Evaluation of adhesion formation after laparoscopic treatment of polycystic ovarian disease

Ovulation induction techniques in women with polycystic ovary syndrome

Anovulation is very common and has several different clinical manifestations, including amenorrhea, oligomenorrhea and abnormal uterine bleeding. Various mechanisms can cause anovulation. The clinical consequences and commonest chronic anovulatory disorder, polycystic ovary syndrome (PCOS), has a prevalence that ranges between 6 to 10% of the global population. While multiple causes can eventually result in PCOS, various methods have been described in the literature for its management, often without ascertaining the underlying cause. Ovulation Induction (OI) is a group of techniques that is used in women with PCOS who are looking to conceive and are unbale to do so with natural means. This narrative review presents a summary of the current evidence and available techniques for OI in women with PCOS, highlighting their performance and applicability.

Laparoscopic ovarian drilling for ovulation induction in women with anovulatory polycystic ovary syndrome

BACKGROUND

Polycystic ovary syndrome (PCOS) is a common condition affecting 8% to 13% of reproductive-aged women. In the past clomiphene citrate (CC) used to be the first-line treatment in women with PCOS. Ovulation induction with letrozole should be the first-line treatment according to new guidelines, but the use of letrozole is off-label. Consequently, CC is still commonly used. Approximately 20% of women on CC do not ovulate. Women who are CC-resistant can be treated with gonadotrophins or other medical ovulation-induction agents. These medications are not always successful, can be time-consuming and can cause adverse events like multiple pregnancies and cycle cancellation due to an excessive response. Laparoscopic ovarian drilling (LOD) is a surgical alternative to medical treatment. There are risks associated with surgery, such as complications from anaesthesia, infection, and adhesions.

OBJECTIVES

To evaluate the effectiveness and safety of LOD with or without medical ovulation induction compared with medical ovulation induction alone for women with anovulatory polycystic PCOS and CC-resistance.

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility Group (CGFG) trials register, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL and two trials registers up to 8 October 2019, together with reference checking and contact with study authors and experts in the field to identify additional studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of women with anovulatory PCOS and CC resistance who underwent LOD with or without medical ovulation induction versus medical ovulation induction alone, LOD with assisted reproductive technologies (ART) versus ART, LOD with second-look laparoscopy versus expectant management, or different techniques of LOD.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, assessed risks of bias, extracted data and evaluated the quality of the evidence using the GRADE method. The primary effectiveness outcome was live birth and the primary safety outcome was multiple pregnancy. Pregnancy, miscarriage, ovarian hyperstimulation syndrome (OHSS), ovulation, costs, and quality of life were secondary outcomes.

MAIN RESULTS

This updated review includes 38 trials (3326 women). The evidence was very low- to moderate-quality; the main limitations were due to poor reporting of study methods, with downgrading for risks of bias (randomisation and allocation concealment) and lack of blinding. Laparoscopic ovarian drilling with or without medical ovulation induction versus medical ovulation induction alone Pooled results suggest LOD may decrease live birth slightly when compared with medical ovulation induction alone (odds ratio (OR) 0.71, 95% confidence interval (CI) 0.54 to 0.92; 9 studies, 1015 women; I² = 0%; low-quality evidence). The evidence suggest that if the chance of live birth following medical ovulation induction alone is 42%, the chance following LOD would be between 28% and 40%. The sensitivity analysis restricted to only RCTs with low risk of selection bias suggested there is uncertainty whether there is a difference between the treatments (OR 0.90, 95% CI 0.59 to 1.36; 4 studies, 415 women; I² = 0%, low-quality evidence). LOD probably reduces multiple pregnancy rates (Peto OR 0.34, 95% CI 0.18 to 0.66; 14 studies, 1161 women; I² = 2%; moderate-quality evidence). This suggests that if we assume the risk of multiple pregnancy following medical ovulation induction is 5.0%, the risk following LOD would be between 0.9% and 3.4%. Restricting to RCTs that followed women for six months after LOD and six cycles of ovulation induction only, the results for live birth were consistent with the main analysis. There may be little or no difference between the treatments for the likelihood of a clinical pregnancy (OR 0.86, 95% CI 0.72 to 1.03; 21 studies, 2016 women; I² = 19%; low-quality evidence). There is uncertainty about the effect of LOD compared with ovulation induction alone on miscarriage (OR 1.11, 95% CI 0.78 to 1.59; 19 studies, 1909 women; I² = 0%; low-quality evidence). OHSS was a very rare event. LOD may reduce OHSS (Peto OR 0.25, 95% CI 0.07 to 0.91; 8 studies, 722 women; I² = 0%; low-quality evidence). Unilateral LOD versus bilateral LOD Due to the small sample size, the quality of evidence is insufficient to justify a conclusion on live birth (OR 0.83, 95% CI 0.24 to 2.78; 1 study, 44 women; very low-quality evidence). There were no data available on multiple pregnancy. The likelihood of a clinical pregnancy is uncertain between the treatments, due to the quality of the evidence and the large heterogeneity between the studies (OR 0.57, 95% CI 0.39 to 0.84; 7 studies, 470 women; I² = 60%, very low-quality evidence). Due to the small sample size, the quality of evidence is not sufficient to justify a conclusion on miscarriage (OR 1.02, 95% CI 0.31 to 3.33; 2 studies, 131 women; I² = 0%; very low-quality evidence). Other comparisons Due to lack of evidence and very low-quality data there is uncertainty whether there is a difference for any of the following comparisons: LOD with IVF versus IVF, LOD with second-look laparoscopy versus expectant management, monopolar versus bipolar LOD, and adjusted thermal dose versus fixed thermal dose.

AUTHORS' CONCLUSIONS

Laparoscopic ovarian drilling with and without medical ovulation induction may decrease the live birth rate in women with anovulatory PCOS and CC resistance compared with medical ovulation induction alone. But the sensitivity analysis restricted to only RCTs at low risk of selection bias suggests there is uncertainty whether there is a difference between the treatments, due to uncertainty around the estimate. Moderate-quality evidence shows that LOD probably reduces the number of multiple pregnancy. Low-quality evidence suggests that there may be little or no difference between the treatments for the likelihood of a clinical pregnancy, and there is uncertainty about the effect of LOD compared with ovulation induction alone on miscarriage. LOD may result in less OHSS. The quality of evidence is insufficient to justify a conclusion on live birth, clinical pregnancy or miscarriage rate for the analysis of unilateral LOD versus bilateral LOD. There were no data available on multiple pregnancy.

Comparison between Unilateral and Bilateral Ovarian Drilling in Clomiphene Citrate Resistance Polycystic Ovary Syndrome Patients: A Randomized Clinical Trial of Efficacy

Background

Laparoscopic ovarian drilling (LOD) is an alternative method to induce ovulation in polycystic ovary syndrome (PCOS) patients with clomiphene citrate (CC) resistant instead of gonadotropins. This study aimed to compare the efficacy of unilateral LOD (ULOD) versus bilateral LOD (BLOD) in CC resistance PCOS patients in terms of ovulation and pregnancy rates.

