Laparoscopic Ovarian Drilling Research Articles

Evaluation and Treatment Strategies for Infertile Patients with Diagnosed Polycystic Ovary Syndrome (PCOS)

Background: PCOS is the most common endocrine disorder in women that can lead to a variety of ailments associated with chronic anovulation and hyperandrogenism, it is also still a common cause of infertility in women. It is the most frequent endocrine and metabolic disorder among reproductive-aged women. PCOS (polycystic ovarian syndrome) is the most frequent cause of anovulatory infertility, accounting for more than 75% of all cases. This widespread problem affects around one in every six marriages and has a variety of causes across countries and social groups. Aims and Objective: The objective of this study was to evaluate the treatment strategies for infertile patients with diagnosed Polycystic Ovary Syndrome (PCOS). Material and Methods: This study looked at 80 cases of infertility caused by polycystic ovarian syndrome. From August 2021 to July 2022, this study evaluated 80 cases of infertility with PCOS at a tertiary medical college. The diagnosis was made using a hormone assay, ultrasound, and laparoscopy. Treatment options included clomiphene citrate, letrozole, and laparoscopic ovarian drilling. Results: In our study, the majority (50%) were between the ages of 26 and 30 years old, and 100% of patients complained of infertility, with 66.25% being of the primary type. Menstrual abnormalities affected 73.75% of women. The LH: FSH ratio was greater than 1.6 in approximately 85% of responders, and 77.5% of women had enlarged polycystic ovaries. Clomiphene citrate had a conception rate of 24%, Letrozole 31% had a rate of 20%, and laparoscopic ovarian drilling followed by Letrozole had a rate of 60%. Conclusion: Polycystic ovarian syndrome is a complex illness that necessitates a variety of treatment techniques based on the reason a patient seeks treatment. Aside from diet and fitness improvements, most patients with good conception rates require lifestyle modification treatment such as C/C and laparoscopic ovarian drilling.

P-698 The ULTRA trial: transvaginal ULTRAsound-guided ovarian ablation using May Health System in women with PCOS-related infertility: clinical and endocrine outcomes of first–in-human feasibility trial

Abstract Study question What is the feasibility of transvaginal ULTRAsound (TVUS)-guided ovarian ablation using the May Health System to improve ovulation, pregnancy, and hormonal abnormalities in PCOS-related infertility? Summary answer The feasibility of TVUS-guided ovarian ablation to improve ovulation, pregnancy, and hormonal abnormalities in PCOS-related anovulatory infertility was demonstrated. A pivotal study is underway. What is known already Laparoscopic ovarian drilling (LOD) is widely accepted as an effective second line treatment in PCOS-related infertility. However, laparoscopy is an invasive procedure that requires general anaesthesia and carries significant risks. Furthermore, there is no standardization of the LOD technique among surgeons. In contrast, the May Health System has been designed to deliver a precisely calculated amount of ovarian ablation via a less invasive route without general anaesthesia. This approach therefore transforms an invasive surgical procedure to an office-based technique similar in ovarian access to the well-established oocyte retrieval. Feasibility and safety results of this trial have previously been reported. Study design, size, duration This study included two feasibility, single-arm clinical trials running in parallel in the EU and US assessing the May Health System in performing TVUS-guided ovarian ablation in anovulatory PCOS women resistant to first-line ovulation induction drugs. Sample size was up to 35 participants with post-procedure follow-up (FU) of 24 months in EU and 12 months in US. Endpoints for this study were technical success, ovulation rates, pregnancy rates, and hormonal changes. Participants/materials, setting, methods Seven fertility centres participated in the trials. Participants were clomiphene/letrozole-resistant PCOS women aged 18-40 years. PCOS was diagnosed according to Rotterdam criteria. Participants underwent TVUS-guided ovarian ablation using the May Health System. The initial five participants underwent laparoscopy concurrent with TVUS-ablation. Post-procedure, serum progesterone was measured weekly until confirmation of ovulation or up to 12 weeks. Women were evaluated at 3 and 6 month, and then telephoned at 9- 12- and 24-month (EU sites only). Main results and the role of chance Thirty-one participants (mean±sd age, 31.9±3.3 years; BMI, 29.84.7kg/m2) underwent May Health TVUS-guided ovarian ablation and 25 completed at least six-months FU, with follow-up ongoing. Fourteen (45.2%) ovulated spontaneously within 3-months. Six more participants (19.3%) ovulated between three and nine months (after restarting CC/LTZ) giving a combined ovulation rate, with and without first-line medication restart, of 64.5% (20/31). Of the 31 participants who underwent the procedure, 10 (32%) have conceived to date, with seven live births, two ongoing, and one miscarriage. In 30 cases (97%), the targeted ablation was achieved successfully, while in one case (3%) the procedure was abandoned for the second ovary due to pain (n = 1). The median (IQR) serum AMH concentrations significantly decreased from baseline 76.1 (32.0, 210.7) to 62.5 (21.2, 253.6) pmol/l at 3-month (p = 0.001) and 56.7 (11.5, 126.8) pmol/l at 6-month (p = 0.001) post-procedure (Figure 2). The magnitude of post-ablation AMH decline was significantly (p = 0.047) greater in those who ovulated (responders) (-23.7% (-36.5, 17.7)) versus non-responders (-7.3% (-25.2, -1.6)). Ovarian volume significantly (p = 0.005) decreased from 13.6±5.1 ml at baseline to 10.1±3.7 ml at 6-month FU. There were no statistically significant changes in mean circulating testosterone, LH, or FAI at 3- or 6-month. Limitations, reasons for caution A limitation of this study is the lack of a comparator treatment / placebo arm. However, this was not necessary for this feasibility trial. It is possible to assume that the post-procedure ovulation and pregnancies could be compared for each participant with pre-procedure lack of ovulation and failure to conceive. Wider implications of the findings These data suggest that the investigational May Health System may offer an effective office-based second line ovulation inducing procedure for PCOS. The observed decline in circulating AMH, which was sustained for at least six months, could be the underlying mechanism of ovarian rebalancing that leads to subsequent resumption of ovulation. Trial registration number NCT03760926

