Surgically induced ovulation in the polycystic ovary syndrome: wedge resection revisited in the age of laparoscopy

Prepubertal administration of estradiol valerate disrupts cyclicity and leads to cystic ovarian morphology during adult life in the rat: role of sympathetic innervation

Administration of estradiol valerate (EV) to adult rats leads to anovulation and cystic ovarian morphology. Sympathetic ovarian nerve denervation (SONX) overcomes this disruption. In this study, we determined whether EV administration to juvenile rats prevents achievement of reproductive competence, disrupts cyclicity, and whether this programming is facilitated via activation of the sympathetic nerve input to the ovary. Prepubertal rats were administered 2 mg EV in corn oil or corn oil alone. One half of the animals from each group underwent SONX on d 71 of life. Rats were euthanized on d 91 for determination of serum gonadotropins, progesterone, Delta4 androstenedione, and estradiol concentrations, ovarian norepinephrine (NE), and 3beta-hydroxysteroid dehydrogenase (3beta-HSD) activities and ovarian dynamics. Results revealed that EV administration during juvenile period advanced pubertal onset, suppressed circulating LH, FSH, and Delta4 androstenedione, increased ovarian NE, estradiol, and 3beta-HSD activities, disrupted ovarian dynamics evidenced as absent corpus luteum and presence of ovarian cysts and culminated in anovulation. SONX restored cyclicity in these animals, normalized LH, estradiol, ovarian 3beta-HSD activities, and ovarian dynamics as evidenced by the disappearance of ovarian cysts and appearance of corpus luteum and restored corpus luteum function. These findings provide evidence that EV exposure during juvenile life leads to long-lasting deleterious reproductive consequences via activation of the sympathetic ovarian nerve.

Polycystic ovary syndrome and cardiovascular disease: a premature association?

Women with polycystic ovary syndrome (PCOS) are often assumed, a priori, to be at increased risk for cardiovascular disease (CVD), given the high prevalence of the metabolic syndrome X among them. There is, however, no single definition of PCOS, and for that reason a comparison of studies that have analyzed its association with CVD is compromised from the start. Long-term studies of well characterized women with PCOS are lacking, and the link to primary cardiovascular events such as stroke or myocardial infarction remains more speculative than substantive. Epidemiological studies that have focused on isolated signs and stigmata of PCOS, such as polycystic ovaries, hyperandrogenism, or chronic anovulation, have found mixed results. There are studies that suggest a slight increase in cardiovascular events in women with polycystic ovaries, with perhaps stronger evidence between an increased risk of cardiovascular events in women with menstrual irregularity. However, there is little evidence for an association between hyperandrogenism per se and cardiovascular events. Furthermore, there are less data to substantiate an increased risk of events in women with PCOS identified on the basis of a combination of signs and symptoms, such as hyperandrogenic chronic anovulation. The existing data suggest that PCOS may adversely affect or accelerate the development of an adverse cardiovascular risk profile, and even of subclinical signs of atherosclerosis, but it does not appear to lower the age of clinical presentation to a premenopausal age group. Future studies to identify the risk of cardiovascular events in women with PCOS will benefit from clear and extensive phenotyping of PCOS abnormalities at baseline, from a prospective design, from larger sample sizes, and from longer follow-up.

Transvaginal hydrolaparoscopic ovarian drilling using bipolar electrosurgery to treat anovulatory women with polycystic ovary syndrome

STUDY OBJECTIVE

To verify the value, feasibility, and reliability of transvaginal hydrolaparoscopic ovarian drilling using the bipolar VersaPoint system to treat clomiphene-resistant, anovulatory women with polycystic ovary syndrome.

DESIGN

Prospective clinical study (Canadian Task Force classification II-2).

SETTING

University teaching hospital.

PATIENTS

Twenty-eight women.

INTERVENTION

Transvaginal hydrolaparoscopic ovarian drilling using the bipolar VersaPoint spring electrode.

MEASUREMENTS AND MAIN RESULTS

After the surgical procedure, ovulation occurred spontaneously in 66.7% of women. Thirteen pregnancies occurred; eight were spontaneous, and four were achieved after induction of ovulation with clomiphene citrate and one after stimulation with gonadotropins. In 21 women whose infertility was due exclusively to anovulation, the cumulative pregnancy rate was 38% at 3 months and 76% at 6 months. No ovarian hyperstimulation or abortion occurred. The single complication was bleeding from an ovary that required conversion to laparoscopy.

CONCLUSION

Transvaginal hydrolaparoscopic ovarian drilling with the bipolar VersaPoint system is a useful therapeutic option in these women.

Ovulation induction--optimizing results and minimizing risks

The aim of ovulation induction therapy should be, wherever possible, to correct the underlying disturbance and achieve safe, repeated unifollicular ovulation to achieve the live birth of singleton babies. This article outlines the main causes of anovulatory infertility but deals mostly with the management of anovulatory polycystic ovary syndrome (PCOS), which is the most common problem to confront specialists in reproductive medicine. PCOS is associated with insulin resistance, particularly in those who are overweight. Thus, strategies to achieve weight loss and improve insulin sensitivity, including the use of drugs such as metformin, enhance reproductive function. Therapies to induce ovulation involve first the use of the anti-oestrogen clomiphene citrate. For those who fail to ovulate in response to clomiphene citrate, the principal options include parenteral gonadotrophin therapy or laparoscopic ovarian diathermy.

Success of laparoscopic ovarian wedge resection is related to obesity, lipid profile, and insulin levels

OBJECTIVE

To evaluate the effects of laparoscopic ovarian wedge resection on hormonal and metabolic parameters of polycystic ovary syndrome (PCOS) and to compare profiles of women who achieved pregnancy with those who did not.

DESIGN

Prospective study.

SETTING

University hospital.

PATIENT(S)

Thirty-three women with PCOS.

