Unilateral or bilateral laparoscopic ovarian drilling in polycystic ovary syndrome: a meta-analysis of randomized trials

Facilitation of Ovarian Response by Mechanical Force-Latest Insight on Fertility Improvement in Women with Poor Ovarian Response or Primary Ovarian Insufficiency

The decline in fertility in aging women, especially those with poor ovarian response (POR) or primary ovarian insufficiency (POI), is a major concern for modern IVF centers. Fertility treatments have traditionally relied on gonadotropin- and steroid-hormone-based IVF practices, but these methods have limitations, especially for women with aging ovaries. Researchers have been motivated to explore alternative approaches. Ovarian aging is a complicated process, and the deterioration of oocytes, follicular cells, the extracellular matrix (ECM), and the stromal compartment can all contribute to declining fertility. Adjunct interventions that involve the use of hormones, steroids, and cofactors and gamete engineering are two major research areas aimed to improve fertility in aging women. Additionally, mechanical procedures including the In Vitro Activation (IVA) procedure, which combines pharmacological activators and fragmentation of ovarian strips, and the Whole Ovary Laparoscopic Incision (WOLI) procedure that solely relies on mechanical manipulation in vivo have shown promising results in improving follicle growth and fertility in women with POR and POI. Advances in the use of mechanical procedures have brought exciting opportunities to improve fertility outcomes in aging women with POR or POI. While the lack of a comprehensive understanding of the molecular mechanisms that lead to fertility decline in aging women remains a major challenge for further improvement of mechanical-manipulation-based approaches, recent progress has provided a better view of how these procedures promote folliculogenesis in the fibrotic and avascular aging ovaries. In this review, we first provide a brief overview of the potential mechanisms that contribute to ovarian aging in POI and POR patients, followed by a discussion of measures that aim to improve ovarian folliculogenesis in aging women. At last, we discuss the likely mechanisms that contribute to the outcomes of IVA and WOLI procedures and potential future directions.

The effect of laparoscopic ovarian drilling in patients with anovulatory polycystic ovary syndrome and high serum levels of anti-Müllerian hormone

Female infertility is often associated with anovulatory polycystic ovary syndrome (PCOS), characterized by high serum levels of anti-Müllerian hormone (AMH). Laparoscopic ovarian drilling (LOD) is commonly used to treat PCOS, especially when drug interventions have failed. This study aimed to evaluate the response to LOD intervention in women with PCOS by assessing AMH serum levels and their ability to restore normal physiological menstrual cycle and achieve conception. Seventy-five infertile women (24-41 years old) with body mass index (BMI) ranging from 19.6-35kg/m2 were included in the study. Among them, 57 had primary infertility, and 18 from secondary infertility, with an average duration of 8.6±4.4 years. Baseline levels of follicle-stimulating hormone (FSH), luteinizing hormone (LH), and AMH were measured, and post-LOD levels of LH and AMH were evaluated. Menstrual cycle regularity was evaluated before and after LOD. Baseline FSH serum level before LOD was 5.2-1.6IU/L. Following LOD, the serum levels of LH and AMH significantly decreased from 14.3±4.1 to 7.8±2.8 IU/L and from 13.7±5.9 to 7.7±3.9 IU/L, respectively (p<0.05). LOD significantly (p<0.05) decreased the menstrual cycles irregularity, such as oligomenorrhea and amenorrhea, from 55 (73.3%) to 22 (29.3%) women and from 2 (2.7%) to 0 (0%) women respectively. Moreover, regular menstrual cycles significantly (p<0.05) increased from 18 (24%) to 53 (70.7%) women. Importantly, 68% of LOD-treated women showed a significant increase in pregnancy rates, with 52.9%, 35.3%, and 11.8% achieving pregnancy within 3, 6, and 9 months after LOD, respectively (p<0.05). Moreover, spontaneous ovulation was observed in 7/75 (9.3%) women within 90 days after LOD, and 71.4% achieved pregnancy. These findings highlight the success of laparoscopic ovarian drilling as an intervention for PCOS, with AMH serving as a reliable test to assess the response to LOD treatment.

