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Association of Insulin Resistance and Elevated Androgen Levels with Polycystic Ovarian Syndrome (PCOS): A Review of Literature. JOURNAL OF HEALTHCARE ENGINEERING 2022; 2022:9240569. [PMID: 35356614 PMCID: PMC8959968 DOI: 10.1155/2022/9240569] [Citation(s) in RCA: 48] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Revised: 02/08/2022] [Accepted: 02/12/2022] [Indexed: 12/14/2022]
Abstract
The polycystic ovary syndrome (PCOS) is the disease featured by elevated levels of androgens, ovulatory dysfunction, and morphological abnormalities. At reproductive stage of women, the rate of PCOS occurrence is measured as 6–10% and the prevalence rate may be double. There are different pathophysiological factors involved in PCOS, and they play a major role in various abnormalities in individual patient. It is clear that there is noteworthy elevation of androgen in PCOS, causing substantial misery and infertility problems. The overexposure of androgen is directly linked with insulin resistance and hyperinsulinaemia. It has been reported previously that PCOS is related to cardiac metabolic miseries and potently increases the risk of heart diseases. Endometrial cancer is also a serious concern which is reported with exceedingly high incidence in women with PCOS. However, the overexposure of androgen has direct and specific influence on the development of insulin resistance. Although many factors are involved, resistance to the insulin and enhanced level of androgen are considered the major causes of PCOS. In the present review, we have focused on the pathophysiology and major revolutions of insulin resistance and excessive levels of androgen in females with PCOS.
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Kathuria D, Raul AD, Wanjari P, Bharatam PV. Biguanides: Species with versatile therapeutic applications. Eur J Med Chem 2021; 219:113378. [PMID: 33857729 DOI: 10.1016/j.ejmech.2021.113378] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 03/04/2021] [Accepted: 03/08/2021] [Indexed: 12/18/2022]
Abstract
Biguanides are compounds in which two guanidine moieties are fused to form a highly conjugated system. Biguanides are highly basic and hence they are available as salts mostly hydrochloride salts, these cationic species have been found to exhibit many therapeutic properties. This review covers the research and development carried out on biguanides and accounts the various therapeutic applications of drugs containing biguanide group-such as antimalarial, antidiabetic, antiviral, anticancer, antibacterial, antifungal, anti-tubercular, antifilarial, anti-HIV, as well as other biological activities. The aim of this review is to compile all the medicinal chemistry applications of this class of compounds so as to pave way for the accelerated efforts in finding the drug action mechanisms associated with this class of compounds. Importance has been given to the organic chemistry of these biguanide derivatives also.
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Affiliation(s)
- Deepika Kathuria
- University Center for Research and Development, Chandigarh University, Gharuan, Punjab, 140413, India
| | - Akshay D Raul
- Department of Medicinal Chemistry, National Institute of Pharmaceutical Education and Research (NIPER), Sector 67, S. A. S. Nagar, 160 062, Punjab, India
| | - Pravin Wanjari
- Department of Medicinal Chemistry, National Institute of Pharmaceutical Education and Research (NIPER), Sector 67, S. A. S. Nagar, 160 062, Punjab, India
| | - Prasad V Bharatam
- Department of Medicinal Chemistry, National Institute of Pharmaceutical Education and Research (NIPER), Sector 67, S. A. S. Nagar, 160 062, Punjab, India.
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Liu Y, Li J, Yan Z, Liu D, Ma J, Tong N. Improvement of Insulin Sensitivity Increases Pregnancy Rate in Infertile PCOS Women: A Systemic Review. Front Endocrinol (Lausanne) 2021; 12:657889. [PMID: 33859621 PMCID: PMC8042389 DOI: 10.3389/fendo.2021.657889] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 03/15/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Polycystic ovary syndrome (PCOS) is the most common cause of infertility in reproductive-age women. Insulin increases steroidogenesis, deranges granulosa cell differentiation, and affects follicle growth. However, results from randomized control trials (RCTs) were heterogeneous, and little strong evidence associated actual achievement of insulin sensitivity (IS) improvement with reproductive outcomes. OBJECTIVES To identify evidence of the reproductive benefit of IS improvement in infertile PCOS women by analyzing eligible RCTs. SEARCH STRATEGY Different search strategies with unlimited keywords, including treatment, therapy, intervention, polycystic ovary syndrome/PCOS, insulin resistance, pregnancy, conceive, live birth, and randomized controlled trials/RCT were used in databases including Pubmed, Embase, and Web of Science to November 20th, 2021. DATA COLLECTION AND ANALYSIS Two authors independently abstracted study details and assessed study quality. MAIN RESULTS Ten RCTs that covered different races and met the inclusion criteria were included for analysis and discussion. Clinical pregnancy rate was increased in infertile PCOS women when they had significant improvement of IS after treatment regardless of the various interventions (non-surgical). The benefits of IS improvement appeared superior in PCOS women without severe obesity. The effect of IS improvement on pregnancy rate was independent of the change of BMI. CONCLUSIONS Nonsurgical therapeutic strategies that promote superior IS improvement may aid infertile PCOS women to increase their possibility of successful pregnancy regardless of the various interventions. The improvement of IS might be more important than the reduction of BMI in the improvement of pregnancy rate in infertile PCOS women.
