Outcomes of subsequent IVF cycles among women with PCOS after the first unstimulated IVM treatment: a single-center matched retrospective case-control study

OBJECTIVE

In-vitro maturation (IVM) is an advanced technique and an alternative to conventional in-vitro fertilization (IVF). It is safe, effective, and cost-effective in patients with polycystic ovary syndrome (PCOS). However, no clinical guidelines state that IVM could work without compromised pregnancy outcomes in patients with PCOS. The purpose of this study was to identify whether previous unstimulated IVM improved the clinical outcomes of women with PCOS in the subsequent IVF cycle.

METHODS

In this matched retrospective case-control study, we compared the results of IVF treatment in two groups of women with PCOS between January 2008 and December 2017. The study group comprised 79 women who underwent a subsequent IVF treatment after IVM failure (IVM-IVF group). Considering the year, age, and BMI, a 1:3 matched control group of 237 women with PCOS who received their first IVF cycle was established (IVF group).

RESULTS

Compared with the IVF group, the IVM-IVF group had a significantly lower initial gonadotropin dose [112.5 IU (112.5-150 IU) vs. 150 IU (150-200 IU), p < 0.001] and total gonadotropin dose [1350 IU (1125-2162.5 IU) vs. 1875 IU (1425.00-2643.75 IU), p < 0.001]. The live birth rate, clinical pregnancy, and miscarriage rates were comparable between the IVM-IVF and IVF groups at 12 months [55.6% vs. 48.6%, (adjusted p = 0.923), 68.1% vs. 59% (adjusted p = 0.677), and 18.8% vs. 17.7% (adjusted p = 0.645), respectively] and the first transfer cycle [36.1% vs. 34.2% (adjusted p = 0.560), 55.6% vs. 41.9% (adjusted p = 0.177), and 35% vs. 18.3% (adjusted p = 0.396), respectively]. The occurrence of moderate/severe OHSS did not significantly differ between the groups [5.1% vs. 7.6% (adjusted p = 0.698)]. Notably, LH levels, the LH/FSH ratio, and androstenedione levels were significantly reduced in the IVM-IVF group after the IVM treatment.

CONCLUSION

Alternatives to IVF are underappreciated in clinical practice and research because of the lack of evidence on the efficacy of IVM in certain populations. IVF treatment given during a follow-up visit after an unstimulated IVM can achieve pregnancy outcomes comparable to those of a first IVF cycle without adversely affecting the subsequent pregnancy outcome.

Ovarian Reserve and Hormone Alteration Following Laparoscopic Ovarian Drilling for Polycystic Ovarian Syndrome: A Systematic Review

We aimed to conduct a systematic review of the data in the literature on ovarian reserve and ovarian hormone following laparoscopic ovarian drilling (LOD). The PubMed, ScienceDirect, and ProQuest databases were comprehensively searched using a combination of keywords such as "ovarian reserve", "laparoscopic ovarian drilling", "luteinizing hormone", "follicle-stimulating hormone", "inhibin", "LH/FSH ratio", "ovulation", and "testosterone". All studies involving females of reproductive age who were officially diagnosed with polycystic ovarian syndrome (PCOS) and had undergone LOD with reported data concerning at least one of the following parameters were considered for inclusion: ovarian reserve, anti-Mullerian hormone (AMH), inhibin, follicle-stimulating hormone (FSH), luteinizing hormone (LH), LH/FSH ratio, and testosterone. All the included studies were evaluated by the GRADE scale for bias and their findings were synthesized by four independent coauthors. A total of 38 studies involving 3118 female patients were included. Based on our findings, a significant number of participants experienced spontaneous ovulation along with a significant decrease in ovarian reserve, and a significant decrease in AMH, LH, and testosterone, with no significant changes in FSH and inhibin B. With the end goal of LOD being to improve fertility and pregnancy rates among females with PCOS, it is important to look at the first few steps that enable this. As expected, there was a significant improvement in ovulation while the ovarian reserve decreased. Along with the decrease in ovarian reserve, there was a significant normalization in AMH, LH, and testosterone levels. LOD may exert its main effects through the manipulation of the ovarian reserves.

First experiences with a diode laser in major gynecological laparoscopic procedures show lack of benefit and impaired feasibility

PURPOSE

The aim of this study is to evaluate feasibility and potential benefit of a diode laser in major laparoscopic procedures in gynecology.

METHODS

Between 2018 and 2020, a total of 42 cases were enrolled in this study comparing standard electrosurgery with diode laser-supported therapy in laparoscopic supracervical hysterectomy (LASH), total laparoscopic hysterectomy (TLH), or laparoscopic myoma enucleation (LME). Dual wavelength 45 W diode laser light was used to cut and coagulate during laparoscopy in the prospective interventional arm consisting of 11 cases, while 31 matching patients who received conventional treatment with monopolar/bipolar current for the same interventions were retrospectively identified in our laparoscopy database. Recruitment in the prospective interventional laser diode arm was terminated after only 11 patients (instead of planned 50) due to intense hemorrhage and massive smoke development.

RESULTS

A total of 42 cases were analyzed (11 LME, 19 LASH, and 12 TLH). Strong smoke development was evident in all 11 cases in the diode laser arm. It was necessary to convert to bipolar or monopolar current in all hysterectomies (n = 9) with initial diode laser implementation due to increased bleeding and smoke development. Conventional current sources had to be used in LMEs (n = 2) due to excessive bleeding and poor visibility during enucleation of the fibroid. A significant difference (p < 0.0001) was observed regarding smoke development when comparing the laser arm with the control arm.