Transvaginal needle versus laparoscopic ovarian drilling in hormonal profile and pregnancy outcomes of polycystic ovary syndrome: a systematic review and meta-analysis

BACKGROUND

Polycystic ovary syndrome (PCOS) is a prevalent hormonal disorder distinguished by a persistent absence of ovulation. Ovarian drilling is a recognized therapeutic approach for PCOS patients who are unresponsive to medication and can be performed through invasive laparoscopic access or less-invasive transvaginal access. The aim of this systematic review and meta-analysis was to assess the efficacy of transvaginal ultrasound -guided ovarian needle drilling with conventional laparoscopic ovarian drilling (LOD) in patients with PCOS.

METHODS

PUBMED, Scopus, and Cochrane databases were systematically searched for eligible randomized controlled trials (RCTs) from articles published from inception to January 2023. We include RCTs of PCOS that compared transvaginal ovarian drilling and LOD and reported on ovulation and pregnancy rates as the main outcome variable. We evaluated study quality using the Cochrane Risk of bias 2 tool. A random-effects meta-analysis was performed and the certainty of the evidence was assessed according to the GRADE approach. We registered the protocol prospectively in PROSPERO (CRD42023397481).

RESULTS

Six RCTs including 899 women with PCOS met the inclusion criteria. LOD was found to significantly reduce anti-Mullerian hormone (AMH) (SMD: -0.22; 95% CI: -0.38, -0.05; I² = 39.85%) and antral follicle count (AFC) (SMD: -1.22; 95% CI: -2.26, -0.19; I² = 97.55%) compared to transvaginal ovarian drilling. Our findings also indicated that LOD significantly increased the ovulation rate by 25% compared to transvaginal ovarian drilling (RR: 1.25; 95% CI: 1.02, 1.54; I2 = 64.58%). However, we found no significant difference between the two groups in terms of follicle stimulating hormone (SMD: 0.04; 95% CI: -0.26, 0.33; I2 = 61.53%), luteinizing hormone (SMD: -0.07; 95% CI: -0.90, 0.77; I2 = 94.92%), and pregnancy rate (RR: 1.37; 95% CI: 0.94, 1.98; I2 = 50.49%).

CONCLUSION

LOD significantly lowers circulating AMH and AFC and significantly increases ovulation rate in PCOS patients compared to transvaginal ovarian drilling. As transvaginal ovarian drillingremains a less-invasive, more cost-effective, and simpler alternative, further studies are warranted to compare these two techniques in large cohorts, with a particular focus on ovarian reserve and pregnancy outcomes.

Anti-mullerian hormone levels before and after ovarian drilling in polycystic ovary syndrome: has this an effect on fertility?

BACKGROUND

Polycystic ovary syndrome (PCOS) is the most common endocrine, metabolic, and multi-causal disorder in the reproductive period with a possible genetic origin. Women with PCOS are characterized by oligo-ovulation, clinical or biochemical hyperandrogenism, and polycystic ovaries. Women with PCOS have an increased number of antral follicles. Anti-Mullerian hormone (AMH), a dimeric glycoprotein produced from the granulosa cells of the pre-antral and antral follicles, is elevated in PCOS. AMH has been implicated in two stages of follicle dysfunction that lead to the development of PCOS. The level of AMH decreases following ovarian drilling in patients with PCOS. The present study compared the level of AMH before and after Laparoscopic ovarian drilling (LOD) in patients with PCOS and its effect on fertility.

MATERIALS AND METHODS

This cohort study was carried out on 84 women with PCOS who underwent LOD in Akbarabadi Hospital in Tehran in 2020. Demographic characteristics, AMH, and estradiol levels were determined before surgery and compared with the amount one week after surgery. The effect of AMH level on pregnancy rate was also evaluated.

RESULTS

The mean age of the patients was 29.01 ± 4.01 years. The mean Body Mass Index (BMI) of the patients was 26.33 ± 4.14 kg/m². The results showed that the mean AMH level decreased significantly after ovarian drilling (P-value < 0.001). Menstrual cycle distribution was significantly different before and after LOD (P < 0.001). None of the variables had an effect on the pregnancy (P-value > 0.05). Oligomenorrhea in the previous menstrual period might cause AMH levels to increase by 3.826 units after LOD (P-value < 0.001).

CONCLUSION

Measuring serum AMH concentration before treatment can be a useful tool to predict LOD outcomes. This can help in selecting the patient for treatment.

TRIAL REGISTRATION

The project was found to be under the ethical principles and the national norms and standards for conducting research in Iran with the approval ID and issue date of IR.IUMS.FMD.REC.1397.206 and 2018.08.26 respectively, which has been registered with the research project number 2766 in the Vice-Chancellor for Research and Technology Development of Iran University of Medical Sciences, School of Medicine, Tehran, Iran. URL: https://ethics.

