Summary
Polycystic ovary syndrome (PCOS) is a common cause of infertility and is associated with chronic anovulation and hyperandrogenemia. It affects 7–8% of reproductive age women.Clomiphene citrate (CC) is still holding its place as the first-line therapy for ovulation induction in these patients however, the use of CC may be associated with poor cervical mucus and endometrial thinning in 15–50% of patients due to prolonged estrogen-receptor depletion in the endometrium and possibly in the cervix.
Clomiphene resistance, that is, failure to ovulate after receiving 150 mg/day, is common and occurs in approximately 15–40% of women with PCOS. Insulin resistance, compensatory hyperinsulinemia and an increase in androgen production are all linked together in PCOS patients. This pathophysiology was the rationale for using insulin-sensitizing drugs to lower circulating insulin levels and ameliorates hyperandrogenemia in an attempt to restore normal ovulation. Metformin a biguanide, is now the most widely used insulin sensitizer for ovulation induction in women with PCOS.
Laparoscopic ovarian drilling has been widely established as an elective second line method of ovulation induction in CC-resistant PCOS patients. Advantages of LOD include less complication rate, less time needed for cycle monitoring and the low risk of multiple pregnancies. The surgical approach is not associated with ovarian hyperstimulation and can lead to consecutive ovulation without the need for further treatment. The main drawbacks of LOD are the need for general anesthesia and the risk of postoperative adhesions. The assertion that it might affect the ovarian reserve is not more than a theoretical concern since a recent report concluded that LOD, when applied properly, does not seem to compromise the ovarian reserve in women with PCOS.
The aim of this study is to compare To compare the hormonal-metabolic profiles and reproductive outcomes between women receiving metformin plus clomiphene and women undergoing bilateral ovarian drilling in clomiphene citrate resistant women.
The study included 160 infertile women diagnosed as having PCO resistance syndrome. Women were randomized into two groups. group 1 include 80 women they received Metformin850 mg(Glucophage 850 mg; MerkSorono) twice daily before lunch and dinner and Clomiphene citrate 100 mg (Clomid 50 mg, SanofiAvenis ) daily for 5 days starting from the third day of spontaneous or induced menses. Group 2 included 80 women who were subjected for bilateral laparoscopic ovarian drilling
Our study concluded that combined metformin–CC and LOD are equally effective regarding affecting hormonal and metabolic profiles and achieving pregnancy in CC‐resistant PCOS patients.
No intra- or postoperative complications were detected in surgically treated patients with PCOS. Throughout the study, clomid and metformin were well tolerated generally and there was no treatment discontinuation because of drug-related adverse events
In view of the invasiveness and cost of surgery, it seems plausible that combined metformin–CC therapy should be tried first for young women with PCOS with previous CC-resistance before resorting to LOD, especially in developing countries where patients have financial constraints.
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