Infertility in women with polycystic ovary syndrome and the role of metformin in management

Abstract

Polycystic ovary syndrome (PCOS) is one of the most common medical conditions in women of reproductive age and the most common cause of anovulatory infertility. Insulin resistance is one of the underpinning features of PCOS in most women. Metformin can improve insulin resistance and was introduced as a pharmacological agent to treat anovulation and infertility in the 1990s. Metformin does not increase ovarian hyperstimulation or multiple pregnancies and may in some clinical situations have a role as a single agent or in combination with clomiphene citrate (CC) however the evidence supports the efficacy of lifestyle intervention as first-line treatment for PCOS anovulatory infertility followed by CC. Here, we discuss the role of metformin in light of other therapies for the treatment of anovulatory infertility in women with PCOS.

Keywords::

• anovulation
• clomiphene citrate
• lifestyle
• metformin
• polycystic ovary syndrome

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with an organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• • Polycystic ovary syndrome (PCOS) is the most common cause of anovulatory infertility and is a prevalent condition (12–21%) in women of reproductive age.

• • Insulin resistance is present in 85% of all women with PCOS.

• • Lifestyle management with small loss of weight is the best first-line treatment for PCOS anovulatory infertility.

• • Clomiphene citrate (CC) is the most efficacious, first-line pharmacological treatment for all women with PCOS anovulatory infertility.

• • Metformin may have a role in women with PCOS and anovulation as a sole agent if BMI <32 kg/m² or if individual circumstances mean specialist treatment and monitoring is difficult to access.

• • Metformin may have a role in combination with CC in women who have CC resistance.

• • Further research will significantly advance knowledge in the natural history of PCOS and of infertility, the role of lifestyle therapies and of pharmacological therapies including metformin and newer agents will become clearer in the setting of the international recognition of the Rotterdam criteria in PCOS and of the different phenotypes.