RESEARCH

ac.ir/EthicsProposalView.php?id=34791 .

The current and future state of surgery in reproductive endocrinology

PURPOSE OF REVIEW

The last decade has witnessed a radical change in the field of reproductive surgery. The increasing success of in-vitro fertilization (IVF) has caused a huge shift in emphasis with many downstream consequences. This review outlines the changes and provides insight into the future of reproductive surgery.

RECENT FINDINGS

With compelling evidence that IVF overcomes the detrimental effects of endometriosis on infertility and with two new oral medications available for management of endometriosis, momentum is shifting towards nonsurgical management of endometriosis. There is increasing recognition that except for submucous myomas, other myomas are unlikely to affect fertility and miscarriage. This, in addition to many emerging alternative modalities for management of myomas (oral GnRH antagonists, radiofrequency ablation), is likely to further decrease classic myomectomies but provide alternative, less invasive options. Caesarean scar defects have been recognized as having significant reproductive consequences and surgical management has become the standard of care. Fallopian tubes are now implicated in development of ovarian cancer, and as a result, salpingectomies are being performed in lieu of tubal ligations. Tubal anastomosis will soon become a historical surgery. Division of uterine septum remains controversial, and a clear answer will remain elusive. Uterine transplant is the single most significant advance in reproductive surgery in the past century.

SUMMARY

Reproductive surgery is evolving with the times. Although some surgical techniques will become historical, others will become mainstream.

[Clinical guidelines «Polycystic Ovary Syndrome»]

Polycystic ovary syndrome (PCOS) is a polygenic endocrine disorder caused by both genetic and epigenetic factors. Depending on the period of a woman's life, the clinical picture, diagnosis, and treatment tactics of the disease are different. PCOS has a complex of reproductive, metabolic and psychological characteristics. The target audience of these clinical recommendations are obstetrician-gynecologists, endocrinologists, general practitioners, general practitioners. In these clinical guidelines, all information is ranked according to the level of persuasiveness of recommendations and the reliability of evidence, depending on the number and quality of studies on this issue.

Ovarian Fragmentation and AKT Stimulation for Expansion of Fertile Lifespan

Since the first baby was born after in vitro fertilization, the female infertility treatment has been well-developed, yielding successful outcomes. However, successful pregnancies for patients with premature ovarian insufficiency and diminished ovarian reserve are still difficult and diverse therapies have been suggested to improve the chances to have their genetically linked offspring. Recent studies demonstrated that the activation Akt pathway by using a phosphatase and tensin homolog enzyme inhibitor and a phosphatidylinositol-3 kinase stimulator can activate dormant primordial follicles in both mice and human ovaries. Subsequent researches suggested that the disruption of Hippo signaling pathway by ovarian fragmentation increased the expression of downstream growth factors and secondary follicle growth. Based on the combination of ovarian fragmentation and Akt stimulation, the in vitro activation (IVA) approach has resulted in successful follicle growth and live births in premature ovarian insufficiency patients. The approach with disruption of Hippo signaling only was also shown to be effective for treating poor ovarian responders with diminishing ovarian reserve, including advanced age women and cancer patients undergoing sterilizing treatments. This review aims to summarize the effectiveness of ovarian fragmentation and Akt stimulation on follicle growth and the potential of IVA in extending female fertile lifespan.

Infertility management in women with polycystic ovary syndrome: a review

Polycystic ovary syndrome is the most common endocrine disorder in women and a major cause of anovulatory infertility. Various medical options are used, alone or in combination, to treat subfertility associated with polycystic ovary syndrome. This narrative review was conducted to provide an update and summarize the available evidence on the management of polycystic ovary syndrome related infertility. A wide literature search was performed and preferably randomized controlled trials and systematic reviews were included. Management is often centered on lifestyle changes. Pharmacological ovulation induction is the next step, with recommended use of letrozole, clomiphene citrate or gonadotropins. When it fails, assisted reproductive technologies or laparoscopic ovarian drilling are frequently advised. Combination treatment with metformin is often recommended. More recent alternative and adjunctive treatments have been suggested, like inositol, vitamin D, bariatric surgery and acupuncture, but further research is needed for recommendation.

