الفهرس 
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Abstract
Polycystic ovarian syndrome (PCOS) is the most common cause of anovulatory infertility and responsible for 70% of infertility due to anovulation.
The line of treatment is usually clomiphene citrate and it induces ovulation in approximately 80% of patients although the pregnancy rate is only about 35 – 40 %.
If patients fail to respond in terms of ovulation to a dose of 150 mg\day, they are considered as clomiphene resistant.
Laparoscopic ovarian drilling has been widely established as an elective second line method of ovulation induction in CC- resistant PCOS patients with high ovulation (70-80 %) and pregnancy rate (60-80 %).
Advantages of LOD over gonadotrophin stimulation include less complication rate, less time need for cycle monitoring and the low risk of multiple pregnancies.
The surgical approach is not associated with ovarian hyprestimulation and can lead to consecutive ovulation without the need for further treatment.
However fixed thermal dosage may not achieve the optimum ovulation rates or even may retain disease manifestations in patients with large ovaries, tubo-ovarian adhesions and theoretical risk of premature ovarian failure (POF) following LOD may occur.
Therefore, the role of adjustment of thermal dosage based on ovarian volume to improve the reproductive outcome and to decrease tubo-ovarian adhesions and theoretical risk of premature ovarian failure (POF) following LOD has been studied recently.
In this study 120 PCOS patients resistant to clomiphene citrate were recruited from outpatient infertility clinic of maternity hospital of Al Minia University.
Complete history was taken as well as physical examination, trans-vaginal ultrasound and hormonal profile (serum FSH, LH, testosterone, progesterone, AMH, and prolactin) were done for all patients before drilling and after six months follow up.
Patients were randomly allocated into one of four groups:
• group I : unilateral drilling with fixed thermal dosage (600J/ovary) was done.
• group II : bilateral drilling with fixed thermal dosage (600J/ovary) was done.
• group III : unilateral drilling with adjusted thermal dosage based on ovarian volume (60J/cm3) was done.
• group IV : bilateral drilling with adjusted thermal dosage based on ovarian volume (60J/cm3) was done.
There was no statistical significant difference between the four groups as regard age, BMI, duration of infertility, abortions, menstrual pattern, hirsutism and hormonal profile.
In this study, all of the patients in the four groups had menstrual irregularities that have been improved after drilling with high significant difference between before and after drilling in the four groups (p value <0.001) but no significant difference in between the four groups after drilling.
Regarding hirsutism, there was significant decrease in the four groups after 6 months of drilling (p value = 0.031, 0.031, 0.022 and 0.031 respectively) but no significant difference in between the four groups.
The mean serum FSH level in the four groups before drilling was (5, 4.9, 4.7, and 5.2 IU/L) respectively and after drilling (5.4, 5.2, 5.1 and 5.5 IU/L) respectively with no significant difference between before and after drilling, also there was no significant difference in between four groups (p value > 0.05).
The mean serum LH level in the four groups before drilling was (6.8, 6.9, 6.6, and 7.8 IU/L) respectively and after drilling (4.7, 4.6, 4.2 and 5.1 IU/L) respectively with high significant difference between before and after drilling (p < 0.001), but there was no significant difference in between the four groups (p value > 0.05).
The mean serum testosterone level (T) in the four groups before drilling was; (2.6, 2.4, 2.4 and 2.3) respectively and after drilling (1.5, 1.6, 1.2 and 1.3) respectively with high significant difference between before and after drilling (p < 0.001), but there was no significant difference in between four groups (p value > 0.05).
As regard serum progesterone, the mean level in the four groups before drilling was; (2.03±0.4, 2.2±0.5, 1.9±0.4 and 2.07±0.4 ng/ml) respectively, and after drilling; (8.3±4.1, 8.1±3.6, 9.4±3.2 and 9.1±3.3 ng/ml) respectively which show significant increase after drilling in four groups (P <0.001). No statistical difference in between the four groups after drilling (p > 0.05).
The ovulation rate after drilling in the four groups respectively by transvaginal ultrasound was (66.7%, 70%, 83.3%, 80%) respectively, which was better in adjusted groups (unilateral and bilateral) than fixed groups but not statistically significant (p= 0.388).
The cumulative pregnancy rate after drilling after one year follow up in the four groups was 33.3% (10 patients), 30 %( 9 patients), 43.3% (13 patients) and 43.3% (13 patients) respectively ,which was better in adjusted groups (unilateral and bilateral) than fixed groups but not statistically significant ( p = 0.612).
The time needed to achieve pregnancy after drilling was in group I ( 2 -9 months) , in group II was ( 2- 7months ),in group III (2-10 months) and in group IV( 4-9 months) (p = 0.971) . There was no statistical difference between four groups as regard pregnancy rate and time needed to achieve pregnancy (p > 0.05).
Regarding ovarian reserve markers; the mean serum level of AMH in the four groups before drilling was (8.4, 8, 7.7 and 8.1 ng/ml) respectively which significantly decreased after drilling to reach (6.6, 5.9, 5.9 and 5.7 ng/ml) respectively, The mean AFC before drilling in the four groups was (15.1, 15.3, 16.2 and 15.8) respectively which also significantly decrease after drilling to became (11.5, 10.6, 12.1 and 11.6) respectively, this decrease in AMH and AFC between before and after is highly significant with (p =0.001), but there is no significant difference between the four groups in AMH level and AFC before and after drilling.