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Sun ML, Bai WP, Song QK, Wang HY, Gao GL, Zheng L, Wang XH. Metformin With or Without Clomiphene Citrate Versus Laparoscopic Ovarian Drilling With or Without Clomiphene Citrate to Treat Patients With Clomiphene Citrate-Resistant Polycystic Ovary Syndrome: A Systematic Review and Meta-Analysis. Front Pharmacol 2022; 13:576458. [PMID: 35814214 PMCID: PMC9256960 DOI: 10.3389/fphar.2022.576458] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 05/27/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction: Which is optimal to treat clomiphene citrate-resistant polycystic ovary syndrome (CCR-PCOS) with LOD or metformin remains a problem. There are three inconsistent or even contradictory views.Objectives: The present meta-analysis aimed to evaluate the effectiveness and safety of Metformin with or without CC and to compare them with LOD with or without CC (Met/Met-CC vs. LOD/LOD-CC) in women with CCR-PCOS who also have anovulation.Data source: The PubMed, Cochrane, and Embase databases were searched to identify relevant studies reported between 1 Jan 1966 and 31 Aug 2019; the search was updated on 17 May 2022.Study eligibility criteria: We included randomized controlled trials (RCTs) of CCR-PCOS that had considered Met/Met-CC and LOD/LOD-CC as the exposure variables and fertility as the main outcome variable.Study appraisal and synthesis methods: We assessed study quality using the Cochrane risk-of-bias tool. The primary effectiveness outcome was live birth/ongoing pregnancy rate and the primary safety outcome was miscarriage rate. A fixed-effect meta-analysis was performed. The robustness of the results was assessed using sensitivity analyses. Meta-regression and subgroup analysis were performed to examine the reasons for heterogeneity. Publication bias was examined using the funnel plot, Egger linear regression, and Begg rank correlation tests. The quality of this meta-analysis was estimated according to the GRADE approach. This meta-analysis has been registered in PROSPERO (CRD42021240156).Results: Among 71 potentially relevant studies, we included five RCTs in our meta-analysis. We found no difference in effectiveness between Met-CC and LOD in terms of live birth/ongoing pregnancy (RR = 1.02, 95% CI: 0.87–1.21, z = 0.28; p = 0.780), and miscarriage rates (RR = 0.79, 95% CI: 0.46–1.36, z = 0.86; p = 0.390). I2 tests results revealed moderate or no heterogeneity (I2 = 51.4%, p = 0.083; I2= 0.0%; p = 0.952). Sensitivity analysis confirmed the robustness of the results. Funnel plot, Egger linear regression, and Begg rank correlation tests implied no publication bias (p > 0.05). LOD was more expensive than Met (€1050 vs. €50.16). The evidence quality was moderate.Conclusion: There is no evidence on the difference in the outcomes between the two interventions regarding ovulation, pregnancy, and live birth. As LOD is an invasive procedure and carries inherent risks, the use of Met/Met-CC should be the second-line treatment for women with CCR-PCOS.Systematic Review Registration: identifier CRD42021240156.
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Affiliation(s)
- Ming-Li Sun
- Phase I Clinical Trial Center, Beijing Shijitan Hospital Affiliated to Capital Medical University, Beijing, China
| | - Wen-Pei Bai
- Department of Gynecology, Beijing Shijitan Hospital Affiliated to Capital Medical University, Beijing, China
| | - Qing-Kun Song
- Department of Science and Technology, Beijing Shijitan Hospital Affiliated to Capital Medical University, Beijing, China
| | - Hui-Ying Wang
- Department of Gynecology, Beijing Shijitan Hospital Affiliated to Capital Medical University, Beijing, China
| | - Guo-Lan Gao
- Department of Gynecology, Shenzhen Hospital Affiliated to Savaid Medical School, University of Chinese Academy of Sciences, Shenzhen, China
- *Correspondence: Guo-Lan Gao, ; Liang Zheng, ; Xing-He Wang,
| | - Liang Zheng
- Research Center for Translational Medicine, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
- *Correspondence: Guo-Lan Gao, ; Liang Zheng, ; Xing-He Wang,
| | - Xing-He Wang
- Phase I Clinical Trial Center, Beijing Shijitan Hospital Affiliated to Capital Medical University, Beijing, China
- *Correspondence: Guo-Lan Gao, ; Liang Zheng, ; Xing-He Wang,
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Yuan L, Wu H, Huang W, Bi Y, Qin A, Yang Y. The function of metformin in endometrial receptivity (ER) of patients with polycyclic ovary syndrome (PCOS): a systematic review and meta-analysis. Reprod Biol Endocrinol 2021; 19:89. [PMID: 34127011 PMCID: PMC8201680 DOI: 10.1186/s12958-021-00772-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 05/28/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This meta-analysis summarizes evidence from studies using metformin (Met) to improve endometrial receptivity (ER) in women with PCOS. METHODS Following the PRISMA protocol, we conducted a comprehensive search of academic literature from various databases, including PubMed, EMbase and Cochrane libraries. Studies published in English before Jan 27, 2021, were recruited for primary screening. Data on endometrial thickness (EMT), endometrial artery resistance index (RI), clinical pregnancy rate (CPR) and miscarriage rate (MR) were extracted and analyzed. RESULTS Sixty-two eligible studies that included 6571 patients were evaluated in this meta-analysis. Primary indicators are EMT and endometrial aetery RI; secondary indicators include the clinical pregnancy rate and miscarriage rate. Metformin significantly increased EMT (SMD = 2.04, 95% CI (0.96,3.12),P = 0.0002) and reduced endometrial artery RI compared to the non-Met group (SMD = - 2.83, 95% CI: (- 5.06, - 0.59), P = 0.01). As expected, metformin also improved CPR and reduced MR in PCOS patients as a result, clinical pregnancy rate (risk ratio [RR] = 1.26, 95% CI: 1.11-1.43, P = 0.0003), and miscarriage rate (RR = 0.73, 95% CI:0.58-0.91, P = 0.006). CONCLUSION Metformin may improve endometrial receptivity (ER) in PCOS patients by increasing EMT and reducing endometrial artery RI. However, the level of most original studies was low, with small sample sizes. More large-scale, long-term RCTs with rigorous methodologies are needed.
