Laparoscopic surgery for ovulation induction in polycystic ovary syndrome
- Jeffrey M Goldberg, MD
Jeffrey M Goldberg, MD
- Professor and Head of Reproductive Endocrinology and Infertility
- Cleveland Clinic
Polycystic ovary syndrome (PCOS) is an etiology of menstrual irregularity, infertility, and androgen excess in women. The definition of PCOS has varied over the years. Based on the Rotterdam criteria, a diagnosis of PCOS requires two of three potential characteristics: oligo- and/or anovulation, clinical and/or biochemical signs of hyperandrogenism, and polycystic ovaries (on pelvic ultrasound) (table 1) . Other causes of these signs or symptoms, such as late-onset congenital adrenal hyperplasia or Cushing's syndrome, must also be excluded .
For women with PCOS and infertility, ovulation induction with oral agents such as clomiphene or letrozole (off-label use for ovulation induction) is the first line of medical therapy. For women who are resistant to this treatment, ovulation may be induced with injections of follicle-stimulating hormone. Laparoscopic ovarian drilling (also referred to as laparoscopic ovarian diathermy or electrocoagulation) is a surgical option for second-line treatment. Ovarian drilling is not used commonly in the United States, but is a focus of the literature as a second-line treatment in Asia, the Middle East, and North Africa [3-5].
Laparoscopic surgery with ovarian drilling in women with PCOS will be reviewed here. The diagnosis and management of PCOS and the use of clomiphene, letrozole, metformin, and gonadotropins for ovulation induction are discussed separately. (See "Diagnosis of polycystic ovary syndrome in adults" and "Treatment of polycystic ovary syndrome in adults" and "Metformin for treatment of the polycystic ovary syndrome" and "Overview of ovulation induction" and "Ovulation induction with clomiphene citrate" and "Ovulation induction with letrozole".)
OVERVIEW OF OVULATION INDUCTION IN PCOS
For women with PCOS and infertility, ovulation induction with oral agents such as clomiphene or letrozole is the first line of medical therapy. For women who are resistant to this treatment, ovulation may be induced with injections of follicle-stimulating hormone (FSH) or laparoscopic ovarian drilling as second-line treatment. FSH injections are used more commonly in clinical practice because these do not require surgery and avoid adnexal adhesions that may result from ovarian drilling. Ovarian drilling, however, appears to be as effective as FSH and has several advantages compared with FSH.
Ovulation induction in women with PCOS is discussed briefly here to provide a context for the role of laparoscopic ovarian drilling. A comparison of the infertility treatment options for PCOS patients is shown in the table (table 2).
- Rotterdam ESHRE/ASRM-Sponsored PCOS consensus workshop group. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome (PCOS). Hum Reprod 2004; 19:41.
- Azziz R, Carmina E, Dewailly D, et al. The Androgen Excess and PCOS Society criteria for the polycystic ovary syndrome: the complete task force report. Fertil Steril 2009; 91:456.
- Lebbi I, Ben Temime R, Fadhlaoui A, Feki A. Ovarian Drilling in PCOS: Is it Really Useful? Front Surg 2015; 2:30.
- Arain F, Arif N, Halepota H. Frequency and outcome of treatment in polycystic ovaries related infertility. Pak J Med Sci 2015; 31:694.
- Zahiri Sorouri Z, Sharami SH, Tahersima Z, Salamat F. Comparison between Unilateral and Bilateral Ovarian Drilling in Clomiphene Citrate Resistance Polycystic Ovary Syndrome Patients: A Randomized Clinical Trial of Efficacy. Int J Fertil Steril 2015; 9:9.
- Flyckt RL, Goldberg JM. Laparoscopic ovarian drilling for clomiphene-resistant polycystic ovary syndrome. Semin Reprod Med 2011; 29:138.
- Legro RS, Brzyski RG, Diamond MP, et al. Letrozole versus clomiphene for infertility in the polycystic ovary syndrome. N Engl J Med 2014; 371:119.
- Stein IF, Leventhal ML. Amenorrhea associated with bilateral polycystic ovaries. Am J Obstet Gynecol 1935; 29:181.
- Gjönnaess H. Polycystic ovarian syndrome treated by ovarian electrocautery through the laparoscope. Fertil Steril 1984; 41:20.
- Thessaloniki ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group. Consensus on infertility treatment related to polycystic ovary syndrome. Fertil Steril 2008; 89:505.
