A Review of First Line Infertility Treatments and Supporting Evidence in Women with Polycystic Ovary Syndrome

Is combined letrozole and clomiphene superior to either as monotherapy: a systemic review and meta-analysis based on clinical trials

OBJECTIVE

This research was conducted to assess the therapeutic advantage of combined letrozole and clomiphene citrate versus monotherapy for polycystic ovarian syndrome (PCOS) patients.

STUDY DESIGN

Five databases were searched using the search string: (letrozole and clomiphene) AND (clomiphene OR clomiphene citrate OR CC) AND (letrozole OR LE) AND (ovulation induc* OR fertility induc* OR fertility preserv*) AND (polycystic ovarian syndrome OR PCOS). All statistical analyses were conducted in Review Manager 5.4.1. Random effect-effect model was used to pool risk ratio (RR), mean difference (MD), and odds ratio (OR) and their corresponding 95% confidence interval (CI). Moreover, qualitative analysis was conducted to qualitatively analyze ovulation, secondary outcomes, and cycle characteristics.

RESULTS

One clinical trial and three randomized clinical trials (RCTs) were used in the study. Two studies were used in a quantitative analysis showing that combination was superior for ovulation induction (RR = 1.86 [1.37, 2.53]; p < 0.0001; I2 = 0%), but the number of follicles ≥15 mm was significantly associated with the combination (MD = 0.40[0.14, 0.66]; p = 0.002; I2 = 0%). On subgroup analysis, only hot flushes were significantly associated with the combination (RR = 2.67[1.12, 6.36]; p = 0.03; I2 = 0%). The meta-analysis of two studies reported a significantly higher ovulation rate and number of dominant follicles in the combination therapy group compared with the LE alone arm but no significant difference in pregnancy rate, endometrial thickness, and adverse events.

CONCLUSION

Our study demonstrates a significant effect of the combination on ovulation induction. The combination yielded a better chance of conception and viable pregnancy. Further studies are needed to determine the live birth rate. HighlightsCombined Letrozole and Clomiphene is superior to either of these drugs alone for ovulation induction in PCOS.Our results conclude that the combination results in better ovulation, cycle characteristics, and secondary changes.Only the incidence of hot flushes as an adverse effect is increasingly reported in combination.

Primer on Female Infertility for the Reproductive Urologist

This review is intended to serve as an aid in decision-making and patient counseling for the reproductive urologist when female factor infertility is found concurrently with male factor infertility. This review pairs the pathophysiology of female infertility with its implications for the treatment of male infertility, which most commonly includes ovulatory disorders, tubal abnormalities, and uterine abnormalities. By gaining a deeper understanding of these factors, reproductive urologists can employ a tailored approach to managing male factor infertility, taking into account the female partner's specific medical history.

The effect of metformin on cognitive function: A systematic review and meta-analysis

Most people are familiar with metformin as a diabetic treatment option. Different positive benefits have been found for it, in addition to its anti-diabetes properties. Cognitive function enhancement is the most recent characteristic that has been studied. This study aimed to look at the evidence on the effects of metformin on cognitive performance. Web of Science, PubMed, Scopus, the Cochrane Library, EMBASE, and PsycINFO databases were searched systematically. After eliminating duplicates and irrelevant documents, the findings were screened. The documents that remained were scanned and data were extracted. Nineteen studies were qualified for meta-analysis after evaluating 3827 identified records. There was no significant relationship between metformin therapy and cognitive performance in none of the studies including cross-sectionals, cohorts, and clinical trials (p > 0.05). Results show that metformin has no significant effect on improving cognitive function or protecting against any dementia including vascular dementia and Alzheimer's disease, and cognitive impairment as well.

Efficacy and Safety of Cangfu Daotan Decoction in Patients with Polycystic Ovary Syndrome: A Systematic Review and Meta-Analysis

Background

The infertility caused by polycystic ovary syndrome (PCOS) has received considerable attention. Considerable efforts have been made to improve the rates of pregnancy and live birth. Cangfu Daotan Decoction (CFDTD) is a classic prescription for treating infertility in obese women. The efficacy of CFDTD in PCOS is controversial.

Objective

To evaluate the effectiveness and safety of CFDTD in treating infertility with PCOS.