INTERVENTION(S)

Laparoscopic ovarian wedge resection using harmonic scalpel.

MAIN OUTCOME MEASURE(S)

Pregnancy; levels of testosterone, DHEAS, gonadotropins, sex hormone-binding globulin (SHBG), and glucose and insulin during 2-hour glucose tolerance test; lipid profile; body mass index; and waist-to-hip ratio.

RESULT(S)

Twenty-two women (67%) achieved clinical pregnancy within the mean of 4.9 months after surgery. Baseline parameters of women who became pregnant differed from those who did not: those who became pregnant were less obese, had lower levels of total cholesterol, low-density lipoprotein, and triglycerides; higher levels of SHBG; lower levels of fasting insulin; lower insulin area under the curve; and higher insulin sensitivity index. Subjects not pregnant by 12 weeks after surgery underwent repeat endocrine and metabolic evaluations. In these women, wedge resection was followed by declines in testosterone, LH, and insulin sensitivity index. Wedge resection had no significant effect on SHBG, DHEAS, or lipid profile.

CONCLUSION(S)

Laparoscopic wedge resections are associated with the highest pregnancy rates among less obese subjects with favorable lipid profiles and lower insulin. In this study, the postoperative decline of serum testosterone and LH is not attributable to improvement of insulin sensitivity.

Application of transvaginal hydrolaparoscopy for ovarian drilling using Nd:YAG laser in infertile women with polycystic ovary syndrome

Since transvaginal hydrolaparoscopy (THL) was introduced as the first-line procedure in the early stage of the exploration of the tubo-ovarian structures in infertile women, it has been shown that THL is a less traumatic and a more suitable outpatient procedure than diagnostic laparoscopy. In the present study, a minimally invasive surgery was carried out in infertile women with polycystic ovary syndrome (PCOS) by THL. Ovarian drilling using Nd:YAG laser vaporization by THL was performed in two clomiphen citrate-resistant infertile women with PCOS. After ovarian drilling with THL, a patient recovered an ovulatory cycle. These findings suggest that ovarian drilling by THL seems to be a safe procedure in infertile women with PCOS. However, further investigations are required to evaluate the effectiveness and risks of this minimally invasive operation. (Reprod Med Biol 2003; 2: 37-40).

A randomized controlled trial of laparoscopic ovarian diathermy versus gonadotropin therapy for women with clomiphene citrate-resistant polycystic ovary syndrome

OBJECTIVE

To compare the effectiveness of laparoscopic ovarian diathermy with gonadotropin ovulation induction for women with clomiphene citrate-resistant polycystic ovary syndrome.

DESIGN

Randomized controlled trial.

SETTING

A tertiary referral fertility clinic.

PATIENT(S)

Women with anovulatory infertility secondary to clomiphene-resistant polycystic ovary syndrome. Inclusion criteria were age of <39 years, body mass index of <35 kg/m(2), failure to ovulate with 150 mg of clomiphene citrate for 5 days in the early follicular phase, >12 months of infertility, and no other causes of infertility.

INTERVENTION(S)

Laparoscopic ovarian diathermy versus three cycles of urinary or recombinant gonadotropins.

MAIN OUTCOME MEASURE(S)

Cumulative pregnancy and miscarriage rates.

RESULT(S)

Cumulative pregnancy rates were 28% at 6 months for laparoscopic ovarian diathermy and 33% for three cycles of ovulation induction with gonadotropins. There were three miscarriages in each group. Women in the laparoscopic ovarian diathermy arm of the study had four additional spontaneous pregnancies 6 to 12 months after surgery.

CONCLUSION(S)

There was no statistically significant difference in pregnancy or miscarriage rates during the 6-month follow-up period or the three cycles. Laparoscopic ovarian diathermy is a safe and effective alternative to ovulation induction with gonadotropins.

Transvaginal hydrolaparoscopy

Transvaginal hydrolaparoscopy (THL) correlates well with standard laparoscopy for evaluation of the cul-de-sac in women with unexplained infertility. Office THL, chromopertubation, and hysteroscopy appear well tolerated, safe, and suitable for most patients, and may be more cost effective than hysterosalpingogram in the infertility work-up. Gynecologic and operative THLs are applicable for selected indications.

Optimizing ovulation induction in women with polycystic ovary syndrome

Recent developments in our understanding of the pathophysiology of polycystic ovary syndrome led to the introduction of new therapeutic approaches. It is apparent that a significant proportion of women with polycystic ovary syndrome have insulin resistance and compensatory hyperinsulinemia. Growing evidence indicates that elevated serum insulin induces hyperandrogenism, which in turn leads to anovulation and infertility. Hyperinsulinemia also contributes to the increased risk for cardiovascular disorders and type 2 diabetes mellitus. These concepts provide rationale for therapies focused on treatments of insulin resistance. In particular, weight loss and exercise have been shown to increase insulin sensitivity and improve ovulatory function. Metformin, an insulin-sensitizing agent, is particularly effective in women with polycystic ovary syndrome who have significant insulin resistance. Metformin use leads to a decrease in serum insulin and androgen levels as well as an improvement in ovulatory function. Moreover, it appears to ameliorate cardiovascular risk factors. Other approaches to ovulation induction in women with polycystic ovary syndrome include traditional therapies using clomiphene citrate or gonadotropins. In clomiphene-resistant subjects, one can consider laparoscopic ovarian drilling and other forms of partial ovarian resection or destruction.

Ovulation induction for polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is the commonest cause of anovulatory infertility. Various factors influence ovarian function, and fertility is adversely affected by an individual being overweight or having high serum concentrations of LH. Strategies to induce ovulation include weight loss, oral anti-oestrogens (principally clomiphene citrate), parenteral gonadotrophin therapy and laparoscopic ovarian surgery. There have been no adequately powered randomized studies to determine which of these therapies provides the best overall chance of an ongoing pregnancy. Women with PCOS are at risk of ovarian hyperstimulation syndrome (OHSS) and so ovulation induction has to be monitored carefully with serial ultrasound scans. The recognition of an association between hyperinsulinaemia and PCOS has resulted in the use of insulin sensitizing agents, such as metformin, which appear to ameliorate the biochemical profile and improve reproductive function.