O-189 Letrozole-resistant PCOS: prevalence, further options and course of fertility treatment

Abstract Study question What is the prevalence of letrozole-resistance in infertile women with polycystic ovary syndrome (PCOS) and what is the course of clinical management for such women? Summary answer Even after 10 mg/day dose of letrozole, 2.7% women did not ovulate. Clomiphene citrate (CC) should be tried first in these women, followed by gonadotrophins What is known already Letrozole is the preferred drug for ovulation induction (OI) in infertility associated with PCOS because it results in better pregnancy and live birth rates than CC. Women not responding to conventional dose of letrozole, may require alternate regimens like two-step, higher and extended dose. But some women may remain refractory even to the maximum dose of letrozole. While CC-resistance and its management are well established, clinical management of women with PCOS resistant to the maximum dose of letrozole remains largely undocumented. Study design, size, duration A prospective observational study was conducted in a Fertility Centre between April 2018 and March 2023 after obtaining Institutional Ethics Committee approval and informed written consent from all the participants. Out of total 1851 women with PCOS and infertility, 1522 were included in the study, of which 50 were found to be resistant to letrozole. Participants/materials, setting, methods Infertile women with PCOS (defined by Rotterdam criteria), age 21-35 years, with patent fallopian tubes and normal semen reports of partner, who received no previous OI were recruited. Women who failed to ovulate (confirmed with transvaginal ultrasound) after 3 consecutive cycles of incremental (5, 7.5 and 10 mg/day) doses of letrozole were switched to CC. In case of CC-resistance, options of laparoscopic ovarian drilling (LOD) or gonadotrophins were offered. Clinical and pregnancy-associated parameters were assessed. Main results and the role of chance Out of 50 letrozole-resistant women, 19 (38%) ovulated after subsequent OI with CC, of which seven (36.8%) conceived and two (28.8%) had twin pregnancy. Out of 31 CC-resistant women, seven were lost to follow up. The singlet woman who opted for LOD did not have subsequent spontaneous ovulation and therefore, required gonadotrophins later on. All 24 women who received gonadotrophins ovulated. Most of them developed one (11, 45.83%) or two (12, 50%) follicles. However, one woman developed 10 follicles leading to ovarian hyperstimulation syndrome, for which the OI cycle was converted to in-vitro fertilization (IVF). With gonadotrophins, nine (37.5%) women conceived and one (11.1%) had triplet pregnancy that miscarried in the first trimester. The remaining 16 women who failed to conceive were offered three cycles of intrauterine insemination followed by IVF. The mean time to pregnancy from the start of treatment was 10.81 (±7.71) months. The live birth rate was similar (P = 0.0416) between gonadotrophins (6, 27.2%) and CC (5, 22.7%), Between CC-resistant and CC-responsive women, all clinical, biochemical and biophysical parameters were similar except the mean levels of luteinizing hormone, which were significantly higher in CC-resistant group (16.3 ±5.3 versus 13.2 ±4.7 mU/ml, P = 0.036). Limitations, reasons for caution The study was conducted in a single center and the results may be difficult to extrapolate on women belonging to other ethnicities. The sample size was small. Wider implications of the findings Some women with PCOS may not respond even to the maximum dose (10 mg/day) of letrozole. Correct identification of letrozole-resistance and choosing the subsequent appropriate methods of OI are of paramount importance in timely management of infertility in these couples. Trial registration number NA

