The prevalence of incidental endometriosis in women undergoing laparoscopic ovarian drilling for clomiphene-resistant polycystic ovary syndrome: a retrospective cohort study and meta-analysis
Open accessAbstract
To evaluate the incidence of endometriosis in polycystic ovary syndrome (PCOS) patients who did not present with any endometriosis symptoms and underwent laparoscopic ovarian drilling (LOD) for clomiphene citrate (CC) resistance, 225 and 630 women with CC-resistant PCOS without classic endometriosis symptoms were included in a retrospective study and a meta-analysis, respectively. All women underwent LOD. The main outcome parameter was the prevalence of incidental endometriosis. Laparoscopy revealed endometriosis in 38/225 (16.9%) women (revised American Fertility Society (rAFS) stage I: 33/38, 86.8%; rAFS stage II: 5/38, 13.2%). When women with CC-resistant PCOS without endometriosis were compared, lower body mass index (BMI) and lower 25-hydroxy-vitamin D levels were associated with the presence of endometriosis at laparoscopy (odds ratios (OR): 0.872, 95% confidence intervals (95%CI): 0.792–0.960; p = 0.005 and OR: 0.980, 95%CI: 0.962–0.999; p = 0.036; respectively). The inclusion criteria for the meta-analysis were fulfilled by 4/230 reports about LOD. After correction for study heterogeneity, the pooled prevalence of incidental endometriosis was 7.7% in women with CC-resistant PCOS. In conclusion, the rate of incidental endometriosis in women with CC-resistant PCOS might reflect the prevalence of asymptomatic endometriosis. All cases were affected by minimal or mild disease. Since the literature lacks reports on associated clinical outcomes, the relevance of this entity in such patients should be the subject of further studies.
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A meta-analysis of studies assessing presence of endometriosis in women with PCOS undergoing ovarian drilling found that overall 7.7% of women with PCOS demonstrated evidence of endometriosis, all minimal or mild.
“A meta‐analysis of studies assessing the presence of endometriosis in women with PCOS undergoing ovarian drilling found that, overall, 7.7% of women with PCOS demonstrated evidence of endometriosis, all of which was minimal or mild (Hager et al., 2019).”
From Endometriosis and polycystic ovary syndrome are diametric disorders (2021) · cites this paper as Hager et al., 2019
Results §3.2 reports a 7.7% estimated prevalence of endometriosis across five studies of women with clomiphene-resistant PCOS. The Discussion says all cases were minimal or mild only in the authors’ retrospective data set; it does not establish severity for every case in the meta-analysis. Page numbers were not supplied. (LLM, conf=0.90)
Experimental — accuracy not yet measuredThe 5% co-occurrence of endometriosis and PCOS in the operative cohort is in line with the 7% to 8% co-occurrence found in previous studies among asymptomatic women with minimal to mild endometriosis.
“Our finding of 5% of women with both conditions in the operative cohort is in line with the 7% to 8% co-occurrence found in previous studies among asymptomatic women with minimal to mild endometriosis,32,33 which made up 71% of endometriosis staging in the ENDO operative cohort.”
From Examining the co-occurrence of endometriosis and polycystic ovarian syndrome (2023) · cites this paper as [32]
Results §3.2 reports 7.7% co-occurrence of endometriosis and PCOS across five studies of women with clomiphene-resistant PCOS. Discussion §4 states that all endometriosis cases were minimal or mild in this paper’s retrospective cohort, but it does not establish that staging for the women in the 7.7% meta-analysis. The Introduction also distinguishes these infertile patients from women with completely asymptomatic endometriosis. Page numbers are unavailable in our copy. (LLM, conf=0.86)
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Cites
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“The meta-analysis on the incidence of GDM in women with triplet pregnancies was performed as published previously [24]: The library “metafor” in the open source statistical package “R” (The R Project for Statistical Computing) was used.”
