Polycystic ovary syndrome (PCOS) is a common endocrine disorder in women characterized by abnormal menstrual cycles and hyperandrogenism (1). PCOS is still the most common cause of infertility due to anovulation in patients, and clomiphene citrate is the first line of medical treatment in infertility of PCOS (2).
The rates of ovulation and pregnancy were improved to 85–70% and 35–35%, respectively, when clomiphene citrate was used (3); however, about 15–20% of women do not respond to this treatment (4).
Laparoscopic ovarian drilling (LOD) is a surgical treatment that can stimulate ovulation in PCOS patients who are resistant to clomiphene citrate (5). This method could have appropriate results in ovulation and pregnancy (83–89% and 80–70%, respectively) (6). However, studies have shown that, on average, 20–30% of women with PCOS cannot respond well to LOD, which is probably due to inadequate ovarian stromal destruction or inherent resistance of ovaries (7).
An increase in the number of punctures is associated with improved response, but the probability of risk of adhesion and premature ovarian failure (POF) is likely to increase, which has not yet been proven (8).
Several prognostic factors were evaluated to predict successful outcomes of LOD (9, 10). However, the potential risk of it leads to excessive destruction of the ovarian follicular pool, diminished ovarian reserve, or production of anti-ovarian antibodies (especially if the ovarian blood supply is accidentally damaged, or if a large number of punctures have been created) (11, 12).
Diminished ovarian reserve can be detected through hormonal blood panels, particularly in the serum levels of follicle-stimulating hormone (FSH) and anti-Mullerian hormone (AMH) (13, 14). Studies have shown that AMH and FSH independently reflect ovarian reserve (15, 16), and it is worth mentioning that AMH is a more sensitive biomarker than FSH and luteinizing hormone (LH) to monitor ovarian reserve (17, 18).
Studies which evaluate ovarian reserve markers following LOD doing have controversial results (19, 20).
Therefore, considering the above-mentioned issues and the need to evaluate ovarian reserve markers after LOD in Iranian women, the aim of this study was to evaluate the serum levels of AMH and FSH before and after unilateral and bilateral LOD in infertile women with PCOS.

 

This study was a prospective cohort study. The study population included infertile women with clomiphene citrate-resistant PCOS referred to the Infertility Clinic of Yas Hospital in Tehran. They were candidates for LOD according to the infertility clinic protocol in 2016–2017.
Inclusion criteria included women aged 20–35 years with PCOS (according to the Rotterdam criteria), history of infertility for at least 1 year, failure of previous treatment with clomiphene citrate (150 mg/day for 5 days), absence of male infertility, absence of contraindication for laparoscopy, normal oral glucose tolerance test (OGTT), free androgen index more than 4, and LH level more than 10 or LH/FSH ratio more than 2.
Exclusion criteria included confirmation of other diseases with a similar manifestation of PCOS, women with fallopian tubes obstruction, contraindications for surgery and anesthesia, women with one ovary, history of previous ovarian surgery.
The estimated sample size was 40 with related parameters (i.e., an alpha error of 5%, study power of 90%, Pre Mean=7.4, Post Mean=4.2, SD Pre Mean=4.6, and SD Post Mean=2.5).
Five patients excluded from the study and totally the number of patients for the final analysis was 35. To ensure that the study power is optimal, with the present study result parameters, the study power was calculated using Stata software (version 12.0, StataCorp, College Station, TX), which it obtained 93%.
The study was approved by the Local Ethical Committee of Tehran University of Medical Sciences (IR.TUMS.MEDICINE.REC.1395.1241). Verbal and written consent was obtained from all LOD subjects.
The serum levels of AMH and FSH were determined in all patients. Demographic parameters, such as age, body mass index (BMI), and duration of infertility, were recorded. The patients then underwent surgery based on the surgeon's estimation of the size of the ovaries regarding LOD, either unilateral or bilateral, with monopolar electrocautery and four punchers with the power of 30 W for 4 s. The serum levels of AMH and FSH were measured 3 months after surgery using available commercial enzyme immunoassay kits (CoBase and Elecsys, Roche Company).
The data were analyzed using Stata software. The process of data cleaning and exploration was done. The mean, SDs, and other dispersion indicators were utilized to describe quantitative variables, while the frequency tables and graphs were utilized to describe qualitative variables.
The Mann–Whitney non-parametric test was used to test the hypotheses of the study based on variables. A significant level of 0.05 was considered for all analyzes.