Laparoscopic ovarian drilling as first line of treatment in infertile women with polycystic ovary syndrome

Molecular Mechanisms of Laparoscopic Ovarian Drilling and Its Therapeutic Effects in Polycystic Ovary Syndrome

Polycystic ovary syndrome (PCOS) is a common endocrinopathy, characterized by chronic anovulation, hyperandrogenism, and multiple small subcapsular cystic follicles in the ovary during ultrasonography, and affects 5–10% of women of reproductive age. PCOS is frequently associated with insulin resistance (IR) accompanied by compensatory hyperinsulinemia and, therefore, presents an increased risk of type 2 diabetes mellitus (DM). The pathophysiology of PCOS is unclear, and many hypotheses have been proposed. Among these hypotheses, IR and hyperandrogenism may be the two key factors. The first line of treatment in PCOS includes lifestyle changes and body weight reduction. Achieving a 5–15% body weight reduction may improve IR and PCOS-associated hormonal abnormalities. For women who desire pregnancy, clomiphene citrate (CC) is the front-line treatment for ovulation induction. Twenty five percent of women may fail to ovulate spontaneously after three cycles of CC treatment, which is called CC-resistant PCOS. For CC-resistant PCOS women, there are many strategies to improve ovulation rate, including medical treatment and surgical approaches. Among the various surgical approaches, one particular surgical method, called laparoscopic ovarian drilling (LOD), has been proposed as an alternative treatment. LOD results in an overall spontaneous ovulation rate of 30–90% and final pregnancy rates of 13–88%. These benefits are more significant for women with CC-resistant PCOS. Although the intra- and post-operative complications and sequelae are always important, we believe that a better understanding of the pathophysiological changes and/or molecular mechanisms after LOD may provide a rationale for this procedure. LOD, mediated mainly by thermal effects, produces a series of morphological and biochemical changes. These changes include the formation of artificial holes in the very thick cortical wall, loosening of the dense and hard cortical wall, destruction of ovarian follicles with a subsequently decreased amount of theca and/or granulosa cells, destruction of ovarian stromal tissue with the subsequent development of transient but purulent and acute inflammatory reactions to initiate the immune response, and the continuing leakage or drainage of “toxic” follicular fluid in these immature and growth-ceased pre-antral follicles. All these factors contribute to decreasing local and systemic androgen levels, the following apoptosis process with these pre-antral follicles to atresia; the re-starting of normal follicular recruitment, development, and maturation, and finally, the normalization of the “hypothalamus–pituitary–ovary” axis and subsequent spontaneous ovulation. The detailed local and systematic changes in PCOS women after LOD are comprehensively reviewed in the current article.

Fertility Treatment Options for Women With Polycystic Ovary Syndrome

Polycystic ovary syndrome is the most common endocrinological disorder in women of reproductive age. It is commonly associated with anovulatory subfertility, for which there are a range of treatment options available to help them conceive. These options are given in a step-wise manner with an appropriate selection of patients to maximise success rates with minimal complications. This review discusses the importance and involvement of multidisciplinary care when offering treatment to women with subfertility. Multidisciplinary care gives an excellent opportunity to identify, assess risk, and potentially prevent future morbidities and complications while treating women for fertility issues. We have also summarised the various options available for fertility treatment: pharmacological treatments, nonpharmacological intervention, and assisted reproductive technology.

Evaluation of a Simple and Safe Tumor Drilling Technique to Potentiate the Effect of Intraperitoneal Chemotherapy in the Treatment of Recurrent Epithelial Ovarian, Tubal, and Peritoneal Cancer: A Matched Retrospective Cohort Study