Clomiphene citrate in the twenty-first century

Clomiphene citrate is the drug most commonly prescribed for ovulation induction. It is the first choice medication in normogonadotrophic oligo/amenorrhoeic infertility (WHO group 2), essentially associated with polycystic ovaries. Anovulatory women who are responsive to clomiphene citrate should be treated for at least six cycles and the treatment should probably be limited to a maximum of 12 cycles. It is necessary to monitor at least the first cycle with ultrasonography because of the risk of multiple pregnancy and the variable response of patients to different doses of clomiphene. In addition, the risk of ovarian hyperstimulation syndrome should not be underestimated. More triplets and higher order pregnancies result from ovulation induction than from in vitro fertilization, and multiple pregnancy has many risks for both mother and babies. The role of empirical clomiphene in the treatment of unexplained infertility is debatable and the present data are inconclusive. Obesity, hyperandrogenaemia and insulin resistance are important factors in clomiphene-resistant patients. Failure to ovulate in response to clomiphene has been approached by either medical or surgical treatment. An effective alternative medical treatment is gonadotrophin injections. Treatment with metformin and the new generation of insulin-sensitizing drugs is under evaluation. The most widely used surgical treatment today is laparoscopic ovarian drilling, which appears to be as effective as gonadotrophin therapy.

Polycystic ovary syndrome: the new millenium

Our understanding of Polycystic Ovary Syndrome (PCOS) has been hampered by varying diagnostic criteria, and ignorance of the etiology of the syndrome. PCOS women are uniquely insulin resistant and obesity aggravates this underlying predisposition to insulin resistance. Diagnostic criteria which focus on hyperandrogenism and/or menstrual irregularity are more likely to identify insulin resistant women, than such criteria as abnormal gonadotropin secretion or ovarian morphology. The lack of a clear etiologic mechanism to the syndrome has led to a multitude of symptom-oriented treatments with few therapies improving all aspects of the endocrine syndrome of PCOS. Improving insulin sensitivity has become established as a baseline treatment strategy in PCOS. There are, however, few randomized controlled trials of adequate power to provide an evidence based guide to treatment in PCOS.

[The ovary and insulin resistance]

Insulin resistance appears to be responsible of approximately half of the cases of polycystic ovaries, the other half being probably provoked by an anomaly of the stimulation of ovaries by an excess of LH. Nevertheless, it is likely that in most cases the two factors conjugate. The excess of androgen production by the ovarian stroma is one of the major symptoms of this disease. Today, however, the diagnosis is carried mainly with the assistance of ultra-sounds which, besides the increased ovarian volume, have permitted to discover an increased ovarian stromal vascularity. Two essential datas derive from the whole works: the increased frequency of ovarian hyperstimulation syndrome and the great number of metabolic complications which requires an endocrinological supervision. But the most recent works focus on the extension to all ages of this form of pathology: from the intra-uterine life to the post menopause; and on the hereditary character of this disease. The mystery remains concerning the mechanism of the favourable effect in clomifene resistant PCOS, of surgical and laparoscopic methods of ovulation induction to which it may be useful to resort after mature consideration. More recently the benefit at the administration of metformine has been confirmed by several works.

Polycystic ovary syndrome. A diagnostic challenge

Polycystic ovary syndrome remains a diagnostic challenge because there is no single defining test. The clinical presentation must dictate the extent of the work-up. The typical PCOS patient has a history of irregular menses and appears hirsute. Demonstration of ovulatory dysfunction and hyperandrogenism can also be made by appropriate hormonal measurements. An ultrasound showing multiple small ovarian follicles can support a diagnosis of PCOS in the patient for whom the clinical diagnosis has been made. Other causes of hyperandrogenism and ovulatory dysfunction should be excluded.

Operative transvaginal hydrolaparoscopy for treatment of polycystic ovary syndrome: a new minimally invasive surgery

OBJECTIVE

To evaluate a new minimally invasive surgery for treatment of the polycystic ovary syndrome (PCOS) in clomiphene-resistant infertile women.

DESIGN

Prospective study.

SETTING

University teaching hospital.

PATIENT(S)

Thirteen clomiphene citrate-resistant anovulatory women with PCOS.

INTERVENTION(S)

Operative transvaginal hydrolaparoscopy (THL) using a coaxial bipolar electrode.

MAIN OUTCOME MEASURE(S)

Feasability, ovulation rate, and pregnancy rate.

RESULT(S)

Ovarian drilling was performed by THL in all patients; no surgical complications occurred. Mean (+/-SD) duration of follow-up time was 6.3 +/- 3.3 months. Six patients recovered to have regular ovulatory cycles. Six pregnancies occurred; three were spontaneous, two occurred after stimulation and intrauterine insemination, and one occurred after IVF. The cumulative pregnancy rate was 33% at 3 months after THL and 71% at 6 months after THL. No miscarriages occurred.

CONCLUSION(S)

Transvaginal hydrolaparoscopy with ovarian drilling using bipolar electrosurgery appears to be an alternative minimally invasive in patients with PCOS who are resistant to clomiphene therapy.

