direct effect of MET on ovarian cells. We found expression of the organic cation transporters OCT1, OCT2 and OCT3, responsible for MET uptake into the cells, in rat granulosa cells and human cumulus cells. Furthermore, MET increased pAMPK and decreased VEGF levels both in vivo and in rat granulosa cells in culture. These last effects were reversed when OCTs were inhibited. Our results suggest that MET acts directly on ovarian cells regulating cell metabolism and VEGF expression. Our findings are relevant to optimize PCOS fertility treatment and to explore ovarian MET actions in other female pathologies.
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Affiliation(s)
- Mariana Di Pietro
- Instituto de Biología y Medicina Experimental-Consejo Nacional de Investigaciones Científicas y Técnicas (IByME-CONICET), Ciudad Autónoma de Buenos Aires, Argentina
| | - Candela Velazquez
- Instituto de Biología y Medicina Experimental-Consejo Nacional de Investigaciones Científicas y Técnicas (IByME-CONICET), Ciudad Autónoma de Buenos Aires, Argentina
| | - María Eugenia Matzkin
- Instituto de Biología y Medicina Experimental-Consejo Nacional de Investigaciones Científicas y Técnicas (IByME-CONICET), Ciudad Autónoma de Buenos Aires, Argentina
| | - Mónica Beatriz Frungieri
- Instituto de Biología y Medicina Experimental-Consejo Nacional de Investigaciones Científicas y Técnicas (IByME-CONICET), Ciudad Autónoma de Buenos Aires, Argentina; Cátedra de Química, Ciclo Básico Común, Universidad de Buenos Aires, Ciudad de Buenos Aires, Argentina
| | - Mariana Gómez Peña
- Centro Médico Pregna Medicina Reproductiva. Ciudad Autónoma de Buenos Aires, Argentina
| | - Ignacio de Zúñiga
- Centro Médico Pregna Medicina Reproductiva. Ciudad Autónoma de Buenos Aires, Argentina
| | - Natalia Pascuali
- Instituto de Biología y Medicina Experimental-Consejo Nacional de Investigaciones Científicas y Técnicas (IByME-CONICET), Ciudad Autónoma de Buenos Aires, Argentina
| | - Griselda Irusta
- Instituto de Biología y Medicina Experimental-Consejo Nacional de Investigaciones Científicas y Técnicas (IByME-CONICET), Ciudad Autónoma de Buenos Aires, Argentina
| | - María Silvia Bianchi
- Instituto de Biología y Medicina Experimental-Consejo Nacional de Investigaciones Científicas y Técnicas (IByME-CONICET), Ciudad Autónoma de Buenos Aires, Argentina
| | - Fernanda Parborell
- Instituto de Biología y Medicina Experimental-Consejo Nacional de Investigaciones Científicas y Técnicas (IByME-CONICET), Ciudad Autónoma de Buenos Aires, Argentina
| | - Dalhia Abramovich
- Instituto de Biología y Medicina Experimental-Consejo Nacional de Investigaciones Científicas y Técnicas (IByME-CONICET), Ciudad Autónoma de Buenos Aires, Argentina.
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16
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Banaszewska B, Pawelczyk L, Spaczynski R. Current and future aspects of several adjunctive treatment strategies in polycystic ovary syndrome. Reprod Biol 2019; 19:309-315. [DOI: 10.1016/j.repbio.2019.09.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 09/20/2019] [Accepted: 09/21/2019] [Indexed: 12/12/2022]
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17
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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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18
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Kemp A, El-Toukhy T. A narrative review of adjuvants in in vitro fertilisation: evidence for good clinical practice. J OBSTET GYNAECOL 2019; 40:295-302. [PMID: 31661334 DOI: 10.1080/01443615.2019.1647518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
A review of studies published between January 1, 1984 and January 31, 2019 was performed with the aim of analysing the efficacy and adverse effects of commonly used adjuvants to in vitro fertilisation. The authors preferentially selected recent systematic reviews and randomised control trials (where available) from an electronic literature search. The review showed that low molecular weight heparin, corticosteroids and embryo glue may be of use in selected patient groups. Other adjuncts (such as growth hormone, assisted hatching, endometrial disruption and dehydroepiandrosterone) cannot currently be recommended as collated results showed no overall benefit to clinical pregnancy rates or live birth rates. There is a significant lack of robust evidence in this field, and areas in particular need of further research have been highlighted. In conclusion, caution should be exercised in prescribing adjuvants in in vitro fertilisation, either individually or in combination as further research is needed to ascertain their efficacy. Many adjuvants carry the risk of adverse effects which should also be considered. Patients should be clearly informed of the evidence, and where it is lacking, for these treatments. There is a need for further good quality trials to address the questions regarding best practice.
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Affiliation(s)
- Annabel Kemp
- Assisted Conception Unit, Guys and St Thomas's Foundation Trust, Guys Hospital, London, UK
| | - Tarek El-Toukhy
- Assisted Conception Unit, Guys and St Thomas's Foundation Trust, Guys Hospital, London, UK
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Wang Q, Shang J, Zhang Y, Zhou W. Metformin and sitagliptin combination therapy ameliorates polycystic ovary syndrome with insulin resistance through upregulation of lncRNA H19. Cell Cycle 2019; 18:2538-2549. [PMID: 31405334 DOI: 10.1080/15384101.2019.1652036] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Insulin resistance (IR) is prevalent in women with polycystic ovary syndrome (PCOS). Improvement in insulin sensitivity remains one of the most effective treatment strategies for women with PCOS. This study aims to investigate the efficacy and potential mechanism of the combination therapy with metformin (DMBG) and sitagliptin (TECOS) in PCOS. To address this, insulin was used to treat rat ovarian granulosa cells to establish the cellular PCOS model. Insulin and human chorionic gonadotropin (HCG) were subcutaneously injected into SD rats to establish a rat model of hyperandrogenism with pathogenesis similar to PCOS. Our results showed that co-treatment with TECOS and DMBG attenuated the induced apoptosis and insulin resistance (IR) in PCOS model cells, and improved reproductive hormone disorders, ovarian polycystic changes, and IR of PCOS rats. Mechanistically, upregulation of H19 by H19-expressing lentiviruses enhanced efficacy of combination therapy. Furthermore, co-treatment with TECOS and DMBG induced H19 expression via suppressing the PI3K/AKT-DNMT1 pathway. Collectively, these findings demonstrate that combination treatment with TECOS and DMBG ameliorates PCOS with IR, at least partially, through upregulation of lncRNA H19.
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Affiliation(s)
- Qiong Wang
- Department of Endocrinology, Henan Provincial People's Hospital , Zhengzhou , Henan , China
| | - Jing Shang
- Department of Endocrinology, Henan Provincial People's Hospital , Zhengzhou , Henan , China
| | - Yun Zhang
- Department of Endocrinology, Henan Provincial People's Hospital , Zhengzhou , Henan , China
| | - Wei Zhou
- Department of Neurosurgery, Henan Provincial People's Hospital , Zhengzhou , Henan , China
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20
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Hirshberg B, Rheinboldt M. Multimodality imaging of acute locoregional and systemic complications in the setting of assisted reproduction. Emerg Radiol 2019; 26:205-219. [PMID: 30631995 DOI: 10.1007/s10140-018-01665-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 12/13/2018] [Indexed: 02/02/2023]
Abstract
Over the past 40 years since the first in vitro fertilization was performed, both the role of assisted reproductive technology (ART) in establishing viable pregnancy as well as the available treatment options have expanded enormously. Annually in the USA, nearly 2% of pregnancies now employ some form of ART assistance, with in vitro fertilization (IVF) being the most commonly utilized methodology. Both maternal and fetal risks are elevated in ART pregnancies, the latter including adverse outcome due to both increased gestational number as well as advanced maternal age. Maternal risks may be divided into locoregional and systemic complications. Adverse pelvic complications include those relating to gamete harvesting and transfer, ovarian hyperstimulation, the sequela of ectopic and heterotopic pregnancies, as well as ovarian torsion, all of which are elevated in the ART cohort. Ovarian hyperstimulation syndrome is the most commonly encountered complication, with both systemic and pelvic features relating to increased vascular permeability, hemoconcentration, and ascites. While life-threatening cases are relatively rare, moderate and severe manifestations may occur in up to 10% of ART cycles and, as such, are a not infrequent cause for ER visitation. Familiarity with the clinical and imaging manifestations of ART complications as well as their prognostic implications will facilitate a timely diagnosis and assist the interpreting radiologist in best expediting appropriate clinical care. In this article, we will briefly discuss the current methodology of ART then present an imaging-based multimodality review of the potentially encountered adverse maternal sequela, highlighting key diagnostic features and differential considerations as well as potential prognostic implications.
