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Objective: To compare the effect of letrozole with combined metformin and clomiphene citrate (CC) for ovulation induction in CC-resistant women with polycystic ovary syndrome (PCOS). Design: A randomized controlled trial. Setting: University teaching hospital and a private practice setting. Patient(s): Two hundred fifty anovulatory women (582 cycles) with CC-resistant PCOS. Intervention(s): Patients received 2.5 mg of letrozole daily (123 patients, 285 cycles) or combined metformin–CC (127 patients, 297 cycles) for three treatment cycles. Main Outcome Measure(s): Ovulation rate, number of follicles, serum E2, serum P, endometrial thickness, pregnancy, and miscarriage rates. Result(s): Ovulation occurred in 185/285 cycles (64.9%) in the letrozole group versus 207/297 cycles (69.6%) in the combined metformin–CC group, without statistically significant difference. The total number of follicles was significantly more in the combined metformin–CC group (4.4 ± 0.4 vs. 6.8 ± 0.3). A nonsignificant increase in endometrial thickness on the day of hCG administration was observed in the letrozole group (9.5 ± 0.2 mm vs. 9.1 ± 0.1 mm). No statistically significant difference regarding the pregnancy rate (PR) was observed between both groups (14.7% vs. 14.4%). Conclusion(s): Letrozole and combined metformin–CC are equally effective for inducing ovulation and achieving pregnancy in patients with CC-resistant PCOS. [Copyright &y& Elsevier]

Orally active aromatase inhibitors (AIs) have gained attention for treatment of infertile women with endometriosis in whom aromatase p450 is aberrantly expressed. This review aimed to critically appraise and summarize the available evidence concerning the use of AIs for management of endometriosis-associated infertility. PubMed was searched to May 2015 with the following key words: endometriosis, infertility and aromatase. Priority was given for randomized controlled trials (RCTs) followed by other study designs. Main outcome measures were as follows: rates of clinical pregnancy, miscarriage and live birth as well as endocrine outcomes. Eighty-two abstracts were screened and six original articles were included. A RCT demonstrated that post-operative letrozole treatment did not improve spontaneous pregnancy rate. Another RCT reported no superiority of letrozole superovulation over clomiphene citrate (each combined with intrauterine insemination) in minimalmild endometriosis and previous laparoscopic treatment. Anastrozole significantly inhibited the growth of endometriotic cells and their estrogen production in culture. In assisted reproductive technology (ART) cycles, dual suppression (Agonist/anastrozole) was tested in a pilot study with a pregnancy rate of 45% however, high pregnancy loss (30%) occurred. A retrospective study showed that letrozole may improve endometrial receptivity in endometriotic patients undergoing in vitro fertilization (IVF). An opposite view from an in vitro study showed lower estradiol production and aromatase expression in cultured granulosa cells from endometriotic women undergoing IVF and marked reduction under letrozole. In conclusion, current evidence is limited. More trials are warranted to enhance our knowledge and provide a clear and unequivocal evidence to guide our clinical management of infertile women with endometriosis using AIs.

Objective: Abdominal wall adhesions at laparoscopy may predispose infertile patients to access-related injuries and increase the complexity of the procedure. We have observed concern from referring physicians regarding the safety of surgical laparoscopy in infertile patients who previously underwent surgery because of the risk of abdominal adhesions. To assess the risk of intraabdominal adhesions at laparoscopy, a retrospective cohort study was performed., Methods: All infertile patients who underwent a reproductive laparoscopic procedure in a 6-year period at our institution were included in this study. A chart review was performed to obtain demographic/surgical data and identify preoperative risk factors for intraabdominal adhesions. Operative videotapes were reviewed to determine the presence and location of adhesions. Standard statistical analyses were performed., Results: During the study period, 254 infertile patients underwent reproductive surgical laparoscopy, and videotapes on 164 (65%) were available for review. A total of 88 patients (54%) were identified with preoperative risk factors for intraabdominal adhesions (group 1), while 76 (46%) had no risk factors (group 2). The relative risk of adhesions was 1.34 (95% CI, range 0.89 to 2.01, P=0.18) when risk factors were identified. There were no differences in the groups regarding patient age, operative time, access technique, conversion to open surgery, or complications. Estimated blood loss was significantly higher in group 2, likely due to the predominance of laparoscopic surgery for ovarian endometriomata and complexity of the cases rather than the presence or absence of intraabdominal adhesion risk factors., Conclusions: No difference existed in the risk of intraabdominal adhesions in infertile patients with and without identifiable preoperative risk factors. Preoperative risk factors for intraabdominal adhesions should not contraindicate the surgical laparoscopic approach for reproductive procedures.