Methods

A literature search was performed in the Cochrane Library, PubMed, Embase, the China National Knowledge Infrastructure, the Wanfang Database, the VIP Chinese Biomedical science journal database, and the Chinese BioMedical database from the date of each database establishment to December 2021. Only randomized controlled trials, which were used to evaluate the efficacy of CFDTD in treating subjects with PCOS, were included in the present study. The quality of evidence was assessed using the Cochrane Reviewer Handbook 5.0.0, and meta-analysis was performed using RevMan 5.3.5 software.

Results

Fourteen studies with a total of 1,433 patients were included in this analysis. The present study indicated that CFDTD could significantly improve pregnancy rate (RR = 1.62, 95% CI (1.44, 1.83), P < 0.00001), ovulation rate (RR = 1.40, 95% CI (1.25, 1.56), P < 0.00001), and estradiol levels (SMD = 0.80, 95% CI (0.03, 1.58), P=0.04), while testosterone levels (SMD = −0.92, 95% CI (−1.52, −0.31), P=0.003), homeostatic model assessment for insulin resistance (MD = −0.56, 95% CI (−0.99, −0.12), P=0.01), total cholesterol levels (MD = −0.60, 95% CI (−0.76, −0.44), P < 0.00001), triglyceride levels (MD = −0.48, 95% CI (−0.60, −0.36), P < 0.00001), body mass index (MD = −2.96, 95% CI (−3.88, −2.03), P < 0.00001), and the incidence of adverse reactions (RR = 0.47, 95% CI (0.34, 0.65), P < 0.00001) were significantly reduced.

Conclusions

Evidence from the meta-analysis suggested that CFDTD appeared to be an effective and relatively safe treatment for PCOS. However, the influence of CFDTD on reproductive hormones, glucose metabolism, and blood lipids should be carefully concluded. Due to the low quality of the methods used in the included randomized controlled trials, further studies are required with larger sample sizes and well-designed models to confirm our findings.

Insights into new therapeutic approaches for the treatment and management of polycystic ovary syndrome: An updated review

BACKGROUND

Polycystic ovary syndrome (PCOS) is a long-term, highly prevalent, complex heterogeneous, polygenic endocrine disorder characterized by both metabolic and reproductive disorders. It affects 6-23% of reproductive age women globally.

OBJECTIVE

This review aims to facilitate an understanding of novel PCOS management approaches and highlights the results from relevant interventional studies from animal and human studies.

METHODS

Manual search on PubMed, Cochrane, Scopus databases was performed for relevant articles, preclinical and clinical trials based on related keywords.

RESULTS

According to a multitude of studies, PCOS has evolved over time, but a substantial lag remains in management approaches. New insights into the cross-talk between muscle, brain, fat, and ovaries pointed out new therapeutic targets. This review has highlighted the efficacy of a wide spectrum of novel therapeutic agents [Phosphodiesterase-4 Inhibitors, Glucagon-like peptide-1 receptor agonists, nutritional supplements (Vitamins D and K, omega-3, prebiotics, probiotics and synbiotics), fecal microbiota transplantation (FMT) and intestinal cytokine IL-22] as PCOS therapeutic options. These novel therapies combine anti-inflammatory, insulin sensitizing, anti-obesity, and restoration of the gut microbiota and thus hold the potential to address the basic pathogenic mechanisms of PCOS.

CONCLUSION

Exhaustive, multicentric and multiethnic studies are vital to generate a network of normative data to better figure out the PCOS trajectory and change prognostic outcomes. Preclinical and clinical data is warranted to corroborate the new therapeutics and direct health care resources accordingly.

The Effects of Separate and Combined Treatment of Male Rats with Type 2 Diabetes with Metformin and Orthosteric and Allosteric Agonists of Luteinizing Hormone Receptor on Steroidogenesis and Spermatogenesis