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21
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Rehman R, Abidi SH, Alam F. Metformin, Oxidative Stress, and Infertility: A Way Forward. Front Physiol 2018; 9:1722. [PMID: 30555352 PMCID: PMC6281994 DOI: 10.3389/fphys.2018.01722] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 11/15/2018] [Indexed: 12/11/2022] Open
Affiliation(s)
- Rehana Rehman
- Department of Biological and Biomedical Sciences, Aga Khan University, Karachi, Pakistan
| | - Syed Hani Abidi
- Department of Biological and Biomedical Sciences, Aga Khan University, Karachi, Pakistan
| | - Faiza Alam
- Department of Physiology, University of Karachi, Karachi, Pakistan
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22
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Coughlan C. What to do when good-quality embryos repeatedly fail to implant. Best Pract Res Clin Obstet Gynaecol 2018; 53:48-59. [DOI: 10.1016/j.bpobgyn.2018.07.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 07/12/2018] [Accepted: 07/17/2018] [Indexed: 12/22/2022]
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23
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Abdalmageed OS, Farghaly TA, Abdelaleem AA, Abdelmagied AE, Ali MK, Abbas AM. Impact of Metformin on IVF Outcomes in Overweight and Obese Women With Polycystic Ovary Syndrome: A Randomized Double-Blind Controlled Trial. Reprod Sci 2018; 26:1336-1342. [PMID: 29576001 DOI: 10.1177/1933719118765985] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To evaluate the impact of metformin on in vitro fertilization (IVF) outcomes in overweight and obese women with polycystic ovary syndrome (PCOS). METHODS This was a randomized double-blind placebo-controlled study ( ClinicalTrials.gov : NCT02910817) carried out in a University IVF Center. The study included 102 overweight and obese women (body mass index [BMI] >24 kg/m2) with PCOS who underwent their first fresh autologous IVF-embryo transfer cycle and agreed to participate in the study. The study participants were randomized into 2 groups: metformin group received metformin (1000 mg per day) at the start of controlled ovarian stimulation (COH) until the day of the pregnancy check, and placebo group received placebo tablets in the same duration. The primary outcome measure was the total number of retrieved oocytes. RESULTS Both groups were homogenous in baseline demographic characteristics. Metformin group versus the placebo group demonstrated decrease in the mean number of the retrieved oocytes (9.06 ± 4.23 vs 16.86 ± 8.3, P < .01) and similar live birth rate (LBR; 25.5% vs 17.6%, P = .34). The number of fertilized oocytes was lower in the metformin group (5.65 ± 2.66 vs 9 ± 4.55, P < .01). However, the fertilization rate was similar in both groups (62.3% vs 53.4%, P = .10). There was no difference in the implantation rate (15.7% vs 11.8%, P = .32), multiple pregnancy rate (13.4% vs 3.9%, P = .08), or miscarriage rate (23.5% vs 35.7%, P = .46). No cases of ovarian hyperstimulation syndrome (OHSS) were observed in both groups. CONCLUSION Short-term administration of metformin to overweight or obese women with PCOS undergoing IVF decreased number of the retrieved oocytes but did not improve the LBR. SYNOPSIS Metformin use could decrease the number of retrieved oocytes in overweight and obese women with polycystic ovary syndrome undergoing IVF.
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Affiliation(s)
| | | | | | | | - Mohammed K Ali
- Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Ahmed M Abbas
- Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt
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Dahan MH, Tannus S, Seyhan A, Tan SL, Ata B. Combined modalities for the prevention of ovarian hyperstimulation syndrome following an excessive response to stimulation. Gynecol Endocrinol 2018; 34:252-255. [PMID: 29057693 DOI: 10.1080/09513590.2017.1391206] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Although the classification and management of ovarian hyperstimulation syndrome (OHSS) are well described in the literature, little attention has been given to modalities that aim to prevent its occurrence. In this retrospective study, we sought to investigate whether a combination of modalities in addition to GnRH agonist triggering in GnRH antagonist cycles could result in better prevention of OHSS. The study included 170 hyperresponder patients who were stimulated with GnRH antagonist protocol and were triggered with GnRH agonist for final oocyte maturation. Freeze all embryos was performed in all patients. The intervention group included treatment with dopamine agonist and restarting the GnRH antagonist. Of the 170 patients included, 63 were included in the intervention group. Compared to no intervention, women in the intervention group were more likely to have: menses within 7 days of the oocyte retrieval, smaller ovarian diameter, the absence of free pelvic fluid, less hemoconcentration and higher serum sodium levels. It can be concluded that combining other modalities in addition to triggering with GnRH agonist in GnRH antagonist cycles, results in targeting several pathways that lead to OHSS and result in rapid resolution of signs of ovarian hyperstimulation.
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Affiliation(s)
- Michael H Dahan
- a Department of Obstetrics and Gynecology , Division of Reproductive Endocrinology, McGill University , Montreal , Quebec, Canada
| | - Samer Tannus
- a Department of Obstetrics and Gynecology , Division of Reproductive Endocrinology, McGill University , Montreal , Quebec, Canada
| | - Ayse Seyhan
- a Department of Obstetrics and Gynecology , Division of Reproductive Endocrinology, McGill University , Montreal , Quebec, Canada
| | - Seang Lin Tan
- a Department of Obstetrics and Gynecology , Division of Reproductive Endocrinology, McGill University , Montreal , Quebec, Canada
| | - Baris Ata
- a Department of Obstetrics and Gynecology , Division of Reproductive Endocrinology, McGill University , Montreal , Quebec, Canada
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Rao M, Zeng Z, Tang L. Maternal physical activity before IVF/ICSI cycles improves clinical pregnancy rate and live birth rate: a systematic review and meta-analysis. Reprod Biol Endocrinol 2018; 16:11. [PMID: 29415732 PMCID: PMC5803901 DOI: 10.1186/s12958-018-0328-z] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 01/29/2018] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE This meta-analysis was aimed to evaluate the association between maternal physical activity before IVF/ICSI cycles and reproductive outcomes. METHODS We searched databases of PubMed, EMBASE and Web of Science electronic databases, and ongoing trials up to November 2017 to identify studies that focused on the relationship between maternal physical activity before IVF/ICSI cycles and reproductive outcomes, including implantation rate, clinical pregnancy rate, miscarriage rate and live birth rate. Odds ratio (OR) with 95% confidence intervals, were calculated to assess the results of each outcome. RESULTS Eight published studies encompassing 3683 infertile couples undergoing IVF/ICSI treatment were included into the analysis. There was an increasing, but not statistically significant, trend in implantation rate for physically active women when compared with physically inactive women (OR = 1.95, 95% CI 0.99-3.83, I2 = 77%). No significant difference was found in miscarriage rate between physically active women and physically inactive women (OR = 0.76, 95% CI 0.41-1.44, I2 = 49%). However, rates of clinical pregnancy and live births in physically active women were significantly higher than those in physically inactive women (OR = 1.96, 95% CI 1.40, 2.73, I2 = 42% and OR = 1.95, 95% CI 1.06-3.59, I2 = 82%, respectively). Subgroup analysis helped to confirm these results. CONCLUSIONS Female physical activity before IVF/ICSI cycles was associated with increased rates of clinical pregnancy and live births, whereas only a small but not statistically significant increase was found in implantation rate, and no effect was shown on miscarriage rate.
