الفهرس 
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Abstract
Polycystic ovary syndrome “PCOS” is a complex endocrino-metabolic disorder characterized by hyperandrogenism, ovulatory dysfunction, and polycystic ovarian morphologic features. Polycystic ovary syndrome (PCOS) accounts for the vast majority of anovulatory symptoms and hyperandrogenism in women. It has life-long implications, with increased risk for infertility, metabolic syndrome, and type 2 diabetes mellitus, and possibly for cardiovascular disease and endometrial carcinoma.In this study we focused on anovulation as a result of PCOS and the effect of metformin in combination with letrozole on ovulation and reproductive outcome in clomiphene resistant PCOS women. Eighty Women with PCOS and clomiphene citrate resistance were recruited in the beginning of the study after taking in consideration the inclusion and exclusion criterion. Exclusion of other causes of infertility was done by complete medical history,physical examination,basal hormonal essays,hystrosalpingography and husband’s semen analysis. The participants were divided randomly into 2 groups,group (1) that received letrozole plus metformin, and group (2) that received letrozole only.In both groups,5 mg of letrozole oral tablets were administered only for 5 days from day 3 of menses each month of spontaneous or induced bleeding.In group (1) only,metformin was started from the first day with a dose of 500 mg daily for 1 week to avoid nausea and vomiting then the dosage increased to 1500 mg daily and continued.
All participants were followed up for 6 cycles through transvaginal ultrasonography every other day from day 12 of the cycle to assess follicular growth,number of follicles and endometrial thickness until at least one follicle reach 18 mm or more or reaching day 18.Atotal of 10.000 IU of HCG were administered to those in whom at least one ovarian follicle reached 18 mm or more in size with advice to have intercourse every other day for one week starting 24-36 h after receiving HCG with luteal support for 2 weeks or continued if pregnancy test is positive. Two hundred and six cycles in group 1 and two hundred and twenty four cycles in group 2 were studied.There were no statistically significant differences between the two groups with regard to age,BMI,duration of marriage,parity,previous abortions,type of infertility and duration of infertility. There were no statistically significant differences between the two groups regarding the number of follicles in each cycle.Regarding follicular growth there was non significant increase in group 1 than group 2.The number of follicles reaching ≥ 18 mm in which HCG was administered was significantly more in group 1 in the 1st cycle only with no other significant difference in the following cycles between the two groups.Moreover there was no significant differences between both groups regarding ovulation.Eight women got pregnant in group 1,while in group 2 only 5 women achieved pregnancy in group 2 with no statistically significant differences between both groups. The results may not satisfy the assumption of achieving ovulation and consequent pregnancy with metformine.Perhaps with a longer period of treatment or larger sample size,it could overcome that conflict and come up with different results.To our knowledge no studies yet compared the effects of combined letrozole-metformin with letrozole only in clomiphene resistant PCOS women. Finally we could conclude that our findings suggest that combined letrozole-metformin and letrozole alone are equally effective for induction of ovulation and achieving pregnancy in patients with clomiphene resistant PCOS.Metformin has no additional effect on ovulation or pregnancy rates.