Ovarian Reserve and Hormone Alteration Following Laparoscopic Ovarian Drilling for Polycystic Ovarian Syndrome: A Systematic Review.

Weaimed to conduct a systematic review of the data in the literature on ovarian reserve and ovarian hormone following laparoscopic ovarian drilling (LOD). The PubMed, ScienceDirect, and ProQuest databases were comprehensively searched using a combination of keywords such as "ovarian reserve", "laparoscopic ovarian drilling", "luteinizing hormone", "follicle-stimulating hormone", "inhibin", "LH/FSH ratio", "ovulation", and "testosterone". All studies involving females of reproductive age who were officially diagnosed with polycystic ovarian syndrome (PCOS) andhad undergone LOD with reported data concerning at least one of the following parameters were considered for inclusion: ovarian reserve, anti-Mullerian hormone (AMH), inhibin, follicle-stimulating hormone (FSH), luteinizing hormone (LH), LH/FSH ratio, and testosterone. All the included studies were evaluated by the GRADE scale for bias and their findings were synthesized by four independent coauthors. A total of 38 studies involving3118 female patients were included. Based on our findings, a significant number of participants experienced spontaneous ovulation along with a significant decrease in ovarian reserve, and a significant decrease in AMH, LH, and testosterone, with no significant changes in FSH and inhibin B. With the end goal of LOD being to improve fertility and pregnancy rates among females with PCOS, it is important to look at the first few steps that enable this. As expected, there was a significant improvement in ovulation while the ovarian reserve decreased. Along with the decrease in ovarian reserve, there was a significant normalization in AMH, LH, and testosterone levels. LOD may exert its main effects through the manipulation of the ovarian reserves.

Retraction.

Retraction: El Behery, M. M., Diab, A. E., Mowafy, H., Ebrahiem, M. A., Shehata, A. E. (2010) Effect of laparoscopic ovarian drilling on vascular endothelial growth factor and ovarian stromal blood flow using 3-dimensional power Doppler. International Journal of Gynecology & Obstetrics, 112: 119-121. https://doi.org/10.1016/j.ijgo.2010.08.018. The above article, published online on 08 December 2010 in Wiley Online Library (wileyonlinelibrary.com), has been retracted by agreement between the journal Editor-in-Chief, Professor Michael Geary, the International Federation of Gynecology and Obstetrics, and John Wiley and Sons Ltd. The retraction has been agreed due to major overlap between this article and the following article: Amin, A.F., Abd El Aal, D.E.M., Darwish, A.M, Meki, A.-R.M.A. (2003). Evaluation of the impact of laparoscopic ovarian drilling on Doppler indices of ovarian stromal blood flow, serum vascular endothelial growth factor, and insulin-like growth factor-1 in women with polycystic ovary syndrome. Fertility and Sterility, 79: 938-941. https://doi.org/10.1016/S0015-0282(02)04849-5. Following a complaint from a third party, an investigation by the editorial office and Wiley concluded that there are extensive duplications in the study design, sample sizes, tables, and results between the two articles. The authors did not respond to a request for an explanation and original data by the publisher. Representatives at Zagazig University did not respond to requests to begin an investigation.

Expression of Concern: Laparoscopic ovarian drilling versus GnRH antagonist combined with cabergoline as a prophylaxis against the re-development of ovarian hyperstimulation syndrome

Expression of Concern: Laparoscopic ovarian drilling versus GnRH antagonist combined with cabergoline as a prophylaxis against the re-development of ovarian hyperstimulation syndrome