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Affiliation(s)
- Meng Rao
- Department of reproduction and genetics, the First Affiliated Hospital of Kunming Medical University, No. 295 Xi Chang road, Kunming, 650032, China
| | - Zhengyan Zeng
- Department of Neurology, the First Affiliated Hospital of Kunming Medical University, Kunming, 650032, China
| | - Li Tang
- Department of reproduction and genetics, the First Affiliated Hospital of Kunming Medical University, No. 295 Xi Chang road, Kunming, 650032, China.
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Di Pietro M, Pascuali N, Parborell F, Abramovich D. Ovarian angiogenesis in polycystic ovary syndrome. Reproduction 2018; 155:R199-R209. [PMID: 29386378 DOI: 10.1530/rep-17-0597] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 01/30/2018] [Indexed: 12/16/2022]
Abstract
Polycystic ovary syndrome (PCOS) is the most prevalent endocrine pathology among women in reproductive age. Its main symptoms are oligo or amenorrhea, hyperandrogenism and the presence of ovarian cysts. It is also associated with infertility, obesity and insulin resistance. Mainly due to its heterogeneity, PCOS treatments are directed to manage its symptoms and to prevent associated diseases. The correct formation and regression of blood vessels during each ovarian cycle is indispensable for proper follicular development, ovulation and corpus luteum formation. The importance of these processes opened a new and promising field: ovarian angiogenesis. Vascular alterations characterize numerous pathologies, either with increased, decreased or abnormal angiogenesis. In the last years, several anomalies of ovarian angiogenesis have been described in women with PCOS. Therefore, it has been suggested that these alterations may be associated with the decreased - or lack of - ovulation rates and for the formation of cysts in the PCOS ovaries. Restoration of a proper vessel formation in the ovaries may lead to improved follicular development and ovulation in these patients. In the present review, we attempt to summarize the alterations in ovarian angiogenesis that have been described in women with PCOS. We also discuss the therapeutic approaches aimed to correct these alterations and their beneficial effects on the treatment of infertility in PCOS.
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Affiliation(s)
- Mariana Di Pietro
- Instituto de Biología y Medicina Experimental (IByME-CONICET)Buenos Aires, Argentina
| | - Natalia Pascuali
- Instituto de Biología y Medicina Experimental (IByME-CONICET)Buenos Aires, Argentina
| | - Fernanda Parborell
- Instituto de Biología y Medicina Experimental (IByME-CONICET)Buenos Aires, Argentina
| | - Dalhia Abramovich
- Instituto de Biología y Medicina Experimental (IByME-CONICET)Buenos Aires, Argentina
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Fraga F, Romeiro G, Sá LBPCD, Arbex AK. Polycystic Ovary Syndrome and the Role of Metformin in Ovulation Induction. Health (London) 2018. [DOI: 10.4236/health.2018.105045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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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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Al-Ruthia YS, Al-Mandeel H, AlSanawi H, Balkhi B, Mansy W, AlGasem R, AlMutairi L. The effect of metformin use on pregnancy rates among polycystic ovary syndrome patients undergoing in vitro fertilization: A retrospective-cohort study. Saudi Pharm J 2017; 25:906-910. [PMID: 28951677 PMCID: PMC5605958 DOI: 10.1016/j.jsps.2017.02.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2016] [Accepted: 02/12/2017] [Indexed: 11/26/2022] Open
Abstract
Background Metformin is widely used with gonadotropins by women with polycystic ovary syndrome (PCOS) during in vitro fertilization (IVF) to increase their chances of pregnancy. The aim of this study was to evaluate the efficacy of metformin in improving the rates of clinical pregnancy among women with PCOS undergoing IVF. Methods This was a retrospective cohort study of women with PCOS, aged 18–40 years, undergoing IVF during 2006–2012 at a University Hospital in Riyadh, Saudi Arabia. Baseline patient data including menstrual frequency, biochemical parameters such as fasting serum insulin (FSI) concentration, comorbidities, and the rates of ovulation and pregnancy were collected. Pregnancy rates were compared between the metformin and non-metformin groups. Results A total of 210 women with PCOS met the inclusion criteria and were included in the study. Of the 210 women with PCOS, 109 of them received metformin in addition to gonadotropins. Patients who received metformin were 16% less likely to be pregnant in comparison with those who did not receive metformin (OR = 0.840; 95% CI = 0.710–0.993; P = 0.0415), when controlled for baseline prolactin level, testosterone level, lipid panel, FSI concentration, fasting plasma glucose (FPG) concentration, comorbidities, duration of infertility, daily metformin dosage, and the previous use of clomiphene and/or leuprolide. Conclusions Metformin co-treatment during IVF may negatively affect pregnancy rates. Further well-designed, randomized, double-blind placebo-control clinical trials are needed to confirm the findings of this study.
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Affiliation(s)
- Yazed Sulaiman Al-Ruthia
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Hazem Al-Mandeel
- Department of Obstetrics and Gynecology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Hisham AlSanawi
- Department of Orthopedic Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Bander Balkhi
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Wael Mansy
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Reem AlGasem
- Prince Muhammad Bin Abdulaziz Hospital, Riyadh, Saudi Arabia
| | - Lama AlMutairi
- King Abdulaziz University Hospital, Riyadh, Saudi Arabia
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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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Trenkić M, Mitić D, Pop-Trajković Dinić S, Kutlešić R, Živadinović R, Stefanović M, Vukomanović P, Krstić M, Aracki-Trenkić A, Trenkić-Božinović M. THE USE OF METFORMIN IN PATIENTS WITH POLYCYSTIC OVARY SYNDROME UNDERGOING IN VITRO FERTILIZATION. ACTA MEDICA MEDIANAE 2017. [DOI: 10.5633/amm.2017.0203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Kahyaoğlu S, Yılmaz B, Işık AZ. Pharmacokinetic, pharmacodynamic, and clinical aspects of ovulation induction agents: A review of the literature. J Turk Ger Gynecol Assoc 2017; 18:48-55. [PMID: 28506951 PMCID: PMC5450211 DOI: 10.4274/jtgga.2016.0107] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Controlled ovarian hyperstimulation is a key step for successful outcomes of assisted reproductive technique cycle outcomes. Many medications are available, which are commonly useed solely or in combination to achieve multiple follicular development. Pharmacokinetic, pharmacodynamic, and clinical information of ovulation induction drugs deserve to be elucidated for every individual patient before commencing infertility treatment. New concepts and new treatment protocols are introduced as ovulation physiology is understood by infertility specialists. Increasing treatment success by minimizing aderse effects is a milestone of all ovarian stimulation protocols that use these novel interventions. Achievement of a satisfactory cycle outcome includes retrieval of sufficient oocytes, a single clinical pregnancy, and avoidance of ovarian hyperstimulation syndrome. In this review, we evaluate the current literature to determine the most reliable and relevant information about the most used ovulation induction drugs.
