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

Abstract

Polycystic ovary syndrome (PCOS) is the most common cause of anovulatory infertility in women of reproductive age. Lifestyle change is considered the first line treatment for the management of infertile anovulatory women with PCOS, and weight loss for those who are overweight or obese. First line medical ovulation induction therapy to improve fertility outcomes is letrozole, whilst other less efficacious ovulation induction agents, such as clomiphene citrate, metformin, and metformin combined with clomiphene citrate, may also be considered. Metformin combined with clomiphene citrate is more effective than clomiphene citrate alone. In obese women with PCOS, clomiphene citrate could be used in preference to metformin alone whilst clomiphene citrate could be added to metformin alone in order to improve reproductive outcome in all women with PCOS. Gonadotrophins, which are more effective than clomiphene citrate in therapy naïve women with PCOS, can be considered a first line therapy in the presence of ultrasound monitoring, following counselling on the cost and the potential risk of multiple pregnancy.

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

“…We consider the baseline characteristics robust despite the small sample size. Taking the initial patient population into account which additionally included all women who did not develop a follicle after CC stimulation, the pregnancy rate achieved was about 30% which is considerably high when compared with the previous literature [10, 32, 33]. We presume that this result might be due to the design of our study.…”

New Insight into Metformin Mechanism of Action and Clinical Application

“…Gastrointestinal side effects were more common in metformin combined with clomiphene citrate than clomiphene citrate alone, but the combined therapy may have beneficial effects in the rates of ovulation and pregnancy [93,101]. Combination of metformin with clomiphene citrate can be considered as the first line therapy in anovulatory PCOS women without other infertility factors [102]. Metformin was less effective than clomiphene citrate in obese women with PCOS [93,102].…”

“…Combination of metformin with clomiphene citrate can be considered as the first line therapy in anovulatory PCOS women without other infertility factors [102]. Metformin was less effective than clomiphene citrate in obese women with PCOS [93,102]. Combined therapy of metformin and spironolactone showed greater improvement in menstrual cycles and hyperinsulinemia.…”

Comparação da eficácia dos medicamentos para indução de ovulação em mulheres com Síndrome do Ovário Policístico resistentes ao citrato de clomifeno

“…A diferença nas taxas de gravidez múltipla ou abortos não foi significativa(WANG R, et al, 2019). Uma revisão narrativa de 2019 aponta o letrozol como uma opção eficaz e segura para induzir a ovulação em mulheres com SOP, considerando-o, inclusive, como primeira linha de tratamento(COSTELLO M, et al, 2019). O letrozol demonstra taxas satisfatórias de ovulação e gestação e, por isso, pode ser considerada a primeira alternativa medicamentosa, com resposta satisfatória e segura em casos de resistência ao HMG, porém, a evidência gerada não foi suficiente para apontar superioridade das preparações do segundo em relação ao primeiro.…”

“…).MacielGA (2018) eCostello M et al (2019) sugerem que a metformina pode melhorar as taxas de ovulação, gravidez clínica e nascidos vivos, quando comparadas ao placebo. Nestes estudos, no entanto, não se evidenciaram de forma objetiva uma diferença nas taxas de aborto espontâneo.…”