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Affiliation(s)
- Yuqi Liu
- Department of Endocrinology and Metabolism, West China Hospital of Sichuan University, Chengdu, China
- Laboratory of Diabetes and Islet Transplantation Research, Center for Diabetes and Metabolism Research, West China Hospital of Sichuan University, Chengdu, China
| | - Juan Li
- Department of Endocrinology and Metabolism, West China Hospital of Sichuan University, Chengdu, China
- Laboratory of Diabetes and Islet Transplantation Research, Center for Diabetes and Metabolism Research, West China Hospital of Sichuan University, Chengdu, China
| | - Zhe Yan
- Department of Endocrinology and Metabolism, West China Hospital of Sichuan University, Chengdu, China
- Laboratory of Diabetes and Islet Transplantation Research, Center for Diabetes and Metabolism Research, West China Hospital of Sichuan University, Chengdu, China
| | - Dan Liu
- Department of Obstetrics and Gynecology, Nantong Rich Hospital of Nantong University, Nantong, China
| | - Jinfang Ma
- Department of Endocrinology and Metabolism, West China Hospital of Sichuan University, Chengdu, China
- Laboratory of Diabetes and Islet Transplantation Research, Center for Diabetes and Metabolism Research, West China Hospital of Sichuan University, Chengdu, China
| | - Nanwei Tong
- Department of Endocrinology and Metabolism, West China Hospital of Sichuan University, Chengdu, China
- Laboratory of Diabetes and Islet Transplantation Research, Center for Diabetes and Metabolism Research, West China Hospital of Sichuan University, Chengdu, China
- *Correspondence: Nanwei Tong,
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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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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 2020; 13:257-270. [PMID: 31710185 PMCID: PMC6875858 DOI: 10.22074/ijfs.2020.5608] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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 reproductiveaged 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 undergoing in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI), the addition of metformin to gonadotrophins 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 populations 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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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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Laganà AS, Garzon S, Casarin J, Franchi M, Ghezzi F. Inositol in Polycystic Ovary Syndrome: Restoring Fertility through a Pathophysiology-Based Approach. Trends Endocrinol Metab 2018; 29:768-780. [PMID: 30270194 DOI: 10.1016/j.tem.2018.09.001] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Revised: 08/28/2018] [Accepted: 09/04/2018] [Indexed: 12/21/2022]
Abstract
Myo-inositol (MI) and D-chiro-inositol (DCI) are insulin second messengers, and MI is involved in follicular gonadotropin pathways which orchestrate ovulation. The tissue-specific MI/DCI ratio is modulated by insulin through aromatase and is altered in insulin resistance (IR), with reduced epimerization of MI to DCI in insulin-sensitive tissues. In ovaries, the MI/DCI ratio is 100:1, but is dramatically reduced by insulin-stimulated epimerase in hyperinsulinemic women with polycystic ovary syndrome (PCOS). Inositols have proved to be effective in PCOS, improving metabolic and hormonal state, and restoring spontaneous ovulation. In assisted reproductive technology, inositol improved ovarian stimulation parameters, although data concerning fertility outcomes are conflicting. Given their functions, inositols are an attractive treatment option for PCOS, although well-designed studies on spontaneous and non-spontaneous fertility are needed.