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Affiliation(s)
- Serkan Kahyaoğlu
- Department of Obstetrics and Gynecology, Zekai Tahir Burak Women's Health Training and Research Hospital, Ankara, Turkey
| | - Bülent Yılmaz
- Department of Obstetrics and Gynecology, İzmir Katip Çelebi University Faculty of Medicine, Tepecik Training and Research Hospital, IVF Unit, İzmir, Turkey
| | - Ahmet Zeki Işık
- Assisted Reproductive Technologies Unit, Medical Park Hospital, İzmir, Turkey
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Palomba S, Daolio J, La Sala GB. Oocyte Competence in Women with Polycystic Ovary Syndrome. Trends Endocrinol Metab 2017; 28:186-198. [PMID: 27988256 DOI: 10.1016/j.tem.2016.11.008] [Citation(s) in RCA: 137] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Revised: 11/17/2016] [Accepted: 11/23/2016] [Indexed: 02/06/2023]
Abstract
Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in women of reproductive age and affects fertility and pregnancy in cases of oligoanovulation. Ovulation induction is often used to treat anovulatory patients with PCOS, but many of these women fail to conceive and resort to assisted reproductive technologies. Alterations in oocyte competence (OC) are considered potential causative factors for subfertility in women with PCOS. In this review we present and critically assess all recent clinical and experimental data regarding OC in women with PCOS. Our analysis demonstrates that the contribution of OC to reproductive potential in women with PCOS varies and largely depends on the PCOS phenotype and comorbidities associated with PCOS.
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Affiliation(s)
- Stefano Palomba
- Unit of Gynecology and Obstetrics, IRCCS - Arcispedale Santa Maria Nuova, Viale Risorgimento 80, Reggio Emilia 42123, Italy.
| | - Jessica Daolio
- Unit of Gynecology and Obstetrics, IRCCS - Arcispedale Santa Maria Nuova, Viale Risorgimento 80, Reggio Emilia 42123, Italy
| | - Giovanni Battista La Sala
- Unit of Gynecology and Obstetrics, IRCCS - Arcispedale Santa Maria Nuova, Viale Risorgimento 80, Reggio Emilia 42123, Italy; University of Modena and Reggio Emilia, Via Università 4, Modena 41100, Italy
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Abstract
This review attempts to summarize the known literature on high responders to ovarian stimulation during assisted reproductive techniques (ART). Response to gonadotrophins is subject to significant interindividual and intercycle variation, thus carrying a risk of high response or poor response to ovarian stimulation regimens. The main risk for high responders is the development of ovarian hyperstimulation syndrome (OHSS) which is associated with significant morbidity. Hence, the definition of high responders in the literature has primarily focussed on risk factors for OHSS. Strategies to reduce OHSS including tailoring of the ovarian stimulation regimens and adjusting gonadotrophin doses according to patient characteristics and findings during the cycle of stimulation. In addition, modifying the type of ovulation trigger used and adjuvant therapies, such as metformin, intravenous colloids and vascular endothelial growth factor blockers, have also been studied as options to reduce OHSS. Apart from the risk of OHSS, high response also appears to have an adverse impact on the oocyte and endometrium, though there is a paucity of data regarding the extent and mechanisms behind this impact.
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Affiliation(s)
- Mariano Mascarenhas
- a Seacroft Hospital , Leeds Centre for Reproductive Medicine , Leeds , United Kingdom
| | - Adam H Balen
- a Seacroft Hospital , Leeds Centre for Reproductive Medicine , Leeds , United Kingdom
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Romanski P, Stanic AK. Practical Approach to the PCOS Patient. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2017. [DOI: 10.1007/s13669-017-0190-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Kollmann M, Martins WP, Lima MLS, Craciunas L, Nastri CO, Richardson A, Raine-Fenning N. Strategies for improving outcome of assisted reproduction in women with polycystic ovary syndrome: systematic review and meta-analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 48:709-718. [PMID: 26924636 DOI: 10.1002/uog.15898] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 02/22/2016] [Accepted: 02/22/2016] [Indexed: 06/05/2023]
Abstract
OBJECTIVES To identify, appraise and summarize the current evidence regarding the efficacy of strategies aimed at improving assisted reproductive techniques in women with polycystic ovary syndrome (PCOS). METHODS A comprehensive literature search of the standard medical databases was performed. The last electronic search was run in July 2015. The primary outcome measures were live birth/ongoing pregnancy and ovarian hyperstimulation syndrome (OHSS). The secondary outcome measures were clinical pregnancy and miscarriage. RESULTS We screened 1021 records and completely assessed 173, finally including 66 studies in the quantitative analysis. Many different interventions were assessed, however the overall quality of the studies was low. We observed moderate-quality evidence that there is no clinically relevant difference in live birth/ongoing pregnancy rates (relative risk (RR), 0.95 (95% CI, 0.84-1.08)), or clinical pregnancy (RR, 1.02 (95% CI, 0.91-1.15)) when comparing antagonist and agonist protocols for ovarian stimulation. Additionally, we found low-quality evidence that metformin improves live birth/ongoing pregnancy (RR, 1.28 (95% CI, 1.01-1.63)) and clinical pregnancy rates (RR, 1.26 (95% CI, 1.04-1.53)) when compared with placebo or no intervention. We further found low-quality evidence that there is no clinically relevant difference in live birth/ongoing pregnancy rates (RR, 1.03 (95% CI, 0.80-1.34)) and clinical pregnancy rates (RR, 0.99 (95% CI, 0.81-1.22)) when comparing human menopausal gonadotropin for inducing ovulation and artificial preparation with estradiol valerate for endometrial preparation for frozen embryo transfer (FET). Low-quality evidence suggests that mannitol compared with no intervention (RR, 0.54 (95% CI, 0.39-0.77)) and antagonist protocols compared with agonist protocols (RR, 0.63 (95% CI, 0.49-0.80)) reduce rates of OHSS. CONCLUSION There is low- to moderate-quality evidence suggesting that antagonist protocols are preferable to agonist ones, because they reduce the incidence of OHSS without interfering with clinical pregnancy and live birth for women with PCOS. Additionally there is low-quality evidence pointing to a benefit of metformin supplementation on clinical pregnancy and live birth; and that ovulation induction and administration of estradiol seem to be equally effective for endometrial preparation before FET for women with PCOS. For all other interventions, the evidence is of very low quality, not allowing any meaningful conclusions to be drawn. Estrategias para mejorar el resultado de la reproducción asistida en mujeres con síndrome de ovario poliquístico: revisión sistemática y metaanálisis RESUMEN OBJETIVOS: Identificar, evaluar y resumir la evidencia actual sobre la eficacia de las estrategias para mejorar las técnicas de reproducción asistida en mujeres con síndrome de ovario poliquístico (SOP). MÉTODOS: Se realizó una búsqueda exhaustiva de literatura en las bases de datos médicas estándar. La última búsqueda electrónica se realizó en julio de 2015. Las medidas de resultado primarias fueron los nacimientos vivos/embarazos en curso y el síndrome de hiperestimulación ovárica (SHO). Las medidas de resultado secundarias fueron el embarazo confirmado ecográficamente y el aborto. RESULTADOS Se cribaron 1021 registros, de los que se evaluaron por completo 173, para finalmente incluir 66 estudios en el análisis cuantitativo. Aunque se evaluaron muchas intervenciones diferentes, en general la calidad de los estudios fue baja. Se observó evidencia de calidad moderada de que no hay diferencias relevantes clínicamente en las tasas de nacimientos vivos/embarazos en curso (riesgo relativo (RR): 0,95 (IC 95%, 0,84-1,08)), o de embarazos confirmados ecográficamente (RR: 1,02 (IC 95%, 0,91-1,15)), cuando se comparan los protocolos de antagonistas y agonistas para la estimulación ovárica. Además, se encontró evidencia de baja calidad en que la metformina mejora las tasas de nacimientos vivos/embarazos en curso (RR: 1,28 (IC 95%, 1,01-1,63)) y de embarazos confirmados ecográficamente (RR: 1,26 (IC 95%, 1,04-1,53)) en comparación con un placebo o la no intervención. Se encontró también evidencia de baja calidad en que no hay diferencias relevantes clínicamente en las tasas de nacimientos vivos/embarazos en curso (RR: 1,03 (IC 95%, 0,80-1,34)) y las tasas de embarazos confirmados ecográficamente (RR: 0,99 (IC 95%, 0.81-1,22)) al comparar la gonadotropina menopáusica humana para la inducción de la ovulación y la preparación artificial con el valerato de estradiol para preparar el endometrio para la transferencia de embriones congelados (TEC). La baja calidad de la evidencia sugiere que el manitol, en comparación con la no intervención (RR: 0,54 (IC 95%, 0,39-0,77)), y los protocolos de antagonistas, en comparación con los protocolos de agonistas (RR: 0,63 (IC 95%, 0,49-0,80)), reducen las tasas de SHO. CONCLUSIÓN: Hay evidencia de calidad baja a moderada que sugiere que los protocolos de antagonistas son preferibles a los de agonistas, ya que reducen la tasa de SHO sin interferir con el embarazo confirmado ecográficamente y los nacimientos vivos en las mujeres con SOP. Además, existe evidencia de baja calidad que indica un beneficio del uso de metformina como aporte suplementario en embarazos confirmados ecográficamente y en nacimientos vivos; y que la inducción de la ovulación y la administración de estradiol parecen ser igualmente eficaces para la preparación del endometrio antes de la TEC en mujeres con SOP. Para el resto de procedimientos, la evidencia es de muy baja calidad, y por ello no permite extraer conclusiones importantes.
