Variation in gestational outcomes among PCOS phenotypes in natural and art-conceived pregnancies

OBJECTIVE: Polycystic ovary syndrome (PCOS) is the most common endocrine disorder affecting women of reproductive age. While diagnostic criteria have historically varied, the Rotterdam criteria, established in 2003, are now the standard. This classification identifies four PCOS phenotypes based on the presence and/or absence of three key features: ovulatory dysfunction (OD), hyperandrogenism (HA), and polycystic ovarian morphology (PCOM). Despite phenotypic differences, current clinical guidelines treat PCOS as a homogeneous condition when assessing pregnancy risks. Therefore, this narrative review examines variations in gestational outcomes across PCOS phenotypes in both natural and assisted reproductive technology (ART)-conceived pregnancies. METHODS: A search of three databases (PubMed, Cochrane, and Google Scholar) using key terms identified 13 eligible retrospective and prospective studies reporting gestational outcomes in PCOS phenotypes. RESULTS: Findings indicate that phenotypes characterized by HA (A, B, and C) are at higher risk for preeclampsia, gestational diabetes, and miscarriage in natural pregnancies. However, in ART-conceived pregnancies, Phenotypes A and D exhibited higher risks of adverse outcomes, while Phenotypes A and C showed significantly lower live birth and cumulative live birth rates. CONCLUSION: These results reveal inconsistencies in pregnancy risks across phenotypes and conception methods, suggesting differences in the underlying mechanisms. The findings challenge the one-size-fits-all approach to pregnancy counseling in PCOS. Incorporating phenotype-specific risk stratification into clinical guidelines could enhance maternal and neonatal outcomes, particularly for high-risk phenotypes. Further research is needed to refine pregnancy care strategies tailored to individual PCOS phenotypes.