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Affiliation(s)
- Antonio Simone Laganà
- Department of Obstetrics and Gynecology, 'Filippo Del Ponte' Hospital, University of Insubria, Varese, Italy; Equal contributions.
| | - Simone Garzon
- Department of Obstetrics and Gynecology, Azienda Ospedaliera Universitaria Integrata di Verona (AOUI Verona), University of Verona, Verona, Italy; Equal contributions
| | - Jvan Casarin
- Department of Obstetrics and Gynecology, 'Filippo Del Ponte' Hospital, University of Insubria, Varese, Italy
| | - Massimo Franchi
- Department of Obstetrics and Gynecology, Azienda Ospedaliera Universitaria Integrata di Verona (AOUI Verona), University of Verona, Verona, Italy
| | - Fabio Ghezzi
- Department of Obstetrics and Gynecology, 'Filippo Del Ponte' Hospital, University of Insubria, Varese, Italy
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Gadalla MA, Huang S, Wang R, Norman RJ, Abdullah SA, El Saman AM, Ismail AM, van Wely M, Mol BWJ. Effect of clomiphene citrate on endometrial thickness, ovulation, pregnancy and live birth in anovulatory women: systematic review and meta-analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2018; 51:64-76. [PMID: 29055102 DOI: 10.1002/uog.18933] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 10/08/2017] [Accepted: 10/11/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVES To compare the impact of clomiphene citrate (CC) vs other drug regimens on mid-cycle endometrial thickness (EMT), ovulation, pregnancy and live birth rates in women with World Health Organization (WHO) group II ovulatory disorders. METHODS We searched MEDLINE, EMBASE, Scopus, Web of Science, The Cochrane Central Register of Clinical Trials (CENTRAL) and the non-MEDLINE subset of PubMed from inception to December 2016 and cross-checked references of relevant articles. We included only randomized controlled trials (RCTs) comparing CC used alone vs other drug regimens for ovulation induction in women with WHO group II anovulation. Outcomes were mid-cycle EMT, ovulation, pregnancy and live birth rates. We pooled weighted mean differences (WMD) with 95% confidence intervals (CI) for continuous variables (EMT) and risk ratios (RR) with 95% CI for binary variables (ovulation, pregnancy and live birth rates). RESULTS We retrieved 1718 articles of which 33 RCTs (4349 women, 7210 ovulation induction cycles) were included. In 15 RCTs that compared CC with letrozole, EMT was lower in the CC group (1957 women, 3892 cycles; WMD, -1.39; 95% CI, -2.27 to -0.51; I2 = 100%), ovulation rates after CC and letrozole were comparable (1710 women, 3217 cycles; RR, 0.97; 95% CI, 0.90-1.04; I2 = 47%), while CC led to a lower pregnancy rate (1957 women, 3892 cycles; RR, 0.78; 95% CI, 0.63-0.95; I2 = 43%) and a lower live birth rate (RR, 0.70; 95% CI, 0.49-0.98; I2 = 35%). In two RCTs that compared CC with CC plus metformin, EMT, ovulation and pregnancy rates were comparable (101 women, 140 cycles; WMD, -0.23; 95% CI, -0.92 to 0.45; I2 = 78%; RR, 0.84; 95% CI, 0.67-1.06; I2 = 0%; and RR, 0.79; 95% CI, 0.33-1.87; I2 = 0%). In three studies that compared CC with CC plus N-acetyl cysteine (NAC), EMT was lower in the CC group (340 women, 300 cycles; WMD, -1.51; 95% CI, -1.98 to -1.04; I2 = 45%). In two studies that compared CC with CC + nitric oxide (NO) donor, EMT was lower in the CC group (120 women, 304 cycles; WMD, -1.75; 95% CI, -2.08 to -1.41; I2 = 0%). Compared with CC plus NO donor or NAC, CC showed statistically significant lower ovulation and pregnancy rates. Compared with tamoxifen in three studies, CC showed a tendency towards lower EMT (571 women, 844 cycles; WMD, -1.34; 95% CI, -2.70 to 0.01; I2 = 96%) with comparable ovulation and pregnancy rates. CONCLUSIONS In women with WHO group II ovulatory disorders, ovulation induction with CC might result in lower EMT than other ovulation induction regimens. Whether the lower EMT caused the lower pregnancy and live birth rates remains to be elucidated. Letrozole seems to be beneficial for these women. However, our findings should be interpreted with caution as the quality of evidence was very low. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- M A Gadalla
- Women's Health Hospital, Department of Obstetrics and Gynecology, Assiut University, Assiut, Egypt
- Robinson Research Institute, Adelaide Medical School, University of Adelaide, Adelaide, Australia
| | - S Huang
- Robinson Research Institute, Adelaide Medical School, University of Adelaide, Adelaide, Australia
