Transvaginal ultrasound-guided follicular aspiration in the management of anovulatory infertility associated with polycystic ovaries

Drug-free in-vitro activation of follicles for infertility treatment in poor ovarian response patients with decreased ovarian reserve

RESEARCH QUESTION

The recently developed in-vitro activation (IVA) approach provides a promising infertility treatment for patients with premature ovarian insufficiency. The IVA method promotes growth of residual ovarian follicles following ovarian tissue fragmentation leading to Hippo signalling disruption, together with in-vitro incubation with Akt stimulators. As poor ovarian response (POR) patients with decreased ovarian reserve (DOR) have multiple secondary follicles, this study tested whether Hippo signalling disruption alone using in-vitro ovarian cortical fragmentation, followed by autologous grafting, was sufficient to promote follicle growth.

DESIGN

A case series study.

RESULTS

In 9 out of 11 POR patients with DOR treated with a simplified IVA procedure, increases in antral follicle numbers in multiple growth waves were detected following FSH treatment. Subsequent injection with human chorionic gonadotrophin allowed retrieval of more mature oocytes for IVF (median antral follicle counts before and after IVA per ovarian stimulation: 1.0 versus 2.6) with 68.7% fertilization rates and 56.9% showing high-quality embryonic development. One natural conception and 16 embryo transfers in five patients resulted in one live birth, two ongoing pregnancies and one miscarriage. Three additional patients and the miscarriage patient have cryopreserved embryos for future transfer.

CONCLUSIONS

The present drug-free IVA approach may be suitable for POR patients with DOR, as it increased the number of antral follicles. The procedure also eliminated the need for 2-day incubation with drugs and required only one surgery. This approach could allow the retrieval of more oocytes in middle-aged women to achieve higher pregnancy rates and deserves proper evaluation in future randomized controlled trials.

The effect of ovarian puncture on the endocrine profile of PCOS patients who undergo IVM

BACKGROUND

To examine whether ovarian puncture for immature oocyte retrieval and in-vitro maturation (IVM) has an effect on the endocrine profile of patients with polycystic ovary syndrome (PCOS).

METHODS

Twenty-two consecutive patients with PCOS undergoing IVM treatment were included. Serum anti-Müllerian hormone (AMH), sex hormone-binding globulin (SHBG), total testosterone (TT) and luteinized hormone (LH) levels were analyzed at the start of the cycle, on the day of immature oocyte retrieval (OR) and at fixed intervals thereafter, for up to three months after OR.

RESULTS

Five days after OR circulating AMH, TT, calculated free testosterone (FTc), and LH levels were significantly reduced and circulating SHBG was significantly increased. Two weeks after OR, TT, FTc and LH remained reduced, whereas circulating AMH and SHBG levels recovered to pre-puncture values. Three months after OR, all circulating hormone levels had recovered to baseline values.

CONCLUSION

Ovarian puncture for the retrieval of immature oocytes and IVM in patients with PCOS has a significant impact on the ovarian endocrine profile, but this impact is brief and transient.

Ultrasound-guided transvaginal ovarian needle drilling (UTND) for treatment of polycystic ovary syndrome: a randomized controlled trial

OBJECTIVE

To evaluate the outcome of ovarian needle drilling using transvaginal ultrasound guidance as an alternative to the traditional laparoscopic electrosurgical drilling for patients with polycystic ovary syndrome (PCOS).

DESIGN

A randomized controlled study.

SETTING

University teaching hospital and private practice setting.

PATIENT(S)

The study comprised 163 patients with clomiphene-resistant PCOS.

INTERVENTION(S)

Patients were randomly allocated to either treatment with ultrasound-guided transvaginal needle ovarian drilling (UTND; n = 82) or laparoscopic electrosurgery ovarian drilling (n = 81).

MAIN OUTCOME MEASURE(S)

Hormonal changes (FSH, LH, T), ovulation and pregnancy.

RESULT(S)

There were no significant differences between the two groups with regard to body mass index, hormonal profiles, clinical manifestations, and ultrasound findings of PCOS. The duration of UTND was 15.3 +/- 5.61 minutes (10.5-22.3 minutes), while it was 25.6 +/- 8.2 minutes (20.3-38.1 minutes) in laparoscopic drilling, with a statistically significant difference between the two groups. There were no significant differences between the two groups with regard to resumption of normal menstruation, hirsutism, acne, ovulation, and pregnancy. UTND resulted in significant improvement in the ovulation, pregnancy, hirsutism, and acne. There were significant decreases in the serum LH and T levels but not in the FSH or LH/FSH levels after UTND as well.

