Algorithm of ovulation induction in patients with polycistic ovary syndrome

Abstract

As a conclusion of this systematic survey of the efficiency of ovulation induction methods, which confirms and supplements the knowledge in this field, it is possible to form the algorithm for ovulation induction in infertile patients having polycystic ovary syndrome, consisting of the following subsequent steps: 1) modification of life style, 2) induction with clomiphene citrate 3) use of metformin, 4) use ofaromatase inhibitors, 5) application ofgonadotropins and laparoscopic ovarian drilling--as a second-line treatment, and 6) assisted reproductive techniques.

Efficacy of metformin use to induce ovulation in women with polycystic ovarian syndrome

“…18 Metformin is an appropriate alternative to decrease menstrual regularities and improve weight reduction in women with PCOS, but evidence does not suggest it should be considered a first-line pharmaceutical agent for ovulation induction at this time. 32…”

“…29 Metformin and clomid combined will increase the chances of ovulation and gestation and can be considered from the beginning of treatment. 32 A Cochrane systematic review and meta-analysis of RCT's comparing metformin with placebo or no treatment in women with PCOS showed that metformin improved ovulation rates and clinical pregnancy rates but not live birth rates. They further concluded that the addition of metformin to clomiphene citrate is superior to clomiphene citrate alone in women who appear resistant.…”

“…31 Letrozole is a selective aromatase inhibitor that works by decreasing estrogen production without affecting receptors, in turn reducing the negative feedback on the hypothalamus and pituitary and stimulating FSH release. 30 Bjelica et al 32 also explored metformin use as well as metformin and clomid combined. They formed an algorithm of ovulation induction that illustrates the entire process of infertility and PCOS, with the first piece being that modification of lifestyle combined with use of metformin, aimed at optimizing body mass index and eliminating insulin resistance, should be the first line treatment for women with elevated body mass index.…”

“…The second step of the algorithm stated that clomiphene citrate should still be used as firstline therapy for patients with PCOS. 32 Bjelica et al 32 also states that the third part to the puzzle suggests that metformin and clomid combined will increase the chances of ovulation and gestation and can be considered from the beginning of treatment, and part four suggests that application of aromatase inhibitors (such as letrozole) can substitute clomid as first line treatment, though evidence is still insufficiently strong. The fifth tier of the algorithm states that application of gonadotropins and laparoscopic ovarian drilling should be second line treatment, with the sixth and final piece stating that assisted reproductive technics (such as Intrauterine Insemination and/ or In vitro Fertilization) should be considered if pregnancy does not occur after six cycles of induction with gonadotropins that is after six months following laparoscopic ovarian drilling, or when there are some associated causes of infertility.…”

“…The fifth tier of the algorithm states that application of gonadotropins and laparoscopic ovarian drilling should be second line treatment, with the sixth and final piece stating that assisted reproductive technics (such as Intrauterine Insemination and/ or In vitro Fertilization) should be considered if pregnancy does not occur after six cycles of induction with gonadotropins that is after six months following laparoscopic ovarian drilling, or when there are some associated causes of infertility. 32…”