Materials and Methods

In a prospective randomized clinical trial study, we included 100 PCOS patients with CC resistance attending to Al-Zahra Hospital in Rasht, Guilan Province, Iran, from June 2011 to July 2012. Patients were randomly divided into two ULOD and BLOD groups with equal numbers. The clinical and biochemical responses on ovulation and pregnancy rates were assessed over a 6-month follow-up period.

Results

Differences in baseline characteristics of patients between two groups prior to laparoscopy were not significant (p>0.05). There were no significant differences between the two groups in terms of clinical and biochemical responses, spontaneous menstruation (66.1 vs. 71.1%), spontaneous ovulation rate (60 vs. 64.4%), and pregnancy rate (33.1 vs. 40%) (p>0.05). Following drilling, there was a significant decrease in mean serum concentrations of luteinizing hormone (LH) (p=0.001) and testosterone (p=0.001) in both the groups. Mean decrease in serum LH (p=0.322) and testosterone concentrations (p=0.079) were not statistically significant between two groups. Mean serum level of follicle stimulating hormone (FSH) did not change significantly in two groups after LOD (p>0.05).

Conclusion

Based on results of this study, ULOD seems to be equally efficacious as BLOD in terms of ovulation and pregnancy rates (Registration Number: IRCT138903291306N2).

Laparoscopic drilling by diathermy or laser for ovulation induction in anovulatory polycystic ovary syndrome

BACKGROUND

Surgical ovarian wedge resection was the first established treatment for women with anovulatory polycystic ovary syndrome (PCOS) but was largely abandoned both due to the risk of postsurgical adhesions and the introduction of medical ovulation induction. However, women with PCOS who are treated with medical ovulation induction, with drugs such as gonadotrophins, often have an over-production of follicles which may result in ovarian hyperstimulation syndrome and multiple pregnancies. Moreover, gonadotrophins, though effective, are costly and time-consuming and their use requires intensive monitoring. Surgical therapy with laparoscopic ovarian 'drilling' (LOD) may avoid or reduce the need for medical ovulation induction, or may facilitate its usefulness. The procedure can be done on an outpatient basis with less trauma and fewer postoperative adhesions than with traditional surgical approaches. Many uncontrolled observational studies have claimed that ovarian drilling is followed, at least temporarily, by a high rate of spontaneous ovulation and conception, or that subsequent medical ovulation induction becomes easier.

OBJECTIVES

To determine the effectiveness and safety of laparoscopic ovarian drilling compared with ovulation induction for subfertile women with clomiphene-resistant PCOS.

SEARCH METHODS

We used the search strategy of the Menstrual Disorders and Subfertility Group (MDSG) to search the MDSG Trials Register, CENTRAL, MEDLINE, EMBASE, CINAHL and PsycINFO. The keywords included polycystic ovary syndrome, laparoscopic ovarian drilling, electrocautery and diathermy. Searches were conducted in September 2011, and a further search of the MDSG Trials Register was made on 14 May 2012.

SELECTION CRITERIA

We included randomised controlled trials of subfertile women with clomiphene-resistant PCOS who undertook laparoscopic ovarian drilling in order to induce ovulation.

DATA COLLECTION AND ANALYSIS

This is an update of a previously updated review. There were nine RCTs in the previous version; an additional 16 trials were added in the current (2012) update. All trials were assessed for quality. The primary outcomes were live birth and multiple pregnancy. The secondary outcomes were rate of miscarriage, ovulation and pregnancy rates, ovarian hyperstimulation syndrome (OHSS), quality of life and cost.

MAIN RESULTS

Nine trials, including 1210 women, reported on the primary outcome of live birth rate per couple. Live births were reported in 34% of women in the LOD groups and 38% in other medical treatment groups. There were five different comparisons with LOD and there was no evidence of a difference in live births when compared with clomiphene citrate + tamoxifen (OR 0.81; 95% CI 0.42 to 1.53; P = 0.51, 1 trial, n = 150), gonadotrophins (OR 0.97; 95% CI 0.59 to 1.59; P = 0.89, I(2) = 0%, 2 trials, n = 318), aromatase inhibitors (OR 0.84; 95% CI 0.54 to 1.31; P = 0.44, I(2) = 0%, 2 trials, n = 407) or clomiphene citrate (OR 1.21; 95%CI 0.64 to 2.32; 1 trial, n=176, P= 0.05). There was evidence of significantly fewer live births following LOD compared with clomiphene citrate + metformin (OR 0.44; 95% CI 0.24 to 0.82; P = 0.01, I(2) = 78%, 2 trials, n = 159); the high heterogeneity in this subgroup could not be explained by population differences or differences in quality of the trials.Thirteen trials reported on multiple pregnancies (n= 1305 women). There were no cases of multiple pregnancies in either group for clomiphene citrate or aromatase inhibitors compared with LOD. The rate of multiple pregnancies was significantly lower in the LOD group compared with trials using gonadotrophins (OR 0.13; 95% CI 0.03 to 0.52; P=0.004, I(2) = 0%, 5 trials, n = 166).

AUTHORS' CONCLUSIONS

There was no evidence of a significant difference in rates of clinical pregnancy, live birth or miscarriage in women with clomiphene-resistant PCOS undergoing LOD compared to other medical treatments. The reduction in multiple pregnancy rates in women undergoing LOD makes this option attractive. However, there are ongoing concerns about the long-term effects of LOD on ovarian function.

Achieving a successful pregnancy in women with polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a disease of complex and still poorly understood cause and of variable phenotypes. It is characterized by anovulation, hyperandrogenism, and polycystic ovaries. Infertility is commonly present. A variety of methods has been used successfully to achieve pregnancy in women with PCOS. Maintenance of pregnancy is complicated by a higher rate of premature spontaneous abortions and high risk of gestational diabetes, hypertension, and preeclampsia. However, with careful monitoring and treatment, the outcome of pregnancy in most women with PCOS is excellent.

Surgical Approach for Polycystic Ovarian Syndrome in Management of Infertility

BACKGROUND

In patients with Polycystic Ovarian Syndrome (PCOS), resolution of infertility is an important goal of treatment. Wedge resection of the ovaries described as a means to achieve this was practiced in the middle of twentieth century. With the advent of endoscopic surgery, surgical approach for the same condition has been modified. Multi point biopsy, multiple needle puncture, electofulguration and laser fulguration are being tried in the context of PCOS. This project was taken up to evaluate the scope of electo fulguration in clomiphene resistant PCOS.