CONCLUSION(S)

UTND can be adopted as an outpatient office procedure. The ease of scheduling, reduced costs, and rapid recovery suggest it as a first-line treatment for PCOS cases resistant to clomiphene citrate.

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.

Ovarian interstitial YAG-laser: an effective new method to manage anovulation in women with polycystic ovary syndrome

OBJECTIVE

This study was undertaken to assess the effectiveness of transvaginal ultrasound-guided ovarian interstitial laser-coagulation treatment in anovulatory women with polycystic ovary syndrome (PCOS).

STUDY DESIGN

Nineteen anovulatory women with clomiphene citrate-resistant PCOS underwent ultrasound-guided transvaginal ovarian interstitial YAG-laser treatment. In this study, serum hormonal level, spontaneous ovulation rate, and pregnancy rate were assessed.

RESULTS

With a spontaneous ovulation rate of 84.2%, 16 of 19 cases ovulated regularly during the 6-month postoperative period. The mean serums luteinizing hormone and serum testosterone levels in the second, fourth, and sixth postoperative months were significantly lower than preoperative levels: 5.87 +/- 2.04 IU/L versus 13.17 +/- 3.03 IU/L (P < .001) and 2.98 +/- 1.79 nmol/L versus 5.49 +/- 3.23 nmol/L (P < .001), respectively. The mean luteinizing hormone/follicle-stimulating hormone ratio was also significantly lower postoperatively at 1.09 +/- 0.30 compared with the preoperative 2.85 +/- 1.14 (P < .001). There was a cumulative pregnancy rate at 6 months of 32.3% (6/19) among the subjects. No significant operative complications were encountered.

CONCLUSION

The ultrasound-guided transvaginal ovarian interstitial laser treatment may be an effective new method to manage anovulation in PCOS patients.

Transvaginal, ultrasound-guided, ovarian, interstitial laser treatment in anovulatory women with clomifene-citrate-resistant polycystic ovary syndrome

OBJECTIVE

To assess the effectiveness of transvaginal, ultrasound-guided, ovarian, interstitial laser coagulation treatment in anovulatory women with polycystic ovary syndrome (PCOS).

DESIGN

A pilot study.

SETTING

Assisted reproductive technology unit.

SAMPLE

Twenty-three anovulatory women with clomifene-citrate-resistant PCOS.

METHODS

Ultrasound-guided, transvaginal, ovarian, interstitial yttrium-aluminium-garnet laser treatment.

MAIN OUTCOME MEASURES

Serum luteinizing hormone (LH), follicle-stimulating hormone (FSH), testosterone, prolactin and estradiol levels, spontaneous ovulation rate and pregnancy rate were measured over 6 months of follow up.

RESULTS

Regular ovulation occurred in 19 out of 22 (86.4%) women in the 6 months following ovarian treatment (one woman was lost to follow up). On the postoperative second, fourth and sixth month, the mean serum LH levels were 4.54 SD 1.21 iu/l, 4.90 SD 2.18 iu/l and 4.42 SD 1.03 iu/l, significantly (P < 0.001, P < 0.001, P < 0.001) lower than the preoperative level of 13.89 +/- 3.62 iu/l; the mean serum testosterone levels were 2.69 SD 1.83 nmol/l, 2.42 SD 1.11 nmol/l and 2.28 SD 1.96 nmol/l and significantly (P < 0.001, P < 0.001, P < 0.001) lower than the preoperative baseline value of 5.37 SD 3.09 nmol/l; the mean LH/FSH ratios of 0.93 SD 0.26, 0.88 SD 0.17 and 0.81 SD 0.14 were also significantly lower than the preoperative value of 2.78 SD 1.21 (P < 0.001). Pregnancy occurred in eight women and there was a cumulative pregnancy rate at 6 months of 36% (8/22) among the subjects. There were no significant operative complications.

CONCLUSION

Ultrasound-guided, transvaginal, ovarian, interstitial laser treatment appears effective in improving hormonal profiles and inducing ovulation and successful pregnancy in women with clomifene-resistant PCOS.