Long-term GnRH analogue treatment is equivalent to laparoscopic laser diathermy in polycystic ovarian syndrome patients with severe ovarian dysfunction

This prospective, randomized study included 18 polycystic ovarian syndrome (PCOS) patients with severe ovarian dysfunction, who were evaluated by standard clomiphene and FSH stimulation. In this group of patients, a 6 month down-regulation with gonadotrophin-releasing hormone (GnRH) analogues gave outcomes similar to laparoscopic ovarian laser diathermy with respect to stimulatory outcome and pregnancy rate. Clomiphene stimulation with 50 mg of clomiphene/day and FSH stimulation in a low-dose, step-up protocol with purified FSH did not result in oligofollicular development; thus patients were divided into two subgroups: one subgroup received laparoscopic laser drilling and the other received 6 months of therapy with GnRH analogues plus add-back therapy after diagnostic laparoscopy. Subsequently, three cycles of low-dose, step-up stimulation with recombinant FSH were started. In both groups, approximately 30% of cycles still remained anovulatory. In the down-regulated subgroup, this mainly happened in the first cycle. In each group, ovulation was achieved in 14 cycles, intrauterine insemination was performed, and five pregnancies were obtained. This resulted in a pregnancy rate of 36% per ovulatory cycle in both groups. Overall, 50% of the formerly unreactive patients in both groups overcame childlessness. In achieving this, long-term treatment with GnRH analogues was as successful as laparoscopic laser diathermy.

Effects of laparoscopic ovarian drilling on serum vascular endothelial growth factor and on insulin responses to the oral glucose tolerance test in women with polycystic ovary syndrome

OBJECTIVE

To evaluate the serum vascular endothelial growth factor concentrations and insulin responses to the oral glucose tolerance test before and after laparoscopic ovarian drilling in women with PCOS.

DESIGN

Prospective study.

SETTING

University teaching center.

PATIENT(S)

Twenty-seven women with clomiphene citrate-resistant polycystic ovary syndrome.

INTERVENTION(S)

Laparoscopic ovarian drilling.

MAIN OUTCOME MEASURE(S)

VEGF levels and insulin responses to OGTT before and after ovarian drilling.

RESULT(S)

No difference was found in VEGF levels in women with PCOS before (6.0 +/- 1.2 ng/mL) and after ovarian drilling (5.5 +/- 1.2 ng/mL). VEGF levels before and after ovarian drilling in women who conceived were, respectively, 5.9 +/- 1.0 and 5.1 +/- 0.9 ng/mL and in those who did not conceive were 6.0 +/- 1.3 and 5.7 +/- 1.2 ng/mL. No correlation was found between baseline serum insulin and VEGF levels. VEGF concentrations in women with normal ovaries (4.5 +/- 1.7 ng/mL) were significantly lower than in women with PCOS. There was no difference in glucose and insulin responses to OGTT before and after ovarian drilling.

CONCLUSION(S)

VEGF levels in women with PCOS are higher than in normal women, and ovarian drilling does not affect these levels. The procedure does not change insulin responses to OGTT.

Distribution of steroidogenic enzymes involved in androgen synthesis in polycystic ovaries: an immunohistochemical study

To find an explanation for the possible working mechanism of laparoscopic ovarian electrocautery for the treatment of anovulation in polycystic ovarian syndrome (PCOS), we evaluated the distribution of steroidogenic enzymes involved in the synthesis of ovarian androgens in surgical pathology specimens of entire polycystic ovaries. A total of 13 formalin-fixed and paraffin-embedded samples of the ovaries of patients with clinically proven PCOS were immunostained with specific antibodies against cholesterol side-chain-cleavage enzyme (P450scc), 3beta-hydroxysteroid dehydrogenase (3beta-HSD), 17alpha-hydroxylase (P450c17) and adrenal 4-binding protein (Ad4BP), a transcription factor of steroidogenic enzymes. Follicular theca cells of all ovaries demonstrated marked immunoreactivity for Ad4BP, P450scc, 3beta-HSD and P450c17. Granulosa cells of seven ovaries expressed Ad4BP, while granulosa cells of three ovaries also showed P450scc. In the granulosa cells of all ovaries, 3beta-HSD and P450c17 immunoreactivity was not observed. In the stroma, luteinized cells of most ovaries demonstrated Ad4BP, P450scc, 3beta-HSD and P450c17 immunoreactivity, but at a much lower level compared with the follicular theca cells. Non-luteinized stromal cells sporadically demonstrated Ad4BP, P450scc, 3beta-HSD and P450c17 immunoreactivity. The stromal steroidogenic cells were mainly located in the ovarian cortex, except for some hilus steroidogenic cells. These data demonstrate that in polycystic ovaries, androgens are mainly produced in the follicular theca cells and to some extent in luteinized stromal cells. This suggests that the working mechanism of laparoscopic electrocautery of the ovary is primarily explained through the reduction of ovarian hyperandrogenism by coagulation of follicular theca cells and concomitant stroma.

Predictive value of serum androstenedione basal levels on the choice of gonadotropin or laparoscopic ovarian electrocautery as ovulation induction in clomiphene citrate-resistant patients with polycystic ovary syndrome

Therapeutic approaches to chronic anovulation from polycystic ovaries in clomiphene-resistant infertile patients are under debate. This study discusses evidence that supports the possible predictive value of serum basal level of androstenedione in the choice of the better therapy between laparoscopic ovarian electrocautery and ovulation induction. Lower androstenedione levels seem to be correlated with a better ovarian response after ovulation induction with gonadotropins, while high androstenedione levels are associated with a higher incidence of conception after laparoscopic ovarian electrocautery. Obesity does not seem to represent a hindrance to laparoscopic treatment.

Laparoscopic treatment of polycystic ovaries with insulated needle cautery: a reappraisal

OBJECTIVE

To evaluate the reproductive outcome and adhesion formation after a standardized laparoscopic treatment of polycystic ovary syndrome (PCOS) in clomiphene-resistant infertile women.

DESIGN

Retrospective study.

SETTING

University teaching hospital.

PATIENT(S)

One hundred twelve clomiphene-resistant anovulatory women with PCOS.

INTERVENTION(S)

Laparoscopic ovarian drilling using an insulated needle cautery.

MAIN OUTCOME MEASURE(S)

Ovulatory rate, pregnancy rate, and adhesion formation.

