Myo-inositol in reproductive management of women with PCOS: holy grail for medical practice or demon for scientific evidence?

Myo-inositol has gained widespread use in the management of infertility associated with polycystic ovary syndrome (PCOS), driven by its proposed role in improving insulin sensitivity and ovarian function. Despite its popularity in clinical practice, the evidence supporting myo-inositol's efficacy in enhancing fertility outcomes remains limited and inconclusive. Current international and national guidelines do not endorse myo-inositol as a first-line treatment for PCOS-related infertility, either as monotherapy or in combination with ovulation induction agents. Even if early studies suggest potential benefits when used alongside clomiphene citrate or gonadotrophins, these findings are often outdated or misaligned with contemporary treatment protocols that favour letrozole and gonadotrophin-releasing hormone antagonist regimens. In the context of IVF, myo-inositol may reduce gonadotrophin requirements and improve some intermediate/secondary outcomes, although data on live births and long-term efficacy are lacking. This commentary critically evaluates the current literature on use of myo-inositol in PCOS fertility care, emphasizing the need for well-designed, adequately powered randomized controlled trials that reflect current clinical standards. Until stronger evidence is available, myo-inositol should not be routinely recommended in fertility protocols for PCOS but reserved for individualized cases within an evidence-based framework.