Laparoscopic "drilling" by diathermy or laser for ovulation induction in anovulatory polycystic ovary syndrome
Abstract
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 methods
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 1.08 (95% CI 0.67, 1.75) 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.
PICOs
Plain language summary
Ovarian surgery in women with clomiphene resistant polycystic ovarian syndrome reduces the risk of multiple pregnancy without decreasing the pregnancy rate
Women with polycystic ovary syndrome (PCOS) have trouble ovulating. Gonadotrophins are hormones produced by the pituitary gland. Women with PCOS may be treated with gonadotrophins (either from urinary sources or recombinant techniques) but gonadotrophins can overstimulate the ovary and cause multiple pregnancy. An alternative is a minor surgical procedure called laparoscopic ovarian drilling where a long telescope is passed through a small cut in the umbilicus. The ovaries are then surgically treated by drilling with either heat or laser. This review of trials found that ovarian drilling, followed by clomiphene or gonadotrophins if necessary, was as effective as gonadotrophin therapy alone in inducing ovulation, but the risk of multiple pregnancy was lower in the group who had laparoscopic ovarian drilling. Approximately 50% of women will have a live birth and 16% will have a miscarriage with either procedure.