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Affiliation(s)
- Lifang Yuan
- Reproductive Medical Center, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Hongbo Wu
- Reproductive Medical Center, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
- Reproductive Medical Center, Qinzhou Women and Children Hospital, Qinzhou, China
| | - Weiyu Huang
- Reproductive Medical Center, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Yin Bi
- Reproductive Medical Center, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Aiping Qin
- Reproductive Medical Center, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Yihua Yang
- Reproductive Medical Center, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
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Seow KM, Chang YW, Chen KH, Juan CC, Huang CY, Lin LT, Tsui KH, Chen YJ, Lee WL, Wang PH. Molecular Mechanisms of Laparoscopic Ovarian Drilling and Its Therapeutic Effects in Polycystic Ovary Syndrome. Int J Mol Sci 2020; 21:ijms21218147. [PMID: 33142702 PMCID: PMC7663012 DOI: 10.3390/ijms21218147] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 10/27/2020] [Accepted: 10/27/2020] [Indexed: 02/06/2023] Open
Abstract
Polycystic ovary syndrome (PCOS) is a common endocrinopathy, characterized by chronic anovulation, hyperandrogenism, and multiple small subcapsular cystic follicles in the ovary during ultrasonography, and affects 5–10% of women of reproductive age. PCOS is frequently associated with insulin resistance (IR) accompanied by compensatory hyperinsulinemia and, therefore, presents an increased risk of type 2 diabetes mellitus (DM). The pathophysiology of PCOS is unclear, and many hypotheses have been proposed. Among these hypotheses, IR and hyperandrogenism may be the two key factors. The first line of treatment in PCOS includes lifestyle changes and body weight reduction. Achieving a 5–15% body weight reduction may improve IR and PCOS-associated hormonal abnormalities. For women who desire pregnancy, clomiphene citrate (CC) is the front-line treatment for ovulation induction. Twenty five percent of women may fail to ovulate spontaneously after three cycles of CC treatment, which is called CC-resistant PCOS. For CC-resistant PCOS women, there are many strategies to improve ovulation rate, including medical treatment and surgical approaches. Among the various surgical approaches, one particular surgical method, called laparoscopic ovarian drilling (LOD), has been proposed as an alternative treatment. LOD results in an overall spontaneous ovulation rate of 30–90% and final pregnancy rates of 13–88%. These benefits are more significant for women with CC-resistant PCOS. Although the intra- and post-operative complications and sequelae are always important, we believe that a better understanding of the pathophysiological changes and/or molecular mechanisms after LOD may provide a rationale for this procedure. LOD, mediated mainly by thermal effects, produces a series of morphological and biochemical changes. These changes include the formation of artificial holes in the very thick cortical wall, loosening of the dense and hard cortical wall, destruction of ovarian follicles with a subsequently decreased amount of theca and/or granulosa cells, destruction of ovarian stromal tissue with the subsequent development of transient but purulent and acute inflammatory reactions to initiate the immune response, and the continuing leakage or drainage of “toxic” follicular fluid in these immature and growth-ceased pre-antral follicles. All these factors contribute to decreasing local and systemic androgen levels, the following apoptosis process with these pre-antral follicles to atresia; the re-starting of normal follicular recruitment, development, and maturation, and finally, the normalization of the “hypothalamus–pituitary–ovary” axis and subsequent spontaneous ovulation. The detailed local and systematic changes in PCOS women after LOD are comprehensively reviewed in the current article.