RESULT(S)

After surgery, ovulation occurred spontaneously in 73.2% of patients. The cumulative probability of conception at 12, 18, and 24 months after surgery was 54%, 68%, and 72%, respectively. With use of Cox's proportional hazards model, the effects of age, body mass index, and duration of infertility were evaluated. These factors were not associated with the pregnancy rate. Of 15 women who underwent a second-look laparoscopy, 11 women were found to be free of adhesions. Four women had periadnexal adhesions that were filmy, minimal, and found on the ovarian surface only.

CONCLUSION(S)

Laparoscopic ovarian drilling is an effective alternative treatment in clomiphene-resistant anovulatory women with PCOS. The use of an insulated needle cautery is associated with a minimal amount of adhesion formation.

Pregnancy following the laparoscopic bipolar electrocoagulation of polycystic ovaries resistant to medicamentous ovulation induction--a case report

The case of a primarily infertile patient with polycystic ovaries (PCOS) resistant to medicamentous ovulation induction is presented. The preoperative condition, laparoscopic ovarian drilling using an original technique of bipolar electrocoagulation and consecutive spontaneous pregnancy and delivery are described. This case suggests that bipolar forceps with jaws 1 mm wide could be a useful instrument for laparoscopic ovarian drilling.

Short- and long-term effects of ovulation induction

Ovulation induction using clomiphene citrate, gonadotropins, and gonadotropin-releasing hormone is reviewed. The short- and long-term consequences of these therapies are discussed in detail.

Polycystic ovary syndrome: current and future treatment paradigms

Polycystic ovary syndrome is characterized by excess levels of circulating androgens and by chronic anovulation. Although the fundamental pathophysiologic defect has not been determined, women with polycystic ovary syndrome are known to be uniquely insulin resistant. Obesity in polycystic ovary syndrome aggravates the underlying predisposition towards insulin resistance. Diagnostic criteria that focus on menstrual irregularity are more likely to discriminate insulin-resistant women than are such criteria as abnormal gonadotropin secretion or ovarian morphologic characteristics. About 40% of patients with polycystic ovary syndrome demonstrate glucose intolerance (either impaired glucose tolerance or type 2 diabetes) in response to an oral glucose challenge. The lack of a clear causal mechanism in the syndrome has led to a multitude of symptom-oriented treatments, with few therapies improving all aspects of the endocrine abnormalities associated with polycystic ovary syndrome. Many of these therapies-such as ovulation induction with medical agents-hold increased risks for women with polycystic ovary syndrome, including ovarian hyperstimulation syndrome and multiple gestation. Empirical studies of interventions that improve insulin sensitivity in polycystic ovary syndrome (either weight loss and diet programs or pharmaceutical agents) have been shown to improve the endocrine abnormalities in the syndrome. Initial results with antidiabetic agents (specifically insulin-sensitizing agents) are promising but need to be confirmed with larger, randomized studies.

Insulin resistance in polycystic ovary syndrome: treating a phenotype without a genotype

PCOS women are uniquely insulin resistant. The underlying genetic defect in insulin action is unknown. Obesity aggravates the underlying predisposition to insulin resistance. Diagnostic criteria which focus on menstrual irregularity are more likely to identify insulin resistant women. About 40% of PCOS women display glucose intolerance (either impaired glucose tolerance or type 2 diabetes) in response to an oral glucose challenge. The lack of a clear etiologic mechanism to the syndrome has led to a multitude of symptom-oriented treatments with few therapies improving all aspects of the endocrine syndrome of PCOS. Empirical studies of interventions improving insulin sensitivity in PCOS, either weight loss/diet programs or pharmaceutical agents, have been shown to improve the endocrine abnormalities in the syndrome. These initial results with anti-diabetic agents, though promising, need to be confirmed in larger, randomized studies.

Serum total renin levels after ovarian electrocautery in women with polycystic ovary syndrome

Recent observations have suggested an enhanced activity of the ovarian renin-angiotensin system in polycystic ovary syndrome (PCOS). Owing to technical restrictions, the direct measurement of ovarian renin-angiotensin activity is impossible. The measurement of total renin (active renin + prorenin) in serum is particularly valuable for analyzing the ovarian renin-angiotensin system, as 90% of circulating renin is in the form of prorenin and ovaries are the major extrarenal source of prorenin in females. Also, the renin synthesized by ovaries is in the form of prorenin. In the present study we hypothesized that ovarian trauma caused by electrocautery 'impairs' the activity of the ovarian renin-angiotensin system, which in turn would interrupt the endocrine vicious cycle of PCOS, and restore normal ovarian function. To test this, we examined the effect of ovarian electrocautery on serum levels of total renin in 11 oligomenorrheic women, aged 25 to 36 years, with PCOS and anovulatory infertility. Against our basic hypothesis the serum total renin levels remained unaltered after ovarian electrocautery, while the serum levels of luteinizing hormone, testosterone and androstenedione declined. The mechanism that induces ovulation without altering total renin levels in serum remains to be resolved.

Mortality of women with polycystic ovary syndrome at long-term follow-up

Metabolic disturbances associated with insulin resistance are present in most women with polycystic ovary syndrome. This has led to suggestions that women with polycystic ovary syndrome may be at increased risk of cardiovascular disease in later life. We undertook a long-term follow-up study to test whether cardiovascular mortality is increased in these women. A total of 786 women diagnosed with polycystic ovary syndrome in the United Kingdom between 1930 and 1979 were traced from hospital records and followed for an average of 30 years. Standardized mortality ratios (SMRs) were calculated to compare the death rates of these women with national rates. The SMR for all causes was 0.90 (95% CI, 0.69-1.17), based on 59 deaths. There were 15 deaths from circulatory disease, yielding an SMR of 0.83 (95% CI, 0.46-1.37). Of these 15 deaths, 13 were from ischemic heart disease (SMR 1.40; 95% CI, 0.75-2.40) and two were from other circulatory disease (SMR 0.23; 95% CI, 0.03-0.85). There were six deaths from diabetes mellitus as underlying or contributory cause, compared with 1.7 expected (odds ratio 3.6; 95% CI, 1.5-8.4). Breast cancer was the commonest cause of death (SMR 1.48 based on 13 deaths; 95% CI, 0.79-2.54). We conclude that women with polycystic ovary syndrome do not have markedly higher than average mortality from circulatory disease, even though the condition is strongly associated with diabetes, lipid abnormalities, and other cardiovascular risk factors. The characteristic endocrine profile of women with polycystic ovary syndrome may protect against circulatory disease in this condition.

