European Journal of Cardiovascular Medicine

Polycystic ovarian syndrome (PCOS) is one of the most prevalent endocrine disorders affecting reproductive-aged women, characterized by menstrual irregularity, anovulation, hyperandrogenism, and polycystic ovaries. PCOS affects approximately 6–10% of women globally, significantly impacting fertility and overall quality of life. The pathophysiology of PCOS involves complex interactions between genetic predispositions, hormonal dysregulation, and environmental factors, ultimately leading to ovarian dysfunction and infertility(1,2).

Clomiphene citrate remains the first-line pharmacological treatment to induce ovulation in PCOS. However, approximately 20–30% of patients are resistant to clomiphene therapy, necessitating alternative treatment option. Among these alternatives, laparoscopic ovarian drilling has emerged as an effective surgical option. Laparoscopic ovarian drilling involves making punctures in the ovarian cortex using electrocautery or laser to reduce ovarian androgen production, normalize luteinizing hormone (LH) secretion, and improve ovulatory function.

Despite its recognized effectiveness, concerns have been raised regarding the potential adverse effect of drilling on ovarian reserve. Ovarian reserve, typically assessed using anti-Mullerian hormone (AMH) and antral follicle count (AFC), reflects the remaining reproductive lifespan and fertility potential of a woman. Previous studies reported reductions in ovarian reserve following ovarian drilling, indicating a trade-off between short-term fertility benefits and potential long-term fertility risks. Therefore, understanding the exact impact of ovarian drilling  on ovarian reserve and hormonal regulation is crucial for guiding clinical decision-making, especially for women wishing to preserve fertility potential(3-8).

This study aimed to prospectively evaluate the impact of laparoscopic ovarian drilling on ovarian reserve, hormonal profile, ovulatory function, and menstrual regularity in women diagnosed with PCOS who were resistant to clomiphene citrate therapy. Our findings may help clinicians and patients better balance immediate reproductive benefits against potential long-term fertility implications when selecting appropriate interventions for PCOS-related infertility.

Study Design and Participants: This prospective study included 48 women diagnosed with polycystic ovarian syndrome (PCOS), who were resistant to clomiphene citrate therapy. The participants were recruited from a tertiary care hospital and provided informed consent for participation in the study. The study aimed to evaluate the effects of laparoscopic ovarian drilling on ovarian reserve markers and hormonal changes in women with PCOS. Inclusion criteria required participants to have been diagnosed with PCOS according to the Rotterdam criteria and to have failed clomiphene citrate therapy. Women with other causes of anovulation, those who had undergone previous ovarian surgery, or those with concurrent endocrine disorders were excluded from the study.

At baseline, demographic data, including age, body mass index (BMI), and the presence of menstrual irregularities (oligomenorrhea or amenorrhea), were collected. Hormonal assays were performed to measure baseline levels of Anti-Mullerian Hormone (AMH), luteinizing hormone (LH), follicle-stimulating hormone (FSH), and testosterone. Blood samples were drawn in the early follicular phase of the menstrual cycle to ensure accurate hormonal measurement.

The participants underwent laparoscopic ovarian drilling as a treatment to improve ovulatory function. The procedure was performed under general anesthesia, and a standard laparoscopic technique was used. Bilateral ovarian drilling was carried out using electrocautery or a diathermy needle to create multiple small punctures (4–8 punctures) in each ovary. The objective of this procedure was to reduce androgen production and restore normal hormonal balance by damaging the ovarian stroma and improving follicular development.

Hormonal assays were performed at three time points: baseline, 3 months after ovarian drilling, and 6 months after ovarian drilling. AMH, LH, FSH, and testosterone levels were measured using chemiluminescent immunoassays (CLIA). All participants were monitored for hormonal changes at the follow-up points to assess the impact of the procedure on ovarian function.

