Medical vs. surgical treatment for clomiphene citrate-resistant women with polycystic ovary syndrome

Abstract

This study was conducted to evaluate the efficacy of metformin compared with ovarian drilling in the treatment of clomiphene citrate (CC) resistant women with polycystic ovary syndrome. A total of 161 infertile, CC-resistant women with PCOS aged 22-34 years (mean 25.5 +/- 4.4) were evaluated prospectively during the period between January 2000 and December 2001. Patients were allocated into two groups; group 1 includes 64 women who received metformin, 850 mg twice daily throughout the cycle, and group 2 which includes 97 women who underwent laparoscopic ovarian drilling. If spontaneous ovulation or pregnancy was not achieved within 3 months after treatment, CC was added with increments of 50 mg (up to 150 mg/day) for both groups. Clinical and menstrual characteristics in addition to the hormonal profile were evaluated before and after the treatment. There were no significant differences between the two groups in terms of age, body weight, BMI, duration of infertility and serum hormone levels (androgens, gonadotrophins, insulin) before starting the treatment. A significant improvement in the regularity of menstrual cycles (P < 0.05) and a significant reduction in the serum levels of testosterone(P<0.01), androstenedione (P<0.01), DHEAS (P <0.05), LH (P<0.01) and LH:FSH ratio (P<0.05) were noted after the treatment. There were no significant differences between the metformin group compared with the drilling group in the rates of ovulation (79.7% vs. 83.5%) and pregnancy (64.1% vs. 59.8%). It is concluded that CC-resistant patients with polycystic ovary syndrome can be treated effectively either by metformin or by laparoscopic ovarian drilling. Menstrual cycle pattern and the rates of ovulation and pregnancy are improved significantly, due most probably to the significant decrease in the levels of androgens and luteinising hormone.

High BMI and Insulin Resistance Are Risk Factors for Spontaneous Abortion in Patients With Polycystic Ovary Syndrome Undergoing Assisted Reproductive Treatment: A Systematic Review and Meta-Analysis

“…It is worth noting that the use of metformin before pregnancy may reduce the abortion rate (67,68), but the evidence is insufficient. Other studies seemed to believe that the use of metformin has no significant impact on the abortion rate (69)(70)(71)(72). Regarding the role of metformin in ovulation in infertile PCOS patients in the guidelines of the Practice Committee of the American Society for Reproductive Medicine, it has been pointed out that there is fair evidence that metformin used while attempting pregnancy and stopped at the initiation of pregnancy does not affect the rate of miscarriage (Grade B) and that there is insufficient evidence to recommend metformin during pregnancy to reduce the chance of miscarriage (Grade C) (73).…”

Laparoscopic ovarian drilling: An alternative but not the ultimate in the management of polycystic ovary syndrome

“…Improvement in hormonal profiles does not translate into a comparable improvement in insulin sensitivity or reduction in risk of gestational diabetes mellitus (GDM). [ 10 14 61 78 ] Although patients with metabolic syndrome should not be precluded from LOD, adjuvant therapy with insulin sensitizers should be considered. [ 61 ] Few studies have demonstrated no impact on metabolic parameters.…”

“…[ 10 14 61 78 ] Although patients with metabolic syndrome should not be precluded from LOD, adjuvant therapy with insulin sensitizers should be considered. [ 61 ] Few studies have demonstrated no impact on metabolic parameters. [ 79 80 81 ] Although, lower ovulation and pregnancy rates are reported in obese PCOS compared to lean counterparts,[ 48 49 50 57 ] one prospective study contradicts this.…”

“…Trials comparing metformin with LOD in CC-resistant PCOS have shown variable results. [ 61 78 94 ] with some favoring LOD,[ 94 ] some favoring metformin[ 78 ] and others reporting equal efficacy. [ 61 95 ] Some studies have demonstrated higher ovulation and pregnancy rates with LOD but better attenuation of IR as well as lower GDM rates in those who conceived with metformin.…”

“…[ 61 78 94 ] with some favoring LOD,[ 94 ] some favoring metformin[ 78 ] and others reporting equal efficacy. [ 61 95 ] Some studies have demonstrated higher ovulation and pregnancy rates with LOD but better attenuation of IR as well as lower GDM rates in those who conceived with metformin. [ 70 78 94 ] Even combined treatment with metformin, and CC is equally efficacious as LOD.…”