Frontline intraperitoneal chemotherapy (IPCT) in the treatment of epithelial ovarian cancer has been well established. However, the role of second-line IPCT is yet to be confirmed. With a view to implementing IPCT to treat recurrent disease, a prerequisite is to perform a cytoreductive procedure to minimize residual tumor size. However, the role of cytoreductive procedure is still in debate due to a higher chance of complications. A matched retrospective cohort study was conducted. From 2008 to 2015, we adopted a relatively simple and safe tumor drilling technique to maximize tumor exposure to second-line IPCT. Patients who received tumor drilling followed by second-line IPCT constituted the cohort group. Concurrently, patients who received standard second-line systemic chemotherapy were selected as the comparison group. After propensity score matching, 85 patients in each group entered into the final analysis. The median progression-free survival was 7.3 months (95% confidence interval [CI], 6.2-7.8) for the cohort group versus 4.1 months (95% CI, 4.0-4.3) for the comparison group (hazard ratio = 0.25 [95% CI, 0.17-0.36]; P < .001, by log-rank test). The median overall survival was 33.6 months (32.1-36.6) for the cohort group versus 25.9 months (20.5-26.9) for the comparison group (hazard ratio = 0.33 [95% CI, 0.23-0.48]; P < .001, by log-rank test). Toxicities in the cohort group were not different from those that were published in reports of IPCT for ovarian cancer. The most commonly observed toxicity was gastrointestinal origin (51.7%), and it may be attributed to the intraperitoneal pharmacokinetic clearance of cisplatin and taxol and we also discussed the mechanism of gastrointestinal toxicity. Tumor drilling followed by second-line IPCT may confer a survival advantage over standard second-line systemic chemotherapy in the treatment of recurrent ovarian cancer.

Hormonal Changes After Laparoscopic Ovarian Diathermy in Patients with Polycystic Ovarian Syndrome

AIM OF THE PRESENT STUDY

To assess the changes in hormonal profile (serum FSH, LH, prolactin and total testosterone) following laparoscopic ovarian drilling (LOD) in patients with polycystic ovarian syndrome.

MATERIALS AND METHODS

Fifty patients with PCOS have been included in this study. Serum prolactin, total testosterone, follicular-stimulating hormone (FSH) and luteinizing hormone (LH) levels have been used as biochemical markers, before and after procedures.

RESULTS

Laparoscopic ovarian drilling was successfully employed without any surgical complications and on an average follow-up time of 24 weeks after the procedure. During the follow-up serum values for prolactin, total testosterone and LH have decreased significantly and FSH levels remained unchanged after the procedure.

CONCLUSIONS

The LOD in patients with PCOS may avoid or reduce the risk of OHSS and the multiple pregnancy rate induced by gonadotropin therapy. The high pregnancy rate and the economic aspect of the procedure offer an attractive management for patients with PCOS. However, LOD can be considered as second-line treatment after clomiphene citrate treatment failure and/or resistance.

Laparoscopic ovarian drilling: An alternative but not the ultimate in the management of polycystic ovary syndrome

Since its introduction in 1984, laparoscopic ovarian drilling has evolved into a safe and effective surgical treatment for anovulatory, infertile women with polycystic ovary syndrome (PCOS), unresponsive to clomiphene citrate. It is as effective as gonadotropins in terms of pregnancy and live birth rates, but without the risks of ovarian hyperstimulation syndrome and multiple pregnancies. It improves ovarian responsiveness to successive ovulation induction agents. Its favorable reproductive and endocrinal effects are sustained long. Despite its advantages, its use in unselected cases of PCOS or for non-fertility indications is not prudent owing to the potential risks of iatrogenic adhesions and ovarian insufficiency.

[Ovarian drilling by fertiloscopy: feasibility, results and predictive values]

OBJECTIVES

The aims of this study were to assess the effectiveness of the ovarian drilling, compare the techniques by fertiloscopy or by laparoscopy, and search for prognostic factors of success.

PATIENTS AND METHODS

This retrospective study focused on 154 ovarian drilling carried out between June 1998 and December 2010 where the drilling has been proposed after failure of the clomifene and before stimulation by FSH among PCOS patients.