MethodSelf-citationVitamin D—The Iceberg in Endometriosis—Review and Meta-Analysis
Ursache, A., Lozneanu, L., Bujor, I., Mandici, C., Boiculese, L., Baușic, A., Grigore, M., Socolov, D., & Matasariu, D. (2024) · Journal of Personalized Medicine · doi:10.3390/jpm14010119 · Cited by 10 · see citing works
“However, when contrasting the findings of studies conducted in more sunny regions with those conducted in less sunny regions, statistically significant differences were found with a p value of 0.004 (Yarmolinskaya et [8,30,34–36].”
BackgroundMethodResultInfluentialHolzer, I., Parry, J. P., Beitl, K., Pozderovic, B., Marculescu, R., & Ott, J. (2022) · Journal of Clinical Medicine · doi:10.3390/jcm11092597 · Cited by 8 · see citing works
“Cobas electrochemiluminescence immunoassays (ECLIA) were performed on Cobas e 602 analyzers (Roche, Mannheim, Germany) for the determination of serum estradiol, follicle-stimulating hormone (FSH), luteinizing hormone (LH), anti-Mullerian hormone (AMH), testosterone and sex hormone binding globuline (SHBG) as reported…”
MethodSelf-citationExamining the co-occurrence of endometriosis and polycystic ovarian syndrome
Schliep, K. C., Ghabayen, L., Shaaban, M., Hughes, F. R., Pollack, A. Z., Stanford, J. B., Brady, K. A., Kiser, A., & Peterson, C. M. (2023) · AJOG Global Reports · doi:10.1016/j.xagr.2023.100259 · Cited by 9 · see citing works
“Moderate 152 (36) 53 (37) 12 (32) 12 (52) 75 (35)”
Hager, M., Hörath, S., Frigo, P., Koch, M., Marculescu, R., & Ott, J. (2019) · Journal of Ovarian Research · doi:10.1186/s13048-019-0564-7 · Cited by 17 · see citing works
Self-citationHolzer, I., Marculescu, R., Begemann, V., Haaser, S. S., Dewailly, D., & Ott, J. (2024) · Reproductive Medicine and Biology · doi:10.1002/rmb2.12591 · Cited by 8 · see citing works
Self-citationGhobrial, S., Parry, J. P., Holzer, I., Aschauer, J., Selzer, C., Brezina, A., Helmy-Bader, S., & Ott, J. (2022) · Journal of Clinical Medicine · doi:10.3390/jcm11195610 · Cited by 5 · see citing works
“Additionally, bilateral tubal spasm or intermittent tubal blockage could not be ruled out for most participants, since patients with proximal tubal blockage diagnosed by either HSG or sonosalpingography can have false positives with open tubes in a subsequent examination [35,36].”
BackgroundSelf-citationMenstrual Blood as a Non-Invasive Alternative for Monitoring Vitamin Levels
Whitbread, A., Mittelmeier, L., Rao, R. P., Mittelmeier, W., & Osmanski-Zenk, K. (2024) · Journal of Clinical Medicine · doi:10.3390/jcm13237212 · Cited by 5 · see citing works
Hager, M., Ott, J., Göbl, C., Holzer, I., Seemann, R., Kurz, C., & Parry, J. (2021) · Archives of Gynecology and Obstetrics · doi:10.1007/s00404-021-05993-0 · Cited by 5
Self-citationOctavia, L., Panjarwanto, D. A., Nabila, P. A., Geany, P. L., Javier, R. M., Rahman, A., Yora, V. S., Sutanto, L., Tandayu, A. P., Varsha, S., et al. (2025) · Frontiers in Medicine · doi:10.3389/fmed.2025.1589193 · Cited by 1 · see citing works
Mayrhofer, D., Parry, J., Hager, M., Marculescu, R., & Ott, J. (2022) · Clinical and Experimental Obstetrics & Gynecology · doi:10.31083/j.ceog4903070 · Cited by 3
“In a retrospective case series of our study group, eight percent of women with PCOS (showing signs of elevated testosterone levels) were found to have occluded fallopian tubes during laparoscopy [4].”