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Affiliation(s)
- Kok-Min Seow
- Department of Obstetrics and Gynecology, Shin-Kong Wu Ho-Su Memorial Hospital, Taipei 111, Taiwan;
- Department of Obstetrics and Gynecology, National Yang-Ming University, Taipei 112, Taiwan; (C.-Y.H.); (L.-T.L.); (K.-H.T.); (Y.-J.C.)
- Institute of Physiology, National Yang-Ming University, Taipei 112, Taiwan;
| | - Yi-Wen Chang
- Institute of Biochemistry and Molecular Biology, National Yang-Ming University, Taipei 112, Taiwan;
- Institute of Clinical Medicine, National Yang-Ming University, Taipei 112, Taiwan
| | - Kuo-Hu Chen
- Department of Obstetrics and Gynecology, Taipei Tzu-Chi Hospital, The Buddhist Tzu-Chi Medical Foundation, Taipei 108, Taiwan;
- School of Medicine, Tzu-Chi University, Hualien 970, Taiwan
| | - Chi-Chang Juan
- Institute of Physiology, National Yang-Ming University, Taipei 112, Taiwan;
| | - Chen-Yu Huang
- Department of Obstetrics and Gynecology, National Yang-Ming University, Taipei 112, Taiwan; (C.-Y.H.); (L.-T.L.); (K.-H.T.); (Y.-J.C.)
- Institute of Clinical Medicine, National Yang-Ming University, Taipei 112, Taiwan
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei 112, Taiwan
| | - Li-Te Lin
- Department of Obstetrics and Gynecology, National Yang-Ming University, Taipei 112, Taiwan; (C.-Y.H.); (L.-T.L.); (K.-H.T.); (Y.-J.C.)
- Institute of Clinical Medicine, National Yang-Ming University, Taipei 112, Taiwan
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei 112, Taiwan
- Department of Obstetrics and Gynecology, Kaohsiung Veterans General Hospital, Kaohsiung 813, Taiwan
| | - Kuan-Hao Tsui
- Department of Obstetrics and Gynecology, National Yang-Ming University, Taipei 112, Taiwan; (C.-Y.H.); (L.-T.L.); (K.-H.T.); (Y.-J.C.)
- Institute of Clinical Medicine, National Yang-Ming University, Taipei 112, Taiwan
- Department of Obstetrics and Gynecology, Kaohsiung Veterans General Hospital, Kaohsiung 813, Taiwan
- Institute of BioPharmaceutical Sciences, National Sun Yat-sen University, Kaohsiung 804, Taiwan
- Department of Pharmacy and Master Program, College of Pharmacy and Health Care, Tajen University, Pingtung County 907, Taiwan
| | - Yi-Jen Chen
- Department of Obstetrics and Gynecology, National Yang-Ming University, Taipei 112, Taiwan; (C.-Y.H.); (L.-T.L.); (K.-H.T.); (Y.-J.C.)
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei 112, Taiwan
| | - Wen-Ling Lee
- Institute of Clinical Medicine, National Yang-Ming University, Taipei 112, Taiwan
- Department of Medicine, Cheng-Hsin General Hospital, Taipei 112, Taiwan
- Correspondence: (W.-L.L.); (P.-H.W.); Tel.: +886-2-28757566 (P.-H.W.)
| | - Peng-Hui Wang
- Department of Obstetrics and Gynecology, National Yang-Ming University, Taipei 112, Taiwan; (C.-Y.H.); (L.-T.L.); (K.-H.T.); (Y.-J.C.)
- Institute of Clinical Medicine, National Yang-Ming University, Taipei 112, Taiwan
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei 112, Taiwan
- Female Cancer Foundation, Taipei 104, Taiwan
- Department of Medical Research, China Medical University Hospital, Taichung 404, Taiwan
- Correspondence: (W.-L.L.); (P.-H.W.); Tel.: +886-2-28757566 (P.-H.W.)