METHODS

Forty patients who did not show sonographic evidence of ovulation with clomiphene citrate (CC) 100mg OD for 05 days in two cycles were subjected to laparoscopy. The patients who did not show any pelvic factor for infertility were alternately assigned to electro - fulguration treatment of ovaries or no fulguration during laparoscopy. These were designated as 'Lap EC' & 'Only CC' group respectively. For 'Only CC' group' stimulation with CC was continued for four cycles with a higher dose 150 mg OD for 05 days. Lap EC group were subjected to CC 100mg OD for 5 days for two cycles in case of non achievement of ovulation in the first two drug free cycles following EC. Folliculometry, HCG administration and Intra Uterine Insemination (IUI) was performed for both groups.

RESULTS

Total percentage of ovulatory cycles were 51.8% in EC group compared to 5.26% in the CC group. Overall pregnancy rate of 30% was achieved in the Lap EC group as compared to only 10% in the CC group (p<0.05).

CONCLUSION

Laparoscopic electrofulguration of ovaries increases the chances of ovulation and conception. This being a cheaper one time procedure as compared to other expensive ovulation inducing agents, should be the preferred mode and the primary procedure wherever polycystic ovaries are encountered while evaluating a case of infertility by laparoscopy.

Coagulation versus excision of primary superficial endometriosis: a 2-year follow-up

OBJECTIVE

Even the common mild forms of endometriosis can strongly affect quality of life due to dysmenorrhea, dyspareunia, dyschezia, or subfertility. We compared the effectiveness of the two laparoscopic methods, coagulation versus excision, for intraperitoneal superficial endometriosis with regard to recurrence and symptom control.

STUDY DESIGN

In a retrospective analysis we evaluated the postoperative follow-up of 79 patients, aged 16-42, with superficial manifestation of endometriosis (median rASRM score 9.2) operated on in the Department of Gynecology and Obstetrics at the Jena University Hospital. Forty-three patients were treated by electrocoagulation and 36 underwent sharp excision. Therapy success was evaluated by using a questionnaire after a mean follow-up of 29 months. Patients were interviewed about pain associated with endometriosis such as dysmenorrhea, dyspareunia, dyschezia and possible medical treatment after surgery. We evaluated the number of surgically proven relapses and questionnaire results using a pain score on an ordinal scale (1-5) for the three categories dysmenorrhea, dyspareunia, and dyschezia.

RESULTS

Both treatment methods resulted in a low number of endometriosis-related symptoms after surgical intervention and in recurrences of 2.8% in the coagulation group and 18.6% in the excision group. The recurrence rate in the coagulation group was lower (p=0.001). The coagulation group was also presented with a significantly lower postoperative pain score at our long-term follow-up (p=0.0067).

CONCLUSION

In cases of superficial endometriosis, laparoscopic surgery achieved low recurrence rates and good symptom control. Compared to sharp excision the use of bipolar electrocoagulation might result in fewer endometriosis-related symptoms as well as fewer relapses with need for surgical re-intervention after a more than 2-year interval. Due to the retrospective, non-randomized character of this study the results should be interpreted carefully. Further prospective studies are needed to assess the value of both surgical approaches in the treatment of endometriosis.

Laparoscopic redo surgery for recurrent hepatocellular carcinoma in cirrhotic patients: feasibility, safety, and results

BACKGROUND

Recurrence of cancer and the need for several surgical treatments are the Achilles' heel of the treatment for hepatocellular carcinoma (HCC) in cases of cirrhosis. The difficulty of reintervention is increased by the formation of adhesions after the previous hepatectomy that can make a new surgical procedure more difficult and less safe. With a minimally invasive approach, the formation of postoperative adhesions seems to be minimized, and the adhesiolysis procedure seems to be faster and safer in terms of blood loss and risk of visceral injuries.

METHODS

This report describes a series of 15 patients submitted to a laparoscopic reintervention (hepatic resection or radiofrequency ablation) for a recurrence of HCC after a previous open (group 1) or laparoscopic (group 2) procedure for a primary tumor. It aims to explain the feasibility, safety, and results of repeated laparoscopic liver surgery.

RESULTS

The rates for overall postoperative mortality and morbidity were respectively 0% and 26.6% (4/15). No patients had a severe postoperative complication. Only one patient in group 2 presented with moderate ascites postoperatively, whereas two patients in group 1 reported atelectasis requiring physiotherapy and one experienced pneumonia, which was treated with antibiotics. In this series, the findings indicated that patients submitted first to an open hepatic resection (group 1) experience more intraabdominal adhesions. Moreover, in group 1, hypervascularized adhesions typical of cirrhotic patients were several and thicker, with a major potential risk of bleeding and bowel injuries at the time of reintervention. Although for group 2 the length of the intervention was shorter, for group 1, the operating times and safety in terms of bowel injuries were acceptable, demonstrating the feasibility of iterative laparoscopic surgery also for cirrhotic patients previously treated by the open surgical approach. The operative time for the second surgical procedure was shorter and the adhesiolysis easier for the patients previously treated with the laparoscopic approach (group 2). This underscores the advantages of the minimally invasive approach for managing the long oncologic history of cirrhotic patients.

CONCLUSION

Laparoscopic redo surgery for recurrent HCC in cirrhotic patients is a safe and feasible procedure with good short-term outcomes, but further prospective studies are needed to support these results.

Evaluation of ovarian adhesion formation after laparoscopic ovarian drilling by second-look minilaparoscopy

OBJECTIVE

To determine the incidence, site, and grade of ovarian adhesion formation after laparoscopic ovarian drilling (LOD) and analyze the association between the number of punctures made and the incidence and grade of adhesions, and evaluate the lateral distribution of the adhesions.

DESIGN

Prospective clinical study.

SETTING

University hospital endocrine and infertility center.

PATIENT(S)

Ninety-six anovulatory infertile women with polycystic ovarian syndrome (PCOS) treated with LOD.

INTERVENTION(S)

Women were randomized into two study groups of 48 women each, one treated with 6 punctures on the left ovary and 12 on the right, and the other treated with 6 punctures on the right ovary and 12 on the left. A short-term second-look minilaparoscopy was performed to evaluate postsurgical adhesion formation.

MAIN OUTCOME MEASURE(S)

[1] Evaluation of the incidence and grade (thin, dense, cohesive) of ovarian adhesions; [2] comparative analysis of the incidence and grade of ovarian adhesions between ovaries treated with 6 and 12 punctures; and [3] comparative analysis of the incidence and grade of ovarian adhesions between the two sides.

RESULT(S)

Adhesion formation was detected in 54 of the 90 women (60%) and in 83 of the 180 ovaries treated (46%). Dense adhesions were more likely to develop on the left ovaries to a statistically significant extent, and independently of the number of ovarian punctures performed (odds ratio [OR] = 4.34, 95% confidence interval [CI] = 1.72-10.94). Logistic regression analysis showed that the incidence of ovarian adhesions was independent of both number of punctures (OR = 1.05, 95% CI = 0.58-1.88) and side (OR = 1.37, 95% CI = 0.76-2.46).