BackgroundSelf-citationSurgical aspects of treating polycystic ovary syndrome
Andreeva, E. N., Sheremetyeva, E. V., & Arakelyan, A. S. (2020) · Russian Journal of Human Reproduction · doi:10.17116/repro20202605165 · Cited by 4 · see citing works
Ott, J., Loimer, R., Marculescu, R., Robin, G., Dewailly, D., & Hager, M. (2025) · Reproductive Biology and Endocrinology · doi:10.1186/s12958-025-01482-0 · Cited by 2 · see citing works
“As reported previously Cobas electrochemilu-minescence immunoassays (ECLIA) were performed on Cobas e 602 analyzers (Roche, Mannheim, Germany) for the determination of serum estradiol, FSH, LH, AMH, testosterone, DHEA-S, thyroid-stimulating hormone (TSH) and SHBG [21, 22].”
Self-citationIsmail, S., Majdell, C., Badgheish, A., Baghlaf, H., & Dahan, M. H. (2024) · Archives of Gynecology and Obstetrics · doi:10.1007/s00404-024-07589-w · Cited by 2 · see citing works
“This appears to be lower than a meta-analysis’ finding of approximately 7.7% of women with PCOS demonstrating evidence of endometriosis [16].”
InfluentialBoegl, M., Kasper, I., Dewailly, D., Mayrhofer, D., Hager, M., & Ott, J. (2026) · Gynecological Endocrinology · doi:10.1080/09513590.2026.2677994 · Cited by 1 · see citing works
Self-citationHager, M., Patsch, A., Thieme, S., Robin, G., Dewailly, D., & Ott, J. (2025) · Gynecological Endocrinology · doi:10.1080/09513590.2025.2495604 · Cited by 1
Self-citationKaya, C., Akhan, B. S., & Ertürk, H. (2026) · Journal of Health Sciences and Medicine · doi:10.32322/jhsm.1839088
Makolkin, M. A. A., & Kalugina, A. S. (2022) · Journal of obstetrics and women s diseases · doi:10.17816/jowd72255
Farhad, S., Roknuzzman, M., & Akhtar, A. (2024) · Obstetrics and Gynecology Research · doi:10.26502/ogr0163
“For instance, a meta-analysis of asymptomatic patients with clomiphene-resistant polycystic ovary syndrome found a prevalence of surgically confirmed endometriosis of 7.7% [11].”
Influential
- Authors
- Hager, M., Wenzl, R., Riesenhuber, S., Marschalek, J., Kuessel, L., Mayrhofer, D., Ristl, R., Kurz, C., & Ott, J.
- Affiliations
- Medical University of Vienna (AT)
- Corresponding author
- Ott, Johannes
- ORCID
- Venue
- Journal of Clinical Medicine
- Publisher
- MDPI AG
- Published
- 2019-08-14
- Volume
- 8
- Issue
- 8
- Pages
- 1210
- ISSN
- 2077-0383 (ISSN-L)
- PMC
- PMC6722764
- OpenAlex
- W2967935144
- Cited by
- 46
- References
- 52
- Citations by year
- 2026: 3 · 2025: 3 · 2024: 10 · 2023: 2 · 2022: 13 · 2021: 8 · 2020: 5 · 2019: 2
- FWCI
- 6.70
- Type
- journal article
- Language
- en
- Open access
- gold
- dx.doi.org
- Licence
- Locations
- Journal of Clinical Medicine (publishedVersion, cc-by)
- Europe PMC (PubMed Central) (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Topics
- Health Sciences › Medicine › Reproductive Medicine › Endometriosis Research and Treatment
- Health Sciences › Medicine › Reproductive Medicine › Ovarian function and disorders
- Health Sciences › Medicine › Obstetrics and Gynecology › Gynecological conditions and treatments
- Keywords
- polycystic ovary syndrome, clomiphene citrate resistance, laparoscopic ovarian drilling, asymptomatic endometriosis, endometriosis prevalence, body mass index, 25-hydroxyvitamin D
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