Comparison of the effects of bilateral and unilateral laparoscopic ovarian drilling on pregnancy rates in infertile patients with polycystic ovary syndrome

AIM

This study aims to investigate the effects of unilateral and bilateral laparoscopic ovarian drilling (LOD) on pregnancy rates in patients with clomiphene citrate (CC) resistant infertile polycystic ovary syndrome.

METHODS

This prospective cohort study included 75 patients who were admitted to the Department of Obstetrics and Gynecology of the Antalya Training and Research Hospital between July 2016 and December 2017 and underwent LOD operation. Among these patients, 37 underwent unilateral laparoscopic ovarian drilling (ULOD) and 38 underwent bilateral laparoscopic ovarian drilling (BLOD). The drilling procedure was carried out using the following equation: Number of punctures (np) = 60 J/cm³ /30 watt × 4 s by selecting the larger ovary in the patients who underwent ULOD and by taking the ovarian volume of each ovary in the BLOD group.

RESULTS

During the 1-year follow-up, 20 of the ULOD patients (54.1%) and 13 of the BLOD patients (34.2%) were observed to be pregnant. Although a higher number of pregnancies were obtained in the ULOD group, no statistically significant difference was found between the two groups (P = 0.083). The pregnancies occurred more in the first 6 months during the postoperative follow-ups of the patients. A total of 14 (70%) of the 20 pregnancies in the ULOD group and 9 (69.2%) of the 13 pregnancies in the BLOD group occurred in the first 6 months.

CONCLUSION

ULOD with respect to a larger ovarian volume should be preferred to BLOD for CC-resistant PCOS patients because of the high pregnancy rates and fewer potential side effects.

Molecular Mechanisms of Laparoscopic Ovarian Drilling and Its Therapeutic Effects in Polycystic Ovary Syndrome

Polycystic ovary syndrome (PCOS) is a common endocrinopathy, characterized by chronic anovulation, hyperandrogenism, and multiple small subcapsular cystic follicles in the ovary during ultrasonography, and affects 5–10% of women of reproductive age. PCOS is frequently associated with insulin resistance (IR) accompanied by compensatory hyperinsulinemia and, therefore, presents an increased risk of type 2 diabetes mellitus (DM). The pathophysiology of PCOS is unclear, and many hypotheses have been proposed. Among these hypotheses, IR and hyperandrogenism may be the two key factors. The first line of treatment in PCOS includes lifestyle changes and body weight reduction. Achieving a 5–15% body weight reduction may improve IR and PCOS-associated hormonal abnormalities. For women who desire pregnancy, clomiphene citrate (CC) is the front-line treatment for ovulation induction. Twenty five percent of women may fail to ovulate spontaneously after three cycles of CC treatment, which is called CC-resistant PCOS. For CC-resistant PCOS women, there are many strategies to improve ovulation rate, including medical treatment and surgical approaches. Among the various surgical approaches, one particular surgical method, called laparoscopic ovarian drilling (LOD), has been proposed as an alternative treatment. LOD results in an overall spontaneous ovulation rate of 30–90% and final pregnancy rates of 13–88%. These benefits are more significant for women with CC-resistant PCOS. Although the intra- and post-operative complications and sequelae are always important, we believe that a better understanding of the pathophysiological changes and/or molecular mechanisms after LOD may provide a rationale for this procedure. LOD, mediated mainly by thermal effects, produces a series of morphological and biochemical changes. These changes include the formation of artificial holes in the very thick cortical wall, loosening of the dense and hard cortical wall, destruction of ovarian follicles with a subsequently decreased amount of theca and/or granulosa cells, destruction of ovarian stromal tissue with the subsequent development of transient but purulent and acute inflammatory reactions to initiate the immune response, and the continuing leakage or drainage of “toxic” follicular fluid in these immature and growth-ceased pre-antral follicles. All these factors contribute to decreasing local and systemic androgen levels, the following apoptosis process with these pre-antral follicles to atresia; the re-starting of normal follicular recruitment, development, and maturation, and finally, the normalization of the “hypothalamus–pituitary–ovary” axis and subsequent spontaneous ovulation. The detailed local and systematic changes in PCOS women after LOD are comprehensively reviewed in the current article.

Insulin Sensitizers for Improving the Endocrine and Metabolic Profile in Overweight Women With PCOS

OBJECTIVE

To evaluate the efficacy of insulin sensitizers on menstrual frequency, sex hormone, and metabolic parameters in overweight women with polycystic ovary syndrome (PCOS).

