Sarcouncil Journal of Medical Sciences

Abstract: Background: Polycystic ovary syndrome (PCOS) is the leading cause of anovulatory infertility, accounting for 70–80% of anovulatory cases worldwide. Reproductive failure reflects convergent dysregulation of hypothalamic-pituitary-ovarian signaling, AMH-mediated follicular arrest, insulin resistance-driven hyperandrogenism, impaired oocyte competence, and endometrial receptivity failure. When ovulation induction fails, assisted reproductive technology (ART) becomes the definitive intervention, though PCOS-specific biology necessitates individualized protocol modification. Objective: To critically evaluate the efficacy, safety, and emerging adjunctive strategies of ART in PCOS-associated infertility, emphasizing cumulative live birth rate (CLBR) and ovarian hyperstimulation syndrome (OHSS) as primary efficacy and safety endpoints. Methods: A structured narrative review was conducted per PRISMA 2020 guidelines, searching PubMed/MEDLINE, Embase, Cochrane CENTRAL, Scopus, and Web of Science (January 2000–March 2025) using MeSH/Emtree terms and free-text keywords across condition, intervention, and outcome domains. Eligible studies enrolled adult women (≥18 years) with confirmed PCOS (Rotterdam, AE-PCOS, or NIH criteria) undergoing ART, using RCT, cohort, case-control, systematic review, or meta-analytic designs. Following Zotero-based deduplication and dual-reviewer screening (Cohen's κ = 0.84), data were extracted using a standardized form. Methodological quality was appraised via RoB 2.0, Newcastle-Ottawa Scale, and AMSTAR-2, with GRADE-rated evidence certainty. Narrative synthesis was primary; random-effects (DerSimonian–Laird) pooling in RevMan 5.4 supplemented outcomes reported by ≥3 comparable studies. Results: Antagonist protocols with agonist triggering and freeze-all strategies eliminated late-onset OHSS while achieving CLBR comparable to normo-ovulatory populations. Frozen embryo transfer conferred superior CLBR and reduced OHSS versus fresh transfer; elective single embryo transfer reduced multiple pregnancy to 1–2% without compromising CLBR. Conclusion: Risk-stratified, phenotype-adapted ART achieves reproductive outcomes equivalent to normo-ovulatory populations when individualized protocols are systematically applied. Phenotype-stratified RCTs powered on CLBR remain a priority.