- Reproductive Medicine Centre, Peking University Third Hospital, Beijing, China
| | - R Wang
- Robinson Research Institute, Adelaide Medical School, University of Adelaide, Adelaide, Australia
| | - R J Norman
- Robinson Research Institute, Adelaide Medical School, University of Adelaide, Adelaide, Australia
| | - S A Abdullah
- Women's Health Hospital, Department of Obstetrics and Gynecology, Assiut University, Assiut, Egypt
| | - A M El Saman
- Women's Health Hospital, Department of Obstetrics and Gynecology, Assiut University, Assiut, Egypt
| | - A M Ismail
- Women's Health Hospital, Department of Obstetrics and Gynecology, Assiut University, Assiut, Egypt
| | - M van Wely
- Center for Reproductive Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - B W J Mol
- Robinson Research Institute, Adelaide Medical School, University of Adelaide, Adelaide, Australia
- South Australian Health and Medical Research Institute, Adelaide, Australia
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9
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Morley LC, Tang T, Yasmin E, Norman RJ, Balen AH. Insulin-sensitising drugs (metformin, rosiglitazone, pioglitazone, D-chiro-inositol) for women with polycystic ovary syndrome, oligo amenorrhoea and subfertility. Cochrane Database Syst Rev 2017; 11:CD003053. [PMID: 29183107 PMCID: PMC6486196 DOI: 10.1002/14651858.cd003053.pub6] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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 increased risk of cardiovascular disease and diabetes mellitus. Insulin-sensitising agents such as metformin may be effective in treating PCOS-related anovulation. OBJECTIVES To evaluate the effectiveness and safety of insulin-sensitising drugs in improving reproductive and metabolic outcomes for women with PCOS undergoing ovulation induction. SEARCH METHODS We searched the following databases from inception to January 2017: 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 insulin-sensitising drugs compared with placebo, no treatment, or an ovulation-induction agent for women with oligo and anovulatory PCOS. 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, menstrual frequency and metabolic effects. 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 using GRADE methodology. MAIN RESULTS We assessed the interventions metformin, clomiphene citrate, metformin plus clomiphene citrate, D-chiro-inositol, rosiglitazone and pioglitazone. We compared these with each other, placebo or no treatment. We included 48 studies (4451 women), 42 of which investigated metformin (4024 women). Evidence quality ranged from very low to moderate. Limitations were risk of bias (poor reporting of methodology and incomplete outcome data), imprecision and inconsistency. Metformin versus placebo or no treatmentThe evidence suggests that metformin may improve live birth rates compared with placebo (OR 1.59, 95% CI 1.00 to 2.51, 4 studies, 435 women, I2 = 0%, low-quality evidence). The metformin group experienced more gastrointestinal side effects (OR 4.76, 95% CI 3.06 to 7.41, 7 studies, 670 women, I2 = 61%, moderate-quality evidence) but had higher rates of clinical pregnancy (OR 1.93, 95% CI 1.42 to 2.64, 9 studies, 1027 women, I2 = 43%, moderate-quality evidence), ovulation (OR 2.55, 95% CI 1.81 to 3.59, 14 studies, 701 women, I2 = 58%, moderate-quality evidence) and menstrual frequency (OR 1.72, 95% CI 1.14 to 2.61, 7 studies, 427 women, I2 = 54%, low-quality evidence). There was no clear evidence of a difference in miscarriage rates (OR 1.08, 95% CI 0.50 to 2.35, 4 studies, 748 women, I2 = 0%, low-quality evidence). Metformin plus clomiphene citrate versus clomiphene citrate alone There was no conclusive evidence of a difference between the groups in live birth rates (OR 1.21, 95% CI 0.92 to 1.59, 9 studies, 1079 women, I2 = 20%, low-quality evidence), but gastrointestinal side effects were more common with combined therapy (OR 3.97, 95% CI 2.59 to 6.08, 3 studies, 591 women, I2 = 47%, moderate-quality evidence). However, the combined therapy group had higher rates of clinical pregnancy (OR 1.59, 95% CI 1.27 to 1.99, 16 studies, 1529 women, I2 = 33%, moderate-quality evidence) and ovulation (OR 1.57, 95% CI 1.28 to 1.92, 21 studies, 1624 women, I2 = 64%, moderate-quality evidence). There was a statistically significant difference in miscarriage rate per woman, with higher rates in the combined therapy group (OR 1.59, 95% CI 1.03 to 2.46, 9 studies, 1096 women, I2 = 0%, low-quality evidence) but this is of uncertain clinical significance