Laser vaporization of the ovarian surface in polycystic ovary disease results in reduced ovarian hyperstimulation and improved pregnancy rates

The Role of Laser and Microwave in Treatment of Endocrine Disorders: A Systematic Review

Introduction: The treatment of endocrine problems like thyroid disease, diabetes mellitus (DM), and polycystic ovary syndrome (PCOS) faces significant challenges so that medical professionals worldwide try to find a new therapeutic approach. However, along with common treatments which include medications, hormone replacement therapy, and surgery; there is a growing interest in alternative therapies like laser therapy, which offers a non-invasive and unique technique for treating endocrine disorders alone or in combination with traditional methods. The main goal of this review was to do a systematic review on the role of the laser and Microwave in the treatment endocrine disorders. Methods: In the present systematic review, the most important databases, including PubMed, Scopus and Google Scholar, were searched for the studies examining the effect of lasers on the treatment of endocrine problems by using appropriate keywords and specific strategies from 1995 to 2023. All the studies that were not about lasers and endocrine were excluded. Results: Based on 51 reviewed studies, lasers and radiofrequency ablation such as RFA are effective in the treatment of thyroid diseases, hyperparathyroidism, pancreatic disorders, and sexual dysfunctions. Laser-induced interstitial thermal therapy (LITT) and microwave ablation (MWA) are genuine minimally invasive methods for the treatment of benign nodules, adenomas, and tumor ablation including pancreatic carcinomas and adrenal tumors. Intravenous laser blood irradiation (ILBI) which uses red, UV, and blue light could be effective in treating various metabolic disorders, such as DM. Conclusion: Laser as a cutting-edge and minimally invasive approach could treat various endocrine disorders. It has a great potential to treat and regulate hormonal imbalances, decrease inflammation, and relieve symptoms of various ailments, such as endocrine disorders.

How do red and infrared low-level lasers affect folliculogenesis cycle in rat's ovary tissue in comparison with clomiphene under in vivo condition

Folliculogenesis is a cycle that produces the majority of oocyte. Any disruption to this cycle leads to ovulation diseases, like polycystic ovarian syndrome (PCOS). Treatments include drugs and surgery; lasers have also been used complementarily. Meanwhile, still there is no definite treatment for PCOS. This study investigated the photo-bio stimulation effect of near-infrared and red low-level laser on producing follicles and compared the result with result of using common drug, clomiphene. Therefore, the aim of this study was to propose the use of lasers autonomously treatment. So, there was one question: how do lasers affect folliculogenesis cycle in rat’s ovary tissue? In this study, 28 rats were assigned to four groups as follows: control (CT), clomiphene drug (D), red laser (RL), and near-infrared laser (NIRL). Afterwards, 14 rats of RL and NIRL groups received laser on the first 2 days of estrous cycle, each 6 days, for 48 days. During treatment period, each rat received energy density of 5 J/cm². Seven rats in D group received clomiphene. After the experiment, lasers’ effects at two wavelengths of 630 and 810 nm groups have been investigated and compared with clomiphene and CT groups. Producing different follicles to complement folliculogenesis cycle increased in NIRL and RL groups, but this increase was significant only in the NIRL group. This indicates that NIRL increases ovarian activity to produce oocyte that certainly can be used in future studies for finding a cure to ovarian negligence to produce more oocyte and treat diseases caused by it like PCOS.

Effect of Laparoscopic Ovarian Drilling on Outcomes of In Vitro Fertilization in Clomiphene-Resistant Women with Polycystic Ovary Syndrome

BACKGROUND

Recently the laparoscopic ovarian drilling (LOD) has been used as a surgical treatment for ovulation in women with polycystic ovarian syndrome (PCOS), although its mechanism and outcomes are still unclear. This study was undertaken to evaluate the in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) outcomes in clomiphene-resistant women with PCOS who were treated with LOD.

MATERIALS AND METHODS

In this retrospective study, we reviewed the medical records of 300 women between 20 to 35 years old with clomiphene-resistant PCOS who had an ovulatory infertility and who were nominated for IVF/ICSI. Based on their treatment history, they were located into the following two groups: group I (n=150) including PCOS women who had history of LOD at least 6 months to 3 years before IVF/ICSI, and group II (n=150) including PCOS patients without history of drilling. Both groups were treated with antagonist protocol in the assisted reproductive technology (ART) process. The duration of treatment cycles, number of oocytes and embryos obtained, chemical and clinical pregnancy rate, the number of embryos transferred, and presence of ovarian hyper stimulation syndrome (OHSS) were measured. To compare means and frequencies, Student's t test, Mann-whitney and chi-square tests were used.