CONCLUSION(S)

The incidence of ovarian adhesion formation after LOD was high, and their extent and severity was not influenced by the number of ovarian punctures; however, the left ovary appeared more prone to develop severe adhesions than the contralateral one.

Laparoscopic 'drilling' by diathermy or laser for ovulation induction in anovulatory polycystic ovary syndrome

BACKGROUND

Surgical ovarian wedge resection was the first established treatment for women with anovulatory polycystic ovary syndrome (PCOS) but was largely abandoned due to the risk of postsurgical adhesions and the introduction of medical ovulation induction with clomiphene and gonadotrophins. However, women with PCOS who are treated with gonadotrophins often have an over-production of follicles which may result in ovarian hyperstimulation syndrome (OHSS) and multiple pregnancies. Moreover, gonadotrophins, though effective, are costly and time-consuming requiring intensive monitoring. Surgical therapy with laparoscopic ovarian 'drilling' (LOD) may avoid or reduce the need for gonadotrophins or may facilitate their usefulness. The procedure can be done on an outpatient basis with less trauma and fewer postoperative adhesions than with traditional surgical approaches. Many uncontrolled observational studies have claimed that ovarian drilling is followed, at least temporarily, by a high rate of spontaneous ovulation and conception or that subsequent medical ovulation induction becomes easier.

OBJECTIVES

To determine the effectiveness and safety of laparoscopic ovarian drilling compared with ovulation induction for subfertile women with clomiphene-resistant PCOS.

SEARCH STRATEGY

We used the search strategy of the Menstrual Disorders and Subfertility Group.

SELECTION CRITERIA

We included randomised controlled trials of subfertile women with clomiphene-resistant PCOS who undertook laparoscopic ovarian drilling in order to induce ovulation.

DATA COLLECTION AND ANALYSIS

Sixteen trials were identified and nine were included in the review. All trials were assessed for quality criteria. The primary outcomes were live birth, ovulation and pregnancy rates and the secondary outcomes were rates of miscarriage, multiple pregnancy, ovarian hyperstimulation syndrome and cost.

MAIN RESULTS

There was no evidence of a difference in live birth or clinical pregnancy rate between LOD and gonadotrophins and the pooled odds ratios (OR) (all studies) were 1.04 (95% CI 0.59 to 1.85) and 1.08 (95% CI 0.69 to 1.71) respectively. Multiple pregnancy rates were lower with ovarian drilling than with gonadotrophins (1% versus 16%; OR 0.13, 95% CI 0.03 to 0.52). There was no evidence of a difference in miscarriage rates between the two groups (OR 0.81, 95% 0.36 to 1.86).

AUTHORS' CONCLUSIONS

There was no evidence of a difference in the live birth rate and miscarriage rate in women with clomiphene-resistant PCOS undergoing LOD compared to gonadotrophin treatment. The reduction in multiple pregnancy rates in women undergoing LOD makes this option attractive. However, there are ongoing concerns about long-term effects of LOD on ovarian function.

Efficacy of laparoscopic ovarian drilling for polycystic ovary syndrome resistant to clomiphene citrate

AIM

It is difficult to induce ovulation in patients with polycystic ovary syndrome (PCOS) resistant to clomiphene citrate (CC) because of the narrow safety margin of human menopausal gonadotropin preparations. In the present study, patients diagnosed as having PCOS according to the Japanese diagnostic criteria were divided into two groups (Groups H and N). Testosterone level was used as a cut-off value between Groups H and N to examine the usefulness of laparoscopic ovarian drilling (LOD) to induce ovulation.

METHODS

Thirty-two women with PCOS resistant to CC who underwent LOD were evaluated. The patients were divided into a high and a normal androgen group (Groups H and N with 19 and 13 patients, respectively) based on the level of testosterone measured 1 week before surgery using a cut-off value of 50 ng/dL. LOD was performed with microlaparoscopy under intravenous anesthesia.

RESULTS

After LOD, spontaneous ovulation occurred in 16 (84.2%) and nine (69.2%) patients in Groups H and N, respectively. Additional treatment with CC was given to 12 (63.2%) and 11 (84.6%) patients, respectively. No significant difference was noted with regard to the spontaneous ovulation rate after LOD. Eighteen pregnancies were established in 17 patients (53.1%). The pregnancy rate after LOD was not significantly different between Groups H and N: 42.1% (8 patients) and 76.9% (10 patients), respectively.

CONCLUSION

Patients with PCOS as diagnosed based on the Japanese diagnostic criteria include those with increased and normal androgen levels. LOD is considered an effective ovulation induction method for both types of patients with PCOS.

Surgical treatment in polycystic ovary syndrome

PURPOSE OF REVIEW

The purpose of this review is to provide a critical summary of current knowledge on the role and effectiveness of ovarian surgery in the treatment of polycystic ovary syndrome.

RECENT FINDINGS

Clomiphene citrate is used as a first-line treatment for ovulation induction in infertile anovulatory patients with polycystic ovary syndrome. In clomiphene citrate-resistant women, other treatment modalities such as laparoscopic electrocautery or ovulation induction with gonadotropins have been proposed as alternative therapies. Although gonadotropin treatment and laparoscopic ovarian drilling have demonstrated similar reproductive outcomes, laparoscopic ovarian drilling has some advantages over gonadotropin treatment such as lower cost per pregnancy, improvement in menstrual regularity, and better long-term reproductive performance. On the other hand, knowledge about the pathogenesis of polycystic ovary syndrome has been growing and insulin-sensitizing drugs have gained popularity as a new treatment option.

SUMMARY

According to current data, metformin has gained popularity as first-line management in clomiphene citrate-resistant women with polycystic ovary syndrome. If ovulation does not occur within several months after treatment with metformin, after the evaluation of all pros and cons related to each treatment, laparoscopic ovarian drilling or gonadotropins may be considered as an effective option according to patient choice.

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.

Hyperprolactinemia after laparoscopic ovarian drilling: an unknown phenomenon

BACKGROUND

The effects of ovarian drilling on the serum levels of gonadotropins and androgens have been studied previously. The aim of this study is to evaluate the effects of ovarian drilling on the serum prolactin levels and its relation to ovulation in women with polycystic ovary syndrome.

METHODS

This is a prospective controlled study. Thirty-six women with PCOS underwent ovarian electrocauterization in university hospitals. Control group consisted of 35 ovulatory women with unexplained infertility. Hormonal assessment performed in early follicular phase of spontaneous or induced cycle before operation in the two groups and repeated one week after operation. Hormonal assay was also performed in the early follicular phase of the first post-operative menstruation, folliculometry and progesterone assay were also performed in the same cycle. Data were analyzed by "repeated measurement design, discriminant analysis, correlation coefficient, and Fisher exact test".