Laparoscopic Ovarian Drilling in Women with Anovulatory Infertility

Background: Polycystic ovaries are common condition mostly found in reproductive aged women. Conventionally clomiphene is used instead of letrozole as first line drug in patients presenting with infertility as later is off label. 20% women are clomiphene resistant, those can be treated with gonadotrophins, other ovulation induction drugs or laparoscopic ovarian drilling. Objective: As PCOS is one of the leading cause of anovulatory infertility among women of reproductive age group. We study different factors to speculate the effect of laparoscopic ovarian drilling. Study Design: Quasi experimental study. Setting: Department of Gynecology & Obstetrics, Faisalabad Medical University, Faisalabad Pakistan. Duration: One year from August 2021 to August 2022. Methods: Our study includes 100 anovulatory PCOS patients resistant to conceive by medical treatment like clomiphene, later selected for LOD. Various clinical and biochemical parameters of PCOS were examined. Outcome was measured between different categories by using SPSS V 25 system. Results: Polycystic anovulatory women with BMI >35kg/m2, serum testosterone concentration > 4.5 and span of infertility > 3 years showed lack of response to LOD. Whereas response was seen in patients with less BMI and testosterone concentration along with decrease span of infertility. Conclusion: Ovarian drilling by laparoscopy is an efficient second choice for infertile anovulatory patients resistant to clomiphene citrate, main benefits are single time treatment, as opposed to several trials of ovulation induction, cost effective and a method to replace gonadotrophins effectively for ovulation induction while maintaining pregnancy rate.

The effect of laparoscopic ovarian drilling on pregnancy outcomes in polycystic ovary syndrome women with more than 2 in-vitro fertilization cycle failures: A pilot RCT.

Background: The effect of laparoscopic ovarian drilling (LOD) before in vitro fertilization/ intracytoplasmic sperm injection (IVF/ICSI) cycles on pregnancy outcomes is an unclear and challenging subject. Objective: To evaluate the impact of LOD before IVF/ICSI cycles on controlled ovarian stimulation and pregnancy outcomes in polycystic ovary syndrome (PCOS) women with a history of more than 2 IVF failures. Materials and Methods: In this randomized clinical trial, women with PCOS diagnosis who referred to Arash Women's hospital, Tehran, Iran for IVF/ICSI cycle from August 2015-January 2018 were evaluated. Eligible participants were allocated into 2 groups randomly (n = 17/each group). The participants in the LOD group (intervention) were treated with laparoscopic couture, and after one month, they underwent IVF/ICSI cycles using the gonadotropin-releasing hormone antagonist protocol. The control group had no intervention. The oocyte and embryo qualities, ovarian hyperstimulation syndrome rate, the rates of chemical and clinical pregnancy and early miscarriage, live birth, and pregnancy complications, were compared between groups. Results: Finally, 34 participants were evaluated. The controlled ovarian stimulation outcomes were similar between groups. The ovarian hyperstimulation syndrome rate in the LOD group was significantly lower than in the control group (p = 0.04). One case of spontaneous pregnancy was reported in the LOD group. No significant difference was observed between groups in clinical pregnancy, miscarriage, and live birth rates. The rates of pregnancy complications (gestational diabetes mellitus, preeclampsia, and preterm birth) were similar between groups. Conclusion: Performing LOD before IVF/ICSI cycles did not improve the pregnancy outcomes in PCOS women, a clinical trial with a larger sample size is needed to prove these results.

#140 : Combined Use of Letrozole, Cabergoline and GnRH Antagonist to Prevent Ovarian Hyperstimulation Syndrome Completely in Polycystic Ovarian Syndrome Treatment

Background and Aims: The main difficulty to treat polycystic ovarian syndrome (PCOS) is the possibility of ovarian hyperstimulation syndrome (OHSS). There are several clinical approaches to avoid dangerous complications of OHSS: laparoscopic ovarian drilling (LOD), in vitro maturation (IVM), and GnRH antagonist-GnRH agonist based controlled ovarian stimulation (COS) with low dose of gonadotrophin. However, clinical outcomes after using these methods are less satisfactory than COS in normal ovarian function. We started a new approach combining the use of three kinds of medicine, Letrozole, Cabergoline and GnRH antagonist from just after the oocyte pick up and continue for five consecutive days to prevent the occurrence of OHSS in the PCOS treatment. Method: We compared the severity of OHSS after using a new treatment (the novel COS) in 53 women (55 cycles) with the severity of OHSS in a group of 37 women (37 cycles) who received the most widely used conventional GnRH antagonist-GnRH agonist- based COS for PCOS in retrospective cohort study. Results: This table shows the comparison of clinical outcomes between two groups. Conclusion: PCOS patients have been treated with hypostimulation methods and IVM to prevent OHSS. However, our method is considered to be more effective, safer and more versatile than any other treatment method. It seems to be an important alternative treatment method for PCOS patients. We believe this new treatment is highly recommended for the complete prevention of OHSS.