Role of GnRH drive in the pathophysiology of polycystic ovary syndrome

Polycystic ovary syndrome may result from multiple mechanisms, but full expression of the PCO syndrome with hyperandrogenic anovulation depends upon sustained LH drive and relative FSH deficiency. We have described possible intrinsic and extrinsic factors capable of modifying the hypothalamic-pituitary-ovarian axis. Available evidence suggests the presence of an intrinsic alteration in GnRH-LH drive. The long-term natural history of HAA is variable and depends on several factors including obesity, aberrations in insulin action, intrinsic ovarian function, and end-organ responsiveness to androgens. Figure 1 presents a conceptualization of the pathogenesis of PCOS diagramming the multiple modulators of its expression. Long-term suppression of androgens when fertility is not desired should modify the full expression of the PCO syndrome. It is important to appreciate that therapy with oral contraceptive agents has few drawbacks and many immediate and potential long-term benefits for women with HAA. This therapy may be of greatest benefit when started in adolescence prior to the progression of obesity, hirsutism, and thecal-stromal hyperplasia. Women with HAA represent a large subgroup of patients who require individualization of their health care with sensitivity to issues surrounding anovulation, obesity, hirsutism, and infertility.

A possible approach to the treatment of polycystic ovarian syndrome using focused ultrasound

A new method of treatment for infertility caused by polycystic ovarian syndrome (PCOS) using thermal lesion formation by high intensity ultrasound has been suggested. Current options for PCOS therapy and the achievements of focused ultrasound surgery technique are reviewed and discussed. A prototype of a low-cost commercial device for the treatment of PCOS has been designed and tested to prove the feasibility of the method. A transducer with curvature radius of 36 mm and aperture diameter of 36 mm, operating at 0.97 MHz, was designed and tested. It provided a maximum acoustic power output of 180 W. Well-defined tissue damage was obtained within 10 s in a pig's liver in vitro at 3 cm depth within an area 5 mm in diameter and 12 mm in length without damaging the surrounding tissue. Evaluation of the size of the lesions produced at different frequencies, sonication times and output power has been carried out by visual inspection of the colour changes in cut tissue sections. Results demonstrate that a surgical tool based on the method suggested should be feasible and warrants further investigation.

Androgens stimulate early stages of follicular growth in the primate ovary

The concept that androgens are atretogenic, derived from murine ovary studies, is difficult to reconcile with the fact that hyperandrogenic women have more developing follicles than normal-cycling women. To evaluate androgen's effects on primate follicular growth and survival, normal-cycling rhesus monkeys were treated with placebo-, testosterone-(T), or dihydrotestosterone-sustained release implants, and ovaries were taken for histological analysis after 3-10 d of treatment. Growing preantral and small antral follicles up to 1 mm in diameter were significantly and progressively increased in number and thecal layer thickness in T-treated monkeys from 3-10 d. Granulosa and thecal cell proliferation, as determined by immunodetection of the Ki67 antigen, were significantly increased in these follicles. Preovulatory follicles (> 1 mm), however, were not increased in number in androgen-treated animals. Follicular atresia was not increased and there were actually significantly fewer apoptotic granulosa cells in the T-treated groups. Dihydrotestosterone treatment had identical effects, indicating that these growth-promoting actions are mediated by the androgen receptor. These findings show that, over the short term at least, androgens are not atretogenic and actually enhance follicular growth and survival in the primate. These new data provide a plausible explanation for the pathogenesis of "polycystic" ovaries in hyperandrogenism.

Late endocrine effects of ovarian electrocautery in women with polycystic ovary syndrome

OBJECTIVE

To examine the duration of the changes in endocrine indices produced by ovarian electrocautery in women with polycystic ovary syndrome (PCOS).

DESIGN

Long-term observational study.

SETTING

University hospital.

PATIENT(S)

Infertile women with PCOS.

INTERVENTION(S)

Ovarian electrocautery was performed through the laparoscope. Blood was sampled before the operation and at defined intervals thereafter. After the establishment of regular cycles, sampling was performed 1 week before the menstrual period.

MAIN OUTCOME MEASURE(S)

The patients were observed before and at defined intervals for up to 20 years after ovarian electrocautery. Serum concentrations of hypophyseal and ovarian hormones were determined, including sex hormone-binding globulin (SHBG).

RESULT(S)

There was a clear shift from anovulation to ovulatory cycles and a significant decrease in androgens and gonadotropins. The concentration of SHBG increased. These effects lasted for many years; after 18-20 years, two thirds of the women were still ovulating.

CONCLUSION(S)

Ovarian electrocautery for PCOS normalizes ovarian function, including androgen production, and the results seem to be stable for 18-20 years.

Factors affecting the outcome of laparoscopic ovarian drilling for polycystic ovarian syndrome in women with anovulatory infertility

OBJECTIVE

To describe and analyse the factors affecting the pregnancy rate of laparoscopic ovarian drilling for polycystic ovarian syndrome in women with anovulatory infertility.

DESIGN

A retrospective study.

SETTING

A specialist infertility clinic based at a teaching hospital in England.