RESULTS

The post-drilling ovulation rate is 62%. The spontaneous on-going pregnancy rate is 31% and the total pregnancy rate scalable including secondary stimulation is 58%. No significant difference was found between laparoscopy and the fertiloscopy. The peroperative complications in fertiloscopy were more frequent but without consequences and 20% of the fertiloscopy had to be converted to laparoscopy, half of them for complications and half of them for technical difficulties. The only found preoperative predictors of success are an euthyroidy that increases the chances of pregnancy in general (including the side stimulation) and a lower FSH levels. However, it appears that the chances of pregnancy in FSH stimulation are dramatically decreased if the drilling did not induce ovulation versus the cases where it induced ovulation but no pregnancy (28.8% versus 58.1%, P<0.003).

DISCUSSION AND CONCLUSION

Fertiloscopy results are comparable with those of laparoscopy, which suggests an advantage to this technique in terms of cost, comfort, and length of hospital stay. No usable in practice patient selection criteria could be highlighted. The study suggests that the absence of ovulation after drilling may be a direct indication for IVF.

Impact of obesity on reproductive outcomes after ovarian ablative therapy in PCOS: a collaborative meta-analysis

Obesity is known to interfere with reproductive outcomes in polycystic ovary syndrome. There is no consensus regarding the impact of obesity on reproductive outcomes after ovarian ablative therapy (OAT) and there is no level I evidence to answer this question. This systematic review and meta-analysis assessed the strength of the association between obesity and ovulation or pregnancy rates after OAT. MEDLINE and several other databases were searched from 2000 to September 2011 for studies reporting on OAT and reproductive outcomes. Data were synthesized to determine the relative risk of reproductive outcomes (ovulation and pregnancy) in lean (body mass index <25 kg/m(2)) compared with overweight or obese women. The study obtained 15 data sets (14 articles) for analysis, which included 905 subjects in the obese group and 879 subjects in the lean group. Lean women had increased ovulation rates (RR 1.43, 95% CI 1.22-1.66) compared with obese women. Pregnancy rates also showed a similar trend (RR 1.73, 95% CI 1.39-2.17). Reproductive outcomes were generally better in younger women, more recent studies and randomized controlled trials. It is concluded that lean women respond better to OAT than their obese counterparts. These epidemiological observations indicate that obesity alters reproductive outcomes after OAT negatively. Obesity is known to interfere with reproductive outcomes in polycystic ovary syndrome. There is no consensus regarding the impact of obesity on ovarian ablative therapy (OAT) and there is no level I evidence to answer this question. We therefore undertook a systematic review and meta-analysis to assess the strength of the association between obesity and ovulation or pregnancy rates after OAT. We searched MEDLINE and several other databases from 2000 to September 2011 for studies reporting on OAT and reproductive outcomes. Data were synthesized to determine the risk ratio of reproductive outcomes (ovulation and pregnancy) in lean (BMI <25 kg/m(2)) as opposed to overweight or obese women. We obtained 15 datasets (14 articles) for analysis, which included 905 subjects in the obese group and 879 subjects in the lean group. Lean women had increased ovulation rates (RR 1.43, 95% CI 1.22-1.66) as compared to obese women. Pregnancy rates also showed a similar trend (RR 1.73, 95% CI 1.39-2.17). Reproductive outcomes were generally better in younger women, more recent studies and randomized controlled trials. We conclude that lean women respond better to OAT than their obese counterparts. These epidemiological observations indicate that obesity alters reproductive outcomes after OAT negatively.

Laparoscopic ovarian diathermy after clomiphene failure in polycystic ovary syndrome: is it worthwhile? A randomized controlled trial

PURPOSE

Laparoscopic ovarian diathermy (LOD) represents a successful treatment option for women with clomiphene citrate (CC)-resistant polycystic ovary syndrome (PCOS). However, in case of CC failure PCOS, LOD offers several theoretical advantages. This study was conducted to compare the efficacy of LOD versus continuation of CC up to six further cycles in PCOS patients who failed to achieve pregnancy despite the previous successful CC induced ovulation.