Follicular aspiration during the selection phase prevents severe ovarian hyperstimulation in patients with polycystic ovary syndrome who are undergoing in vitro fertilization

OBJECTIVE

The objective was to assess the effectiveness of follicular aspiration in the selection phase of infertile women with polycystic ovary syndrome (PCOS) under controlled ovarian hyperstimulation (COH).

STUDY DESIGN

In group A, 13 infertile patients with PCOS failed at previous IVF or intracytoplasmic sperm injection (ICSI) treatment due to ovarian hyperstimulation syndrome (OHSS; a total of 13 cycles). In group B, new IVF cycles with ultrasound-guided transvaginal follicular aspirations during the selection phase (a total of 13 cycles) were conducted using the same patients. No more than ten follicles remained in bilateral ovaries. Parameters monitored included ovarian size, number of dominant follicles, estradiol (E2) level on the day of human chorionic gonadotrophin (HCG) injection, maturation of oocytes, fertilization rate, cleavage rate, embryo implantation rate, pregnancy rate, and level of serum hormone.

RESULTS

In group B, the average number of follicles>or=12 mm and average serum E2 level were 15.5+/-4.0 and 9899+/-1430 pmol/l, respectively, which were significantly lower than 29.1+/-8.4 (P<0.001) and 15,544+/-1766 pmol/l (P<0.001) in group A. No cycles with moderate or severe OHSS occurred in group B, while nine out of 13 (69.2%) cycles did have this problem in group A. Oocyte maturation rate, fertilization rate and cleavage rate in group B were 80.7%, 76.9%, and 80.3%, respectively; and all of them are significantly higher than 56.4% (P<0.01), 58.7% (P<0.01), and 70.2% (P<0.02) respectively in group A.

CONCLUSION

Follicular aspiration during the selection phase can prevent severe OHSS and reduce OHSS prevalence in patients with PCOS undergoing COH.

Ultrasonographic guided ovarian stroma hydrocoagulation for ovarian stimulation in polycystic ovary syndrome

OBJECTIVE

To evaluate the safety and effectiveness of transvaginal ultrasound guided injection of hot saline into the ovarian stroma in polycystic ovary syndrome (PCOS) cases in an office based gynecology practice under local anesthesia.

SETTING

Outpatient gynecologic clinic.

STUDY DESIGN

Pilot study.

PARTICIPANTS

Fifty-two anovulatory infertile females diagnosed as PCOS by clinical, chemical and ultrasound criteria were recruited for the study. All cases were resistant to clomiphene citrate for more than 6 months.

INTERVENTION

Injection of warm sterile saline (75C) into the ovarian stroma under transvaginal monitoring using ovum pickup needle.

OUTCOME MEASURES

Cycle regularity, ovulation rate and safety were primary outcomes. Pregnancy rate and patient convenience were our secondary outcomes.

RESULTS

Ovulation has been achieved in 73.1% of clomiphene citrate resistant PCOS cases and resulted in pregnancy in 26.9% of these cases. No adverse effects were recorded and the procedure was tolerable in most cases.

CONCLUSION

Transvaginal ultrasound guided ovarian stroma hydrocoagulation (TOSH) in an office setting seems to be a safe, economic and practical procedure that is acceptable by the patients. If larger studies confirm its effectiveness it may be an attractive alternative to conventional ovarian drilling.

Transvaginal ovarian drilling: a new surgical treatment for improving the clinical outcome of assisted reproductive technologies in patients with polycystic ovary syndrome

OBJECTIVE

To evaluate the efficacy of transvaginal ovarian drilling (TVOD) in patients with polycystic ovary syndrome (PCOS) who were undergoing IVF treatment.

DESIGN

Pilot study.

SETTING

Reproductive medicine unit.

PATIENT(S)

Eleven patients with PCOS undergoing treatment with assisted reproductive technology (ART).

INTERVENTION(S)

Selection criterion for TVOD was repeated poor performance in > or =2 previous IVF cycles.

MAIN OUTCOME MEASURE(S)

Controlled ovarian hyperstimulation parameters, number of eggs collected, fertilization rate, embryo cleavage rate, implantation rate, pregnancy rate compared with the cycles before TVOD.

RESULT(S)

In the cycle after TVOD, a significantly higher dosage of FSH was used (33.5 +/- 12 IU vs. 52.2 +/- 15 IU) to collect a higher number of oocytes in the presence of similar E2 values at the day of hCG administration. This resulted in significantly higher fertilization and cleavage rates (27% vs. 66% and 54% vs. 72%, respectively). The pregnancy and the implantation rates after TVOD were similar to those for normovulatory patients undergoing IVF for tubal factor infertility during the study period.