POPULATION

One hundred and eighteen women, for whom hospital records and follow up data were available, with polycystic ovarian syndrome who underwent laparoscopic ovarian surgery for anovulatory infertility over a five year period, between January 1991 and December 1995.

MAIN OUTCOME MEASURES

Ovulation and pregnancy rate.

RESULTS

The cumulative conception rate 12 months after the treatment was 54%. Women who conceived following the surgery had a shorter duration of infertility, were treated with diathermy (rather than laser), had higher pre-operative luteinising hormone levels, were younger and were more likely to have ultrasonographic evidence of polycystic ovarian disease. Logistic multiple regression analysis showed that the duration of infertility, modality used in treatment (laser or diathermy) and the pre-operative levels were the main determinants of the outcome.

CONCLUSION

Women with polycystic ovarian syndrome respond favourably to laparoscopic ovarian drilling. The success rate in women with infertility duration of less than three years, treated with diathermy, in whom the pre-operative level was more than 10 IU/L reached 79%.

Cohort size rather than follicle-stimulating hormone threshold level determines ovarian sensitivity in polycystic ovary syndrome

The aim of the presented study was to compare FSH threshold levels and ovarian response to stimulation with one of two standard increments of exogenous FSH above the threshold in patients with polycystic ovary syndrome (PCOS) (n = 12) and eumenorrheic women (n = 11). The individual FSH threshold was determined by treatment according to a low-dose, step-up protocol with urinary FSH (Metrodin; Ares Serono, Geneva, Switzerland). In a subsequent treatment cycle, six PCOS patients and six eumenorrheic women were randomly assigned to double-blind treatment with the threshold dose plus 1/2 ampoule; the other six PCOS patients and five eumenorrheic women were treated with 1 ampoule above the threshold dose. Determination of threshold levels showed no significant differences in median and range between PCOS patients and eumenorrheic women. The number of follicles on the day of human chorionic gonadotropin administration showed no significant correlation with the increase in FSH level above the threshold level. Irrespective of the dose given, the number of follicles in the PCOS group was significantly higher than in eumenorrheic women. The higher sensitivity for gonadotropin stimulation in patients with PCOS compared with women with regular menstrual cycles therefore appears not to be dependent on differences in FSH threshold level, but rather on the larger size of the FSH sensitive cohort of small antral follicles.

Diagnosis and therapy of hyperandrogenism

Diagnostic categories in hyperandrogenism include polycystic ovary syndrome (PCOS) and its variants, adrenal and ovarian steroidogenic enzyme deficiencies, adrenal and ovarian androgen secreting tumours and other endocrine disorders such as hyperprolactinaemia, Cushing syndrome and acromegaly. About 95% of hyperandrogenic women will have PCOS. Endometrial hyperplasia can be prevented in hyperandrogenic, anovulatory women by the oral contraceptive pill or progestins. Hirsutism is best treated by a combination of the oral contraceptive pill and an anti-androgen. The first line of therapy for ovulation induction is clomiphene citrate, with human menopausal gonadotrophins (hMG) or laparoscopic ovulation induction reserved for clomiphene failures. hMG together with gonadotrophin-releasing hormone agonist may decrease the risk of spontaneous abortion following ovulation induction in PCOS. Weight loss should be vigorously encouraged to ameliorate the metabolic consequences of PCOS.

Definition and significance of polycystic ovaries

Defining the polycystic ovarian syndrome (PCOS) has challenged clinicians for many years. The clinical, hormonal and morphological definitions of PCOS have their own limitations and do not correspond exactly. Clinically, PCOS can be schematically divided into three components, i.e. hyperandrogenic, anovulatory and dysmetabolic. No one is specific for the syndrome. Hormonally, PCOS has recently been defined by the GnRH agonist test as a functional abnormality in ovarian androgen synthesis. This functional ovarian hyperandrogenism seems closely linked to hyperinsulinism secondary to an insulin resistance. Morphologically, ovarian ultrasonography has emerged in the last decade or so as a new diagnostic tool. However, the sonographic definition of the polycystic ovary (PCO) is controversial, mainly because of a lack of consensus about normative data. The aim of this review is to present the diagnostic dilemma in the diagnosis of PCOS and to discuss the prognostic significance of the PCO.

Polycystic ovary syndrome: the present position

This article discusses two areas that have seen progress in our understanding and management of women with polycystic ovary syndrome. The first relates to factors responsible for clinical expression of the disorder, the second to the management of infertility by surgical methods. These two areas have been chosen partly because of their intrinsic importance and partly because they indicate the breadth of work being pursued by investigators and clinicians in this field.

An extended 10-day course of clomiphene citrate (CC) in women with CC-resistant ovulatory disorders

OBJECTIVE

To evaluate the effectiveness of extended duration clomiphene citrate (CC) (100 mg for 10 days) as an alternative to complex ovulation induction strategies for women who fail to ovulate despite standard incremental doses of CC of > or = 150 mg for 5 days.

DESIGN

Retrospective case series.

SETTING

University-based infertility practice.

PATIENT(S)

Thirty women with CC-resistant World Health Organization group II ovulatory disorders.

INTERVENTION(S)

At least one cycle of 100 mg CC from days 3 to 12.

RESULT(S)

Fourteen patients (47%) ovulated during 31 of their 48 cycles (65%). Five women (17%) conceived a total of seven singleton pregnancies, including five term deliveries and two spontaneous abortions. Weight, body mass index, and the presence of hyperandrogenism did not predict responsiveness to the extended duration CC. Side effects were similar to those reported during standard CC treatment.

CONCLUSION(S)

An extended 10-day course of CC provides a simple, noninvasive, and inexpensive alternative for a subset of women with ovulatory disorders that are refractory to standard CC treatment.