due to low-quality evidence, and no clear difference between groups when we analysed miscarriage per pregnancy (OR 1.30, 95% CI 0.80 to 2.12, 8 studies; 400 pregnancies, I2 = 0%, low-quality evidence). Metformin versus clomiphene citrateWhen all studies were combined, findings for live birth were inconclusive and inconsistent (OR 0.71, 95% CI 0.49 to 1.01, 5 studies, 741 women, I2 = 86%, 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, I2 = 0%, very low-quality evidence), while data from the non-obese group showed a possible benefit from metformin, with high heterogeneity (OR 1.71, 95% CI 1.00 to 2.94, 3 studies, 241 women, I2 = 78%, very low-quality evidence). Similarly, among obese women taking metformin there were lower rates of clinical pregnancy (OR 0.34, 95% CI 0.21 to 0.55, 2 studies, 500 women, I2 = 0%, very low-quality evidence) and ovulation (OR 0.29, 95% CI 0.20 to 0.43 2 studies, 500 women, I2 = 0%, low-quality evidence) while among non-obese women, the metformin group had more pregnancies (OR 1.56, 95% CI 1.05 to 2.33, 5 studies, 490 women, I2 = 41%, very low-quality evidence) and no clear difference in ovulation rates (OR 0.81, 95% CI 0.51 to 1.28, 4 studies, 312 women, low-quality evidence, I2=0%). There was no clear evidence of a difference in miscarriage rates (overall: OR 0.92, 95% CI 0.50 to 1.67, 5 studies, 741 women, I2 = 52%, very low-quality evidence). D-chiro-inositol (2 studies), rosiglitazone (1 study) or pioglitazone (1 study) versus placebo or no treatmentWe were unable to draw conclusions regarding other insulin-sensitising drugs as no studies reported primary outcomes. AUTHORS' CONCLUSIONS Our updated review suggests that metformin alone may be beneficial over placebo for live birth, although the evidence quality was low. When metformin was compared with clomiphene citrate, data for live birth were inconclusive, and our findings were limited by lack of evidence. Results differed by body mass index (BMI), emphasising the importance of stratifying results by BMI. An improvement in clinical pregnancy and ovulation suggests that clomiphene citrate remains preferable to metformin for ovulation induction in obese women with PCOS.An improved clinical pregnancy and ovulation rate with metformin and clomiphene citrate versus clomiphene citrate alone suggests that combined therapy may be useful although we do not know whether this translates into increased live births. Women taking metformin alone or with combined therapy should be advised that there is no evidence of increased miscarriages, but gastrointestinal side effects are more likely.
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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
| | - Ephia Yasmin
- University College Hospital2nd floor North, 250 Euston RoadLondonUKNW1 2PG
| | - Robert J Norman
- University of AdelaideObstetrics & Gynaecology, Robinson InstituteAdelaideSouth AustraliaAustralia5005
| | - 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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Abstract
Polycystic ovary syndrome (PCOS) is the most prevalent endocrinopathy among women during reproductive age. PCOS is characterised by hyperandrogenaemia, hyperinsulinaemia, and deranged adipokines secretion from the adipose tissue. In addition to the reduced insulin sensitivity, PCOS women exhibit β-cell dysfunction as well. Low birth weight and foetal exposure to androgens may contribute to the development of the PCOS phenotype during life. Further metabolic complications lead to dyslipidaemia, worsening obesity and glucose tolerance, high prevalence of metabolic syndrome, and greater susceptibility to diabetes. PCOS women show age-related existence of hypertension, and subtle endothelial and vascular changes. Adverse reproductive outcomes include anovulatory infertility, and unrecognised potentiation of the hormone-dependent endometrial cancer. The main therapeutic approach is lifestyle modification. Metformin is the primary insulin-sensitising drug to be used as an adjuvant therapy to lifestyle modification in patients with insulin resistance and impaired glucose tolerance, as well as in those referred to infertility treatment. Thiazolidinediones should be reserved for women intolerant of or refractory to metformin, while glucagon-like peptide 1 analogues has a potential therapeutic use in obese PCOS women. Randomised clinical trials and repetitive studies on different PCOS phenotypes for the preventive actions and therapeutic options are still lacking, though.
