Enhancing fertility outcomes in PMOS: The impact of metformin and myo-inositol on assisted reproductive technology success – a systematic review and meta-analysis

Background Polyendocrine metabolic ovarian syndrome (PMOS) is a common hormonal disorder that disrupts ovulation and fertility in women of reproductive age. It is frequently associated with insulin resistance and hormonal imbalances, which can hinder successful conception, primarily through assisted reproductive technologies (ART). Metformin and myo-inositol have emerged as promising interventions to improve reproductive outcomes by enhancing insulin sensitivity and supporting hormonal regulation. While both agents show potential, their precise effects on ART success rates remain unclear, highlighting the need for further research. Methodology We conducted a systematic review and meta-analysis following PRISMA guidelines. We searched PubMed, The Cochrane Library, and Google Scholar for studies published up to July 2025. Two reviewers independently extracted data and assessed the risk of bias. We performed a random-effects meta-analysis using RevMan 5.4.1, and quality appraisal using the JBI checklist. Results A total of 39 studies were included in this meta-analysis. Metformin significantly improved LBR (RR: 1.24, 95% CI: 1.06–1.38; p = 0.006) and reduced the risk of ovarian hyperstimulation syndrome (OHSS) (RR: 0.68, 95% CI: 0.48–0.97; p = 0.03). CPR showed a non-significant improvement (RR: 1.10, 95% CI: 0.99–1.23; p = 0.09). Myo-inositol significantly reduced irregular menstrual periods (RR: 0.78, 95% CI: 0.68–0.89; p = 0.0004) but had no significant effect on CPR. Conclusion In conclusion, this study highlights the potential roles of metformin and myo-inositol in managing PMOS, particularly in the context of assisted reproduction. Myo-inositol may improve menstrual regularity, while metformin may be associated with improved conception-related outcomes and a reduced risk of ovarian hyperstimulation syndrome (OHSS). However, these findings should be interpreted cautiously given the substantial heterogeneity across studies and confidence intervals approaching the null effect for some outcomes. Further high-quality, adequately powered studies are needed to clarify the magnitude and consistency of these benefits. Overall, individualized, goal-oriented therapy remains important when selecting adjunctive treatments for women with PMOS undergoing assisted reproductive technology.