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Affiliation(s)
- M Kollmann
- Division of Obstetrics and Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Medical University of Graz, Graz, Austria
- Division of Child Health, Obstetrics & Gynaecology, School of Medicine, University of Nottingham, Nottingham, UK
| | - W P Martins
- Department of Obstetrics and Gynecology, Medical School of Ribeirao Preto, University of Sao Paulo, Ribeirao Preto, Brazil
| | - M L S Lima
- Department of Obstetrics and Gynecology, Medical School of Ribeirao Preto, University of Sao Paulo, Ribeirao Preto, Brazil
| | - L Craciunas
- Division of Child Health, Obstetrics & Gynaecology, School of Medicine, University of Nottingham, Nottingham, UK
- Clinical Academic Office, Medical School, Newcastle University, Newcastle, UK
| | - C O Nastri
- Department of Obstetrics and Gynecology, Medical School of Ribeirao Preto, University of Sao Paulo, Ribeirao Preto, Brazil
| | - A Richardson
- Division of Child Health, Obstetrics & Gynaecology, School of Medicine, University of Nottingham, Nottingham, UK
- Nurture Fertility, The East Midlands Fertility Centre, Nottingham, UK
| | - N Raine-Fenning
- Division of Child Health, Obstetrics & Gynaecology, School of Medicine, University of Nottingham, Nottingham, UK
- Nurture Fertility, The East Midlands Fertility Centre, Nottingham, UK
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Jacob SL, Brewer C, Tang T, Picton HM, Barth JH, Balen AH. A short course of metformin does not reduce OHSS in a GnRH antagonist cycle for women with PCOS undergoing IVF: a randomised placebo-controlled trial. Hum Reprod 2016; 31:2756-2764. [PMID: 27816925 DOI: 10.1093/humrep/dew268] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 08/23/2016] [Accepted: 09/17/2016] [Indexed: 11/12/2022] Open
Abstract
STUDY QUESTION Does 'metformin' reduce the incidence of ovarian hyperstimulation syndrome (OHSS) for women with polycystic ovary syndrome (PCOS) undergoing a GnRH antagonist assisted conception treatment cycle? SUMMARY ANSWER A short course of metformin does not reduce the incidence of OHSS for women with PCOS undergoing a GnRH antagonist treatment cycle. WHAT IS KNOWN ALREADY Metformin does reduce the incidence of OHSS in a GnRH-agonist treatment cycle. STUDY DESIGN, SIZE, DURATION A randomised placebo-controlled trial (RCT) using metformin or placebo. Randomisation was blinded to both patient and investigator, using a random permuted blocks method with a 50:50 allocation ratio. The study was completed over 5 years (2009-2014) with 153 randomised patients. A sample size calculation based on the incidence of OHSS was completed prospectively suggesting a minimum of 146 recruits was required for the trial with a power of 80% and a type 1 error of 0.05. PARTICIPANTS/MATERIALS, SETTING, METHODS All patients met the Rotterdam criteria for PCOS and were treated with a standard GnRH antagonist IVF/ICSI treatment cycle in a tertiary infertility clinic. The study medication was started prior to stimulation and continued to oocyte retrieval. Of the 153 patients, 77 received metformin and 76 placebo. MAIN RESULTS AND THE ROLE OF CHANCE There was no reduction in the incidence of moderate-severe OHSS (Placebo (PLA) 12.2%, metformin (MET) = 16%, 95% CI -0.08-0.16, P = 0.66). There was no difference in total gonadotrophin dose (PLA = 1200, MET = 1200, 95% CI -118.67-118.67, P = 0.75), oocytes retrieved (PLA = 15, MET = 14, 95% CI -2.37-4.37, P = 0.66) or fertilisation rate (PLA = 60.7%, MET = 53.3%, 95% CI -0.96-14.94, P = 0.07). However, using metformin resulted in a reduced clinical pregnancy rate (CPR) per cycle started (PLA = 48.7%, MET = 28.6%, 95% CI 0.04-0.35, P = 0.02) and live birth rate (PLA = 51.6%, MET = 27.6%, 95% CI 0.05-0.40, P = 0.02). Furthermore, when ethnicity was taken into account there was a significant reduction in pregnancy outcome for the South Asian population irrespective of metformin or placebo use (CPR per cycle started, White Caucasian = 44.4%, South Asian = 19.4%; 95% CI 0.06-0.39, P = 0.01). LIMITATIONS, REASONS FOR CAUTION This study was only undertaken on an infertility population with PCOS with a limited duration of study medication use. WIDER IMPLICATIONS OF THE FINDINGS This is the first adequately powered RCT to assess the impact of metformin on OHSS in a high-risk group (women with PCOS) undergoing a GnRH antagonist cycle. It does not support the empirical prescribing of metformin as an adjunct to a GnRH antagonist treatment cycle. STUDY FUNDING/COMPETING INTERESTS None. TRIAL REGISTRATION NUMBER EudraCT number 2009-010952-81. TRIAL REGISTRATION DATE 21 September 2009. DATE OF FIRST PATIENT'S ENROLMENT 30 October 2009.
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Affiliation(s)
- S L Jacob
- Leeds Centre of Reproductive Medicine, Seacroft Hospital, Leeds LS14 6UH, UK
| | - C Brewer
- Leeds Centre of Reproductive Medicine, Seacroft Hospital, Leeds LS14 6UH, UK
| | - T Tang
- Regional Fertility Centre, Royal Maternity Hospital, Belfast BT12 6BA, UK
| | - H M Picton
- Leeds Centre of Reproductive Medicine, Seacroft Hospital, Leeds LS14 6UH, UK
| | - J H Barth
- Blood Sciences, Leeds General Infirmary, Leeds LS1 3EX, UK
| | - A H Balen
- Leeds Centre of Reproductive Medicine, Seacroft Hospital, Leeds LS14 6UH, UK
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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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Hart RJ. Physiological Aspects of Female Fertility: Role of the Environment, Modern Lifestyle, and Genetics. Physiol Rev 2016; 96:873-909. [DOI: 10.1152/physrev.00023.2015] [Citation(s) in RCA: 102] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Across the Western World there is an increasing trend to postpone childbearing. Consequently, the negative influence of age on oocyte quality may lead to a difficulty in conceiving for many couples. Furthermore, lifestyle factors may exacerbate a couple's difficulty in conceiving due mainly to the metabolic influence of obesity; however, the negative impacts of low peripheral body fat, excessive exercise, the increasing prevalence of sexually transmitted diseases, and smoking all have significant negative effects on fertility. Other factors that impede conception are the perceived increasing prevalence of the polycystic ovary syndrome, which is further exacerbated by obesity, and the presence of uterine fibroids and endometriosis (a progressive pelvic inflammatory disorder) which are more prevalent in older women. A tendency for an earlier sexual debut and to have more sexual partners has led to an increase in sexually transmitted diseases. In addition, there are several genetic influences that may limit the number of oocytes within the ovary; consequently, by postponing attempts at childbearing, a limitation of oocyte number may become evident, whereas in previous generations with earlier conception this potentially reduced reproductive life span did not manifest in infertility. Environmental influences on reproduction are under increasing scrutiny. Although firm evidence is lacking however, dioxin exposure may be linked to endometriosis, phthalate exposure may influence ovarian reserve, and bisphenol A may interfere with oocyte development and maturation. However, chemotherapy or radiotherapy is recognized to lead to ovarian damage and predispose the woman to ovarian failure.