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Affiliation(s)
- Djuro Macut
- Clinic of Endocrinology, Diabetes and Metabolic Diseases, Faculty of Medicine, University of Belgrade, Belgrade, Serbia.
| | - Jelica Bjekić-Macut
- Department of Endocrinology, UMC Bežanijska kosa, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Dario Rahelić
- Department of Endocrinology, Diabetes and Clinical Pharmacology, Clinic for Internal Medicine, School of Medicine Zagreb, Dubrava University Hospital, Zagreb, Croatia
| | - Mirjana Doknić
- Clinic of Endocrinology, Diabetes and Metabolic Diseases, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
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12
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Birch Petersen K, Pedersen NG, Pedersen AT, Lauritsen MP, la Cour Freiesleben N. Mono-ovulation in women with polycystic ovary syndrome: a clinical review on ovulation induction. Reprod Biomed Online 2016; 32:563-83. [PMID: 27151490 DOI: 10.1016/j.rbmo.2016.03.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Revised: 03/14/2016] [Accepted: 03/15/2016] [Indexed: 12/26/2022]
Abstract
Polycystic ovary syndrome (PCOS) affects 5-10% of women of reproductive age and is the most common cause of anovulatory infertility. The treatment approaches to ovulation induction vary in efficacy, treatment duration and patient friendliness. The aim was to determine the most efficient, evidence-based method to achieve mono-ovulation in women diagnosed with PCOS. Publications in English providing information on treatment, efficacy and complication rates were included until September 2015. Systematic reviews, meta-analyses and randomized controlled trials were favoured over cohort and retrospective studies. Clomiphene citrate is recommended as primary treatment for PCOS-related infertility. It induces ovulation in three out of four patients, the risk of multiple pregnancies is modest and the treatment is simple and inexpensive. Gonadotrophins are highly efficient in a low-dose step-up regimen. Ovulation rates are improved by lifestyle interventions in overweight women. Metformin may improve the menstrual cycle within 1-3 months, but does not improve the live birth rate. Letrozole is effective for ovulation induction, but is an off-label drug in many countries. Ovulation induction in women with PCOS should be individualized with regard to weight, treatment efficacy and patient preferences with the aim of achieving mono-ovulation and subsequently the birth of a singleton baby.
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Affiliation(s)
- Kathrine Birch Petersen
- Fertility Clinic, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark.
| | - Nina Gros Pedersen
- Department of Gynecology/Obstetrics, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark
| | - Anette Tønnes Pedersen
- Fertility Clinic and Department of Gynecology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark
| | - Mette Petri Lauritsen
- Department of Gynecology/Obstetrics, Herlev Hospital, Copenhagen University Hospital, Herlev Ringvej 75, 2730 Herlev, Denmark
| | - Nina la Cour Freiesleben
- Fertility Clinic and Department of Gynecology/Obstetrics, Holbæk Hospital, Copenhagen University Hospital, Smedelundsgade 60, 4300 Holbæk, Denmark
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13
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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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14
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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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15
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Naderpoor N, Shorakae S, de Courten B, Misso ML, Moran LJ, Teede HJ. Metformin and lifestyle modification in polycystic ovary syndrome: systematic review and meta-analysis. Hum Reprod Update 2015; 21:560-74. [DOI: 10.1093/humupd/dmv025] [Citation(s) in RCA: 196] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Accepted: 04/29/2015] [Indexed: 12/31/2022] Open
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Abstract
Metformin has a potential role for insulin resistance in polycystic ovary syndrome(PCOS) and has demonstrated efficacy in diabetes. There are a large number of studies and evidence syntheses comparing metformin with control, lifestyle interventions, the oral contraceptive pill, and clomiphene citrate; however, there is still uncertainty about the effectiveness of metformin in women with PCOS. Here we present a systematic overview of the evidence for the use of metformin in women with PCOS. The evidence suggests that metformin continues to have an unclear roll in PCOS until further well designed; methodologically rigorous effectiveness studies with large sample sizes are conducted, and these should include women across the body mass index (BMI) range.
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Affiliation(s)
- Marie L Misso
- Monash Centre for Health Research and Implementation, School Public Health and Preventative Medicine, Monash University, MHRP, 43-51 Kanooka Grove, Clayton, VIC, 3168, Australia,
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17
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Medical and surgical interventions to improve outcomes in obese women planning for pregnancy. Best Pract Res Clin Obstet Gynaecol 2014; 29:565-76. [PMID: 25648680 DOI: 10.1016/j.bpobgyn.2014.12.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Revised: 11/18/2014] [Accepted: 12/13/2014] [Indexed: 01/28/2023]
Abstract
Obesity is a known risk factor for infertility in women. The exact mechanism through which obesity is linked to infertility is still not fully understood. Hyperleptinaemia, hyperinsulinaemia and resultant hyperandrogenism are all thought to play a role. Various medical and surgical interventions have been attempted to improve fertility rates in obese women. Encouraging evidence for pharmacotherapy, bariatric surgery and assisted reproduction are yet to be seen. In this chapter, we review the hormonal changes in obesity and the evidence behind medical and surgical interventions to improve fertility in obese women.