RESULTS

Six to ten weeks after operation the serum mean +/- SD prolactin levels increased from 284.41 +/- 114.32 mIU/ml to 354.06 +/- 204.42 mIU/ml (P = 0.011). The same values for the control group were 277.73 +/- 114.65 to 277.4 +/- 111.4 (P = 0.981) respectively. Approximately 45% of subjects in PCOS group remained anovulatory in spite of decreased level of LH and testosterone. Prolactin level remained elevated in 73.2% of women who did not ovulate 6-10 weeks after the procedure.

CONCLUSION

Hyperprolactinemia after ovarian cauterization may be considered as a possible cause of anovulation in women with polycystic ovaries and improved gonadotropin and androgen levels. The cause of hyperprolactinemia is unknown. Hormonal assay particularly PRL in anovulatory patients after ovarian cauterization is recommended.

Evaluation of a new surgical approach for the treatment of clomiphene citrate-resistant infertility in polycystic ovary syndrome: Laparoscopic ovarian multi-needle intervention

Laparoscopic ovarian drilling (LOD) is the accepted second-line treatment for clomiphene citrate-resistant anovulatory infertility in polycystic ovary syndrome (PCOS). Although multiple pregnancy rates are reduced with ovarian drilling procedures, postoperative adhesion formation is a potential complication in up to 85% of the women subjected to laparoscopic destructive ovarian procedures. Our objective was to determine the effectiveness of a new, specially designed laparoscopic device and technique that might enable treatment for patients with anovulatory PCOS with less trauma and fewer postoperative adhesions. Thirty-five infertile clomiphene citrate-resistant women with PCOS were included. Seventeen women underwent laparoscopic ovarian multi-needle intervention (LOMNI), and 18 women received step-up ovulation induction treatment with recombinant follicle-stimulating hormone followed by intrauterine insemination for three cycles. Patients were followed for a period of 6 months after either laparoscopic surgery or the initiation of ovulation induction therapy. Outcome measures were cycle regularity, pregnancy rate, safety, postoperative adhesion formation, and cost effectiveness. There were no significant differences between the two groups in terms of age, body-mass index, duration of infertility, and basal cycle-day 2 hormone levels. Significant improvement in cycle regularity (p <.01) was found after LOMNI. Cumulative pregnancy rates (35.3% in the LOMNI group vs 33.3% in the ovulation induction group) did not differ between the groups. No adverse events following surgery were noted. Moderate ovarian hyperstimulation syndrome and multiple pregnancies occurred in four and two patients, respectively, in the ovulation induction group. Eight nonpregnant women in the LOMNI group underwent repeat laparoscopy at the end of the follow-up period. No adhesion formation attributable to LOMNI was observed in any of those eight women. The cost of LOMNI was significantly (p <.001) lower than the ovulation induction treatment. In conclusion, LOMNI may be a safe, inexpensive, and effective procedure for the treatment of CC-resistant infertility in patients with PCOS. It seems to preserve the beneficial effects and probably omits unwanted effects (such as adhesion formation) of LOD.

Laparoscopic "drilling" by diathermy or laser for ovulation induction in anovulatory polycystic ovary syndrome

BACKGROUND

Problems in inducing ovulation in women with polycystic ovary syndrome (PCOS) and anovulation (failure to ovulate) are well recognised. Surgical ovarian wedge resection was the first established treatment for anovulatory PCOS patients but was largely abandoned due to the risk of post-surgical adhesions and the introduction of medical ovulation induction with clomiphene and gonadotrophins. However patients with PCOS treated with gonadotrophins often have an over-production of follicles and are exposed to the risks of ovarian hyperstimulation syndrome (OHSS) and multiple pregnancy. Moreover ovulation induction with gonadotrophins, though effective, is an expensive, inconvenient and time-consuming treatment requiring intensive monitoring. Surgical therapy with laparoscopic ovarian "drilling" (LOD) may avoid or reduce the need for gonadotrophins or may facilitate their use. The procedure can be done on an outpatient basis with less trauma and fewer postoperative adhesions. Many uncontrolled observational studies have claimed that ovarian drilling is followed, at least temporarily, by a high rate of spontaneous ovulation and conception, and/or that subsequent medical ovulation induction becomes easier.

OBJECTIVES

To determine the effectiveness and safety of laparoscopic ovarian drilling compared with ovulation induction for subfertile women with clomiphene-resistant PCOS.

SEARCH STRATEGY

We used the search strategy of the Menstrual Disorders and Subfertility Group.

SELECTION CRITERIA

We included randomised controlled trials of subfertile women with clomiphene-resistant PCOS that undertook laparoscopic ovarian drilling in order to induce ovulation.

DATA COLLECTION AND ANALYSIS

Fifteen trials were identified and six were included in the review. All trials were assessed for quality criteria. The primary outcomes were live birth, ovulation and pregnancy rates and the secondary outcomes were rates of miscarriage, multiple pregnancy, ovarian hyperstimulation syndrome and cost.

MAIN RESULTS

There was no evidence of a difference in live births or ongoing pregnancies between LOD and gonadotrophins and the pooled Odds Ratio (OR) (all studies) was 1.04 (95% CI 0.74, 1.99) and 1.16 (95% CI 0.72, 1.86) respectively. Multiple pregnancy rates were lower with ovarian drilling than with gonadotrophins (1% vs 16%, OR: 0.13, 95% CI: 0.03 to 0.59). There was no evidence of a difference in miscarriage rates between the two groups (OR 0.81, 955% 0.36, 1.86).

AUTHORS' CONCLUSIONS

There was no evidence of a difference in the live birth rate and miscarriage rate in women with clomiphene resistant PCOS undergoing LOD compared to gonadotrophin treatment. The reduction in multiple pregnancy rates in women undergoing LOD makes this option attractive. However, there are ongoing concerns about long term effects of LOD on ovarian function.

Predictors for treatment failure after laparoscopic electrocautery of the ovaries in women with clomiphene citrate resistant polycystic ovary syndrome

BACKGROUND

Laparoscopic electrocautery has been put forward as the treatment of choice in women with clomiphene citrate (CC)-resistant polycystic ovary syndrome (PCOS). In order to make an informed treatment decision it would be helpful if we could identify women with PCOS with a high probability of treatment failure following electrocautery of the ovaries.

METHODS

Eighty-three women with CC-resistant PCOS were allocated to receive laparoscopic electrocautery followed by CC when anovulation persisted as part of a randomized controlled trial. Multivariable logistic regression analyses using clinical, ultrasonographic and endocrinological parameters were performed to predict (i) failure to ovulate within 8 weeks after electrocautery, and (ii) failure to reach an ongoing pregnancy after electrocautery with or without CC.