METHODS

We searched multiple databases from inception to September 2019 for randomized controlled trials. Network meta-analysis was conducted using multivariate random effects method.

RESULTS

Fourteen trials reporting on 619 women were included. Compared with metformin, metformin + thiazolidinediones (TZDs) was more superior in menstrual recovery (weighted mean difference [WMD] 3.68; 95% credibility interval [CrI], 1.65 to 8.20), metformin +  glucagon-like peptide-1 (GLP-1) receptor agonists was more effective in decreasing androstenedione (WMD -2.53; 95% CrI, -3.96 to -1.09), both metformin + GLP-1 receptor agonists (WMD 9.22; 95% CrI, 5.46 to 12.98) and metformin + TZDs (WMD 4.30; 95% CrI, 0.78 to 7.82) were more effective in increasing sex hormone-binding globulin (SHBG), while TZDs were less effective in decreasing body mass index (BMI) (WMD 1.69; 95% CrI, 0.72 to 2.66). Compared with GLP-1 receptor agonists, metformin + GLP-1 receptor agonists was associated with higher SHBG (WMD 7.80; 95% CrI, 4.75 to 10.85), lower free testosterone (WMD -1.77; 95% CrI, -3.25 to -0.29), lower androstenedione (WMD -2.70; 95% CrI, -3.91 to -1.50) and lower fasting blood glucose (WMD -0.41; 95% CrI, -0.73 to -0.08).

CONCLUSION

For overweight women with PCOS, both metformin combined with GLP-1 receptor agonists and metformin combined with TZDs appear superior to monotherapy in improving hyperandrogenemia. Metformin combined with TZDs could be particularly effective in promoting the recovery of menstruation. Metformin combined with GLP-1 receptor agonists has the additional advantage of improving fasting glucose when compared with GLP-1 receptor agonists alone. TZDs are inferior to metformin in decreasing BMI.

Variation of Laparoscopic Ovarian Drilling for Clomiphene Citrate-resistant Patients with Polycystic Ovary Syndrome and Infertility: A Meta-analysis

OBJECTIVE

To evaluate novel surgical variations of laparoscopic ovarian drilling (LOD) and compare with standard bilateral LOD.

DATA SOURCES

Electronic databases were searched, including Cochrane database, CENTRAL, Ovid MEDLINE, Embase, PsycINFO, PubMed, Virtual Health Library, OpenSIGLE, ClinicalTrials.gov, ISRCTN, and The Chinese Clinical Trial Register in February 2019.

METHODS OF STUDY SELECTION

Randomized controlled trials (RCTs) evaluating LOD for patients with clomiphene citrate-resistant polycystic ovary syndrome and infertility and reporting reproductive outcomes, surgical complications, serum indexes, menses resumption, and ultrasound results were included. Quality and risk of bias were evaluated by 2 authors, respectively.

TABULATION, INTEGRATION, AND RESULTS

A total of 20 RCTs with 1615 patients were included. Evaluation of the quality of evidence for each study was based on each study's limitations of 5 outcome domains described by the Grading of Recommendations, Assessment, Development, and Evaluation and found to be moderate to very low. Live births were only reported by 4 studies. Unilateral LOD did not differ with bilateral LOD in reproductive outcomes, such as pregnancy (p = .11, I² = 75%), ovulation (p = .08, I² = 0%), miscarriage (p = .61), and menstruation resumption (p = .06). There was insufficient evidence regarding efficacy and safety of novel methods of LOD, such as transvaginal hydrolaparoscopy (1 RCT) and micro-LOD (3 RCTs). Evidence regarding the suitable number of ovarian punctures, duration of drilling, and antimüllerian hormone or antral follicle numbers following LOD were inconclusive.

CONCLUSION

Unilateral LOD seems to be suitable replacement for conventional bilateral LOD for clomiphene citrate-resistant polycystic ovary syndrome, although more studies involving long-term reproductive efficacy, adverse events, and varying forms of LOD are warranted.

The impact of repetitive oocyte retrieval on the ovarian reserve: a retrospective cohort study

PURPOSE

To investigate a possible influence of repetitive micro-traumata on the ovaries in the course of oocyte retrieval during IVF/ICSI treatment on serum anti-Müllerian hormone (AMH) levels.

METHODS

The study included retrospectively collected data from women who underwent three or more consecutive IVF/ICSI treatments between 2007 and 2017. The primary endpoint of the study was to evaluate changes in serum AMH levels on cycle days 1-3 during the course of repetitive IVF/ICSI treatments.