METHODS

One hundred and seventy six infertile women with CC failure PCOS were selected in this randomized controlled trial. Patients (n = 87) underwent LOD with 6 months follow-up or received CC (n = 89) up to six cycles. Outcome measures were; clinical pregnancy rate, midcycle endometrial thickness, cycle length, miscarriage and live birth rates.

RESULTS

The clinical pregnancy rate per patient and the cumulative pregnancy rate after six cycles were comparable in both groups (39 vs. 33.7% and 47 vs. 39.2%, respectively). Four twin pregnancies occurred in CC group and none in LOD group and the difference was statistically significant (p < 0.05). No significant difference in midcycle endometrial thickness was observed (8.8 ± 1.2 mm vs. 7.7 ± 1.1 mm). Improvement in cycle length, miscarriage and live birth rates were comparable in both groups. No cases of ovarian hyperstimulation syndrome occurred in either group.

CONCLUSIONS

LOD during the 6 months follow-up period and CC for up to six further cycles are equally effective for achieving pregnancy in CC failure PCOS patients.

Laparoscopic ovarian diathermy vs clomiphene citrate plus metformin as second-line strategy for infertile anovulatory patients with polycystic ovary syndrome: a randomized controlled trial

OBJECTIVE

The purpose of this study was to compare the effectiveness of laparoscopic ovarian diathermy (LOD) vs clomiphene citrate (CC) plus metformin in infertile patients with CC-resistant polycystic ovary syndrome (PCOS).

STUDY DESIGN

Fifty primary infertile patients with CC-resistant PCOS were assigned randomly to receive LOD followed by a 6-month observation (group A) or 6-cycle course of CC plus metformin (group B). Reproductive and safety outcomes were analyzed.

RESULTS

No significant difference between 2 groups in pregnancy (15/92 women [16.3%] vs 14/107 women [13.1%]; P = .521) and live-birth (13/92 women [14.1%] vs 12/107 women [11.2%]; P = .536) rates per cycle was observed. With the use of a Cox regression analysis, patients under medical treatment, compared with patients who received surgical treatment, had a relative risk of pregnancy of 1.2 (95% confidence interval, 0.61-2.44; P = .582) and a relative risk of live-birth of 1.4 (95% confidence interval, 0.63-2.96; P = .425).

CONCLUSION

LOD and CC plus metformin seem to be 2 effective approaches to treat infertility in patients with CC-resistant PCOS.

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

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

Surgical 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.

Efficacy of laparoscopic ovarian diathermy in clomiphene citrate-resistant women with polycystic ovary syndrome: relationships with chronological and ovarian age

BACKGROUND

Laparoscopic ovarian diathermy (LOD) has been used successfully as a first-, second- and third-line treatment for ovulation induction in women with polycystic ovary syndrome (PCOS). However, little is known about the predictors for LOD efficacy. The aim of the present study was to evaluate reproductive outcomes in clomiphene citrate (CC)-resistant PCOS patients treated with LOD according to ovarian and chronological age.

METHOD

A total of 60 non-obese, primary infertile, CC-resistant women with PCOS were enrolled and treated with LOD. During the following 6 months, all patients underwent ovulation monitoring and timed intercourse. If spontaneous ovulation did not occur within 3 months from surgery, CC (100 mg/day) was administered for 5 days from day 3 of the remaining cycles. The ovulation, abortion and pregnancy rates were assessed and analyzed with patients categorized according to chronological age (group A, <25 years; group B, 25-30 years; group C, 30-35 years; group D, >35 years) and ovarian age (group 1, follicle stimulating hormone (FSH) < 10 mIU/ml; group 2, FSH > 10 mIU/ml).

RESULTS

At the end of the study, total ovulation, pregnancy and abortion rates were 57.1, 13.0 and 18.2%, respectively. No difference in all reproductive outcomes was observed between groups A, B and C, whereas the efficacy of LOD was significantly lower in group D. A significant difference in all clinical endpoints was detected between groups 1 and 2.

CONCLUSIONS

Our data show that chronological age >35 years and basal FSH value > 10 mIU/ml are related to poor reproductive prognosis in CC-resistant PCOS patients treated with LOD.