RESULTS

Of the 83 women, 56 (67%) ovulated within 8 weeks after electrocautery. The model for predicting anovulation after electrocautery included LH/FSH rate, year of menarche and glucose level. Women who were younger at menarche, had a lower LH/FSH ratio and a lower glucose level were more likely to have persistent anovulation. The area under the curve was 0.74. After electrocautery and CC, 41 women reached an ongoing pregnancy. No prognostic parameters could be identified to predict failure to reach an ongoing pregnancy after electrocautery followed by CC.

CONCLUSIONS

Persistence of anovulation after electrocautery could be predicted and women with a high risk of persisting anovulation could be distinguished. We were, however, not able to predict treatment failure after electrocautery followed by CC.

Laparoscopic ovarian drilling in polycystic ovary syndrome

BACKGROUND AND OBJECTIVE

Patients with polycystic ovary syndrome (PCOS) treated with gonadotrophins often have a polyfollicular response and are exposed to the risks of ovarian hyperstimulation syndrome (OHSS) and multiple pregnancy. The aim of the present study was to evaluate the efficacy of laparoscopic ovarian drilling (LOD) on the endocrinologic, clinical parameters and reproductive outcome of clomiphene-resistant anovulatory infertile patients with PCOS using monopolar diathermy.

MATERIAL AND METHODS

Forty-five clomiphene-resistant anovulatory women with PCOS have participated in the study. Serum testosterone (T), follicle stimulating hormone (FSH) and luteinizing hormone (LH), fasting insulin and glucose levels, body mass indexes, modified Ferriman Gallwey (FG) hirsutism scores of the subjects are recorded before and after the procedure. Endocrinologic and clinical profile and reproductive outcome of the patients were analysed.

RESULTS

Ovarian drilling was successfully employed without any surgical complications and mean +/- S.D. duration of follow-up time was 29.73 +/- 10.64 months. In the follow-up period 93.3% of the subjects were recorded to have regular cycles and 64.4% pregnancy rate was achieved, spontaneously. The serum levels of T, free T, LH, LH:FSH ratio, insulin and FG scores were significantly reduced after LOD, although glucose levels and glucose/insulin ratio remained unchanged.

CONCLUSION

In choosing ovulation induction method in clomiphene resistant PCOS patients, LOD may avoid or reduce the risk of OHSS and multiple pregnancy than gonadotrophins with the same success rate of conception. The high pregnancy rate, and economic aspect of the procedure offer an attractive management for patients with PCOS.

Management of Infertility in Women with Polycystic Ovary Syndrome

The management of infertility in women with polycystic ovary syndrome (PCOS) centers around options for inducing ovulation. This is an evidence-based review of the management of PCOS, which includes a MEDLINE search of publications between 1986 and May 2005 and a search of the Cochrane Database. Weight loss, exercise, and metformin will induce ovulation in many insulin-resistant women and obese women with PCOS, and should always be the first-line treatment. Ovulation induction has been performed with clomiphene citrate (clomifene) as the first-line treatment, but the use of aromatase inhibitors has been shown to be as successful. The strategies for reducing the risks of gonadotropin therapy such as low-dose follicle-stimulating hormone (FSH) stimulation and the addition of metformin are discussed. Both gonadotropin releasing-hormone agonists and antagonists are equally effective in in vitro fertilization stimulation in conjunction with FSH therapy. Metformin may have a benefit in pregnancy in reducing the risks of miscarriage and diabetes mellitus; however, prospective trials are still lacking.

Laparoscopic treatment of polycystic ovaries: is its place diminishing?

PURPOSE OF REVIEW

The purpose of this review is to provide a critical discussion on the place of laparoscopic ovarian drilling and medical treatment with metformin for polycystic ovary syndrome.

RECENT FINDINGS

Laparoscopic ovarian drilling remains popular. It is associated with an ovulation rate of approximately 80% and a pregnancy rate of 50-60% within 1 year of the procedure. The technique results in a decrease in ovarian stromal blood flow. An increasing amount of data, however, suggests that treatment with metformin is equally as effective. The use of metformin in pregnancy appears to be safe; it decreases the miscarriage rate and possibly the incidence of gestational diabetes.

SUMMARY

Laparoscopic ovarian drilling and metformin improve ovulatory dysfunction and pregnancy rate to a similar extent. The advantages of metformin continue beyond conception. It reduces the miscarriage rate and also decreases the likelihood of developing gestational diabetes. A randomized trial comparing the effects of metformin and laparoscopic ovarian drilling in women with polycystic ovary syndrome is recommended.

Is ovulation induction still a therapeutic problem in patients with polycystic ovary syndrome?

Polycystic ovary syndrome (PCOS) is one of the most common endocrine diseases affecting women of fertile age, and is characterized by hyperandrogenism, chronic anovulatory cycles and oligomenorrhea or amenorrhea. Given the repercussions of chronic anovulation on sterility, PCOS is a heavy social burden. Here we describe the procedures used to induce ovulation in PCOS patients, the surgical approach and medical treatments that are still being experimented.

Review of nonsurgical and surgical treatment and the role of insulin-sensitizing agents in the management of infertile women with polycystic ovary syndrome

OBJECTIVES

To review the nonsurgical and surgical treatment and the role of insulin-sensitizing agents in the management of anovulatory infertile women with polycystic ovary syndrome (PCOS).

MATERIALS AND METHODS

The search term of subfertile women with anovulation and PCOS was used for identification of randomized controlled trials. Nonrandomized controlled studies were identified through computer MEDLINE and EMBASE searches for the years 1980-2002.

RESULTS

For obese PCOS women weight loss of > 5% of pretreatment weight restores menstrual regularity in 89%, of whom 30% achieved spontaneous pregnancy. It was estimated that 75-80% of anovulatory PCOS women will respond to clomiphene citrate (CC) and 35-50% will achieve pregnancy. For CC-resistant PCOS women (20-25%), CC + metformin (1.5 g/day) for 3-6 months has a 70% chance of restoration of regular menses and ovulation, and a 23% chance of pregnancy. Laparoscopic ovarian drilling (LOD) can be offered to CC-resistant PCOS women. There was no statistically significant difference in the ovulation rate following LOD with electrocoagulation and laser [83% vs. 77.5%; odds ratio (OR) 1.4; 95% CI 0.9-2.1], while there was a significantly higher cumulative pregnancy rate at 12 months after surgery (65% vs. 54.5%; OR 1.5; 95% CI 1.1-2.1).

CONCLUSION

Diet and exercise followed by CC should be used for nonsurgical ovulation induction. For CC-resistant PCOS women, metformin may be included in a stepwise approach before a surgical approach. LOD with electrocautery is superior to laser drilling and gonadotropin therapy.

Laparoscopic treatment of polycystic ovaries: is it time to relinquish the procedure?