Ovulation was monitored by tracking serum progesterone levels and ultrasound follicular monitoring. Spontaneous ovulation was confirmed by elevated progesterone levels, indicating luteal phase activity. Menstrual regularity was evaluated by tracking the occurrence of menstrual cycles within 6 months after ovarian drilling. The resolution of oligomenorrhea and amenorrhea was defined as the return to regular menstrual cycles.

Statistical Analysis:

Statistical analysis was performed using SPSS software (version X.X). Descriptive statistics were used to summarize demographic and baseline characteristics. Paired t-tests or Wilcoxon signed-rank tests were used to compare the hormonal levels at baseline, 3 months, and 6 months post ovarian drilling. A p-value of <0.05 was considered statistically significant for all analyses.

The study was approved by the institutional review board and conducted in accordance with the ethical standards outlined in the Declaration of Helsinki.

1. Demographic Baseline Characteristics of Participants: A total of 48 women diagnosed with polycystic ovarian syndrome (PCOS) participated in the prospective study. The demographic characteristics of the participants at baseline are presented in Table 1. All participants were resistant to clomiphene citrate therapy before undergoing laparoscopic ovarian drilling.

Table 1: Demographic Baseline Characteristics of Participants

2. Hormonal Changes Post Laparoscopic Ovarian Drilling: After undergoing laparoscopic ovarian drilling, significant hormonal changes were observed in the participants. The changes in AMH, LH, FSH, and Testosterone are presented in Table

Table 2: Hormonal Changes Post laparoscopic ovarian drilling

• AMH (Anti-Mullerian Hormone): There was a significant decrease in AMH levels after laparoscopic ovarian drilling. At 3 months, AMH levels decreased by 16%, and by 6 months, the reduction was 25%.
• LH (Luteinizing Hormone): LH levels showed a marked decrease, with a 28% reduction at 3 months and a 35% reduction at 6 months, indicating a normalization of LH levels.
• FSH (Follicle-Stimulating Hormone): FSH levels remained largely stable, with a slight 1% increase at 3 months and a 2% increase at 6 months post laparoscopic ovarian drilling.
• Testosterone levels significantly decreased, with a 30% reduction at 3 months and a 33% reduction at 6 months post-surgery, consistent with the reduction in hyperandrogenism in PCOS patients.

3. Menstrual and Ovulatory Outcomes: A significant 78% of patients experienced spontaneous ovulation after ovarian drlling, reflecting the success of the procedure in restoring ovulatory function. By 6 months after ovarian drilling , 72% of participants returned to regular menstrual cycles, with marked improvements in the resolution of oligomenorrhea and amenorrhea.

This study aimed to evaluate the effects of laparoscopic ovarian drilling on ovarian reserve and hormonal changes in women with polycystic ovarian syndrome. Our findings demonstrate that while ovarian drilling leads to significant hormonal improvements and increased ovulation rates, it also results in a decrease in ovarian reserve markers. The hormonal changes observed in this study align with the therapeutic goals of ovarian drilling, but the associated reduction in ovarian reserve requires careful consideration in terms of long-term fertility preservation (9,10).

The decrease in Anti-Mullerian Hormone levels observed in the participants is consistent with the expected outcomes following ovarian drilling. AMH is a key marker of ovarian reserve, and a 25% reduction in AMH by 6 months post-surgery indicates a loss of follicles, a common consequence of the ovarian tissue destruction caused by ovarian drilling. This reduction in ovarian reserve, reflected by both AMH and Antral Follicle Count (AFC), is a well-documented side effect of ovarian drilling,  though it improves ovulatory function and fertility outcomes in the short term .

While laparoscopic ovarian drilling is a successful short-term intervention for women with clomiphene citrate resistant PCOS, it should be noted that the reduction in ovarian reserve could be a concern for women who wish to delay pregnancy or who may want to preserve their fertility. The decrease in ovarian reserve markers, although expected, highlights the need for patients to carefully weigh the risks and benefits of laparoscopic ovarian drilling in consultation with their healthcare providers (11,12).