CONCLUSION(S)

Our data suggest that the TVOD is effective in improving IVF results in difficult to treat patients with PCOS, and it is less invasive and less expensive when compared with laparoscopic ovarian diathermy.

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.

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

OBJECTIVE

Our purpose was to examine the efficacy of laser vaporization of the ovarian surface in polycystic ovary disease to reduce repeated ovarian hyperstimulation syndrome and thereby improve pregnancy outcome.

STUDY DESIGN

Twenty-six infertile patients with polycystic ovary disease who previously had ovarian hyperstimulation syndrome after stimulation with human menopausal gonadotropin and who failed to conceive were studied. All patients were treated by potassium titanyl phosphate and neodymium-yttrium-aluminum-garnet laser and evaluated. Patients not ovulating spontaneously after vaporization were treated with either clomiphene citrate or human menopausal gonadotropin.

RESULTS

After vaporization spontaneous ovulation was confirmed in six patients. For ovulation induction three patients received clomiphene citrate and 17 received human menopausal gonadotropin. Of the patients treated with human menopausal gonadotropin, mild ovarian hyperstimulation syndrome was found in three patients, and the incidence of ovarian hyperstimulation syndrome decreased significantly. Pregnancy was confirmed in 19 of 26 patients.

CONCLUSION

Laser vaporization is promising for the prevention of ovarian hyperstimulation syndrome and improving pregnancy outcome in patients with polycystic ovary disease who have previously had ovarian hyperstimulation syndrome.

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

OBJECTIVE

To provide an up-to-date comprehensive review of published data on laparoscopic methods of ovulation induction in the polycystic ovary syndrome (PCOS). Areas to be considered include the historical background of these procedures, their outcomes as reported in the literature, and their potential adverse effects. Through the careful review of these issues, some recommendations for clinical use and further study are offered.

DESIGN

Relevant studies were identified through a the search of a computerized bibliographic database of holdings in the National Library of Medicine as well as the manual scanning and cross-referencing of relevant medical journals.

RESULTS

Twenty-nine relevant studies were identified in the English language literature. These studies consist almost exclusively of uncontrolled case series. Pregnancies after laparoscopic ovulation induction procedures have been reported in an average of 55% of treated subjects (range 20% to 65%). Potential advantages of laparoscopic ovulation induction over gonadotropin therapy may include possible cost savings, serial repetitive ovulatory events resulting from a single treatment, no increased risk of ovarian hyperstimulation or multiple gestation, and the prospect for a higher live birth rate owing to a seemingly lower incidence of miscarriage. Reported adverse effects include a high rate of intra-abdominal adhesion formation and a single case of iatrogenic premature menopause due to postoperative ovarian atrophy.

CONCLUSIONS

The available circumstantial evidence suggests that laparoscopic procedures designed to induce ovulation may be of value in the PCOS subject who, despite an exhaustive trial of clomiphene citrate therapy, remains anovulatory and is unable or unwilling to undergo gonadotropin therapy. However, because of the risks of postoperative ovarian adhesions, carefully constructed controlled trials must be performed before these procedures can be viewed as efficacious and safe.

Reproductive health and polycystic ovary syndrome

Women with hyperandrogenic disorders represent a unique group among those with infertility due to anovulation. Although antiestrogens are effective in restoring ovulation in most women, it remains unclear whether these treatments restore fecundability per ovulatory cycle and the ability to maintain pregnancy in these individuals. Moreover, antiestrogens are ineffective in restoring ovulation in some hyperandrogenic anovulatory women, whose condition poses unique and vexing challenges for the infertility therapist. Gonadotropin treatment in antiestrogen-resistant women often leads to ovarian hyperstimulation syndrome, which has been addressed by modification of dosing schedules (e.g., low-dose administration), pretreatment with gonadotropin-releasing hormone (GnRH) analogs, and elimination of luteinizing hormone from the administered gonadotropins. Surgical reduction in ovarian volume has met with some success, although there may be a risk of inducing surgical adhesions of the adnexa. The second major reproductive adversity facing these patients is their elevated risk of endometrial cancer. Unopposed estrogen exposure probably contributes to this risk, but hyperandrogenicity and hyperinsulinism may act independently or in concert with estrogen to amplify the risk in these women. While the risks and strategies for preventive care in these women need to be better defined, reproductive health specialists are urged to continue using presently accepted measures, including education, to maintain these women's reproductive health.

