The Differences of Folliculogenesis between Treated with Letrozole and Letrozole-Electroacupuncture in Women with Polycystic Ovary Syndrome

Yulyanti Yulyanti, Uki Retno Budihastuti, Eriana Melinawati, Sri Sulistyowati, Ida Nurwati


Background: Polycystic Ovary Syndrome (PCOS) is an endocrine disorder that most often causes infertility. It occurs due to the failure of folliculogenesis, thus causing non-ovulation. Letrozole is a 3rd generation drug of non-ste­roidal aromatase inhibitors, which can increase ovulation rates. Electroacupuncture is the insert­ion and manipu­lation of needles into acupunc­ture points (acu­points) that are selected speci­fically based on the meridian system and con­nected to the electrode stimulator. This study aimed to determine the differences of the effects of letrozole and letrozoleelectroacupuncture (letrozole-EA) on the improve­ment of folliculo­genesis in women with PCOS.

Subjects and Method: This was an analytic observational study with a case-control design. This study was conducted at the Gynecology Polyclinic and Sekar Clinic, Dr. Moewardi Hos­pital, Surakarta. A sample of 30 infertile women aged 20-45 years was selected by fixed disease sampling. The criteria of the PCOS were deter­mined based on Rotterdam criteria. The depen­dent variable was the diameter of the follicle. The independent vari­ables were the administration of letrozole and letrozole-EA. Transvaginal ultra­sound of Voluson P6 was used to measure the folliculo­genesis. The data were analyzed by independent t-test.

Results: On the second day after treatment, the diameter of the follicles in the letrozole-EA group (mean= 6.92; SD= 1.60) was bigger than the letrozole group (mean=5.66; SD=1.11), and it was statistically significant (p=0.004).

Conclusion: Combination of letrozole and letrozole-EA therapy is more effective in increasing follicular diameter development than letrozole therapy only.

Keywords: polycystic ovary syndrome, folli­culogenesis, Letrozole, electro-acupuncture

Correspondence: Yulyanti. Department of Obstetrics and Gyneco­logy, Faculty of Medicine, Universitas Sebelas Maret/ Dr. Moewardi Hospital, Surakarta, Cen­tral Java, Indonesia. Email: dr.yulyanti­@gmail­.­com. Seluler: +6285264806570.

Indonesian Journal of Medicine (2020), 05(03): 214-223

Full Text:



American College of Obstetricians and Gyne-cologists (2018). Polycystic ovary syn-drome. ACOG practice bulletin. 194: e157-71. doi: 10.1097/AOG.00000000-00002657.

Burt Solorzano CM, Beller JP, Abshire AY, Collins JS, McCartney CR, Marshall JC (2012). Neuroendocrine dysfunction in polycystic ovary syndrome. Steroids. 77(4): 1-13. Doi: 10.1016/j.steroids.20-11.12.007.

Budihastuti UR, Melinawati E, Sulistyowati S, Nurwati I (2019). Electroacupunc-ture effect on polycystic ovary syndrome to improve oocytes’ growth. Medical acupuncture. 31(6): 1-5. Retrieved from

Farquhar C, Lilford RJ, Marjoribanks J (2012). Laparoscopic 'drilling' by diathermy or laser for ovulation induction in anovulatory polycystic ovary syn-drome. Cochrane Database of Systematic Reviews. 6(CD001122): 1-2. Retrieved from

Fauser BC, Tarlatzis BC, Rebar RW, Legro RS, Balen AH, Lobo R, Carmina E, et al (2012). Consensus on women’s health aspects of polycystic ovary syndrome (PCOS): The Amsterdam ESHRE/ASRM-Sponsored 3rd PCOS Consensus Workshop Group. Fertility and Sterility. 97(1): 25–38. Doi:

Fauser BCJM, Diedrich K, Bouchard P, Dominguez F, Matzuk M, Frank S, et al (2012). Contemporary genetic technologies and female reproduction. Human Reproduction Update. 17(6): 829–47.

Feng Y, Johansson J, Shao R, Louise Manneras Holm, Hakan Billig dan Elisabet Stener Victorin (2012). Electrical and manual acupuncture stimulation affect to estrous cyclicity and neuroendocrine function in an 5𝛼-dihydrotestosterone-induced rat polycysticovary syndrome model. Experimental Physiology. 97(5): 651–62. Retrieved from

Hestiantoro A, Wiweko B, Maidarti M, Fernando D, Puspita CG (2014). Hesti-antoro A, Natadisastra M, Wiweko B, Sumapraja K, Harzif AK, penyunting. Sindrom ovarium polikistik (SOPK). Current updates on polycystic ovary syndrome endometriosis adenomyosis. Cet 1. Jakarta: Sagung seto.

Homburg R (2014). Ovulation induction and controlled ovarian stimulation. 2nd ed. London: Springer.

Hogg K, Young JM, Oliver EM, Souza CJ, McNeilly AS, Duncan WC (2012). Enhanced thecal androgen production is prenatally programmed in an ovine model of polycystic ovary syndrome. Endocrinology. 153(1): 450–61.

Teede H, Misso M, Costello M, Dokras A, Laven J, Moran L, Piltonen T, et al (2018). International evidence-based guideline for the assessment and management of polycystic ovary syndrome. Melbourne: Monash university: 36-106.

Jain S, Dahiya P. Yadav J, Jain N (2018). A comparative study of efficacy of letrozole and clomiphene citrate for ovulation induction. International Journal of Reproduction, Contraception, Obstetrics and Gynecology. 7(10): 4133-4138. DOI: 10.18203/2320-1770.ijrcog2018-4141.