RESULTS

Our results showed that ovarian cauterization before IVF/ICSI in patients with PCOS reduced the risk of OHSS (P=0.025). Despite the same pregnancy rate in both groups (P=0.604), more obtained oocytes and embryos were seen on women without ovarian drilling than women with LOD (P˂0.001 and P=0.033, respectively).

CONCLUSION

There is no difference between the pregnancy rate in both groups. Due to significant reduction in OHSS in women undergoing LOD, this surgical treatment may be considered as a useful technique in the management of patients who have previously developed OHSS. However, there are ongoing concerns about long-term effects of LOD on ovarian function.

Consensus statement on prevention and detection of ovarian hyperstimulation syndrome

BACKGROUND

Ovarian hyperstimulation syndrome is an important condition with considerable morbidity and a small risk of mortality, which most commonly results as an iatrogenic condition following follicular stimulation of the ovaries.

AIM

To produce evidence-based and consensus statements on the prevention and detection of ovarian hyperstimulation syndrome (OHSS).

METHOD

The CREI Consensus Group met in 2008 and identified issues for inclusion and review. Review of the available evidence was conducted and consensus statements prepared. Areas of dissent of expert opinion and for further research were noted.

RESULTS

The group considered that there is a need for standardisation of the definition and classification of the clinical syndrome of OHSS to allow further conclusive research. Interventions with evidence of effect in reducing OHSS include the use of metformin in women with PCOS, use of GnRH antagonist rather than GnRH agonist and use of GnRH agonist triggers in GnRH antagonist stimulation cycles. The consensus view was that reducing the dose of FSH, freezing all embryos and transferring a single embryo were appropriate interventions to reduce OHSS. Agreement could not be reached on coasting, the lowest number of oocytes to consider freezing all embryos and management after cancellation of oocyte collection.

CONCLUSION

OHSS is a serious condition for which there are a number of proven preventative strategies. OHSS is an area requiring ongoing research and development of a universally agreed definition will allow development of optimal prevention strategies and facilitate improved early detection of women at risk.

[Ovarian hyperstimulation syndrome: pathophysiology, risk factors, prevention, diagnosis and treatment]

The ovarian hyperstimulation syndrome is a major complication of ovulation induction for in vitro fertilization, with severe morbidity and possible mortality. Whereas its pathophysiology remains ill-established, the VEGF may play a key role as well as coagulation disturbances. Risk factors for severe OHSS may be related to patients characteristics or to the management of the ovarian stimulation. Two types of OHSS are usually distinguished: the early OHSS, immediately following the ovulation triggering and a later and more severe one, occurring in case of pregnancy. As no etiologic treatment is available, the therapeutic management of OHSS should focus on its related-complications. Thrombotic complications that can occur in venous or arterial vessels represent the major risk of OHSS, possibly conducting to myocardial infarction and cerebrovascular accidents. Once the OHSS is diagnosed, prevention of thrombotic accidents remains the major issue.

Does coasting, a procedure to avoid ovarian hyperstimulation syndrome, affect assisted reproduction cycle outcome?

OBJECTIVE

To evaluate the effects of coasting (withdrawing gonadotropin administration) on IVF outcome.

DESIGN

Retrospective study.

SETTING

Department of Infertility of Zekai Tahir Burak Women's Health Research and Education Hospital.

PATIENT(S)

Ninety-four patients in whom coasting was applied (group 1). One control group consisted of 22 patients in whom coasting was not applied despite E(2) > 3000 pg/mL (group 2). A control group consisted of 111 normally responsive patients with peak E(2) < 3000 pg/mL level (group 3).

INTERVENTION(S)

When E(2) levels were greater than 3000 pg/mL in the presence of at least 20 follicles, each measuring >or=10 mm in diameter with >or=20% of them of diameter >or=15 mm, recombinant FSH administration was discontinued while GnRH agonist was maintained.

MAIN OUTCOME MEASURE(S)

Hormonal characteristics, IVF outcome, OHSS in coasted and noncoasted groups.

RESULT(S)

There was no statistically significant difference between number of total oocytes retrieved, metaphase II oocytes, and fertilization rates among the group 1 vs. group 2. However, the implantation rates and pregnancy rates were significantly higher in group 1 compared with group 2. Group 1 had more total oocytes retrieved and metaphase II oocytes compared with group 3. However, there was no significant difference in implantation and pregnancy rates between groups 1 and 3.