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Sari U, Kaygusuz I, Kafali H. Is pentraxin 3 a new cardiovascular risk marker in polycystic ovary syndrome? Gynecol Obstet Invest 2014; 78:173-8. [PMID: 25011417 DOI: 10.1159/000363744] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2013] [Accepted: 05/18/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIMS Polycystic ovary syndrome (PCOS) patients have an increased rate of subclinical inflammation, which plays a role in the pathogenesis of atherosclerosis. Pentraxin 3 (PTX3) is an inflammatory mediator which belongs to the same family as the well-established cardiovascular biomarker C-reactive protein (CRP). The present study was performed to investigate plasma PTX3 levels in patients with PCOS and to determine the relationship between PTX3 and other known cardiovascular risk factors. METHODS 40 patients with PCOS and 40 age- and BMI-matched healthy controls were included in the study. The groups were divided into subgroups according to BMI. Insulin resistance indexes, lipid profile, CRP and PTX3 levels were analyzed. RESULTS There was no difference for insulin resistance indexes and lipid profile between the PCOS and control groups. CRP levels were significantly higher in obese PCOS and control subjects than in lean subjects, whereas no difference in PTX3 concentrations was observed between subgroups. CONCLUSION PTX3 and CRP levels were similar in the PCOS group compared with the non-PCOS control group.
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Affiliation(s)
- Umut Sari
- Department of Obstetrics and Gynecology, Acibadem Levent Medical Center, Istanbul, Turkey
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19
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Abstract
The purpose of this paper is to provide a stepwise approach to treating the infertility/subfertility associated with polycystic ovary syndrome. Defining polycystic ovary syndrome in a patient requires first investigating other possible causes for polycystic ovary morphology, acne, hirsutism, obesity, and the metabolic derangements that often accompany polycystic ovary syndrome. Beginning with lifestyle modification and use of metformin, the progressive inclusion of more intensive therapies for induction of ovulation is described. Second-line treatments are discussed and the new findings from a large multicenter trial are discussed in the context of evidence-based treatment strategies for first-line agents. Finally, monofollicular development as a treatment goal and in vitro fertilization are discussed for those with recalcitrant disease.
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Affiliation(s)
- Joshua J Berger
- University of Alabama at Birmingham, Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Birmingham, AL, USA
| | - G Wright Bates
- University of Alabama at Birmingham, Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Birmingham, AL, USA
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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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Fuhrmeister IP, Branchini G, Pimentel AM, Ferreira GD, Capp E, Brum IS, von Eye Corleta H. Human granulosa cells: insulin and insulin-like growth factor-1 receptors and aromatase expression modulation by metformin. Gynecol Obstet Invest 2014; 77:156-62. [PMID: 24603137 DOI: 10.1159/000358829] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2013] [Accepted: 01/18/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIM Granulosa cells are the source of the most important ovarian steroids. Even in patients without significant improvement in metabolic parameters, metformin has apparently an important effect on the ovary. The aim of this study was to evaluate gene and protein expression of an insulin receptor (IR), insulin-like growth factor-1 (IGF1) receptor (IGF1R) and aromatase in granulosa cells treated with metformin and insulin. METHODS Luteinized granulosa cells were collected from 27 patients during in vitro fertilization procedures. Cells were isolated, stored in culture for 24 h and divided into four groups: control; metformin for 30 min, and metformin for 30 min plus insulin for 30 or 60 min. RESULTS IR and IGF1R mRNA expression was significantly enhanced by metformin but was not affected by insulin. Aromatase mRNA expression was significantly reduced in metformin-incubated cells following stimulation with insulin for 30 min. No statistical differences were found in IGF1R and aromatase protein expression, and IR expression was not detected. CONCLUSION A direct effect of metformin on the gene expression of IGF1R, IR and aromatase was observed. Further studies should investigate the role of IGF1R, IR and aromatase in ovarian physiology for a better understanding of the effect of metformin.