OBJECTIVE

To evaluate the role of laparoscopic ovarian drilling and treatment with metformin in the management of the polycystic ovary syndrome (PCOS).

DESIGN

A literature search was conducted using the keywords laparoscopy, laparoscopic ovarian drilling, laparoscopic ovarian diathermy, PCOS, metformin, and ovulation. The MEDLINE and EMBASE databases and the Cochrane Database of Systematic Reviews were searched.

RESULTS

No randomized comparisons have been done between laparoscopic ovarian drilling and metformin therapy. However, the ovulation and pregnancy rates appear to be similar for both techniques. Both treatments decrease the incidence of ovarian hyperstimulation and the cancellation rate of IVF cycles. However, unlike laparoscopic ovarian drilling, metformin may decrease the incidence of type 2 diabetes and coronary heart disease.

CONCLUSION(S)

Given the similar magnitude of the results without the potential risks and complication of surgery, we propose that laparoscopic ovarian drilling should be used sparingly in favor of less invasive treatment with metformin.

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.

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.

Treatment of the infertile patient with polycystic ovarian syndrome

Polycystic ovarian syndrome is associated with infertility due to anovulation caused by this disorder. Many treatments can increase both ovulation and fertility rates in these women. This is a comprehensive review of the literature, with an emphasis on randomized controlled trials of the medical and surgical treatment options for women with polycystic ovarian syndrome and infertility. Both standard and novel treatments are addressed. In the past, clomiphene citrate was the first-line medical treatment for subfertility in these women, followed by gonadotropins with or without gonadotropin releasing-hormone agonists for those women with clomiphene-resistance. Surgical treatments such as ovarian drilling were occasionally added to these regimens. The introduction of the insulin-sensitizing agents as adjuvants to clomiphene citrate and gonadotropins has changed the treatment strategy. The evidence in support of this change will be discussed. Data on the use of glucocorticoids, opioid receptor antagonists, and antiandrogens as adjuvants to standard therapies, as well as surgical treatments such as wedge resection and ovarian drilling will also be discussed. Based upon the evidence, medical treatment remains the primary therapy for women with this syndrome, especially in light of the recent introduction of insulin-sensitizing agents to the treatment armamentarium. These drugs have allowed us to develop less aggressive therapies that are safer and easier for women to utilize, and may in the future become the primary treatment for women with this syndrome.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader will be able to explain the pathophysiology of PCOS, to list the factors that predispose women to develop PCOS, and to outline the treatment regiments for PCOS-associated infertility.

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.

Reduction of post-surgical adhesions with ferric hyaluronate gel: a European study

BACKGROUND

The objective of this study was to assess the safety and efficacy of a 0.5% ferric hyaluronate gel, in reducing adhesions in patients undergoing peritoneal cavity surgery by laparotomy, with a planned 'second-look' laparoscopy.

METHODS

The study was a randomized (by computer-generated schedule), third party blinded, placebo-controlled, parallel-group design conducted at five centres in Europe. Females aged 18-46 years received 300 ml ferric hyaluronate (n = 38) or lactated Ringer's (n = 39) as an intraperitoneal instillate at the completion of surgery. At second-look 6-12 weeks later, the presence of adhesions was evaluated at 24 abdominal sites.

RESULTS

Patients treated with ferric hyaluronate had significantly fewer adhesions compared with controls. When adhesions formed, they were significantly less extensive and less severe in the treated group. The American Fertility Society score for adnexal adhesions was reduced by 69% in the treatment group compared with controls. The safety profile of ferric hyaluronate-treated patients was comparable with those treated with lactated Ringer's solution.

CONCLUSIONS

In conclusion, ferric hyaluronate was safe and highly efficacious in reducing the number, severity and extent of adhesions throughout the abdomen following peritoneal cavity surgery.

Reduction of postsurgical adhesions with Intergel adhesion prevention solution: a multicenter study of safety and efficacy after conservative gynecologic surgery

OBJECTIVE

To assess the safety and efficacy of the Intergel adhesion prevention solution, a 0.5% ferric hyaluronate gel, in reducing adhesions in patients undergoing peritoneal cavity surgery by laparotomy with a planned second-look laparoscopy.

DESIGN

Randomized, third-party blinded, placebo-controlled, parallel group.

SETTING

Eleven centers in the United States, and five centers in Europe.

PATIENT(S)

Women aged 18-46 years who wanted to retain their fertility.

INTERVENTION(S)

Patients received 300 mL of Intergel solution (n = 143) or lactated Ringer's solution (n = 138) as an intraperitoneal instillate at the completion of surgery.

MAIN OUTCOME MEASURE(S)

At second-look laparoscopy 6-12 weeks later, the presence of adhesions was evaluated at 24 abdominal sites.

RESULT(S)

Patients treated with Intergel solution (n = 131) had significantly less adhesions compared to controls (n = 134). Adhesion extent and severity were also significantly reduced. The American Fertility Society score for adnexal adhesions was reduced 59% in the patients in whom the Intergel solution was used. The safety profile of the patients treated with the Intergel solution was comparable to those treated with lactated Ringer's solution.

CONCLUSION(S)

The Intergel solution was safe and highly efficacious in reducing the number, severity, and extent of adhesions throughout the abdomen after peritoneal cavity surgery.

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.

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.

The rates of adhesion development and the effects of crystalloid solutions on adhesion development in pelvic surgery

OBJECTIVE

To document rates of adhesion development after abdomino-pelvic surgery, stratified by adhesion type, access method, and use of crystalloid solution instillates.

DESIGN

Reports from a MEDLINE search (1/1/1966-12/18/1996) detailing rates of adhesion development and meeting the inclusion criteria were subjected to meta-analysis.

SETTING

Meta-analysis.

PATIENT(S)

Patients undergoing abdomino-pelvic surgery.

INTERVENTION(S)

Intraperitoneal crystalloid solution instillates.

MAIN OUTCOME MEASURE(S)

Percentage adhesion-free outcome in patients ("patients") or surgical sites ("sites").

RESULT(S)

Adhesion-free outcome (sites) was lowest for reformed (26.3% laparotomy; 14.3% laparoscopy), higher for de novo 1b (direct trauma) (45.2% laparotomy, 37.2% laparoscopy), and highest for de novo 1a (indirect trauma) adhesions (82.4% laparoscopy). Crystalloid solution instillates reduced adhesion-free outcome at sites (45.2% versus 20% de novo 1b adhesions in laparotomy) and in patients (43.5% versus 19.9% reformed, laparotomy; 71.7% versus 25% de novo 1b, laparoscopy).

CONCLUSION(S)

Adhesion-free outcome was lowest for reformed, higher for de novo 1b, and highest for de novo 1a adhesions. Surprisingly, it was lower in laparoscopy than in laparotomy for de novo 1b and reformed adhesions. Crystalloid instillates did not increase adhesion-free outcome. Although limited by the retrospective and heterogeneous nature of the data, these conclusions nonetheless provide a basis on which to formulate future hypotheses.