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Affiliation(s)
- Roger J. Hart
- School of Women's and Infants Health, University of Western Australia & Fertility Specialists of Western Australia, Subiaco, Perth Western Australia
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Gozukara I, Dokuyucu R, Özgür T, Özcan O, Pınar N, Kurt RK, Kucur SK, Dolapcioglu K. Histopathologic and metabolic effect of ursodeoxycholic acid treatment on PCOS rat model. Gynecol Endocrinol 2016; 32:492-7. [PMID: 26772475 DOI: 10.3109/09513590.2015.1134478] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
The aim of this study was to determine the effect of ursodeoxycholic acid (UDCA) treatment on a polycystic ovary syndrome (PCOS) rat model. Thirty-two female Wistar-Albino rats were randomly divided into four groups as follows - group 1: sham group (n: 8), group 2: letrozole-induced PCOS group (n: 8), group 3: letrozole-induced PCOS plus metformin-treated (500 mg/kg) group (n: 8) and group 4: letrozole-induced PCOS plus UDCA (150 mg/kg)-treated group (n: 8). Histopathologic examination of the ovaries, circulating estrone (E1), estradiol (E2), testosterone, androstenedione, glucose, insulin and lipid profiles were evaluated. Histopathologic examination results revealed that groups 3 and 4 had significantly lower cystic and atretic follicles compared to group 2. Besides, group 4 had significantly higher antral follicles than group 2 (8.5 ± 2.9 versus 5.4 ± 1.1; p: 0.001). Furthermore, total testosterone (4.9 ± 2.8 versus 8.8 ± 2.9; p= 0.004) and insulin levels were significantly lower in group 4 compared to group 2 (1.7 ± 0.08 versus 2.1 ± 0.5; p = 0.02). However, lipid parameters, E1, E2, glucose and HOMA-IR were comparable between the groups. Our study results demonstrated that UDCA therapy improves ovarian morphology and decreases total testosterone and insulin levels.
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Affiliation(s)
- Ilay Gozukara
- a Department of Obstetric and Gynecology , School of Medicine, Mustafa Kemal University , Hatay , Turkey
| | - Recep Dokuyucu
- b Department of Physiology , Mustafa Kemal University , Hatay , Turkey
| | - Tümay Özgür
- c Department of Pathology , Mustafa Kemal University , Hatay , Turkey
| | - Oguzhan Özcan
- d Department of Biochemistry , Mustafa Kemal University , Hatay , Turkey
| | - Neslihan Pınar
- e Department of Pharmacology , Mustafa Kemal University , Hatay , Turkey , and
| | - Raziye Keskin Kurt
- a Department of Obstetric and Gynecology , School of Medicine, Mustafa Kemal University , Hatay , Turkey
| | - Suna Kabil Kucur
- f Department of Obstetric and Gynecology , Dumlupinar University, School of Medicine , Kütahya , Turkey
| | - Kenan Dolapcioglu
- a Department of Obstetric and Gynecology , School of Medicine, Mustafa Kemal University , Hatay , Turkey
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Guo JL, Zhang DD, Zhao Y, Zhang D, Zhang XM, Zhou CQ, Yao SZ. Pharmacologic Interventions in Preventing Ovarian Hyperstimulation Syndrome: A Systematic Review and Network Meta-Analysis. Sci Rep 2016; 6:19093. [PMID: 26752241 PMCID: PMC4707491 DOI: 10.1038/srep19093] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Accepted: 12/04/2015] [Indexed: 01/20/2023] Open
Abstract
Ovarian hyperstimulation syndrome (OHSS) is a severe iatrogenic complication of controlled ovarian stimulation. Randomised controlled trials (RCTs) have proven several pharmacologic interventions to be effective in OHSS prevention, but these trials have seldom compared multiple drugs. We identified randomised controlled trials (RCTs) through June 2015 by searching databases and compared 11 intervention strategies in preventing OHSS (primary outcome) and their influence on pregnancy rate (secondary outcome). A network meta-analysis was used to evaluate the relative effectiveness among treatments and to create a rank probability table. Thirty-one RCTs were identified, including 7181 participants. Five pharmacologic interventions were superior to placebo in decreasing OHSS incidence: aspirin [relative risk (RR) 0.07, 95% credible interval (CrI) 0.01-0.30, p < 0.05], intravenous (IV) calcium [RR 0.11, 95% CrI 0.02-0.54, p < 0.05], cabergoline [RR 0.17, 95% CrI 0.06-0.43, p < 0.05], metformin [RR 0.20, 95% CrI 0.07-0.59, p < 0.05] and IV hydroxyethyl starch (HES) [RR 0.26, 95% CrI 0.05-0.99, p < 0.05]. The rank probability demonstrated aspirin (Rank 1: 36%) and IV calcium (Rank 1: 35%) to be the most efficacious. Additionally, albumin might decrease the pregnancy rate when compared with placebo [RR 0.85, 95% CI 0.74-0.97, p < 0.05]. This conclusion provides a relative standard and objective reference for choosing an OHSS prophylactic agent.
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Affiliation(s)
- Jun-Liang Guo
- Department of Obstetrics & Gynaecology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou City, 510080, P.R. China
- Zhong-shan School of Medicine, Sun Yat-sen University, Guangzhou City, 510082, P.R. China
| | - Duo-Duo Zhang
- Department of Obstetrics & Gynaecology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou City, 510080, P.R. China
- Zhong-shan School of Medicine, Sun Yat-sen University, Guangzhou City, 510082, P.R. China
| | - Yue Zhao
- Zhong-shan School of Medicine, Sun Yat-sen University, Guangzhou City, 510082, P.R. China
| | - Dan Zhang
- Department of Obstetrics & Gynaecology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou City, 510080, P.R. China
| | - Xi-Meng Zhang
- Zhong-shan School of Medicine, Sun Yat-sen University, Guangzhou City, 510082, P.R. China
| | - Can-Quan Zhou
- Department of Obstetrics & Gynaecology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou City, 510080, P.R. China
| | - Shu-Zhong Yao
- Department of Obstetrics & Gynaecology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou City, 510080, P.R. China
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Melo AS, Ferriani RA, Navarro PA. Treatment of infertility in women with polycystic ovary syndrome: approach to clinical practice. Clinics (Sao Paulo) 2015; 70:765-9. [PMID: 26602525 PMCID: PMC4642490 DOI: 10.6061/clinics/2015(11)09] [Citation(s) in RCA: 95] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 08/25/2015] [Indexed: 12/02/2022] Open
Abstract
Polycystic ovary syndrome represents 80% of anovulatory infertility cases. Treatment initially includes preconception guidelines, such as lifestyle changes (weight loss), folic acid therapy to prevent the risk of fetal neural tube defects and halting the consumption of tobacco and alcohol. The first-line pharmacological treatment for inducing ovulation consists of a clomiphene citrate treatment for timed intercourse. The second-line pharmacological treatment includes the administration of exogenous gonadotropins or laparoscopic ovarian surgery (ovarian drilling). Ovulation induction using clomiphene citrate or gonadotropins is effective with cumulative live birth rates of approximately 70%. Ovarian drilling should be performed when laparoscopy is indicated; this procedure is typically effective in approximately 50% of cases. Finally, a high-complexity reproduction treatment (in vitro fertilization or intracytoplasmic sperm injection) is the third-line treatment and is recommended when the previous interventions fail. This option is also the first choice in cases of bilateral tubal occlusion or semen alterations that impair the occurrence of natural pregnancy. Evidence for the routine use of metformin in infertility treatment of anovulatory women with polycystic ovary syndrome is not available. Aromatase inhibitors are promising and longer term studies are necessary to prove their safety.
