الفهرس يوجد فقط 14 صفحة متاحة للعرض العام
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المستخلص
Polycystic ovary syndrome, in its most typical form, the
association of hyperandrogenism and chronic anovulation- is
one of the common most endocrine disorders. The clinical and
biochemical features are heterogeneous, and there has been
much debate as to whether it represents a single disorder or
several. In recent years, it has become that the PCOS not only
is the most frequent of anovulation and of hirsutism, but is also
associated with a characteristic metabolic disturbance
(resistance to the action of insulin) that may have important
implications for long term health .
Although the exact etiology of PCOS is still debated,
studies conducted with family members of women with PCOS
have suggested that there is a genetic role in its pathogenesis.
In a study group of 15 prepubertal daughters of women with
PCOS, all but one were found to have PCO by ultrasound.
PCOS usually arises during puberty and is marked by
hyperinsulinemia and hyperandrogenism. Adolescents with
PCOS are at increased risk of developing health problems later
on in life such as diabetes, cardiovascular disease and
infertility.
Early diagnosis and treatment of PCOS in adolescent are
essential in assuring adulthood health and restoring self
esteem. Treatments for adolescent with PCOS include diet and
exercise, metformin and oral contraceptive pills. Each of these
options has been shown to be effective in improving certain
aspects of PCOS, and probably the best treatment plan
involves some combination of them.
The preferred treatment has been used is ovulation
induction with clomiphene citrate, with rates of ovulation
reported at 70% after first treatment. Women who did not
ovulate after clomiphene citrate treatment are described as
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clomiphene citrate resistant . Stein, Leventhal proposed wedge
resection of the ovaries as a treatment option for clomiphene
resistant PCOS patients. It was the only treatment for a long
time. This treatment was abandoned because of post operative
peri ovarian adhesions. With trends towards minimally
invasive endoscopic surgery different laparoscopic techniques
were developed in clomiphene citrate resistant PCOS women.
A revived surgical approach was LOD. In the past few years
different techniques (biopsy, cauterization, laser) were used.
LOD is a safe and cost effective procedure. A single
treatment results in unifollicular ovulation. No need for
continuous monitoring as seen with hormonal treatment. No
fear of multiple births and ovarian hyper stimulation.
Correction of hormonal levels prevents miscarriage. LOD
increases the sensitivity to gonadotropins in PCOS. Because of
the safety and ease of the procedure it can be used as the first
line of treatment in PCOS.
The success rates for LOD appear to be better in patients at
or near their ideal body weight, as opposed to those with
obesity. Over dozen studies have been published with success
rates for ovulation between 53 % and 92 %.
AMH which is produced by fetal sertoli cells, is
responsible for regression of mullerian ducts, the anlagen for
uterus and fallopian tubes, during male sex differentiation.
Ovarian granulose cells also secrete AMH from late in fetal
life. The patterns of expression of AMH and its type ІІ
receptor in the postnatal ovary indicate that AMH may play an
important role in ovarian folliculogenesis.
AMH levels correlate well with the number of antral
follicles measured by ultrasound and are believed to be the
best presentation of the gradual decline in reproductive
capacity among proven fertile women.
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To assess an individual’s ovarian reserve, early follicular
phase serum levels of FSH, E2 and inhibin B have been
measured. Inhibin B and E2 are produced by early antral
follicles in response to FSH, and contribute to the classical
feedback of the pituitary gonadal axis to suppress FSH
secretion. With the decline of the follicle pool, serum levels of
inhibin B and E2 decrease and subsequently serum FSH levels
rise.
Because these factors are part of a feedback system,
their serum levels are not independent of each other.
Furthermore, changes in serum levels of FSH, E2 and inhibin
B occur relatively late in the reproductive ageing process.
So Far, assessment of the number of antral follicles by
ultrasonography, the antral follicle count, best predicts the
quantitative aspect of ovarian reserve.
However, measurement of the AFC requires an
additional TVS examination during the early follicular phase.
Therefore, a serum marker that reflects the number of follicles
that have made the transition from the primordial follicle pool
into the growing follicle pool, and that is not controlled by
gonadotropins, would benefit both patients and clinicians. In
recent years, accumulated data indicate that AMH may fulfil
this role.
One of the advantages of the use of AMH as ovarian
reserve test over established markers like basal FSH, the
clomiphene citrate challenge test, and the antral follicle count
is its presumed menstrual cycle independence.
In current study, we aimed to assess the ovarian reserve by
AMH and TVS in women with PCOS undergoing LOD.
We choose 20 patients having age <40 years and having
the criteria of PCOS like irregular menstruation,
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hyperandrogenism and the typical ultrasonographic appearance
of bilateral polycystic ovaries. After full history and clinical
examination, we took a venous sample for AMH on the third
day of menstrual cycle, we performed TVS for them for
measuring AFC and ovarian volume and we recorded BMI on
the same day. At the end of menstruation we performed LOD
for them. After 3 months from the drilling another venous
sample was taken for AMH on the third day of menstrual cycle
, we determined AFC and ovarian volume using TVS and we
recorded BMI on the same day.
The results of our study showed that 50% of the studied
cases were above 25 years and 50 % were below 25 years. The
average volume was 5.57cm 2before LOD and decreased to be
5.40cm2 after but with no statistical significant difference in
between . The average AFC before LOD was 22.05 and
decreased to be 18.9 after with highly significant change. The
average AMH was 2.4IU before LOD and decreased to be
1.8IU after with highly statistical significant change. The
average E2 was 46 while TSH was 1.02 among the studied
cases. There was no statistical significant correlation could be
detected between AMH versus age and BMI whether before or
after LOD. There was a statistical significant positive
correlation between AMH and ovarian volume before and after
LOD. whereas, there was no statistical significant correlation
between AMH and E2, FSH, LH, TSH, AFC or prolactin
whether before LOD or after it.