Laparoscopic electrosurgical furrowing technique for the treatment of polycystic ovaries

A retrospective analysis of reproductive outcomes was conducted in 30 anovulatory women treated with a new laparoscopic electrosurgical furrowing technique. All patients had polycystic ovary syndrome refractory to ovulation induction with clomiphene citrate and gonadotropin therapy. Bilateral ovarian furrowing was successfully accomplished in all 30 patients without technical difficulty or surgical complications. Average furrowing time was 5 minutes per ovary and all patients were discharged by 12 hours postoperatively. Regular ovulatory function resumed in 25 women (83.3%); the 5 refractory patients were administered clomiphene citrate. Spontaneous conception occurred in 21 ovulatory patients (70.0%) and clomiphene-assisted conception occurred in 3 of the 5 refractory women, for an overall pregnancy rate of 80% (24/30). Twenty-three pregnancies resulted in viable term deliveries; one (4.2%) ended in a first-trimester abortion. These results suggest that the laparoscopic electrosurgical furrowing technique for the treatment of anovulatory infertility in women with polycystic ovary syndrome refractory to clomiphene citrate and gonadotropin therapy is effective, safe, and easily performed. Further evaluation is warranted to confirm the appropriateness of this procedure.

Ovarian drilling in infertile women with polycystic ovary syndrome

Ovarian drilling is a laparoscopic treatment for polycystic ovary syndrome. As with wedge resection, it is unclear why women with this syndrome ovulate after the procedure. Studies describing the clinical response of over 600 patients to this treatment have appeared in the medical literature. Attention to detailed steps can guide experienced laparoscopic surgeons to apply this technique to appropriate patients who are experiencing infertility due to polycystic ovary disease.

Surgical ovulation induction: the role of ovarian diathermy in polycystic ovary syndrome

Notwithstanding the shortcomings of the available data, this review of the available literature strongly suggests some real benefits of laparoscopic treatment for carefully selected patients who fail clomiphene citrate therapy. While we very cautiously endorse a place for this procedure in the armamentarium of the clinician, we would like to state emphatically that this procedure has not been shown to be free of risks to the fertility status of women. The notion that this procedure is not associated with adhesion formation is false, and the reports of ovarian atrophy, while rare, are also of serious concern. These issues, as well as the cost and risk associated with any operative procedure, underscore the importance of performing this operation only when all other available options have been exhausted. It is, in our opinion, a great disservice to the patient to perform laparoscopic equivalents of ovarian wedge resection after only a cursory infertility evaluation and a brief attempt at clomiphene citrate ovulation induction. Until it can be conclusively shown that laparoscopic ovulation induction does no harm to fertility potential or to long-term health, these procedures should be used when all available non-invasive options have been explored.

Neuroendocrinology of the polycystic ovary syndrome

The clinical and biochemical heterogeneity of the PCOS is mirrored by the range of neuroendocrine disturbances described in women with PCOS. An increased serum LH concentration is a common, although not ubiquitous, feature and occurs primarily as a result of an increase in the amplitude of pulsatile LH, and presumably GnRH, secretion. The frequency of pulsatile GnRH secretion may, however, be increased in certain patients and may conceivably increase LH bioactivity by altering glycosylation of the molecule. Vigorous debate continues as to whether the observed changes in gonadotrophins are a primary abnormality or occur secondary to alterations in peripheral steroid concentrations. The proponents of the frequency hypothesis point to the discordant changes in gonadotrophin secretion that may be induced by rapid frequency exogenous GnRH stimulation in patients with hypogonadotrophic hypogonadism. Those who believe that the inappropriate gonadotrophin secretion is a secondary phenomenon argue that manipulation of peripheral steroid levels, by either administration of oestrogen/progesterone, induced ovulation or ovarian diathermy, may correct the disturbance of gonadotrophin secretion, which is therefore presumably a consequence of changes in ovarian steroid feedback signals. The weight of evidence at present suggests that the inappropriate gonadotrophin secretion is usually a secondary abnormality, although there may be groups of patients with a primary increase in GnRH pulsatility. The search for a unifying neuroendocrine disturbance in PCOS has been frustrated by the inability to find consistent evidence of disordered central dopaminergic, opioidergic, noradrenergic or serotoninergic pathways. Those abnormalities which have been uncovered appear to be secondary to chronic anovulation rather than of primary pathological import, and emphasize the central importance of the ovary as culprit rather than victim in PCOS.

Polycystic ovary syndrome: induction of ovulation

In summarizing the treatment of infertility associated with PCOS, basically the induction of ovulation may be achieved by boosting FSH stimulation of the ovaries, either indirectly with clomiphene or native pulsatile GnRH, or directly with gonadotrophin preparations. There seem to be two main determinants of the success of this treatment in achieving a live birth: the degree of hyperinsulinaemia and the concentration of circulating LH. Either of these, when in excess, not only makes induction of ovulation and conception relatively difficult but is also associated with a high rate of early miscarriage. Their correction, particularly in obstinate cases, should be a major consideration in the attempt to achieve optimal results. With such a range of reasonably successful treatments for the induction of ovulation in PCOS, the emphasis in the selection of therapy should now be placed on minimizing the prevalence of undesired side-effects while retaining acceptable efficiency.

Polycystic ovarian disease: current insights into an old problem

Recent studies have led to significant advances in the understanding of the pathogenesis of polycystic ovary syndrome (PCOS), as well as to improvements in the treatment of the commonly associated symptoms. New data continue to implicate etiologic alterations in the hypothalamic-pituitary axis, beginning in the perimenarcheal period, as well as derangements in insulin and insulin-like growth factor metabolism. Current observations also support a role for an increase in adrenal androgen production and an increase in adrenal sensitivity to trophic hormone stimulation in the development of PCOS. Therapeutic regimens for those patients unsuccessfully treated with traditional approaches have been further validated, including the use of flutamide or gonadotropin-releasing hormone agonist-steroidal "add back" for the treatment of hirsutism. Novel approaches to the treatment of infertility are likewise discussed.