A Cochrane review [Abstract] 1 included 38 studies with a total of 3 326 participants. Treatment consisted of laparoscopic ovarian "drilling" (LOD) in order to induce ovulation in subfertile women with PCOS. Pooled results suggest LOD may decrease live birth slightly when compared with medical ovulation induction alone (odds ratio [OR] 0.71, 95% CI 0.54 to 0.92; 9 studies, n=1015; I²=0%). The sensitivity analysis restricted to only RCTs with low risk of selection bias suggested there is uncertainty whether there is a difference between the treatments (OR 0.90, 95% CI 0.59 to 1.36; 4 studies, n=415; I² = 0%). LOD probably reduces multiple pregnancy rates (Peto OR 0.34, 95% CI 0.18 to 0.66; 14 studies, n=1161).
A network meta-analysis 2 included 26 randomized clinical trials with 2 722 participants and 9 types of therapies: clomiphene citrate (CC), metformin, letrozole, follicle stimulating hormone (FSH), human menopausal gonadotropin (hMG), unilateral laparoscopic ovarian drilling (unilateral drilling), bilateral laparoscopic ovarian drilling (bilateral drilling), the combination of metformin with letrozole (metformin+letrozole), and the combination of metformin with CC (metformin+CC). hMG therapy resulted in higher pregnancy rates than drilling or CC. Pregnancy, live birth and ovulation rates were significantly higher in metformin+letrozole and FSH groups than CC group. Bilateral drilling showed a trend towards higher live birht rates compared with CC, metformin, metformin + CC, and unilateral drilling, but lower compared with FSH or letrozole; however these results were not significant. Apart from gonadotropin (FSH and hMG), metformin+letrozole was potentially more effective in improving reproductive outcomes than other therapies.
Comment: The quality of evidence is downgraded by study quality (unclear allocation concealment and lack of blinding).
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