CONCLUSION(S)

Coasting does not adversely affect assisted reproductive technology outcome and can be applied safely to high responder patients in ICSI.

Why does ovarian surgery in PCOS help? Insight into the endocrine implications of ovarian surgery for ovulation induction in polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a complex disorder with heterogeneity of clinical and endocrine features. Ovarian surgery for ovulation induction has been used in the management of clomiphene citrate-resistant anovulatory women with PCOS. Various types of ovarian surgery have been employed (wedge resection, electrocautery, laser vaporization, multiple ovarian biopsies and others) and all procedures result in an altered endocrine profile after surgery. The mechanism behind the reversal of endocrinological dysfunction in PCOS after ovarian surgery remains incompletely understood. This review scans the literature systematically to identify the endocrine changes after ovarian surgery in PCOS, in order to glean some knowledge of the mechanism involved. After ovarian surgery in PCOS, a rapid reduction in serum levels of all ovarian hormones is seen, in combination with increased serum levels of pituitary hormones. Folliculogenesis is then initiated and ovarian hormone production increases, synchronically with a reduction of pituitary hormones. Continuation of follicle growth in subsequent cycles after ovarian surgery occurs in an environment with less androgens and lower LH and FSH levels compared with pretreatment levels. The endocrine changes found after ovarian surgery in PCOS women seem to be governed by the ovaries themselves. Rapid reduced secretion of all ovarian hormones restores feedback to the hypothalamus and pituitary, resulting in appropriate gonadotrophin secretion. Initiation of follicular development seems to be induced by increasing FSH levels following a reduction of the follicle excess and (intra-ovarian) androgen levels. Additionally, anti-Müllerian hormone and gonadotrophin surge attenuating factor probably have a role in the endocrine changes.

Surgical or medical treatment of polycystic ovary syndrome: a cost-benefit analysis

With the availability of laparoscopic ovarian cautery, there has been a resurgence in interest in the surgical treatment of clomiphene citrate-resistant polycystic ovary syndrome (PCOS). Comparison of ovulation and pregnancy rates has found no difference in success rates between ovarian cautery and gonadotropin ovulation induction for such women. We have therefore compared the cost of laparoscopic ovarian cautery with that of a typical cycle of gonadotropin ovulation induction, and also found that there is little difference. Because of the potential advantages of ovarian cautery, we recommend this surgery as the next line of treatment if clomiphene citrate fails to induce ovulation in PCOS patients, before gonadotropins are introduced.

Early unilateral follicular aspiration compared with coasting for the prevention of severe ovarian hyperstimulation syndrome: a prospective randomized study

Thirty women undergoing in-vitro fertilization or intracytoplasmic sperm injection considered to be at high risk of ovarian hyperstimulation syndrome (OHSS) were randomly allocated to have early unilateral follicular aspiration (EUFA) (group 1) or coasting (group 2) when the serum oestradiol concentration was >6000 pg/ml and there were more than 15 follicles each of >/=18 mm diameter in each ovary. EUFA was performed in group 1 at 10-12 h after the human chorionic gonadotrophin (HCG) trigger injection and human menopausal gonadotrophin (HMG) were withheld for 4.9 +/- 1.6 days until serum oestradiol concentrations fell below 3000 pg/ml when HCG was administered. The mean total dose and duration of administration of HMG were similar in groups 1 and 2 (48.3 +/- 17.4 and 50.2 +/- 16.5 ampoules; 13.7 +/- 2.2 and 14.1 +/- 3.2 days respectively). The mean serum oestradiol concentrations (9911 pg/ml versus 10 055 pg/ml) and number of follicles (43.3 versus 41.4) seen in both ovaries on the day of HCG administration in group 1 and on the day coasting was commenced in group 2 were also similar. After coasting, the mean serum oestradiol concentration on the day of HCG administration in group 2 was lower than in group 1 (1410 pg/ml versus 9911 pg/ml; P < 0.001). The mean serum progesterone concentrations on the day of HCG administration in both groups were similar, and fell in all women in group 2. The mean number of oocytes retrieved and percentage of oocytes retrieved per follicle punctured was significantly higher in group 1 (15.4 +/- 2.1 versus 9.6 +/- 3.2, P < 0.001; 91.4 +/- 4.4% versus 28.3 +/- 3.7%, P < 0.001 respectively). The fertilization and embryo cleavage rates were similar in both groups. Clinical pregnancy was diagnosed in 6/15 (40%) patients in group 1 and in 5/15 (33%) patients in group 2, while four women in group 1 and three in group 2 developed severe OHSS.