Jedel E, Labrie F, Oden A, Holm G, Nilsson L, Janson PO, Lind AK, et al (2011). Impact of electro acupuncture and physical exercise on hyperandrogenism and oligo/amenorrhea in women with polycystic ovary syndrome: a randomized controlled trial. American Journal of Physiology. 300(1): E37–45. Retrieved from

Johansson J, Redman L, Veldhuis PP, Sazo-nova A, Labrie F, Holm G, Johannsson G, et al (2013). Acupuncture for ovulation induction in polycystic ovary syndrome: a randomized controlled trial. American Journal of Physiology Endocrinology and Metabolism. 304(9): E934-43. Doi: 10.1152/ajpendo.00039.2013.

Johansson J, Stener Victorin E (2013). Poly-cystic Ovary Syndrome: Effect and Mechanism of Acupuncture for Ovulation Induction. Evidence-Based Complementary and Alternative Medicine: 1-16.

Kabel AM (2016). Polycystic ovarian syndrome: insights into pathogenesis, diagnosis, prognosis, pharmacological and non-pharmacological treatment. J pharma reports, an open acces journal. 1: 1-5. Retrieved from

Kar S (2012). Clomiphene citrate or letrozole as first-line ovulation induction drug in infertile PCOS women: A prospective randomized trial. Journal of human reproductive sciences. 5(3): 262-65. doi: 10.4103/0974-1208.106338.

Kini S (2012). Polycystic ovary syndrome: diagnosis and management of related infertility. Obstetrics, gynaecology and reproductive medicine. 22-12: P347-53. Retrieved from

Kusuma AC, Oktari N, Mihardja H, Srilestari A, Simadibrata LC, Hestiantoro A, Wiweko B, et al. (2019). Electroacu-puncture Enhances Number of Mature Oocytes and Fertility Rates for In Vitro Fertilization. Medical Acupuncture. 31(5): 1-9. Doi: 10.1089/acu.2019.1368.

Lansdown A, Aled RD (2012). The sympathetic nervous system in polycystic ovary syndrome: a novel therapeutic target? Clinical Endocrinology. 77(6): 791–801. Retrieved from

Legro RS, Brzyski RG, Diamond MP, Coutifaris C, Schlaff WD, Casson P, Christ-man GM, et al (2014). Letrozole versus clomiphene for infertility in the polycystic ovary syndrome. New England Journal of Medicine. 371(2): 119-29. Retrieved from

Lewandowski KC, CajdlerŁuba A, Salata I, Bieńkiewicz M, Lewiński A (2011). The utility of the gonadotrophin releasing hormone (GnRH) test in the diagnosis of polycystic ovary syndrome (PCOS). EndokrynologiaPolska. 62(2): 120–8. Retrieved from

Lim SS, Norman RJ, Davies MJ, and Moran LJ (2013). The effect of obesity on polycystic ovary syndrome: a systematic review and meta-analysis. Obesity Reviews. 14(2): 95–109. Retrieved from

Li J, Ng EHY, Stener-Victorin E, Hu Z, Wu W, Lai M, Wu T, et al (2016). Comparison of acupuncture pretreatment followed by letrozole versus letrozole alone on live birth in anovulatory infer-tile women with polycystic ovary syndrome: a study protocol for a randomised controlled trial. BMJ open. 6(e010955): 1-14. doi: 10.1136/bmj-open-2015-010955.

Nafee T, Metwally M (2014). Induction of ovulation. Obstetrics, gynaecology and reproductive medicine. 24-4: P117-21.

Pastore LM, Williams CD, Jenkins J, Patrie JT (2011). True and sham acupuncture produced similar frequency of ovulation and improved LH to FSH ratios in women with polycystic ovary syndrome. The Journal of Clinical Endocrinology and Metabolism. 96(10): 3143–50. DOI: 10.1210/jc.2011-1126.

Qiao J, Feng HL (2011). Extra and intra-ovarian factors in polycystic ovary syndrome: impact on oocyte matura-tion and embryo developmental competence. Human Reproduction Update. 17(1): 17–33. doi: 10.1093/humupd/dmq032.

Samara N, Casper RF (2018). Aromatase Inhibitors. Infertility in women with polycystic ovary syndrome. 1st ed. Switzerland: Springer.

Saputra K (2017). Akupunktur dasar. Ed 2. Surabaya: Airlangga university press.

Shin Y, Li L, Zhou J, Sun J, Chen L, Zhao J, Wu L, Cui Y, et al (2019). Efficacy of electroacupuncture in regulating the imbalance of AMH and FSH to improve follicle development and hyperandrogenism in PCOS rats. Biomedicine Pharmacotherapy. 113: 1-10. doi: 10.10-16/j.biopha.2019.108687.

Shoham zeev, Howless CM (2018). Gardner DK, Weissman A, Howless CM, Shoham zeev. Drugs used for ovarian stimulation. Textbook of assisted reproductive techniques. 5th Ed. Switzerland: CRC press.

Stener-Victorin E, Benrick A, Fornes R, Mali-queo M (2018). Palomba S. Infertility in women with polycystic ovary syn-drome. 1st ed. Switzerland: Springer.

Xu S, Wang L, Cooper E, Zhang M, Manhei-mer E, Berman B, Shen X, et al (2013). Adverse Events of Acupuncture: A Systematic Review of Case Reports. Evidence Based Complementary and Alternative Medicine: 1-15. doi: 10.1155/2013/581203.

Yu JS, Zeng BY, Hsleh CL (2013). Acupuncture stimulation and neuroendocrine regulation in textbook International review of neurobiology. neurobiology of acupuncture. Vol III. London: Elsevier.


  • There are currently no refbacks.