Sawant, S., & Bhide, P. (2019). Fertility Treatment Options for Women With Polycystic Ovary Syndrome. Clinical medicine insights. Reproductive health, 13, 1179558119890867. https://doi.org/10.1177/1179558119890867
Sawant S, Bhide P. Fertility Treatment Options for Women With Polycystic Ovary Syndrome. Clinical medicine insights. Reproductive health. 2019;13:1179558119890867. doi:10.1177/1179558119890867
Sawant, Shital, and Priya Bhide. "Fertility Treatment Options for Women With Polycystic Ovary Syndrome." Clinical medicine insights. Reproductive health, vol. 13, 2019, pp. 1179558119890867.
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RRM Academy Synopsis
Letrozole produced more live births than clomiphene in PCOS trials
A 2019 review of fertility care in PCOS reports that letrozole gave more live births than clomiphene in pooled randomized trials. The review also describes weight loss, exercise, ovarian drilling and IVF for women who do not ovulate.
Key Findings
A Cochrane review of 42 randomized trials and 7935 women found more live births with letrozole than clomiphene (OR: 1.68, 95% CI: 1.42-1.99; 2954 participants; 13 studies).
In a double-blind trial of 750 women, live births occurred in 27.5% on letrozole and 19.1% on clomiphene (OR: 1.44, 95% CI: 1.10-1.87).
A network meta-analysis of 57 trials and 8082 women reported a lower multiple pregnancy rate with letrozole than clomiphene (OR: 0.46, 95% CI: 0.23-0.92).
Among 5 studies reporting reproductive outcomes after lifestyle intervention, 3 reported significant improvement in menstrual regularity and ovulation.
In a randomized comparison, cumulative pregnancy at 6 months was 34% after laparoscopic ovarian drilling and 67% with FSH stimulation; at 12 months the results were comparable.
Interpretation
The article is a narrative review of randomized trials, meta-analyses and smaller studies. It addresses women with PCOS who do not ovulate and have no other fertility factor. In these women, pooled randomized trials rated moderate to high quality by the authors support the letrozole finding. The lifestyle result comes from a systematic review of exercise in PCOS. The drilling result comes from a randomized multicenter trial. The authors note that letrozole remains off label in many countries. They also state that IVF has not been compared with ovulation induction for time to pregnancy or multiple pregnancy. The review places IVF third in its sequence.
RRM Context
PCOS, now also named PMOS (polyendocrine metabolic ovarian syndrome), ties missed ovulation to weight and insulin resistance. Restorative reproductive medicine works on these drivers. The review recommends a team approach before drugs. Its exercise studies report better ovulation in some women. IVF goes around missed ovulation and leaves the cause unresolved.
Our editorial summary of this paper, not the article's abstract.
Abstract
Polycystic ovary syndrome is the most common endocrinological disorder in women of reproductive age. It is commonly associated with anovulatory subfertility, for which there are a range of treatment options available to help them conceive. These options are given in a step-wise manner with an appropriate selection of patients to maximise success rates with minimal complications. This review discusses the importance and involvement of multidisciplinary care when offering treatment to women with subfertility. Multidisciplinary care gives an excellent opportunity to identify, assess risk, and potentially prevent future morbidities and complications while treating women for fertility issues. We have also summarised the various options available for fertility treatment: pharmacological treatments, nonpharmacological intervention, and assisted reproductive technology.