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Affiliation(s)
- Anderson Sanches Melo
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Departamento de Ginecologia e Obstetrícia, Ribeirão Preto/SP, Brazil
| | - Rui Alberto Ferriani
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Departamento de Ginecologia e Obstetrícia, Ribeirão Preto/SP, Brazil
| | - Paula Andrea Navarro
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Departamento de Ginecologia e Obstetrícia, Ribeirão Preto/SP, Brazil
- Corresponding author: E-mail:
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Twenty years of ovulation induction with metformin for PCOS; what is the best available evidence? Reprod Biomed Online 2015; 32:44-53. [PMID: 26656973 DOI: 10.1016/j.rbmo.2015.09.015] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 09/21/2015] [Accepted: 09/22/2015] [Indexed: 12/18/2022]
Abstract
The potential reproductive benefits of metformin, a drug endowed with the capacity to ameliorate insulin resistance in polycystic ovary syndrome (PCOS), has garnered much interest over the past 2 decades. In this review, randomized-controlled trials (RCT) and meta-analyses of RCT comparing metformin are critically appraised and summarized. PubMed and CENTRAL databases were consulted. Evidence is insufficient to favour the use of metformin or metformin plus clomiphene citrate instead of clomiphene citrate for ovulation induction in women with newly diagnosed PCOS. Evidence is also insufficient to recommend metformin as a primary treatment for non-obese women with PCOS. Metformin plus clomiphene citrate should be considered as an effective option in clomiphene citrate-resistant PCOS. In women with PCOS undergoing gonadotrophin ovulation induction, metformin significantly increased pregnancy and live birth rates (P < 0.0001 and P = 0.020, respectively) with reduced risk of cancelled cycles. A beneficial effect of metformin co-treatment in increasing clinical pregnancy rates and reducing the risk of OHSS in PCOS patients undergoing assisted reproduction techniques has been shown. No evidence was found of reduced risk of spontaneous abortion or increased risk of major anomalies in women with PCOS taking metformin during the first trimester.
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Rocca ML, Venturella R, Mocciaro R, Di Cello A, Sacchinelli A, Russo V, Trapasso S, Zullo F, Morelli M. Polycystic ovary syndrome: chemical pharmacotherapy. Expert Opin Pharmacother 2015; 16:1369-93. [PMID: 26001184 DOI: 10.1517/14656566.2015.1047344] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Polycystic ovary syndrome (PCOS) is the most common reproductive endocrine disease among women of childbearing age. The clinical features are heterogeneous and vary in intensity. Hirsutism, menstrual disorders and infertility are the most frequent conditions observed; however, long-term complications (dyslipidemia, hypertension, cardiovascular disease, type 2 diabetes mellitus, endometrial cancer) are also often described. Each disorder may be managed by tailored strategies, employing sequential or combined pharmacological and/or non-pharmacological treatment. AREAS COVERED The authors review the drugs used for PCOS management and discuss new approaches. A systematic MEDLINE search regarding the randomized controlled trials, retrospective and observational studies about medical treatments of PCOS, the Cochrane library for reviews and also search for registered trials on ClinicalTrials.gov is performed. EXPERT OPINION A uniform treatment for PCOS patients does not exist. Clinicians should perform an accurate evaluation of patients' characteristics, identifying the phenotypic target and, subsequently, the best-tailored treatment to manage one or more clinical issues. Lifestyle intervention should always be the first recommended approach unless other issues indicate that drug or hormonal interventions are superior.
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Affiliation(s)
- Morena Luigia Rocca
- 'Magna Graecia' University, Cancer Center of Excellence "Tommaso Campanella" of Germaneto, Department of Experimental and Clinical Medicine, Unit of Obstetrics and Gynaecology, Oncology Unit , Viale Europa, loc. Germaneto, 88100, Catanzaro , Italy +39 328 5692428 ; +39 0961 883234 ;
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Association between ovarian stimulators with or without intrauterine insemination, and assisted reproductive technologies on multiple births. Am J Obstet Gynecol 2015; 213:511.e1-511.e14. [PMID: 26079626 DOI: 10.1016/j.ajog.2015.06.028] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 05/10/2015] [Accepted: 06/10/2015] [Indexed: 11/21/2022]
Abstract
OBJECTIVE We sought to quantify the risk of multiple births associated with the use of different modalities of medically assisted reproduction. STUDY DESIGN We conducted a case-control study using a birth cohort from 2006 through 2009. This cohort was built with the linkage of data obtained by a self-administered questionnaire and medical, hospital, pharmaceutical, birth, and death databases in Quebec. Cases were pregnancies resulting in multiple live births (International Classification of Diseases, Ninth Revision/International Statistical Classification of Diseases, 10th Revision codes). Each case was matched, on maternal age and year of delivery, with 3 singleton pregnancies (controls) randomly selected among all Quebec singleton pregnancies. Data on the use of different fertility treatments were collected by a self-administered questionnaire. Multiple logistic regression models, adjusted for body mass index, number of previous live births, ethnicity, family income, place of residence, marital status, subfertility, reduction of embryos, diabetes, metformin treatment, folic acid supplementation, and lifestyle factors, were used to calculate the odds ratios (ORs) and confidence intervals (CIs). We evaluated the associations between each type of fertility treatment (ovarian stimulators used alone, intrauterine insemination [IUI] used with ovarian stimulation, and assisted reproductive technologies [ART]) and the risk of multiple births. RESULTS A total of 1407 cases of multiple births and 3580 controls were analyzed. More than half of multiple births following medically assisted reproduction (53.6%) occurred among women having used ovarian stimulation with or without IUI. The use of ovarian stimulators alone and IUI with ovarian stimulation increase the risk of multiple births (adjusted OR, 4.5; 95% CI, 3.2-6.4; and adjusted OR, 9.32; 95% CI, 5.60-15.50, respectively) compared to spontaneous conception. The use of invasive ART was associated with a greatly increased risk of multiple births. Among only the 465 women who used medically assisted reproduction for conception, the use of IUI with ovarian stimulation was associated with an increased risk of multiple births (adjusted OR, 1.98; 95% CI, 1.12-3.49) when compared to ovarian stimulators used alone. Invasive ART were associated with an increased risk of multiple births (adjusted OR, 6.81; 95% CI, 3.72-12.49) when compared to ovarian stimulators used alone. CONCLUSION Although the risk of multiple births associated with invasive ART can be decreased by elective implementing of single embryo transfer, special attention should be paid to the greatly increased risk associated with ovarian stimulation used alone or with IUI.