CONCLUSION

We found a 45-W diode laser to be inferior to electrosurgical techniques for major laparoscopic gynecologic surgeries regarding bleeding control and smoke development.

Decrease in serum anti-Müllerian hormone level per puncture with laparoscopic ovarian drilling using ultrasonically activated device

PURPOSE

To determine the contributing factor in infertility treatment with laparoscopic ovarian drilling (LOD) to the decrease in serum anti-Müllerian hormone (AMH) levels in patients with polycystic ovarian syndrome using an ultrasonically activated device.

METHODS

A retrospective analysis was performed in 60 patients (aged 23-36 years) who received 25-120 punctures in each ovary with LOD treatment from January 2014 to December 2018.

RESULTS

The mean decrease in serum AMH level per puncture with LOD was 0.07 ± 0.04 ng/ml in all 60 patients and 0.08 ± 0.04 ng/ml in patients with ≥10 ng/ml preoperative serum AMH level, which was significantly higher than in those with <10 ng/ml (0.05 ± 0.02 ng/ml). The mean decrease in serum AMH level per puncture in patients with body mass index (BMI) < 18.5 kg/m2 (0.10 ± 0.03 ng/ml) was significantly higher than in those with BMI 18.5-25 kg/m2 (0.07 ± 0.04 ng/ml) and >25 kg/m2 (0.06 ± 0.02 ng/ml).

CONCLUSIONS

The mean decrease in serum AMH levels per puncture with LOD using an ultrasonically activated device depends on the preoperative serum AMH level and BMI of patients.

Transvaginal ovarian drilling followed by controlled ovarian stimulation from the next day improves ovarian response for the poor responders with polycystic ovary syndrome during IVF treatment: a pilot study

BACKGROUND

Poor response patients with PCOS who are not susceptible to gonadotropin stimulation are more likely to have canceled cycles or poor clinical outcomes during IVF treatment. However, some limitations exist in the present therapies. In this study, we evaluated the effects of using the transvaginal ovarian drilling (TVOD) followed by controlled ovarian stimulation (COS) from the second day of these poor responders.

METHODS

During IVF, 7 poor responders with PCOS and 28 PCOS patients (14 normal and 14 high responders) were recruited. All patients received COS with the gonadotropin-releasing hormone antagonist protocol. For the poor responders, after undergoing 10 to 14 days of ovulation induction with no response, the TVOD was applied and then ovarian stimulation was performed from the next day at the same gonadotropin dose. Serum samples during COS and follicular fluid samples from the dominant follicles on the oocyte pick-up (OPU) day in all three groups were collected. Besides, follicular fluid from small follicles (diameter < 1 cm) in the normal and high responders on the OPU day and those in the poor responders on the TVOD day were gathered. Hormonal levels were examined in all samples using immunometric assays.

RESULTS

All the poor responders restored ovary response after receiving TVOD. There was no significant difference in the stimulation duration, total gonadotrophin dose used and the clinical outcomes among the three groups. The body mass index, serum and follicular levels of anti-Müllerian hormone (AMH) and testosterone in poor responders were higher than those in the other two groups, and the application of TVOD significantly decreased the levels of AMH and testosterone in both serum and follicular fluid.

CONCLUSIONS

TVOD followed by ovulation induction from the next day is effective and convenient for poor responders with PCOS. The decline of AMH and testosterone resulted from TVOD may be the main reason resulting in the recovery of ovary sensitivity to gonadotropins. The small sample size is the primary limitation of this study, future studies using a large population cohort and monitoring the long-term outcomes of this strategy will be required.

TRIAL REGISTRATION

ChiCTR1900023612. Registered 04 June 2019-Retrospectively registered.

The role of AMH in the pathophysiology of polycystic ovarian syndrome

Polycystic ovarian syndrome (PCOS) affects 5 - 10% of reproductive age women, but its pathogenesis is still poorly understood. The aim of this review is to collate evidence and summarize our current knowledge of the role of anti-Müllerian hormone (AMH) in PCOS pathogenesis. AMH is increased and correlated with the various reproductive and metabolic/endocrine alterations in PCOS. AMH plays an inhibitory role in follicular development and recruitment, contributing to follicular arrest. AMH inhibitory action on FSH-induced aromatase production likely contributes to hyperandrogenism in PCOS, which further enhances insulin resistance in these women. Elevated serum AMH concentrations are predictive of poor response to various treatments of PCOS including weight loss, ovulation induction and laparoscopic ovarian drilling, while improvement in various clinical parameters following treatment is associated with serum AMH decline, further supporting an important role for AMH in the pathophysiology of this syndrome. This review emphasizes the need for understanding the exact mechanism of action of AMH in the pathophysiology of PCOS. This may lead to the development of new treatment modalities targeting AMH to treat PCOS, as well as help clinicians in prognostication and better tailoring existing treatments for this disease.

Primum Non Nocere

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. Laparoscopic ovarian drilling (LOD) is an alternative method to induce ovulation in PCOS patients with clomiphene citrate resistance instead of gonadotropins. Surgical therapy with LOD may avoid or reduce the need for gonadotropins or may facilitate their use. However, the procedure, though effective, can be traumatic on the ovaries, which may cause postoperative adhesions and/or diminished ovarian reserve. In over-enthusiastic hands, this day-care procedure might lead to iatrogenic premature ovarian failure in young women. Some trials have compared LOD with gonadotropins, but, because of variations in study design and small sample size, the results are inconsistent and definitive conclusions about the relative efficacy of LOD and gonadotropins cannot be extracted from the individual studies. Today, evidence-based reviews conclude that there is 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 is the only pro-LOD argument. However, there are ongoing serious concerns about the long-term effects of LOD on ovarian function.