Medical and Surgical Treatment of Reproductive Outcomes in Polycystic Ovary Syndrome: An Overview of Systematic Reviews

Background Polycystic ovary syndrome (PCOS) is a common and complex condition affecting up to 18% of reproductive-aged women with reproductive, metabolic and psychological dysfunction. We performed an overview and appraisal of methodological quality of systematic reviews assessing medical and surgical treatments for reproductive outcomes in women with PCOS. Methods This was an overview of systematic reviews. Databases (MEDLINE, EMBASE, CINAHL PLUS and PROSPERO) were searched on the 15th of September 2017. We included any systematic review assessing the effect of medical or surgical management of PCOS on reproductive, pregnancy and neonatal outcomes. Eligibility assessment, data extraction and quality assessment (by the AMSTAR tool) were performed in duplicate. Results We identified 53 reviews comprising 44 reviews included in this overview; the majority being 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 again 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 / intra-cytoplasmic sperm injection (IVF/ICSI), adding metformin to gonadotrophins resulted in less ovarian hyperstimulation syndrome (OHSS), higher pregnancy and live birth rate than gonadotrophins alone. Gonadotrophin releasing hormone (GnRH) antagonist was associated with less OHSS, gonadotrophins units and shorter stimulation length than GnRH agonist. Conclusion Letrozole appears to be a good first line treatment and gonadotrophins as second line treatment for anovulatory women with PCOS. LOD results in lower multiple pregnancy rates. However, due to the heterogeneous nature of included populations of women with PCOS, further larger scale trials are needed with more precise assessment of treatments according to heterogeneous variants of PCOS.