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Sharpe A, Morley LC, Tang T, Norman RJ, Balen AH. Metformin for ovulation induction (excluding gonadotrophins) in women with polycystic ovary syndrome. Cochrane Database Syst Rev 2019; 12:CD013505. [PMID: 31845767 PMCID: PMC6915832 DOI: 10.1002/14651858.cd013505] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Polycystic ovary syndrome (PCOS) is characterised by infrequent or absent ovulation, and high levels of androgens and insulin (hyperinsulinaemia). Hyperinsulinaemia occurs secondary to insulin resistance and is associated with an increased biochemical risk profile for cardiovascular disease and an increased prevalence of diabetes mellitus. Insulin-sensitising agents such as metformin may be effective in treating PCOS-related anovulation. This is an update of Morley 2017 and only includes studies on metformin. OBJECTIVES To evaluate the effectiveness and safety of metformin in combination with or in comparison to clomiphene citrate (CC), letrozole and laparoscopic ovarian drilling (LOD) in improving reproductive outcomes and associated gastrointestinal side effects for women with PCOS undergoing ovulation induction. SEARCH METHODS We searched the following databases from inception to December 2018: Cochrane Gynaecology and Fertility Group Specialised Register, CENTRAL, MEDLINE, Embase, PsycINFO and CINAHL. We searched registers of ongoing trials and reference lists from relevant studies. SELECTION CRITERIA We included randomised controlled trials of metformin compared with placebo, no treatment, or in combination with or compared with CC, letrozole and LOD for women with PCOS subfertility. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for eligibility and bias. Primary outcomes were live birth rate and gastrointestinal adverse effects. Secondary outcomes included other pregnancy outcomes and ovulation. We combined data to calculate pooled odds ratios (ORs) and 95% confidence intervals (CIs). We assessed statistical heterogeneity using the I2 statistic and reported quality of the evidence for primary outcomes and reproductive outcomes using GRADE methodology. MAIN RESULTS We included 41 studies (4552 women). Evidence quality ranged from very low to moderate based on GRADE assessment. Limitations were risk of bias (poor reporting of methodology and incomplete outcome data), imprecision and inconsistency. Metformin versus placebo or no treatment The evidence suggests that metformin may improve live birth rates compared with placebo (OR 1.59, 95% CI 1.00 to 2.51; I2 = 0%; 4 studies, 435 women; low-quality evidence). For a live birth rate of 19% following placebo, the live birth rate following metformin would be between 19% and 37%. The metformin group probably experiences more gastrointestinal side effects (OR 4.00, 95% CI 2.63 to 6.09; I2 = 39%; 7 studies, 713 women; moderate-quality evidence). With placebo, the risk of gastrointestinal side effects is 10% whereas with metformin this risk is between 22% and 40%. There are probably higher rates of clinical pregnancy (OR 1.98, 95% CI 1.47 to 2.65; I2 = 30%; 11 studies, 1213 women; moderate-quality evidence). There may be higher rates of ovulation with metformin (OR 2.64, 95% CI 1.85 to 3.75; I2 = 61%; 13 studies, 684 women; low-quality evidence). We are uncertain about the effect on miscarriage rates (OR 1.08, 95% CI 0.50 to 2.35; I2 = 0%; 4 studies, 748 women; low-quality evidence). Metformin plus CC versus CC alone We are uncertain if metformin plus CC improves live birth rates compared to CC alone (OR 1.27, 95% CI 0.98 to 1.65; I2 = 28%; 10 studies, 1219 women; low-quality evidence), but gastrointestinal side effects are probably more common with combined therapy (OR 4.26, 95% CI 2.83 to 6.40; I2 = 8%; 6 studies, 852 women; moderate quality evidence). The live birth rate with CC alone is 24%, which may change to between 23% to 34% with combined therapy. With CC alone, the risk of gastrointestinal side effects is 9%, which increases to between 21% to 37% with combined therapy. The combined therapy group probably has higher rates of clinical pregnancy (OR 1.62, 95% CI 1.32 to 1.99; I2 = 31%; 19 studies, 1790 women; moderate-quality evidence). The combined group may have higher rates of ovulation (OR 1.65, 95% CI 1.35 to 2.03; I2 = 63%;21 studies, 1568 women; low-quality evidence). There was no clear evidence of an effect on miscarriage (OR 1.35, 95% CI 0.91 to 2.00; I2 = 0%; 10 studies, 1206 women; low-quality evidence). Metformin versus CC When all studies were combined, findings for live birth were inconclusive and inconsistent (OR 0.71, 95% CI 0.49 to 1.01; I2 = 86%; 5 studies, 741 women; very low-quality evidence). In subgroup analysis by obesity status, obese women had a lower birth rate in the metformin group (OR 0.30, 95% CI 0.17 to 0.52; 2 studies, 500 women), while the non-obese group showed a possible benefit from metformin, with high heterogeneity (OR 1.71, 95% CI 1.00 to 2.94; I2 = 78%, 3 studies, 241 women; very low-quality evidence). However, due to the very low quality of the evidence we cannot draw any conclusions. Among obese women taking metformin there may be lower rates of clinical pregnancy (OR 0.34, 95% CI 0.21 to 0.55; I2 = 0%; 2 studies, 500 women; low-quality evidence) and ovulation (OR 0.29, 95% CI 0.20 to 0.43; I2 = 0%; 2 studies, 500 women; low-quality evidence) while among non-obese women, the metformin group may have more pregnancies (OR 1.56, 95% CI 1.06 to 2.29; I2 = 26%; 6 studies, 530 women; low-quality evidence) and no clear difference in ovulation rates (OR 0.80, 95% CI 0.52 to 1.25; I2 = 0%; 5 studies, 352 women; low-quality evidence). We are uncertain whether there is a difference in miscarriage rates between the groups (overall: OR 0.92, 95% CI 0.51 to 1.66; I2 = 36%; 6 studies, 781 women; low-quality evidence) and no studies reported gastrointestinal side effects. AUTHORS' CONCLUSIONS Our updated review suggests that metformin may be beneficial over placebo for live birth however, more women probably experience gastrointestinal side effects. We are uncertain if metformin plus CC improves live birth rates compared to CC alone, but gastrointestinal side effects are probably increased with combined therapy. When metformin was compared with CC, data for live birth were inconclusive, and the findings were limited by lack of evidence. Results differed by body mass index (BMI), emphasising the importance of stratifying results by BMI. No studies reported gastrointestinal side effects in this comparison. Due to the low quality of the evidence, we are uncertain of the effect of metformin on miscarriage in all three comparisons.