- Amer SA, Li TC, Metwally M, et al. Randomized controlled trial comparing laparoscopic ovarian diathermy with clomiphene citrate as a first-line method of ovulation induction in women with polycystic ovary syndrome. Hum Reprod 2009; 24:219.
- Farquhar C, Brown J, Marjoribanks J. Laparoscopic drilling by diathermy or laser for ovulation induction in anovulatory polycystic ovary syndrome. Cochrane Database Syst Rev 2012; :CD001122.
- Moazami Goudarzi Z, Fallahzadeh H, Aflatoonian A, Mirzaei M. Laparoscopic ovarian electrocautery versus gonadotropin therapy in infertile women with clomiphene citrate-resistant polycystic ovary syndrome: A systematic review and meta-analysis. Iran J Reprod Med 2014; 12:531.
- Farquhar C, Lilford RJ, Marjoribanks J, Vandekerckhove P. Laparoscopic "drilling" by diathermy or laser for ovulation induction in anovulatory polycystic ovary syndrome. Cochrane Database Syst Rev 2005; :CD001122.
- Kovacs GT, Clarke S, Burger HG, et al. Surgical or medical treatment of polycystic ovary syndrome: a cost-benefit analysis. Gynecol Endocrinol 2002; 16:53.
- Li TC, Saravelos H, Chow MS, et al. Factors affecting the outcome of laparoscopic ovarian drilling for polycystic ovarian syndrome in women with anovulatory infertility. Br J Obstet Gynaecol 1998; 105:338.
- van Wely M, Bayram N, van der Veen F, Bossuyt PM. An economic comparison of a laparoscopic electrocautery strategy and ovulation induction with recombinant FSH in women with clomiphene citrate-resistant polycystic ovary syndrome. Hum Reprod 2004; 19:1741.
- De Frène V, Gerris J, Weyers S, et al. Gonadotropin Therapy versus Laparoscopic Ovarian Drilling in Clomiphene Citrate-Resistant Polycystic Ovary Syndrome Patients: A Retrospective Cost-Effectiveness Analysis. Gynecol Obstet Invest 2015; 80:164.
- Nahuis MJ, Kose N, Bayram N, et al. Long-term outcomes in women with polycystic ovary syndrome initially randomized to receive laparoscopic electrocautery of the ovaries or ovulation induction with gonadotrophins. Hum Reprod 2011; 26:1899.
- Farquhar CM, Williamson K, Gudex G, et al. A randomized controlled trial of laparoscopic ovarian diathermy versus gonadotropin therapy for women with clomiphene citrate-resistant polycystic ovary syndrome. Fertil Steril 2002; 78:404.
- van Wely M, Bayram N, Bossuyt PM, van der Veen F. Laparoscopic electrocautery of the ovaries versus recombinant FSH in clomiphene citrate-resistant polycystic ovary syndrome. Impact on women's health-related quality of life. Hum Reprod 2004; 19:2244.
- Bayram N, van Wely M, van der Veen F, et al. Treatment preferences and trade-offs for ovulation induction in clomiphene citrate-resistant patients with polycystic ovary syndrome. Fertil Steril 2005; 84:420.
- Abu Hashim H. Predictors of success of laparoscopic ovarian drilling in women with polycystic ovary syndrome: an evidence-based approach. Arch Gynecol Obstet 2015; 291:11.
- Elmashad AI. Impact of laparoscopic ovarian drilling on anti-Müllerian hormone levels and ovarian stromal blood flow using three-dimensional power Doppler in women with anovulatory polycystic ovary syndrome. Fertil Steril 2011; 95:2342.
- Abuelghar WM, Bayoumy HA, Ellaithy MI, Khalil MS. Women with clomiphene citrate resistant polycystic ovarian disease: predictors of spontaneous ovulation after laparoscopic ovarian drilling. Eur J Obstet Gynecol Reprod Biol 2014; 175:178.
- Kong GW, Cheung LP, Lok IH. Effects of laparoscopic ovarian drilling in treating infertile anovulatory polycystic ovarian syndrome patients with and without metabolic syndrome. Hong Kong Med J 2011; 17:5.
- Colacurci N, Zullo F, De Franciscis P, et al. In vitro fertilization following laparoscopic ovarian diathermy in patients with polycystic ovarian syndrome. Acta Obstet Gynecol Scand 1997; 76:555.