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Lee HY, Wei D, Loeken MR. Lack of metformin effect on mouse embryo AMPK activity: implications for metformin treatment during pregnancy. Diabetes Metab Res Rev 2014; 30:23-30. [PMID: 23983188 PMCID: PMC3992340 DOI: 10.1002/dmrr.2451] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Revised: 08/07/2013] [Accepted: 08/20/2013] [Indexed: 12/17/2022]
Abstract
BACKGROUND Adenosine monophosphate-activated protein kinase (AMPK) is stimulated in embryos during diabetic pregnancy by maternal hyperglycaemia-induced embryo oxidative stress. Stimulation of AMPK disrupts embryo gene expression and causes neural tube defects. Metformin, which may be taken during early pregnancy, has been reported to stimulate AMPK activity. Thus, the benefits of improved glycaemic control could be offset by stimulated embryo AMPK activity. Here, we investigated whether metformin can stimulate AMPK activity in mouse embryos and can adversely affect embryo gene expression and neural tube defects. METHODS Pregnant nondiabetic mice were administered metformin beginning on the first day of pregnancy. Activation of maternal and embryo AMPK [phospho-AMPK α (Thr172) relative to total AMPK], expression of Pax3, a gene required for neural tube closure, and neural tube defects were studied. Mouse embryonic stem cells were used as a cell culture model of embryonic neuroepithelium to study metformin effects on AMPK and Pax3 expression. RESULTS Metformin had no effect on AMPK in embryos or maternal skeletal muscle but increased activated AMPK in maternal liver. Metformin did not inhibit Pax3 expression or increase neural tube defects. However, metformin increased activated AMPK and inhibited Pax3 expression by mouse embryonic stem cells. Mate1/Slc47a1 and Oct3/Slc22a, which encode metformin transporters, were expressed at barely detectable levels by embryos. CONCLUSIONS Although metformin can have effects associated with diabetic embryopathy in vitro, the lack of effects on mouse embryos in vivo may be due to lack of metformin transporters and indicates that the benefits of metformin on glycaemic control are not counteracted by stimulation of embryo AMPK activity and consequent embryopathy.
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Affiliation(s)
- Hyung-yul Lee
- Section on Islet Cell and Regenerative Biology, Joslin Diabetes Center, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Dan Wei
- Section on Islet Cell and Regenerative Biology, Joslin Diabetes Center, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Mary R. Loeken
- Section on Islet Cell and Regenerative Biology, Joslin Diabetes Center, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
- Correspondence to: Mary R. Loeken, Section on Islet Cell and Regenerative Biology, Joslin Diabetes Center, One Place, Boston, MA 02215, USA.
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Abstract
Polycystic ovarian syndrome (PCOS) is a disorder of androgen excess and ovarian dysfunction. Hirsutism and elevated free testosterone levels are the most consistent signs of the androgen excess. Irregular, infrequent, or absent menses and infertility are symptoms of ovulatory dysfunction. Obesity is also a feature of this syndrome and contributes to associated metabolic abnormalities. Lifestyle modification should be the first treatment and is effective in reducing the signs and symptoms. The ovulatory infertility associated with PCOS can be overcome in most cases with oral (clomiphene citrate or letrozole) or injectable (gonadotropins) agents. Surgical intervention is reserved for cases resistant to medical management.
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Affiliation(s)
- G Wright Bates
- Department of Obstetrics and Gynecology, University of Alabama School of Medicine, 619 19th Street South, Building 176F, Room 10390, Birmingham, AL 35249-7333, USA.
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Abstract
Anovulatory disorders are a primary cause of female infertility. Polycystic ovarian syndrome is the major cause of anovulation and is generally associated with obesity. Lifestyle changes to encourage weight loss are the initial therapy for overweight and obese patients, followed by clomiphene citrate for ovulation induction. For those patients who fail to ovulate on clomiphene citrate, alternatives, such as letrozole; gonadotropins; and complimentary agents to enhance clomiphene citrate, such as metformin and glucocorticoids, are reviewed. Women with unexplained infertility (no identifiable cause of infertility on a routine evaluation) may benefit from ovulation induction with clomiphene citrate, letrozole, or gonadotropins.
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Affiliation(s)
- Anthony M Propst
- Department of Obstetrics and Gynecology, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA
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25
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Gözdemir E, Kaygusuz I, Kafali H. Is Hepcidin a New Cardiovascular Risk Marker in Polycystic Ovary Syndrome? Gynecol Obstet Invest 2013; 75:196-202. [DOI: 10.1159/000348497] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2012] [Accepted: 01/27/2013] [Indexed: 11/19/2022]
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26
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Eskild A. While we are waiting for NFOG 2012 and summer, enjoy this issue of AOGS. Acta Obstet Gynecol Scand 2012; 91:641-2. [PMID: 22587680 DOI: 10.1111/j.1600-0412.2012.01440.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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