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Moghetti P, Carmina E, De Leo V, Lanzone A, Orio F, Pasquali R, Toscano V. How to manage the reproductive issues of PCOS: a 2015 integrated endocrinological and gynecological consensus statement of the Italian Society of Endocrinology. J Endocrinol Invest 2015; 38:1025-37. [PMID: 25835559 DOI: 10.1007/s40618-015-0274-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2014] [Accepted: 03/17/2015] [Indexed: 01/31/2023]
Affiliation(s)
- P Moghetti
- Endocrinology, Diabetes and Metabolism, University and AOUI of Verona, Verona, Italy,
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Palomba S, de Wilde MA, Falbo A, Koster MP, La Sala GB, Fauser BC. Pregnancy complications in women with polycystic ovary syndrome. Hum Reprod Update 2015; 21:575-592. [DOI: 10.1093/humupd/dmv029] [Citation(s) in RCA: 361] [Impact Index Per Article: 40.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Palomba S, Santagni S, Falbo A, La Sala GB. Complications and challenges associated with polycystic ovary syndrome: current perspectives. Int J Womens Health 2015; 7:745-63. [PMID: 26261426 PMCID: PMC4527566 DOI: 10.2147/ijwh.s70314] [Citation(s) in RCA: 111] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Polycystic ovary syndrome (PCOS) represents the most common endocrine dysfunction in fertile women and it is considered a heterogeneous and multifaceted disorder, with multiple reproductive and metabolic phenotypes which differently affect the early- and long-term syndrome’s risks. Women with PCOS present an adverse reproductive profile, including a high risk of pregnancy-induced hypertension, preeclampsia, and gestational diabetes mellitus. Patients with PCOS present not only a higher prevalence of classic cardiovascular risk factors, such as hypertension, dyslipidemia, and type-2 diabetes mellitus, but also of nonclassic cardiovascular risk factors, including mood disorders, such as depression and anxiety. Moreover, at the moment, clinical data on cardiovascular morbidity and mortality in women with PCOS are controversial. Finally, women with PCOS show an increased risk of endometrial cancer compared to non-PCOS healthy women, particularly during premenopausal period. Currently, we are unable to clarify if the increased PCOS early- and long-term risks are totally due to PCOS per se or mostly due to obesity, in particular visceral obesity, that characterized the majority of PCOS patients. In any case, the main endocrine and gynecological scientific societies agree to consider women with PCOS at increased risk of obstetric, cardiometabolic, oncology, and psychological complications throughout life, and it is recommended that these women be accurately assessed with periodic follow-up.
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Affiliation(s)
- Stefano Palomba
- Unit of Obstetrics and Gynecology, Arcispedale Santa Maria Nuova-Scientific Institute of Treatment and Care (IRCCS), Reggio Emilia, Modena, Italy
| | - Susanna Santagni
- Unit of Obstetrics and Gynecology, Arcispedale Santa Maria Nuova-Scientific Institute of Treatment and Care (IRCCS), Reggio Emilia, Modena, Italy
| | - Angela Falbo
- Unit of Obstetrics and Gynecology, Arcispedale Santa Maria Nuova-Scientific Institute of Treatment and Care (IRCCS), Reggio Emilia, Modena, Italy
| | - Giovanni Battista La Sala
- Unit of Obstetrics and Gynecology, Arcispedale Santa Maria Nuova-Scientific Institute of Treatment and Care (IRCCS), Reggio Emilia, Modena, Italy ; Department of Obstetrics and Gynecology, University of Modena and Reggio Emilia, Modena, Italy
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Kollmann M, Klaritsch P, Martins WP, Guenther F, Schneider V, Herzog SA, Craciunas L, Lang U, Obermayer-Pietsch B, Lerchbaum E, Raine-Fenning N. Maternal and neonatal outcomes in pregnant women with PCOS: comparison of different diagnostic definitions. Hum Reprod 2015. [PMID: 26223675 DOI: 10.1093/humrep/dev187] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
STUDY QUESTION Does the prevalence of adverse maternal and neonatal outcomes vary in women diagnosed with polycystic ovary syndrome (PCOS) according to different definitions? SUMMARY ANSWER A comparison of different criteria revealed that there is a substantial risk for perinatal complications in PCOS women, regardless of the used definition. WHAT IS KNOWN ALREADY Pregnant women with PCOS are susceptible to perinatal complications. At present, there are three main definitions for PCOS. So far, we are aware of only one study, which found that the elevated risk for complications varied widely depending on the different phenotypes and features but only considered a relatively small sample size for some of the phenotypes. STUDY DESIGN, SIZE, DURATION Retrospective matched cohort study. PARTICIPANTS/MATERIALS, SETTING, METHODS Data of primiparous women with PCOS according to ESHRE/ASRM 2003 criteria and healthy controls giving birth to neonates ≥500 g were included. A total of 885 women were analysed: out of 177 women with PCOS, 85 (48.0%) met the National Institutes of Health (NIH) 1990 criteria, another 14 (7.9%) featured the additional phenotypes defined by The Androgen Excess and PCOS Society (AE-PCOS) 2006 criteria, 78 (44.1%) were classified as PCOS exclusively by the ESHRE/ASRM 2003 definition, and 708 represented the control group. MAIN RESULTS AND THE ROLE OF CHANCE The prevalence of adverse maternal (49.4 versus 64.3 versus 60.3%, P = 0.313) and neonatal (27.1 versus 35.7 versus 23.1%, P = 0.615) outcomes did not differ within the three PCOS groups (ESHRE/ASRM, NIH, AE-PCOS, respectively). Compared with healthy controls, the risk for maternal complications was increased in PCOS patients [odds ratio (OR) 2.57; 95% confidence interval (CI) 1.82-3.64; P < 0.001] while there was no difference in neonatal complications (OR 0.83; 95% CI 0.56-1.21; P = 0.343). LIMITATIONS, REASONS FOR CAUTION A limitation of our study is its retrospective design and the relatively small sample size, particularly in the AE-PCOS subgroup. WIDER IMPLICATIONS OF THE FINDINGS Since women with PCOS have, regardless of the used definition, a high risk of maternal and neonatal complications they should be informed and advised to follow regular checks in units where problems can be detected early to allow specialized care. STUDY FUNDING/COMPETING INTERESTS Marietta Blau Grant (Austrian Agency for International Cooperation in Education and Research; OeAD-GmbH) and mobility scholarship (Medical University of Graz).
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Affiliation(s)
- M Kollmann
- Division of Obstetrics and Maternal Fetal Medicine, Department of Obstetrics and Gynaecology, Medical University of Graz, Auenbruggerplatz 14, 8036 Graz, Austria
| | - P Klaritsch
- Division of Obstetrics and Maternal Fetal Medicine, Department of Obstetrics and Gynaecology, Medical University of Graz, Auenbruggerplatz 14, 8036 Graz, Austria
| | - W P Martins
- Department of Obstetrics and Gynaecology, Medical School of Ribeirao Preto, University of Sao Paulo, 14048-900 Ribeirao Preto, Brazil
| | - F Guenther
- Division of Obstetrics and Maternal Fetal Medicine, Department of Obstetrics and Gynaecology, Medical University of Graz, Auenbruggerplatz 14, 8036 Graz, Austria
| | - V Schneider
- Division of Obstetrics and Maternal Fetal Medicine, Department of Obstetrics and Gynaecology, Medical University of Graz, Auenbruggerplatz 14, 8036 Graz, Austria
| | - S A Herzog
- Institute for Medical Informatics, Statistics and Documentation (IMI), Medical University of Graz, 8036 Graz, Austria
| | - L Craciunas
- Division of Child Health, Obstetrics & Gynaecology, School of Medicine, University of Nottingham, NG7 2UH Nottingham, UK
| | - U Lang
- Division of Obstetrics and Maternal Fetal Medicine, Department of Obstetrics and Gynaecology, Medical University of Graz, Auenbruggerplatz 14, 8036 Graz, Austria
| | - B Obermayer-Pietsch
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria
| | - E Lerchbaum
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria
| | - N Raine-Fenning
- Division of Child Health, Obstetrics & Gynaecology, School of Medicine, University of Nottingham, NG7 2UH Nottingham, UK
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