RESULTS

A total of 125 patients were included in this study. Median AMH levels before the first, second and third IVF/ICSI cycles were 3.8 ng/mL (IQR 1.8-7.1), 3.3 ng/mL (IQR 1.8-6.1) and 3.0 ng/mL (IQR 1.6-5.3), respectively (p = n.s.). In patients who underwent IVF/ICSI due to polycystic ovary syndrome (PCOS), we found a significant decrease in AMH serum levels between the first [AMH 9.7 ng/mL (IQR 7.4-14.4)] and the third [AMH 5.3 ng/mL (IQR 3.3-10.4)] IVF/ICSI cycles (p = 0.026). When performing a generalized linear model, we found PCOS to be an independent predictor for serum AMH decrease during the course of three oocyte retrievals (p < 0.001).

CONCLUSIONS

When comparing the indications for IVF/ICSI, we observed a significant decrease in AMH serum levels after repetitive oocyte retrievals only in women with PCOS, while the decrease in AMH was not significant in patients with tubal factor, endometriosis, male factor and unexplained infertility. This finding leads us to hypothesize that repetitive micro-traumata on the ovarian cortex might diminish/normalize functional ovarian reserve in women with PCOS. Further prospective studies are highly warranted to allow firm conclusions.

Lean polycystic ovary syndrome (PCOS): an evidence-based practical approach

BACKGROUND

Polycystic ovary syndrome (PCOS) is a common endocrinopathy affecting women of reproductive age. Common features include menstrual irregularities, hyperandrogenism and polycystic ovarian morphology although the presentation can be heterogeneous. Insulin resistance is thought to be responsible for the hormonal and metabolic derangements observed. PCOS has two phenotypes, overweight/obese and lean, the latter being a much less common presentation of the syndrome.

AIMS

The aim of the present review is to summarise cardinal features, and to devise diagnostic and treatment algorithms for lean PCOS based on recent literature.

METHODS

We searched PubMed, EBSCOhost and Google Scholar using search terms such as 'lean polycystic ovary syndrome' OR 'lean polycystic ovarian syndrome' OR 'lean PCOS' OR 'lean polycystic ovary disease' OR 'lean polycystic ovarian disease' OR 'lean PCOD' OR 'hyperandrogenism' AND 'low BMI OR 'low body mass index' to identify potential articles to be included in the review. Citation searches were subsequently performed in order to find relevant literature.

RESULTS

Hormonal, metabolic and haematological profiles were altered in lean women with PCOS compared to healthy counterparts. However, the derangements were either comparable or less obvious compared to obese women with the syndrome. Insulin resistance seemed inherent in PCOS independent of obesity. Treatment options included weight maintenance, restoration of ovulation with insulin-sensitizers such as metformin, relief of symptoms such as hirsutism, acne and menstrual dysfunction, and assisted reproductive technologies in refractory cases, all of which showed promising results. The literature with evidence on lean PCOS is of low to moderate quality and there are still some uncertainties in the evidence base.

CONCLUSION

Carefully designed randomised controlled trials are required to confirm findings of previous studies in lean PCOS and to consolidate diagnostic and management algorithms proposed in this review. This paper will aid health professionals to improve their clinical approach in managing lean women with PCOS.

Changes in ovarian reserve and ovarian blood flow in patients with polycystic ovary syndrome following laparoscopic ovarian drilling

This prospective cohort study was conducted on 80 patients with clomiphene citrate (CC)-resistant polycystic ovary syndrome undergoing laparoscopic ovarian drilling (LOD). Pre- and post-LOD ovarian reserve parameters (anti-Mullerian hormone: AMH, ovarian volume: OV, and antral follicle count: AFC) and ovarian stromal blood flow indices (Vascularization index: VI, flow index: FI, and vascularization flow index: VFI) were measured to explore the effect of LOD and to find out the correlation between serum AMH and different clinical, hormonal, and ultrasonic variables. There was a highly significant reduction of the serum AMH (p < .001) after LOD with significant reduction in OV, AFC and vascular indices (VI, FI and VFI) of the right and left ovaries (p < .05). LOD significantly reduced ovarian reserve parameters (AMH, OV and AFC) and ovarian stromal blood flow indices (VI, FI and VFI) with no observed correlation between AMH levels and Doppler indices.