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Affiliation(s)
| | - Lara C Morley
- The General Infirmary of LeedsDepartment of Obstetrics and GynaecologyUnited Leeds Teaching Hospitals NHS TrustBelmont GroveLeedsUKLS2 9NS
| | - Thomas Tang
- Royal Jubilee Maternity ServiceRegional Fertility CentreGrosvenor RoadBelfastUKBT12 6BA
| | - Robert J Norman
- University of AdelaideObstetrics & Gynaecology, Robinson InstituteAdelaide South Australia 5005AdelaideSouth AustraliaAustralia
- University of AdelaideReproductive Medicine Unit, Department of Obstetrics and GynaecologyLevel 6, Medical School North Frome RoadAdelaideSouth AustraliaAustralia5005
- Fertility SAAdelaideAustralia
| | - Adam H Balen
- The Leeds Centre for Reproductive Medicine, Seacroft HospitalReproductive Medicine and SurgeryYork RoadLeedsUKLS14 6UH
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Penzias A, Bendikson K, Butts S, Coutifaris C, Falcone T, Fossum G, Gitlin S, Gracia C, Hansen K, La Barbera A, Mersereau J, Odem R, Paulson R, Pfeifer S, Pisarska M, Rebar R, Reindollar R, Rosen M, Sandlow J, Vernon M. Role of metformin for ovulation induction in infertile patients with polycystic ovary syndrome (PCOS): a guideline. Fertil Steril 2017; 108:426-441. [DOI: 10.1016/j.fertnstert.2017.06.026] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 06/20/2017] [Indexed: 01/07/2023]
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Mitra S, Nayak PK, Agrawal S. Laparoscopic ovarian drilling: An alternative but not the ultimate in the management of polycystic ovary syndrome. J Nat Sci Biol Med 2015; 6:40-8. [PMID: 25810633 PMCID: PMC4367066 DOI: 10.4103/0976-9668.149076] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Since its introduction in 1984, laparoscopic ovarian drilling has evolved into a safe and effective surgical treatment for anovulatory, infertile women with polycystic ovary syndrome (PCOS), unresponsive to clomiphene citrate. It is as effective as gonadotropins in terms of pregnancy and live birth rates, but without the risks of ovarian hyperstimulation syndrome and multiple pregnancies. It improves ovarian responsiveness to successive ovulation induction agents. Its favorable reproductive and endocrinal effects are sustained long. Despite its advantages, its use in unselected cases of PCOS or for non-fertility indications is not prudent owing to the potential risks of iatrogenic adhesions and ovarian insufficiency.
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Affiliation(s)
- Subarna Mitra
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, Tatibandh, Raipur, Chhattisgarh, India
| | - Prasanta Kumar Nayak
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, Tatibandh, Raipur, Chhattisgarh, India
| | - Sarita Agrawal
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, Tatibandh, Raipur, Chhattisgarh, India
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Cassina M, Donà M, Di Gianantonio E, Litta P, Clementi M. First-trimester exposure to metformin and risk of birth defects: a systematic review and meta-analysis. Hum Reprod Update 2014; 20:656-69. [PMID: 24861556 DOI: 10.1093/humupd/dmu022] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Metformin is generally considered a non-teratogenic drug; however, only a few studies specifically designed to assess the rate of congenital anomalies after metformin use have been published in the literature. The objects of the present study were to review all of the prospective and retrospective studies reporting on women treated with metformin at least during the first trimester of their pregnancy and to estimate the overall rate of major birth defects. METHODS Databases were searched for English language articles until December 2013. Inclusion criteria for the meta-analysis were: a case group of women with PCOS or pre-pregnancy type 2 diabetes and first-trimester exposure to metformin; a disease-matched control group which was not exposed to metformin or other oral anti-diabetic agents; and a list of the major anomalies in both the study and the control groups. A random effects model was used for the meta-analysis of data, using odds ratios. Studies not fulfilling the inclusion criteria for the meta-analysis but reporting relevant data on major malformations in women diagnosed with PCOS were then used to estimate the overall birth defects rate. RESULTS Meta-analysis of nine controlled studies with women affected by PCOS detected that the rate of major birth defects in the metformin-exposed group was not statistically increased compared with the disease-matched control group and that there was no significant heterogeneity among the studies. The metformin-exposed sample was composed of 351 pregnancies and the OR of major birth defects was 0.86 (95% confidence interval: 0.18-4.08; Pheterogeneity = 0.71). By evaluating all of the non-overlapping PCOS studies reported in the literature, even those without an appropriate control group, the overall rate of major anomalies was 0.6% in the sample of 517 women who discontinued the therapy upon conception or confirmation of pregnancy and 0.5% in the sample of 634 women who were treated with metformin throughout the first trimester of their pregnancy. Regarding type 2 diabetic women, we did not identify a sufficient number of studies with metformin exposure during the first trimester to proceed with the meta-analysis. CONCLUSIONS There is currently no evidence that metformin is associated with an increased risk of major birth defects in women affected by PCOS and treated during the first trimester. However larger ad hoc studies are warranted in order to definitely confirm the safety and efficacy of this drug in pregnancy.
