In vitro maturation in subfertile women with polycystic ovarian syndrome undergoing assisted reproduction.

backgroundPolycystic ovarian syndrome (PCOS) occurs in 8% to 13% of all women of reproductive age and 50% of women presenting with infertility (i.e. inability to reach a pregnancy after 12 months or more of regular unprotected sexual intercourse). A proportion of these women ultimately need assisted reproductive technology. In vitro fertilisation (IVF)/intracytoplasmic sperm injection (ICSI) are assisted reproduction techniques used to raise the chances of a pregnancy. In women with PCOS, the supra-physiological doses of gonadotrophins used for controlled ovarian hyperstimulation (COH) often result in an exaggerated ovarian response characterised by the development of a large cohort of follicles of uneven quality, retrieval of immature oocytes, and increased risk of ovarian hyperstimulation syndrome (OHSS). A potentially effective intervention for women with PCOS-related infertility involves earlier retrieval of immature oocytes at the germinal-vesicle stage followed by in vitro maturation (IVM). This is the third update of this Cochrane review on the subject (after the last update on 27 June 2018).

objectivesTo assess the benefits and harms of IVM followed by IVF or ICSI versus conventional IVF or ICSI among women with PCOS. SEARCH

methodsOn 27 February 2023, we searched the Cochrane Gynaecology and Fertility Group Specialised Register of Controlled Trials, CENTRAL, MEDLINE, Embase, and the Open Grey database. We further searched the National Institute for Health and Care Excellence (NICE) fertility assessment and treatment guidelines. We also searched reference lists of relevant papers and Google Scholar for any additional trials. SELECTION CRITERIA: We included randomised controlled trials (RCTs) comparing IVM before IVF or ICSI with conventional IVF or ICSI for infertile women with PCOS, irrespective of language and country of origin. DATA COLLECTION AND ANALYSIS: Two review authors independently selected studies, assessed the risk of bias, extracted data from studies, and, where needed, attempted to contact the authors for missing data. Our primary outcomes were live birth per woman randomised and miscarriage. We performed statistical analysis using Review Manager. We assessed the certainty of the evidence using GRADE and the risk of bias using the Cochrane RoB 2 tool. MAIN

resultsWe found four published trials suitable for inclusion in this update. The studies involved 810 subfertile women undergoing assisted reproductive technology. Two of four were already included in the previous version of the review, were published as abstracts in international conferences, and were at high risk of bias. The two new studies were at low risk of bias in all domains and in terms of all outcomes. We implemented the random-effects model for the quantitative analyses and restricted the primary analysis to studies at low risk of bias in all domains. We are very uncertain about the effect of IVM or capacitation IVM (a new biphasic IVM system improving the developmental competence of oocytes) on live birth when compared to IVF when a GnRH antagonist protocol was applied (odds ratio (OR) 0.47, 95% confidence interval (CI) 0.17 to 1.32; I AUTHORS'

conclusionsThere is continuous scientific interest in IVM, and promising data have been published. Concerning live birth and clinical pregnancy, we are very uncertain about the effect of the technique when compared to IVF after using a GnRH antagonist protocol. In contrast, high-certainty evidence shows that IVM increases miscarriage per clinical pregnancy and reduces the incidence of moderate or severe OHSS in women with PCOS compared to IVF after a GnRH antagonist protocol. Regarding the rest of the outcomes, low- to moderate-certainty evidence showed little to no difference in preterm birth and risk of congenital anomalies between the two modalities. We eagerly anticipate further evidence from high-quality trials in the field (we found five ongoing trials).