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.

Clinical problem of intraperitoneal postsurgical adhesion formation following general surgery and the use of adhesion prevention barriers

Because of multiple studies demonstrating barrier efficacy, adhesion prevention adjuvants have received widespread acceptance in appropriate surgical settings. Many investigators are incorporating adhesion prevention barriers into their routine clinical practice and are achieving good results. Although both Seprafilm and Interceed barriers were shown to be safe and effective in all human clinical trials, their use did not eliminate adhesions in all patients. Efficacy of these barriers is limited to surgical situations in which the area in question can be completely covered. Physician acceptance is constrained by technical difficulties, including the need for hemostasis and removal of excess peritoneal fluid (Interceed), as well as limitations in application and handling properties within the surgical field (Seprafilm).

Laparoscopic ovarian treatment in infertile patients with polycystic ovarian syndrome (PCOS): endocrine changes and clinical outcome

During the years 1991-1994, 97 anovulatory infertile women with polycystic ovarian syndrome (PCOS) were treated with laparoscopic electrocautery of the ovarian surface after they had failed to ovulate under ovarian stimulation. To assess the endocrinological and clinical outcome and in an attempt to determine the mechanism of action, the serum levels of luteinizing hormone (LH), follicle-stimulating hormone (FSH), androstenedione, testosterone and dehydroepiandrosterone sulfate (DHEAS) were determined before and after laparoscopic ovarian cautery. Fifty regularly cycling women undergoing laparoscopy for investigation of infertility or tubal ligation served as controls. In patients with PCOS but not in controls, the reduction of androgen levels and normalization of cycle length were highly significant. In contrast, LH and FSH levels rose during the first 2 days after the operation. These results resemble those reported after ovarian wedge resection. Ovulation was obtained in 90% (81 of 90) and pregnancy in 81.1% (73 of 90) of the patients; that increased to 84.4%, including the non-responders (nine patients) treated with clomiphene citrate (CC), after electrocautery. The response to ovarian electrocautery was influenced by body weight, with an ovulation rate of 95-96% in the slim and moderately obese women, decreasing to 81-82% in the really obese ones. When ovulation was established, the pregnancy rate was independent of body weight. However, a striking relationship was detected between smoking habits and pregnancy rate subsequent to ovarian electrocautery, ranging from 24% in smokers to 92% in non-smoking couples. In 30 second-look operations, de novo adhesions were found in 23.3% of the patients (7 of 30). Therefore, ovarian electrocautery is an effective procedure to improve the intraovarian mechanism of selecting a dominant follicle for patients with PCOS in whom initial medical management fails, and it appears to be one of the possible treatments for this disease. A possible postoperative complication may be adhesion formation that seem to be lower than after ovarian wedge resection.

Treatment of polycystic ovary disease with laparoscopic low-watt bipolar electrocoagulation of the ovaries

STUDY OBJECTIVE

To assess the efficacy of laparoscopic low-watt bipolar electrocoagulation of the ovaries in women with polycystic ovary disease (PCOD).

DESIGN

Prospective case series.

SETTING

Hospital-based infertility clinic.

PATIENTS

Seventy-four consecutive infertile women with PCOD resistant to conventional ovulation-induction regimens.

INTERVENTIONS

Laparoscopic bipolar low-watt electrocoagulation of the ovarian surface (25 W for 5-12 sec/cyst).

MEASUREMENTS AND MAIN RESULTS

Postoperative follow-up ranged from 18 months to 7 years. Menstrual rhythm returned to normal in all 74 women. All 40 women in whom infertility was solely due to anovulation eventually conceived. Overall, 62 (84%) of the 74 women conceived, 42 spontaneously after surgery and 20 after supplementation with clomiphene. These 62 women had a total of 93 pregnancies: 79 singleton live births, 4 sets of twins, and 10 miscarriages. Twenty-five women conceived twice and three conceived three times. At second-look laparoscopy or cesarean section in 20 women, fine stringlike adhesions on the ovaries were found in 2.

CONCLUSION

Laparoscopic low-watt bipolar electrocoagulation of the ovaries is an effective treatment for women with PCOD who fail medical therapy.

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.

Endoscopic surgery in gynecologic practice

In recent decades, the operative approach for several gynecologic diseases has changed from laparotomy to laparoscopy. New techniques and indications are continuously being developed. Laparoscopy offers a lot of advantages for the patient, but still a lot of additional data are required to determine the exact indications. Operative laparoscopy requires not only skill and experience, but also specialized equipment and paramedical staff. The most important topics for the gynecologist will be reviewed in this article.

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.

Operative laparoscopy: surgical modalities

OBJECTIVE

To review basic physics of different surgical modalities and their clinical applications and outcomes.

DESIGN

The relevant literature and personal experience were used to prepare the manuscript.

RESULTS

Operative laparoscopy is safe and effective whether using sharp dissection, electrosurgical, or laser energy. The newer surgical modalities, including the vibrating ultrasound scalpel and argon beam coagulator, need further evaluation.

CONCLUSIONS

The results of laparoscopic surgery are independent of the surgical modality used. The surgeon's skill and experience, his or her preference of the technique, and proper patient selection play a more important role.

Laparoscopic surgery of chronic hyperandrogenic anovulation

The review describes briefly the clinical and endocrinological characteristics of chronic hyperandrogenic anovulation (CHA), as well as ovulation induction by hormone therapy (therapy of first choice) and by classical wedge resection. The main purpose of this study, however, is to compare different laparoscopic treatments of CHA, with emphasis on laser treatments by argon, CO2, Nd:YAG, and frequency-doubled Nd:YAG laser. The overall results of laparoscopic treatments in hormone-therapy-resistant patients with CHA are encouraging and the results are comparable. In the studies considered in this review, ovulation was induced for longer or shorter periods in 21 out of 31 patients (68%) after ovarian biopsy, in 57 out of 73 patients (78%) after electrosurgery, and in 82 out of 118 patients (70%) after laser treatment. Subsequent conception occurred in 44%, 40%, and in 41% of the patients, respectively. Of interest is the fact that some hormone-therapy-resistant patients become sensitive to Clomiphene after laparoscopic treatment, giving an overall percentage of ovulation and an overall pregnancy rate of 89% and 54%, respectively, for electrosurgery, and of 88% and 50%, respectively, for laser treatment. Unfortunately, adhesion formation, a serious complication of surgical treatment of the ovaries, is still a drawback using laparoscopic surgical techniques.

Prevention of adhesions

A survey is given on the literature of the prevention of adhesions. Various methods of adhesion prevention are discussed: limitation of peritoneal injury, inhibition of the inflammatory response, prevention of coagulation of fibrinogen, removal of fibrin and mechanical separation of injured mesothelial surfaces.