Optimising Ovulation Induction in PCOS

Biochemical, Metabolic and Endocrine changes in PCOS result in reproductive impairment in women with PCOS. Controlled ovarian stimulation (COS) may be associated with • Unpredictable response • Response may be slow • Hyper-response - OHSS • Risk of Cyst Formation • Poor oocyte quality • Miscarriage • Cycle cancellation So, the ovulation induction protocol should be efficacious and safe resulting in a singleton live birth, minimising complications, and risks like ovarian hyperstimulation syndrome (OHSS), multiple pregnancies and cancellation of cycles. For this special consideration should be given to prediction of response, pre-treatment, choosing the right ovulation induction (OI) protocol with right dose and analogue, using GnRH agonist trigger instead of hCG, preventing late follicular phase rise in progesterone, or following the segmentation protocol. We can maximize the success rates by stimulation individualization based on age, AMH, AFC and amended further for BMI. AMH is considered as more sensitive marker to define follicle excess than AFC as it appraises more follicle classes - preantral and early antral. One should probably use mild stimulation protocols where gonadotropins are given in combination with oral ovulogens or the low dose step up protocol. It is essential that we use GnRH antagonist protocol and administer GnRH agonist if there is risk of OHSS. If segmentation protocol is used one could also use the progesterone primed ovarian stimulation instead of GnRG antagonist. One could reduce the incidence of OHSS by laparoscopic ovarian drilling and use of Metformin and aspirin before assisted reproduction. If the patient is at risk of developing OHSS during stimulation then one could administer cabergoline, intravenous infusion of calcium gluconate or albumin and methylprednisolone. But freezing all embryos and transferring them in a subsequent cycle increase the efficacy and reduce complications of ART in PCOS women. Elective single embryo transfer(eSET) should be the norm to reduce the multiple pregnancy rate. Conclusion Thus, in all ART cycles individualised COS with freeze all and eSET could help in increasing the success of ART and reducing stress and anxiety and complications in these women.

#369 : A Case of Luteal Phase Deficiency (LPD) and Polycystic Ovarian Syndrome (PCOS). When Routine is not Enough

Background and Aims: Luteal phase deficiency (LPD) is a consequence of the inability of the corpus luteum (CL) to produce an adequate level of progesterone. This manifests clinically as a short menstrual cycle and infertility. Abnormal follicular development and inadequate steroidogenesis in lutein cells of the CL have been implicated in CL dysfunction and LPD. LPD and PCOS are independent disorders sharing a common pathophysiology. The aim of this case report is to highlight the importance of additional luteal phase support for patients with PCOS. Case report: A 34-year-old Indian lady with anovulation secondary to PCOS failed to get pregnant after 7 years of marriage. Her menses were irregular, and she had hirsutism. She was also overweight. (BMI 26.4 kg/m2) Her hormonal profile showed a reversal of the FSH/LH ratio of 2:1, and serum progesterone was low. (<1.6 IU/L). A transvaginal scan showed a classic pearl string sign, which was typical for patients with PCOS. She underwent laparoscopic dye insufflation and ovarian drilling, during which four puncture points were made on each ovary at 4 watts for 4 seconds. Later, she underwent a round of timed sexual intercourse and intrauterine insemination. (IUI) Dydrogesterone (10 mg, 8 hourly) was started for luteal phase support as per unit protocol. However, she complained of per vaginal spotting starting on day 7 after human chorionic gonadotropin (hcg) trigger, and both times, treatment was unsuccessful. Then, she had another round of ovarian stimulation with clomiphene citrate 50 mg daily and had IUI. She was given micronized progesterone 100 mg 12 hours a day in addition to the dydrogesterone. The urine pregnancy test was positive, and she is having a healthy, on-going pregnancy. Conclusion: Patients with PCOS may suffer from a defective luteal phase. Hence, it is important to supplement PCOS patients with additional support during the luteal phase, as this can lead to a successful pregnancy.

Analyzing the Challenges, Consequences, and Possible Treatments for Polycystic Ovary Syndrome.