In men with type 2 diabetes mellitus (T2DM), steroidogenesis and spermatogenesis are impaired. Metformin and the agonists of luteinizing hormone/human chorionic gonadotropin(hCG)-receptor (LH/hCG-R) (hCG, low-molecular-weight allosteric LH/hCG-R-agonists) can be used to restore them. The aim was to study effectiveness of separate and combined administration of metformin, hCG and 5-amino-N-tert-butyl-2-(methylsulfanyl)-4-(3-(nicotinamido)phenyl)thieno[2,3-d]pyrimidine-6-carboxamide (TP3) on steroidogenesis and spermatogenesis in male rats with T2DM. hCG (15 IU/rat/day) and TP3 (15 mg/kg/day) were injected in the last five days of five-week metformin treatment (120 mg/kg/day). Metformin improved testicular steroidogenesis and spermatogenesis and restored LH/hCG-R-expression. Compared to control, in T2DM, hCG stimulated steroidogenesis and StAR-gene expression less effectively and, after five-day administration, reduced LH/hCG-R-expression, while TP3 effects changed weaker. In co-administration of metformin and LH/hCG-R-agonists, on the first day, stimulating effects of LH/hCG-R-agonists on testosterone levels and hCG-stimulated expression of StAR- and CYP17A1-genes were increased, but on the 3-5th day, they disappeared. This was due to reduced LH/hCG-R-gene expression and increased aromatase-catalyzed estradiol production. With co-administration, LH/hCG-R-agonists did not contribute to improving spermatogenesis, induced by metformin. Thus, in T2DM, metformin and LH/hCG-R-agonists restore steroidogenesis and spermatogenesis, with metformin being more effective in restoring spermatogenesis, and their co-administration improves LH/hCG-R-agonist-stimulating testicular steroidogenesis in acute but not chronic administration.

A retrospective cohort study of obstetric complications and birth outcomes in women with polycystic ovarian syndrome

Polycystic ovary syndrome (PCOS) is a common endocrine disorder in women and a high risk factor for adverse pregnancy complications. Therefore, we aimed to analyse the relationship between PCOS and pregnancy complications in a large sample from China. Additionally, since obesity and assisted reproductive technology (ART) are common in women with PCOS, we also aimed to determine whether both of these factors increased the complication incidence for women with PCOS. A retrospective cohort study that included 1357 pregnant women with PCOS and 6940 without PCOS was performed. Our results indicated women with PCOS had higher incidence of gestational diabetes mellitus (GDM), hypertension, postpartum haemorrhage, preterm birth, macrosomia and cervical incompetence. Additionally, obesity was associated with an increased incidence of hypertension and GDM in women with PCOS generally. ART did not result in an increase in the obstetric complication rate in women with PCOS. In conclusion, PCOS appeared to result in an increased risk of adverse pregnancy complications. Obesity may further increase the risks of hypertension and GDM among women with PCOS. However, ART did not increase the risk of pregnancy complications, which suggests that ART is a relatively safe and effective method to address infertility problems in women with PCOS.IMPACT STATEMENTWhat is already known on this subject? There are several studies evaluating the associations of PCOS with the risk of pregnancy complications. However, reports about the risk of pregnancy complications between PCOS women with and without obesity or ART are limited.What do the results of this study add? PCOS appeared to increase the risk of adverse pregnancy complications, including GDM, pregnancy-induced hypertension, postpartum haemorrhage, preterm birth, macrosomia and cervical incompetence. Obesity further increased the risks of hypertension and GDM in women with PCOS, but it did not increase the incidence of macrosomia and postpartum haemorrhage. Additionally, ART did not increase the risk of adverse pregnancy complications among women with PCOS, except for postpartum haemorrhage.What are the implications of these findings for clinical practice and/or further research? This study contributes to the literature because it showed that PCOS independently increased the risk of adverse pregnancy complications in a large sample of patients. Second, obesity is a high risk factor for adverse complications in pregnant women with PCOS. Third, ART is a relatively safe and effective method for addressing infertility problems for women with PCOS.

Secretory products of the corpus luteum and preeclampsia

BACKGROUND

Despite significant advances in our understanding of the pathophysiology of preeclampsia (PE), there are still many unknowns and controversies in the field. Women undergoing frozen-thawed embryo transfer (FET) to a hormonally prepared endometrium have been found to have an unexpected increased risk of PE compared to women who receive embryos in a natural FET cycle. The differences in risk have been hypothesized to be related to the absence or presence of a functioning corpus luteum (CL).

OBJECTIVE AND RATIONALE

To evaluate the literature on secretory products of the CL that could be essential for a healthy pregnancy and could reduce the risk of PE in the setting of FET.

SEARCH METHODS

For this review, pertinent studies were searched in PubMed/Medline (updated June 2020) using common keywords applied in the field of assisted reproductive technologies, CL physiology and preeclampsia. We also screened the complete list of references in recent publications in English (both animal and human studies) on the topics investigated. Given the design of this work as a narrative review, no formal criteria for study selection or appraisal were utilized.