A major objective of ovarian drilling is the normalization of the hormonal imbalance typically seen in women with PCOS, including the high LH/FSH ratio and hyperandrogenism. The decrease in LH levels observed in this study supports the effectiveness of ovarian drilling in restoring this hormonal imbalance. The reduction in LH levels by 28% at 3 months and 35% at 6 months aligns with the procedure's goal of reducing excess LH production, which is a key factor in anovulation and menstrual irregularities in PCOS patients.

The significant reduction in testosterone levels, which decreased by 30% at 3 months and 33% at 6 months, further reflects the positive impact of ovarian drilling on hyperandrogenism, a characteristic feature of PCOS that leads to symptoms such as hirsutism and acne. By reducing testosterone levels, ovarian drilling not only improves fertility outcomes but also alleviates some of the physical symptoms associated with PCOS (13,14).

On the other hand, FSH levels remained stable, with only minor increases (1% at 3 months and 2% at 6 months). This is consistent with previous research showing that ovarian drilling primarily affects LH and testosterone, with FSH levels largely unaffected. The slight increase in FSH likely reflects the normalization of the LH/FSH ratio, which is crucial for the stimulation of ovulation.

The findings related to ovulation and menstrual regularity highlight the efficacy of ovarian drilling in improving fertility outcomes in women with PCOS. A remarkable 78% of patients in this study experienced spontaneous ovulation after ovarian drilling, demonstrating the procedure's effectiveness in restoring ovulatory function. This high ovulation rate is consistent with previous studies that have shown significant improvements in ovulation rates following ovarian drilling.

Furthermore, 72% of participants returned to regular menstrual cycles by 6 months after vovarian drilling, suggesting that ovarian drilling is also effective in resolving oligomenorrhea and amenorrhea, two common menstrual disturbances in PCOS. These findings further support the use of ovarian drilling as an effective treatment for restoring regular menstrual cycles and improving fertility outcomes in women with PCOS who have failed other pharmacological treatments (15,16).

Our results align with those of previous studies, which have demonstrated that laparoscopic ovarian drilling is effective in improving ovulation and fertility rates in women with PCOS. Bordewijk et al. (2020) reported that laparoscopic ovarian drilling significantly improves ovulation in women with PCOS, but also noted a reduction in ovarian reserve markers post-surgery. Similarly, Mercorio et al. (2022) found that while laparoscopic ovarian drilling reduces testosterone levels and improves menstrual regularity, it also leads to a reduction in ovarian reserve, confirming the findings of the present study (17) .

While previous research supports the efficacy of laparoscopic ovarian drilling in restoring fertility in the short term, it also underscores the need for careful consideration of the risks associated with the procedure, especially for women who may wish to preserve their ovarian reserve for future fertility (18,19).

This study has several limitations. The relatively small sample size of 48 participants may limit the generalizability of the results, and larger studies would provide more robust evidence. Additionally, the 6-month follow-up may not be sufficient to fully evaluate the long-term effects of laparoscopic ovarian drilling on ovarian reserve and fertility outcomes. Longer-term follow-up is necessary to assess the sustained impact of the procedure on reproductive function, particularly in women who wish to delay pregnancy.

Moreover, the absence of a control group limits the ability to compare the outcomes of laparoscopic ovarian drilling with those of other treatments, such as clomiphene citrate or gonadotropin therapy. Future studies with randomized controlled trials and longer follow-up periods would help clarify the long-term benefits and risks of laparoscopic ovarian drilling compared to other treatment options.

In conclusion, laparoscopic ovarian drilling is a highly effective treatment for ovulation induction and menstrual regularity in women with polycystic ovarian syndrome. The procedure significantly reduces testosterone and LH levels, while improving ovulation and menstrual cycles, leading to better fertility outcomes. However, the reduction in ovarian reserve, as indicated by decreased AMH and AFC, remains a concern, particularly for women who wish to preserve their fertility for future pregnancies. Given these considerations, laparoscopic ovarian drilling should be considered as a short-term solution for women with clomiphene resistant PCOS, with careful counseling regarding the risks of reduced ovarian reserve and the long-term fertility implications.

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