Polycystic ovary syndrome (PCOS) is a highly widespread disorder caused by a disturbed endocrine system. The Rotterdam criteria have classified 4 phenotypes of PCOS. This syndrome has multifactorial pathophysiology triggered by a disturbed neuroendocrine system, which further produces abnormal levels of luteinizing hormone, follicle-stimulating hormone, androgen, estrogen, and progesterone, leading towards the risk of metabolic and reproductive diseases. PCOS is associated with an increased risk of developing health problems like hyperinsulinemia, diabetes mellitus, hypertension, cardiovascular disorders, dyslipidaemia, endometrial hyperplasia, anxiety and depression. These days, PCOS has become a scientific issue due to complex aetiology with multi- complex physiology. Due to the unavailability of specific medicines, there is no cure for PCOS; however, certain symptoms could be treated. The scientific community is actively looking for various treatment options too. In this context, the current review summarizes the challenges, consequences and various treatment options for PCOS. Various literature reports provide evidence that PCOS can be identified in early infancy, adolescents and women at the menopausal stage. Most commonly, PCOS is caused by multifactorial agents, including genetics and negative lifestyle. Metabolic consequences from obesity, insulin resistance, and vascular disorder have increased the rate of PCOS. This study also highlights psychological morbidity in PCOS women that have an adverse effect on health-related quality of life (HRQoL). PCOS symptoms can be treated using different strategies, including oral contraceptive drugs, surgical treatment (laparoscopic ovarian drilling (LOD), assisted reproductive techniques (ART), and Chinese acupuncture treatment.

Polycystic Ovary Syndrome: A Literature Review With a Focus on Diagnosis, Pathophysiology, and Management.

In females with polycystic ovarian syndrome (PCOS), the most prevalent endocrine conditionis chronic anovulation and hyperandrogenism. This illness influences females from conception to death, posing several risks to the health of a female, thus reducing the quality of life. It also increases the rates of mortality and morbidity. The first years of puberty are when PCOS symptoms first show. Menstrual irregularities, anovulation,and acne are features of both PCOS and typical puberty in females. There are many various phenotypes that fall under the same illness, so it is necessary to examine each one independently because they may need different treatments and result in different outcomes. Depending on the diagnostic criteria, approximately 6%-20% of females in the reproductive age group are believed to be affected by PCOS.As long as PCOS is still a syndrome, no single diagnostic indicator, such as hyperandrogenism or polycystic ovary (PCO), can be used to make a clinical diagnosis. The management of females with PCOS depends on the symptoms. These could include menstruation problems, androgen-related symptoms, or infertility caused by ovulatory disruption. In females with PCOS, anovulation is linked to low follicle-stimulating hormone (FSH) levels and a halt in antral follicle growth during the last stages of maturation. The condition may be treated surgically with laparoscopic ovarian drilling or medically with medications such as aromatase inhibitors, metformin, glucocorticoids, clomiphenecitrate (CC), tamoxifen, or gonadotropins. Patients will experience different androgenic symptoms, such as hirsutism, acne, and/or baldness. Patients who appear with these troubling symptoms need to receive appropriate care. The review emphasizes the role it plays in the management of various conditions.

Value of Assessing AMH in the Management of Polycystic Ovarian Syndrome (PCOS)

Polycystic ovary syndrome (PCOS) is the most common endocrinopathy in reproductive age affecting 5 “ 10% of women and is the leading cause of ovulatory dysfunction. Anti-mullerian hormone (AMH) is a dimeric glycoprotein releases from the granulosa cells of small preantral and antral follicles and these concentrations have shown to be proportional to the number of developing follicles in the ovaries. In women with PCOS serum levels are elevated 2- to 3- fold in comparison with normo-ovulatory women, consistent with the increased number of small antral follicles in these women. AMH production per granulosa cell is increased on average 75-fold in anovulatory PCOS compared with normal ovaries. AMH is a marker for ovarian reserve of the women. It also can be used for diagnosis of PCOS. The high level of PCOS has negative effect on reproduction. It inhibits the function of FSH and causes follicular arrest and anovulation. In presence of high AMH there is poor response to oral ovulation inducing agent, gonadotropin and laparoscopic ovarian drilling. Quality of embryo, implantation rate and live birth rate are significantly reduced in presence of high AMH. High LH, hyperandrogenism, hyperinsulinemia have association with high AMH. Androgen is responsible for increasing the number of preantral follicles, hence AMH. Adjuvant therapy like metformin can correct hyperandrogenism, reduce the serum level of AMH and improve ovulation, pregnancy and live birth rate. Pre-treatment AMH level 7.77ng/ml is a cutoff level to predict the response to fertility treatment in PCOS. Ovulation, pregnancy and live birth rate are significantly lower when AMH level is >7.77ng/ml. So, to predict response to treatment and to fix the treatment plan value of assessment of AMH is important in case of PCOS. Bangladesh J Obstet Gynaecol, 2022; Vol. 37(1): 47-62