OUTCOMES

The CL is a major source of multiple factors regulating reproduction. Progesterone, estradiol, relaxin and vasoactive and angiogenic substances produced by the CL have important roles in regulating its functional lifespan and are also secreted into the circulation to act remotely during early stages of pregnancy. Beyond the known actions of progesterone and estradiol on the uterus in early pregnancy, their metabolites have angiogenic properties that may optimize implantation and placentation. Serum levels of relaxin are almost undetectable in pregnant women without a CL, which precludes some maternal cardiovascular and renal adaptations to early pregnancy. We suggest that an imbalance in steroid hormones and their metabolites and polypeptides influencing early physiologic processes such as decidualization, implantation, angiogenesis and maternal haemodynamics could contribute to the increased PE risk among women undergoing programmed FET cycles.

WIDER IMPLICATIONS

A better understanding of the critical roles of the secretory products of the CL during early pregnancy holds the promise of improving the efficacy and safety of ART based on programmed FET cycles.

Efficacy and Safety of Controlled Ovarian Stimulation With or Without Letrozole Co-administration for Fertility Preservation: A Systematic Review and Meta-Analysis

Background: The co-administration of letrozole during controlled ovarian stimulation (COS) with gonadotropins is used to limit the potentially harmful effects of a supra-physiological rise in estrogen levels on hormone-sensitive cancers. However, the efficacy and safety of adding letrozole to COS remain debated.

Methods: This is a systematic review and meta-analysis of published studies that compared the efficacy and safety of COS with co-administration of letrozole vs. COS without letrozole in all patient populations. A secondary analysis was done including only the studies in breast cancer patients. The primary efficacy endpoint was the number of retrieved mature Metaphase II (MII) oocytes. Secondary efficacy and safety endpoints were total number of oocytes, maturation rate, fertilization rate, number of cryopreserved embryos, peak estradiol levels, progesterone levels, and total gonadotropin dose. Data for each endpoint were reported and analyzed thorough mean ratio (MR) with 95% confidence interval (CI).

Results: A total of 11 records were selected including 2,121 patients (990 patients underwent COS with letrozole and 1,131 COS without letrozole). The addition of letrozole to COS did not have any negative effect on the number of mature oocytes collected (MR = 1.00, 95% CI = 0.87–1.16; P = 0.967) and the other efficacy endpoints. COS with letrozole was associated with significantly decreased peak estradiol levels (MR = 0.28, 95% CI = 0.24–0.32; P < 0.001). Similar results were observed in the secondary analysis including only breast cancer patients.

Conclusions: These findings are reassuring on the efficacy and safety of COS with gonadotropins and letrozole and are particularly important for fertility preservation in women with hormone-sensitive cancers.

Basal Anti Mullerian hormone levels and endometrial thickness at midcycle can predict the outcome after clomiphene citrate stimulation in anovulatory women with PCOS, a retrospective study

Purpose

Recent studies reported that in polycystic ovary syndrome (PCOS) patients, other stimulation agents are superior to the popular first-line regimen, clomiphene citrate (CC) for ovarian stimulation. Nonetheless, CC is still widely used since it is not clear which patients will not respond to it. Furthermore, the prognostic value of endometrium thickness at midcycle is controversial. We aimed to find factors predicting the response to CC and the prognostic value of endometrial thickness at midcycle.

Methods

We collected data retrospectively from 89 anovulatory PCOS patients who had the first stimulation with 50 mg CC. We analyzed the basal levels of AMH, testosterone, LH, LH:FSH ratio and the endometrial thickness at midcycle by univariate, followed by multivariate regression. The outcome measures were pregnancy, follicle maturation and endometrial thickness at midcycle.

Results

Stimulation with 50 mg CC resulted in follicle maturation in 50.6% of the women and in 27.0% pregnancies. In the univariate analysis, greater endometrial thickness, lower LH and AMH levels and a lower LH:FSH ratio were associated with pregnancy (p < 0.05). In the multivariate analysis, only endometrial thickness remained predictive (p = 0.045). The endometrial thickness cutoff level of ≥ 8 mm showed a sensitivity of 87.5% (96% CI 67.6–97.3) and a specificity of 66.7% (95% CI 43.0–85.4) for prediction of pregnancy. In the multivariate analysis AMH levels 5.4 (3.4; 7.0) (ng/mL) predicted pregnancy (β = − 0.194 ± 0.092; p = 0.034)

Conclusion

We suggest to refrain from CC as first-line regimen in patients with AMH > 7 ng/ml. Under CC treatment, the cutoff value of ≥ 8 mm endometrium thickness at midcycle is associated with a better outcome.