- Tozer AJ, Al-Shawaf T, Zosmer A, et al. Does laparoscopic ovarian diathermy affect the outcome of IVF-embryo transfer in women with polycystic ovarian syndrome? A retrospective comparative study. Hum Reprod 2001; 16:91.
- Rimington MR, Walker SM, Shaw RW. The use of laparoscopic ovarian electrocautery in preventing cancellation of in-vitro fertilization treatment cycles due to risk of ovarian hyperstimulation syndrome in women with polycystic ovaries. Hum Reprod 1997; 12:1443.
- Pabuccu R, Pabuccu EG, Gursoy AY, et al. Improved cycle outcomes after laparoscopic ovarian diathermy in hyper-responder patients with previous ART failure. Gynecol Endocrinol 2014; 30:881.
- Eftekhar M, Deghani Firoozabadi R, Khani P, et al. Effect of Laparoscopic Ovarian Drilling on Outcomes of In Vitro Fertilization in Clomiphene-Resistant Women with Polycystic Ovary Syndrome. Int J Fertil Steril 2016; 10:42.
- Zakherah MS, Kamal MM, Hamed HO. Laparoscopic ovarian drilling in polycystic ovary syndrome: efficacy of adjusted thermal dose based on ovarian volume. Fertil Steril 2011; 95:1115.
- Sunj M, Canic T, Baldani DP, et al. Does unilateral laparoscopic diathermy adjusted to ovarian volume increase the chances of ovulation in women with polycystic ovary syndrome? Hum Reprod 2013; 28:2417.
- Salah IM. Office microlaparoscopic ovarian drilling (OMLOD) versus conventional laparoscopic ovarian drilling (LOD) for women with polycystic ovary syndrome. Arch Gynecol Obstet 2013; 287:361.
- Catenacci M, Goldberg JM. Transvaginal hydrolaparoscopy. Semin Reprod Med 2011; 29:95.
- Zhu W, Fu Z, Chen X, et al. Transvaginal ultrasound-guided ovarian interstitial laser treatment in anovulatory women with polycystic ovary syndrome: a randomized clinical trial on the effect of laser dose used on the outcome. Fertil Steril 2010; 94:268.
- Shehata IA, Ballard JR, Casper AJ, et al. High-intensity focused ultrasound for potential treatment of polycystic ovary syndrome: toward a noninvasive surgery. Fertil Steril 2014; 101:545.
- Seow KM, Juan CC, Hwang JL, Ho LT. Laparoscopic surgery in polycystic ovary syndrome: reproductive and metabolic effects. Semin Reprod Med 2008; 26:101.
- Amer SA, Banu Z, Li TC, Cooke ID. Long-term follow-up of patients with polycystic ovary syndrome after laparoscopic ovarian drilling: endocrine and ultrasonographic outcomes. Hum Reprod 2002; 17:2851.
- Gjønnaess H. Late endocrine effects of ovarian electrocautery in women with polycystic ovary syndrome. Fertil Steril 1998; 69:697.
- Naether OG, Baukloh V, Fischer R, Kowalczyk T. Long-term follow-up in 206 infertility patients with polycystic ovarian syndrome after laparoscopic electrocautery of the ovarian surface. Hum Reprod 1994; 9:2342.
- Al-Fadhli R, Tulandi T. Laparoscopic treatment of polycystic ovaries: is its place diminishing? Curr Opin Obstet Gynecol 2004; 16:295.
- Gjønnaess H. Ovarian electrocautery in the treatment of women with polycystic ovary syndrome (PCOS). Factors affecting the results. Acta Obstet Gynecol Scand 1994; 73:407.
- Amer SA, Gopalan V, Li TC, et al. Long term follow-up of patients with polycystic ovarian syndrome after laparoscopic ovarian drilling: clinical outcome. Hum Reprod 2002; 17:2035.
- Api M, Görgen H, Cetin A. Laparoscopic ovarian drilling in polycystic ovary syndrome. Eur J Obstet Gynecol Reprod Biol 2005; 119:76.
- Nahuis MJ, Oude Lohuis EJ, Bayram N, et al. Pregnancy complications and metabolic disease in women with clomiphene citrate-resistant anovulation randomized to receive laparoscopic electrocautery of the ovaries or ovulation induction with gonadotropins: a 10-year follow-up. Fertil Steril 2014; 101:270.
