Association of Metformin With Pregnancy Outcomes in Women With Polycystic Ovarian Syndrome Undergoing In Vitro Fertilization A Systematic Review and Meta-analysis

Question Is metformin associated with improved outcomes among women with polycystic ovarian syndrome undergoing in vitro fertilization? Findings This meta-analysis of 12 randomized clinical trials, which collectively included 1123 women, found that metformin treatment was associated with a decreased risk of ovarian hyperstimulation syndrome among women with polycystic ovarian syndrome undergoing in vitro fertilization but had no association with clinical pregnancy or live birth rates in the total population studied. However, among women with a body mass index of 26 or greater, metformin treatment was associated with an improved clinical pregnancy rate. Meaning The findings of this study suggest that metformin treatment should be carefully considered for women with polycystic ovarian syndrome undergoing in vitro fertilization and may be more preferred among women with a body mass index of 26 or greater. This systematic review and meta-analysis assesses whether metformin is associated with improved outcomes of in vitro fertilization or intracytoplasmic sperm injection and embryo transfer among women with polycystic ovarian syndrome. Importance Metformin is widely used among women with polycystic ovary syndrome (PCOS). However, its associations with outcomes of in vitro fertilization or intracytoplasmic sperm injection and embryo transfer (IVF/ICSI-ET) in women with PCOS remain controversial. Objective To assess whether metformin is associated with improved outcomes of IVF/ICSI-ET in women with PCOS. Data Sources PubMed, Embase, and Cochrane were searched from database inception to January 31, 2020. Study Selection Only randomized clinical trials (RCTs) were included. Eligible studies enrolled women with PCOS undergoing infertility treatment with IVF/ICSI-ET and reported at least 1 outcome of IVF/ICSI-ET. Data Extraction and Synthesis This study followed the Preferred Reporting Items for Systematic Reviews and Meta analyses guidelines. Two authors independently extracted the data. Study quality was evaluated using the GRADE system. Treatment effect was quantified using odds ratios (ORs) with 95% CIs using random-effect models with the Mantel-Haenszel method. Main Outcomes and Measures Ovarian hyperstimulation syndrome (OHSS), clinical pregnancy rate, and live birth rate. Results A total of 12 RCTs, which collectively included 1123 women with PCOS undergoing infertility treatment with IVF/ICSI-ET, were identified. The risk of OHSS in women randomized to metformin was lower than in women not randomized to metformin (OR, 0.43; 95% CI, 0.24-0.78), although this difference was not significant for women with PCOS with a body mass index of less than 26 (OR, 0.67; 95% CI, 0.30-1.51). There was no significant difference in clinical pregnancy rate (OR, 1.24; 95% CI, 0.82-1.86) or live birth rate (OR, 1.23; 95% CI, 0.74-2.04) in the total population studied. However, in a post hoc analysis among women with a body mass index of 26 or greater, metformin treatment was associated with increased clinical pregnancy rates (OR, 1.71; 95% CI, 1.12-2.60). Conclusions and Relevance In this study, metformin treatment was associated with a decreased risk of OHSS but had no association with the overall clinical pregnancy rate or live birth rate among women with PCOS undergoing IVF/ICSI-ET. Metformin treatment should be carefully considered for women with PCOS undergoing IVF/ICSI-ET and may be more preferred for women with a body mass index greater than 26.