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Affiliation(s)
- Matteo Cassina
- Teratology Information Service, Clinical Genetics Unit, Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Marta Donà
- Teratology Information Service, Clinical Genetics Unit, Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Elena Di Gianantonio
- Teratology Information Service, Clinical Genetics Unit, Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Pietro Litta
- Obstetrics and Gynecology Clinic, Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Maurizio Clementi
- Teratology Information Service, Clinical Genetics Unit, Department of Women's and Children's Health, University of Padova, Padova, Italy
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Abu Hashim H, Al-Inany H, De Vos M, Tournaye H. Three decades after Gjönnaess’s laparoscopic ovarian drilling for treatment of PCOS; what do we know? An evidence-based approach. Arch Gynecol Obstet 2013; 288:409-22. [DOI: 10.1007/s00404-013-2808-x] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2012] [Accepted: 03/12/2013] [Indexed: 10/27/2022]
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Office microlaparoscopic ovarian drilling (OMLOD) versus conventional laparoscopic ovarian drilling (LOD) for women with polycystic ovary syndrome. Arch Gynecol Obstet 2012; 287:361-7. [PMID: 22941326 DOI: 10.1007/s00404-012-2526-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2012] [Accepted: 08/13/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE AND DESIGN This was a prospective controlled study to compare the beneficial effects of office microlaparoscopic ovarian drilling (OMLOD) under augmented local anesthesia, as a new modality treatment option, compared to those following ovarian drilling with the conventional traditional 10-mm laparoscope (laparoscopic ovarian drilling, LOD) under general anesthesia. METHODS The study included 60 anovulatory women with polycystic ovary syndrome (PCOS) who underwent OMLOD (study group) and 60 anovulatory PCOS women, in whom conventional LOD using 10-mm laparoscope under general anesthesia was performed (comparison group). Transvaginal ultrasound scan and blood sampling to measure the serum concentrations of LH, FSH, testosterone and androstenedione were performed before and after the procedure. Intraoperative and postoperative pain scores in candidate women were evaluated during the office microlaparoscopic procedure, in addition to the number of candidates who needed extra analgesia. RESULTS Women undergoing OMLOD showed good intraoperative and postoperative pain scores. The number of patients discharged within 2 h after the office procedure was significantly higher, without the need for postoperative analgesia in most patients. The LH:FSH ratio, mean serum concentrations of LH and testosterone and free androgen index decreased significantly after both OMLOD and LOD. The mean ovarian volume decreased significantly (P < 0.05) a year after both OMLOD and LOD. There were no significant differences in those results after both procedures. CONCLUSION Intra- and postoperatively augmented local anesthesia allows outpatient bilateral ovarian drilling by microlaparoscopy without general anesthesia. The high pregnancy rate, the simplicity of the method and the faster discharge time offer a new option for patients with PCOS who are resistant to clomiphene citrate. Moreover, ovarian drilling could be performed simultaneously during the routine diagnostic microlaparoscopy and integrated into the fertility workup of these patients.