PCOS DISEASE CLASSIFICATION USING FEATURE SELECTION RFECV AND EDA WITH KNN ALGORITHM METHOD

Polycystic ovary syndrome is an endocrine disorder of the ovaries that causes hormonal disturbances in women of reproductive age, where androgen secretion in the ovaries of women with Polycystic Ovary Syndrome (PCOS) is excessive compared to normal women. This usually occur in women with obesity which is characterized by irregular menstrual cycles, chronic anovulation, hyperandrogenism, and even infertility. Efforts are used to treat this disease in the form of hormone therapy, laparoscopic ovarian drilling, and in-vitro fertilization. However, these three therapies are focused on symptomatic therapy and are less effective in treating PCOS-related infertility. Detecting PCOS disease early is very necessary so that prevention and treatment can be carried out immediately. Therefore, a classification is carried out to detect PCOS disease by being able to analyze data that has a high degree of accuracy. The method used for the classification of PCOS disease is using the K Nearest Neighbor (KNN), method which previously carried out the feature selection process, namely the Exploratory Data Analysis (EDA), method which is used for the data analysis process by means of an analysis approach to data to find out the most accurate method and using the Recursive Feature Elimination and Cross-Validation (RFECV) selection method which ranks the features based on their level of importance to the prediction process. Further, the data classification process uses the K-Nearest Neighbors (KNN) algorithm. The results of the Exploratory Data Analysis (EDA) feature selection process produce 10 data attributes that are used and are continued by the Recursive Feature Elimination and Cross-Validation (RFECV) process by producing the 7 most important attributes used and finally the K-Nearest Neighbors (KNN) method has a high level high accuracy by producing an accuracy value of 93%, precision 82%, recall 100%, and F1 score 90%.

Effect of laparoscopic ovarian drilling on ovulation rate in women with clomiphene resistant polycystic ovarian syndrome

Effect of laparoscopic ovarian drilling on ovulation rate in women with clomiphene resistant polycystic ovarian syndrome

The effect of laparoscopic ovarian drilling in patients with anovulatory polycystic ovary syndrome and high serum levels of anti-Müllerian hormone.

Female infertility is often associated with anovulatory polycystic ovary syndrome (PCOS), characterized by high serum levels of anti-Müllerian hormone (AMH). Laparoscopic ovarian drilling (LOD) is commonly used to treat PCOS, especially when drug interventions have failed. This study aimed to evaluate the response to LOD intervention in women with PCOS by assessing AMH serum levels and their ability to restore normal physiological menstrual cycle and achieve conception. Seventy-five infertile women (24-41 years old) with body mass index (BMI) ranging from 19.6-35kg/m2 were included in the study. Among them, 57 had primary infertility, and 18 from secondary infertility, with an average duration of 8.6±4.4 years. Baseline levels of follicle-stimulating hormone (FSH), luteinizing hormone (LH), and AMH were measured, and post-LOD levels of LH and AMH were evaluated. Menstrual cycle regularity was evaluated before and after LOD. Baseline FSH serum level before LOD was 5.2-1.6IU/L. Following LOD, the serum levels of LH and AMH significantly decreased from 14.3±4.1 to 7.8±2.8 IU/L and from 13.7±5.9 to 7.7±3.9 IU/L, respectively (p<0.05). LOD significantly (p<0.05) decreased the menstrual cycles irregularity, such as oligomenorrhea and amenorrhea, from 55 (73.3%) to 22 (29.3%) women and from 2 (2.7%) to 0 (0%) women respectively. Moreover, regular menstrual cycles significantly (p<0.05) increased from 18 (24%) to 53 (70.7%) women. Importantly, 68% of LOD-treated women showed a significant increase in pregnancy rates, with 52.9%, 35.3%, and 11.8% achieving pregnancy within 3, 6, and 9 months after LOD, respectively (p<0.05). Moreover, spontaneous ovulation was observed in 7/75 (9.3%) women within 90 days after LOD, and 71.4% achieved pregnancy. These findings highlight the success of laparoscopic ovarian drilling as an intervention for PCOS, with AMH serving as a reliable test to assess the response to LOD treatment.

Retraction.

