Polycystic ovary syndrome (PCOS) is characterized by a combination of symptoms of androgen excess and ovarian dysfunction in the absence of other specific diagnoses [1]. It is a leading cause of anovulatory infertility and one of the most common endocrine and metabolic disorders affecting women of reproductive age, with a global prevalence between 6-10% [2,3]. Clomiphene citrate is traditionally the first-line medication for ovulation induction in women with PCOS [4]. Other pharmacological options for PCOS patients with irregular or absent ovulation include letrozole, metformin, and lastly gonadotropins [5]. Laparoscopic ovarian drilling (LOD) or ultrasound-guided transvaginal ovarian drilling are alternative options for approximately 15-40% of women who are considered “clomiphene-resistant [6,7].”

LOD is a viable second-line treatment. This procedure involves making small perforations in the ovary using heat or laser during laparoscopy to facilitate follicular growth and ovulation [8]. LOD has demonstrated clinical efficacy in terms of pregnancy and live birth rates comparable to that of gonadotropins [9]. Comparatively, ultrasound-guided transvaginal ovarian needle drilling is a novel surgical ovulation induction method. Transvaginal ovarian drilling is undergone using a sharp needle to puncture each ovary, thereby assisting the release of an ovum from the dominant follicle to the cavitas pelvis and aspirating all visible small follicles [10]. After puncture and aspiration, the levels of intraovarian androgen, inhibin B, serum androgen, luteinizing hormone (LH), and other steroid hormones rapidly decrease substantially [11]. Due to the resulting decrease in peripheral androgen to estrogen conversion, feedback is restored, leading to appropriate gonadotropin secretion and increased follicle stimulating hormone (FSH), alongside a thickened ovarian surface that facilitates follicular development and ovulation [12,13].

The potential advantages of transvaginal ovarian drilling compared to LOD include a reduction in the risk of surgical complications, predominantly iatrogenic adhesions and premature ovarian failure, lower costs, and the fact that it can be conducted in an outpatient setting [14]. However, the current literature comparing the effectiveness and safety of LOD and transvaginal ovarian drilling is still inconsistent and controversial in demonstrating credible conclusions. Therefore, we conducted a systematic review and meta-analysis of randomized clinical trials (RCTs) comparing LOD and transvaginal ovarian drilling in PCOS patients, with a particular focus on hormonal profiles following the procedures.