- Campo S. Ovulatory cycles, pregnancy outcome and complications after surgical treatment of polycystic ovary syndrome. Obstet Gynecol Surv 1998; 53:297.
- Greenblatt EM, Casper RF. Adhesion formation after laparoscopic ovarian cautery for polycystic ovarian syndrome: lack of correlation with pregnancy rate. Fertil Steril 1993; 60:766.
- Mercorio F, Mercorio A, Di Spiezio Sardo A, et al. Evaluation of ovarian adhesion formation after laparoscopic ovarian drilling by second-look minilaparoscopy. Fertil Steril 2008; 89:1229.
- Saravelos H, Li TC. Post-operative adhesions after laparoscopic electrosurgical treatment for polycystic ovarian syndrome with the application of Interceed to one ovary: a prospective randomized controlled study. Hum Reprod 1996; 11:992.
- Gürgan T, Urman B, Aksu T, et al. The effect of short-interval laparoscopic lysis of adhesions on pregnancy rates following Nd-YAG laser photocoagulation of polycystic ovaries. Obstet Gynecol 1992; 80:45.
- Dabirashrafi H. Complications of laparoscopic ovarian cauterization. Fertil Steril 1989; 52:878.
- Alborzi S, Tavazoo F, Dehaghani AS, et al. Determination of antiovarian antibodies after laparoscopic ovarian electrocauterization in patients with polycystic ovary syndrome. Fertil Steril 2009; 91:1159.
- Samsami DA, Razmjoei P, Parsanezhad ME. Serum Levels of Anti-histone and Anti-double-Strand DNA Antibodies Before and After Laparoscopic Ovarian Drilling in Women with Polycystic Ovarian Syndrome. J Obstet Gynaecol India 2014; 64:47.
- Samsami Dehaghani A, Karimaghaei N, Parsanezhad ME, et al. Anti-Nuclear Antibodies in Patients with Polycystic Ovary Syndrome before and after Laparoscopic Electrocauterization. Iran J Med Sci 2013; 38:187.
- Seow KM, Juan CC, Hsu YP, et al. Amelioration of insulin resistance in women with PCOS via reduced insulin receptor substrate-1 Ser312 phosphorylation following laparoscopic ovarian electrocautery. Hum Reprod 2007; 22:1003.
- Saleh A, Morris D, Tan SL, Tulandi T. Effects of laparoscopic ovarian drilling on adrenal steroids in polycystic ovary syndrome patients with and without hyperinsulinemia. Fertil Steril 2001; 75:501.
- Hamed HO, Hasan AF, Ahmed OG, Ahmed MA. Metformin versus laparoscopic ovarian drilling in clomiphene- and insulin-resistant women with polycystic ovary syndrome. Int J Gynaecol Obstet 2010; 108:143.
- Lemieux S, Lewis GF, Ben-Chetrit A, et al. Correction of hyperandrogenemia by laparoscopic ovarian cautery in women with polycystic ovarian syndrome is not accompanied by improved insulin sensitivity or lipid-lipoprotein levels. J Clin Endocrinol Metab 1999; 84:4278.
- Tiitinen A, Tenhunen A, Seppälä M. Ovarian electrocauterization causes LH-regulated but not insulin-regulated endocrine changes. Clin Endocrinol (Oxf) 1993; 39:181.
- El Behery MM, Diab AE, Mowafy H, et al. Effect of laparoscopic ovarian drilling on vascular endothelial growth factor and ovarian stromal blood flow using 3-dimensional power Doppler. Int J Gynaecol Obstet 2011; 112:119.
- Amin AF, Abd el-Aal DE, Darwish AM, Meki AR. Evaluation of the impact of laparoscopic ovarian drilling on Doppler indices of ovarian stromal blood flow, serum vascular endothelial growth factor, and insulin-like growth factor-1 in women with polycystic ovary syndrome. Fertil Steril 2003; 79:938.
- OVERVIEW OF OVULATION INDUCTION IN PCOS
- Ovulation induction in PCOS
- Ovarian drilling versus gonadotropins
- Mechanism of laparoscopic ovulation induction
- PATIENT SELECTION
- - Prognostic factors
- PREOPERATIVE EVALUATION AND PREPARATION
- Infertility evaluation
- Informed consent
- Endocrine changes
- SUMMARY AND RECOMMENDATIONS