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Elnashar AM. The role of metformin in ovulation induction: Current status. MIDDLE EAST FERTILITY SOCIETY JOURNAL 2011. [DOI: 10.1016/j.mefs.2010.10.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Fernandez H, Morin-Surruca M, Torre A, Faivre E, Deffieux X, Gervaise A. Ovarian drilling for surgical treatment of polycystic ovarian syndrome: a comprehensive review. Reprod Biomed Online 2011; 22:556-68. [DOI: 10.1016/j.rbmo.2011.03.013] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2010] [Revised: 01/25/2011] [Accepted: 03/09/2011] [Indexed: 10/18/2022]
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Abu Hashim H, El-Shafei M, Badawy A, Wafa A, Zaglol H. Does laparoscopic ovarian diathermy change clomiphene-resistant PCOS into clomiphene-sensitive? Arch Gynecol Obstet 2011; 284:503-7. [PMID: 21594601 DOI: 10.1007/s00404-011-1931-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2011] [Accepted: 05/05/2011] [Indexed: 10/18/2022]
Abstract
PURPOSE To test the role of laparoscopic ovarian diathermy (LOD) in improving the ovarian response to clomiphene citrate (CC) in clomiphene-resistant polycystic ovary syndrome (PCOS) patients. METHODS The study comprised of 234 CC-resistant PCOS women who were treated with LOD. Eighty-four patients that remained anovulatory after LOD received 100-150 mg CC for 5 days starting from day 3 of induced menstruation for 1-3 cycles. Outcome measures were; ovulation, pregnancy, miscarriage and live birth rates. RESULTS Ovulation occurred in 80/162 cycles (49.4%) and in 30/84 patients (35.7%). Pregnancy occurred in 13/84 patients (15.5%) and in 13/80 cycles (16.2%). Miscarriage and live birth rates were 23.1 and 76.9%, respectively. Ovulatory women showed significantly lower baseline BMI (P < 0.001), Ferriman-Gallwey score (P = 0.02), testosterone (P = 0.03), higher sex hormone binding globulin and lower free androgen index (P < 0.001) compared with anovulatory women. The baseline fasting insulin was statistically significantly lower and fasting glucose:insulin ratio was statistically significantly higher (P = 0.003, 0.002) in ovulatory compared with anovulatory patients. CONCLUSIONS LOD improves the ovarian response to CC in at least one-third of CC-resistant patients who remained anovulatory following LOD especially in women who are less hyperandrogenic and less insulin resistant.
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Badawy A, Elnashar A. Treatment options for polycystic ovary syndrome. Int J Womens Health 2011; 3:25-35. [PMID: 21339935 PMCID: PMC3039006 DOI: 10.2147/ijwh.s11304] [Citation(s) in RCA: 258] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2011] [Indexed: 11/23/2022] Open
Abstract
Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in women. The clinical manifestation of PCOS varies from a mild menstrual disorder to severe disturbance of reproductive and metabolic functions. Management of women with PCOS depends on the symptoms. These could be ovulatory dysfunction-related infertility, menstrual disorders, or androgen-related symptoms. Weight loss improves the endocrine profile and increases the likelihood of ovulation and pregnancy. Normalization of menstrual cycles and ovulation could occur with modest weight loss as little as 5% of the initial weight. The treatment of obesity includes modifications in lifestyle (diet and exercise) and medical and surgical treatment. In PCOS, anovulation relates to low follicle-stimulating hormone concentrations and the arrest of antral follicle growth in the final stages of maturation. This can be treated with medications such as clomiphene citrate, tamoxifen, aromatase inhibitors, metformin, glucocorticoids, or gonadotropins or surgically by laparoscopic ovarian drilling. In vitro fertilization will remain the last option to achieve pregnancy when others fail. Chronic anovulation over a long period of time is also associated with an increased risk of endometrial hyperplasia and carcinoma, which should be seriously investigated and treated. There are androgenic symptoms that will vary from patient to patient, such as hirsutism, acne, and/or alopecia. These are troublesome presentations to the patients and require adequate treatment. Alternative medicine has been emerging as one of the commonly practiced medicines for different health problems, including PCOS. This review underlines the contribution to the treatment of different symptoms.
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Affiliation(s)
- Ahmed Badawy
- Department of Obstetrics and Gynecology, Mansoura University, Mansoura, Egypt
| | - Abubaker Elnashar
- Department of Obstetrics and Gynecology, Benha University, Benha, Egypt
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Management strategies for ovulation induction in women with polycystic ovary syndrome and known clomifene citrate resistance. Curr Opin Obstet Gynecol 2009; 21:465-73. [DOI: 10.1097/gco.0b013e328332d188] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Palomba S, Falbo A, Zullo F, Orio F. Evidence-based and potential benefits of metformin in the polycystic ovary syndrome: a comprehensive review. Endocr Rev 2009; 30:1-50. [PMID: 19056992 DOI: 10.1210/er.2008-0030] [Citation(s) in RCA: 281] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Metformin is an insulin sensitizer widely used for the treatment of patients affected by type 2 diabetes mellitus. Because many women with polycystic ovary syndrome (PCOS) are insulin resistant, metformin was introduced in clinical practice to treat these patients also. Moreover, metformin's effect has other targets beside its insulin-sensitizing action. The present review was aimed at describing all evidence-based and potential uses of metformin in PCOS patients. In particular, we will analyze the uses of metformin not only for the treatment of all PCOS-related disturbances such as menstrual disorders, anovulatory infertility, increased abortion, or complicated pregnancy risk, hyperandrogenism, endometrial, metabolic and cardiovascular abnormalities, but also for the prevention of the syndrome.