Surgical management of polycystic ovarian syndrome

The objective of this chapter is to review the role of surgical management of polycystic ovarian syndrome in infertile women. Pertinent studies and their references were identified through computer medline search. To date there is no standardization of the technique of laparoscopic ovarian drilling. However, it appears that the results are promising, with a high ovulation rate ranging between 70% and 90% and a pregnancy rate of 70%. Clomiphene citrate remains the first line of treatment to induce ovulation in infertile women with polycystic ovarian syndrome. Laparoscopic ovarian drilling can be offered to clomiphene-resistant women, especially to those who have also failed to respond to gonadotrophin treatment or who have experienced ovarian hyperstimulation syndrome. It appears that the pregnancy rate after ovarian drilling is comparable with that for gonadotrophin therapy. However, until more complete and long-term data are available, caution must be exercised when offering this type of treatment.

Ovulatory cycles, pregnancy outcome and complications after surgical treatment of polycystic ovary syndrome

The purpose of this review is to survey the literature on the various laparoscopic surgical techniques for ovulation induction in polycystic ovary syndrome (PCOS) patients (multiple biopsies, electrocauterization, laser vaporization, ovarian resection), compared with traditional ovarian resection by laparotomy. Relevant studies were identified through a search of a computerized bibliographic database and cross-referencing of relevant medical journals. Data regarding 1803 anovulatory PCOS patients have been analyzed, 679 of them treated by classical ovarian resection after laparotomy, 720 by laparoscopic electrocauterization, 322 by laparoscopic laser vaporization, and 82 by laparoscopic multiple biopsies. The percentages of miscarriages, twin pregnancies, and ectopic pregnancies have been calculated analyzing 1076 pregnancies achieved spontaneously or after medical therapy after failure of various surgical attempts. The percentage of adhesions has been calculated among 343 patients submitted to second-look surgery. All of the surgical techniques proved equally effective, with an average ovulation rate of 78.8 percent, a cumulative pregnancy rate of 58.5 percent, a miscarriage rate of 15.9 percent, a twin pregnancy rate of 2.1 percent, and an ectopic pregnancy rate of 1.6 percent. Hormone variations after surgery consisted in a remarkable fall in serum androgen levels (androstenedione and testosterone), in an FSH increase, reduced biological activity and reduced amplitude of LH pulses, and an LH/FSH ratio trending toward normal levels. Moreover, after surgery, the ovaries showed higher responsiveness to drug-induced ovulation. Adhesions were less frequent after laparoscopic multiple biopsies, but they were observed in about 90 percent of patients after resection by laparotomy, in 30 percent of patients after laparoscopic electrocauterization, and in 50 percent after laparoscopic laser vaporization. In conclusion, at present laparoscopic methods for inducing ovulation can be performed in PCOS infertile patients if medical treatment fails to give the desired results. However, additional controlled trials are required to assess the long-term effects of these procedures.

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.

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.

Indications for laparoscopic surgery of ovarian tumors

To investigate the criteria for laparoscopic surgery in ovarian tumors, a retrospective review of indications, preoperative assessments using transvaginal ultrasonography, serum CA 125, surgical methods and diagnosis and post-operative complications were analyzed. Forty-three patients underwent surgical treatment for ovarian tumors, from November 1992 to October 1993. Of the 43 patients with ovarian tumors, 19 (44%) underwent laparoscopic surgery, and 24 (56%) underwent laparotomy. Laparoscopic surgery was performed in 18 of 34 (53%) patients with benign ovarian cysts. Eight patients with malignant ovarian tumors were treated by laparotomy. Coincidence of preoperative assessment and surgical diagnosis was 95%. No major complications were observed in the laparoscopic surgery. We suggest that malignant ovarian tumors and inextricable adhesions are contraindications to laparoscopic surgery. We propose the following criteria for laparoscopic surgery by classification into three groups: A) good indication: benign cystic tumors with good mobility, B) deliberation indication: benign tumors with poor mobility, including some dermoid cysts and endometrial cysts, C) contraindication: malignant tumors and dense adhesions. We conclude that indications of laparoscopic surgery for ovarian tumors should be determined by careful preoperative assessment using transvaginal ultrasonography and tumor markers.