Hamed, H.O., Hasan, A.F., Ahmed, O.G. and Ahmed, M.A. (2010), Metformin versus laparoscopic ovarian drilling in clomiphene- and insulin-resistant women with polycystic ovary syndrome. International Journal of Gynecology & Obstetrics, 108: 143-147. https://doi.org/10.1016/j.ijgo.2009.08.033 The above article, published online on 4 November 2009 on Wiley Online Library (wileyonlinelibrary.com), has been retracted by agreement between the journal's Editor-in-Chief, Professor Michael Geary, the International Federation of Gynecology and Obstetrics and John Wiley & Sons Ltd. The journal's Editor-in-Chief was contacted by a third party who raised concerns about the article. Following review, the journal's research integrity team found substantial errors in the study's reported results. Thus, they consider the article's conclusions unreliable.

Transvaginal needle versus laparoscopic ovarian drilling in hormonal profile and pregnancy outcomes of polycystic ovary syndrome: A systematic review and meta-analysis.

Polycystic ovary syndrome (PCOS) is a prevalent hormonal disorder distinguished by a persistent absence of ovulation. Ovarian drilling is a recognized therapeutic approach for PCOS patients who are unresponsive to medication and can be performed through invasive laparoscopic access or less-invasive transvaginal access. The aim of this systematic review and meta-analysis was to assess the efficacy of transvaginal ultrasound -guided ovarian needle drilling with conventional laparoscopic ovarian drilling (LOD) in patients with PCOS. PUBMED, Scopus, and Cochrane databases were systematically searched for eligible randomized controlled trials (RCTs) from articles published from inception to January 2023. We include RCTs of PCOS that compared transvaginal ovarian drilling and LOD and reported on ovulation and pregnancy rates as the main outcome variable. We evaluated study quality using the Cochrane Risk of bias 2 tool. A random-effects meta-analysis was performed and the certainty of the evidence was assessed according to the GRADE approach. We registered the protocol prospectively in PROSPERO (CRD42023397481). Six RCTs including 899 women with PCOS met the inclusion criteria. LOD was found to significantly reduce anti-Mullerian hormone (AMH) (SMD: -0.22; 95% CI: -0.38, -0.05; I2=39.85%) and antral follicle count (AFC) (SMD: -1.22; 95% CI: -2.26, -0.19; I2=97.55%) compared to transvaginal ovarian drilling. Our findings also indicated that LOD significantly increased the ovulation rate by 25% compared to transvaginal ovarian drilling (RR: 1.25; 95% CI: 1.02, 1.54; I2=64.58%). However, we found no significant difference between the two groups in terms of follicle stimulating hormone (SMD: 0.04; 95% CI: -0.26, 0.33; I2=61.53%), luteinizing hormone (SMD: -0.07; 95% CI: -0.90, 0.77; I2=94.92%), and pregnancy rate (RR: 1.37; 95% CI: 0.94, 1.98; I2=50.49%). LOD significantly lowers circulating AMH and AFC and significantly increases ovulation rate in PCOS patients compared to transvaginal ovarian drilling. As transvaginal ovarian drillingremains a less-invasive, more cost-effective, and simpler alternative, further studies are warranted to compare these two techniques in large cohorts, with a particular focus on ovarian reserve and pregnancy outcomes.

Is There Still a Place for Surgery in Patients with PCOS? A Review.

The surgical management of polycystic ovary syndrome (PCOS) represents an unclear option compared to medical therapy, and it is necessary to deepen the role of minimally invasive surgery, represented by laparoscopic ovarian drilling (LOD) and transvaginal hydrolaparoscopy (THL), for the treatment of PCOS in infertile women resistant to drug therapy and to establish its success in terms of ovulation and pregnancy rates. A search was performed in the main electronic databases (MEDLINE, EMBASE, Web of Science, PubMed, and the Cochrane Library) from 1994 to October 2022 in order to evaluate the role of surgery in patients with PCOS resistant to pharmacological treatment. Only original scientific articles in English were included. Seventeen studies were analyzed in this review. In all analyzed studies, more than 50% of the population underwent spontaneous ovulation after surgical treatment without great differences between the two surgical techniques (LOD and THL). More than 40% of patients delivered, with a higher rate after LOD, although eight ectopic pregnancies and sixty-three miscarriages were reported. A lower risk of adhesion formation after THL has been reported. No clear data regarding the effect of surgery on the regularization of the menstrual cycle has been described. A reduction in LH and AMH serum levels as well as the LH/FSH ratio compared to preoperative levels for both surgical techniques has been described. Despite the scarcity and heterogeneity of data, surgical therapy could be considered an effective and safe approach in the management of PCOS patients with resistance to pharmacological treatment who desire to become pregnant.