Transvaginal ultrasonic assessment of the response to clomiphene citrate in polycystic ovarian syndrome

OBJECTIVE

To study the relationship between some ovarian morphological findings based on transvaginal ultrasound (US) and the clomiphene citrate (CC) responsiveness in patients with polycystic ovarian syndrome (PCOS).

DESIGN

A comparative study of ovarian US features between the CC responders and the CC nonresponders.

SETTING

Infertility and Endocrine Clinic, Department of Obstetrics Gynecology, Shimane Medical University Hospital, Izumo, Japan.

PATIENTS

Forty-seven infertile patients with PCOS and 30 healthy volunteers.

INTERVENTIONS

A dose of 50 to 200 mg/d CC was given for ovulation induction in patients with PCOS.

MAIN OUTCOME MEASURES

Ovarian volume and number of follicles; serum LH, FSH, T, delta 4 androstenedione, and DHEAS.

RESULTS

The mean ovarian volume (11.9 mL) and the number of small follicles (13.0) were significantly larger in the CC nonresponders compared with those of the CC responders (7.9 mL and 7.0, respectively). Only 47% of the CC responders and 79% of the CC nonresponders had bilaterally enlarged ovaries (> 6.2 mL). Considerable overlap existed between the different groups. However, 96% of the CC nonresponders had a significantly increased number of follicles (> or = 10 follicles) in each ovary compared with that (16%) of the CC responders. Furthermore, with the combination of these parameters, none of the CC nonresponders had bilaterally normal ovaries, and 96% of patients with PCOS with bilaterally abnormal ovaries were CC nonresponsive.

CONCLUSIONS

Small multiple follicles (> or = 10) and enlarged ovarian volume (> 6.2 mL) were the most prominent transvaginal US features of ovaries in patients with PCOS with CC nonresponsiveness. These US features could be clinically useful for distinguishing clearly a CC nonresponder from a CC responder.

Laparoscopic electrocoagulation of the ovarian surface in infertile patients with polycystic ovarian disease

OBJECTIVE

To assess the endocrinologic and clinical outcome after laparoscopic ovarian electrocautery because of polycystic reaction to ovarian stimulation in anovulatory infertility patients.

DESIGN

Between 1986 and 1989, 133 patients with polycystic ovarian disease underwent laparoscopic electrocoagulation of the ovarian surface in an outpatient clinic after conventional ovarian stimulation had led to polycystic reaction.

SETTING

All patients were referred to our outpatient clinic affiliated with the university hospital.

RESULTS

The reduction of androgen levels and normalization of cycle length were highly significant. The overall pregnancy rate was 70% (73 of 104), ranging from 27% in smokers to 94% in nonsmoking couples. In 26 second-look operations de novo adhesions were found in 26.9% of the patients.

CONCLUSION

Laparoscopic coagulation of the ovarian surface is an effective tool to reduce elevated androgen levels and to improve the intraovarian mechanism of selecting a dominant follicle. A postoperative complication may be adhesion formation.

Luteinized unruptured follicle in the early stages of endometriosis as a cause of unexplained infertility

OBJECTIVE

We attempted to clarify the relationship between luteinized unruptured follicle, which occurs in the early stages of endometriosis, and unexplained infertility.

STUDY DESIGN

Seventy patients who had unexplained infertility were reviewed.

RESULTS

Laparoscopic examination showed that 47 patients (67%) had endometriosis; of these, 40 (85%) had minimal or mild disease. The incidence of luteinized unruptured follicle was higher (p < 0.05) in patients who had endometriosis (35%/patient and 25%/cycle) compared with patients who did not have endometriosis (11%/patient and 7%/cycle). Degenerated oocyte cumuli were collected in 6 (43%) of 14 luteinized unruptured follicles diagnosed by transvaginal ultrasound.

CONCLUSIONS

These results show that luteinized unruptured follicle is common in patients who have mild or minimal endometriosis and that it may be one of the causes of endometriosis-associated infertility. Transvaginal ultrasound-guided follicular puncture of luteinized unruptured follicle during the mid luteal phase may be useful in establishing a definitive diagnosis of luteinized unruptured follicle.