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Affiliation(s)
- Stefano Palomba
- Department of Gynecology and Obstetrics, University "Magna Graecia" of Catanzaro, Via Pio X, 88100 Catanzaro, Italy.
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Insulin-sensitizing agents and reproductive function in polycystic ovary syndrome patients. Curr Opin Obstet Gynecol 2008; 20:364-73. [DOI: 10.1097/gco.0b013e328307ebc5] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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Cataldo NA, Barnhart HX, Legro RS, Myers ER, Schlaff WD, Carr BR, Diamond MP, Carson SA, Steinkampf MP, Coutifaris C, McGovern PG, Gosman G, Nestler JE, Giudice LC. Extended-release metformin does not reduce the clomiphene citrate dose required to induce ovulation in polycystic ovary syndrome. J Clin Endocrinol Metab 2008; 93:3124-7. [PMID: 18505764 PMCID: PMC2515084 DOI: 10.1210/jc.2008-0287] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT When used for ovulation induction, higher doses of clomiphene may lead to antiestrogenic side effects that reduce fecundity. It has been suggested that metformin in combination with clomiphene can restore ovulation to some clomiphene-resistant anovulators with polycystic ovary syndrome (PCOS). OBJECTIVE Our objective was to determine if cotreatment with extended-release metformin (metformin XR) can lower the threshold dose of clomiphene needed to induce ovulation in women with PCOS. DESIGN A secondary analysis of data from the National Institute of Child Health and Human Development Cooperative Multicenter Reproductive Medicine Network prospective, double-blind, placebo-controlled multicenter clinical trial, Pregnancy in Polycystic Ovary Syndrome, was performed. SETTING Study volunteers at multiple academic medical centers were included. PARTICIPANTS Women with PCOS and elevated serum testosterone who were randomized to clomiphene alone or with metformin (n = 209 in each group) were included in the study. INTERVENTIONS Clomiphene citrate, 50 mg daily for 5 d, was increased to 100 and 150 mg in subsequent cycles if ovulation was not achieved; half also received metformin XR, 1000 mg twice daily. Treatment was for up to 30 wk or six cycles, or until first pregnancy. MAIN OUTCOME MEASURES Ovulation was confirmed by a serum progesterone more than or equal to 5 ng/ml, drawn prospectively every 1-2 wk. RESULTS The overall prevalence of at least one ovulation after clomiphene was 75 and 83% (P = 0.04) for the clomiphene-only and clomiphene plus metformin groups, respectively. Using available data from 314 ovulators, the frequency distribution of the lowest clomiphene dose (50, 100, or 150 mg daily) resulting in ovulation was indistinguishable between the two treatment groups. CONCLUSION Metformin XR does not reduce the lowest dose of clomiphene that induces ovulation in women with PCOS.
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Palomba S, Oppedisano R, Tolino A, Orio F, Zullo F. Metformin use in infertile patients with polycystic ovary syndrome: an evidence-based overview. Reprod Biomed Online 2008; 16:327-35. [DOI: 10.1016/s1472-6483(10)60592-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
Up to 10% of women may suffer from polycystic ovary syndrome (PCOS). The clinical symptoms may vary, so the biochemical profile and ultrasonography are used to predict an accurate diagnosis. Many studies have indicated that a relationship may exist between hyperinsulineamia and hyperandrogenism but the exact pathogenesis remains obscure. PCOS is treated by a combination of surgery or pharmacological management. Treatment is not always successful therefore women in these cases require support and care from nursing staff to help overcome the disappointment of treatment failure. To support women with PCOS, nurses need to be knowledgeable about the condition and its clinical manifestations and available treatment options. This article aims to examine the current aetiology, clinical manifestations, pathophysiology, diagnosis and treatment options available to women with a diagnosis of PCOS.
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Affiliation(s)
- Maggi Banning
- Brunel University, School of Health Sciences and Social Care, Middlesex, UK
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Khattab S, Fotouh IA, Mohesn IA, Metwally M, Moaz M. Use of metformin for prevention of ovarian hyperstimulation syndrome: a novel approach. Reprod Biomed Online 2006; 13:194-7. [PMID: 16895631 DOI: 10.1016/s1472-6483(10)60614-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
In the present study, which includes 287 participants, metformin has been used by women undergoing IVF/intracytoplasmic sperm injection for more than 5 weeks before and during treatment and during luteal phase. There was no significant difference in number of gonadotrophins used, days of stimulation, number of oocytes retrieved, and number of embryos replaced. There was no significant difference in clinical pregnancy rate between both groups but there was significant reduction in the incidence of ovarian hyperstimulation syndrome (OHSS) in the group taking metformin. Metformin is a safe, cheap drug that can help in prevention of OHSS.
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Affiliation(s)
- Sherif Khattab
- Department of Obstetrics and Gynecology, Cairo University, Misr International Hospital, 40, Abdel Rehim Sabry St, Dokki, Cairo, Egypt.
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