Smarter Decisions,
Better Care

UpToDate synthesizes the most recent medical information into evidence-based practical recommendations clinicians trust to make the right point-of-care decisions.

  • Rigorous editorial process: Evidence-based treatment recommendations
  • World-Renowned physician authors: over 5,100 physician authors and editors around the globe
  • Innovative technology: integrates into the workflow; access from EMRs

Choose from the list below to learn more about subscriptions for a:


Subscribers log in here


Laparoscopic surgery for ovulation induction in polycystic ovary syndrome

INTRODUCTION

Polycystic ovary syndrome (PCOS) is characterized by menstrual irregularity and evidence of hyperandrogenism, whether clinical (hirsutism, acne, or male pattern balding) or biochemical (elevated serum androgen level). The majority of women who have infertility associated with chronic anovulation in this disorder ovulate in response to clomiphene citrate [1]. However, up to 30 percent remain anovulatory. Furthermore, of the roughly 70 percent who do ovulate in response to clomiphene citrate, only one-half will conceive [2,3]. Although some women who are resistant to clomiphene alone are able to ovulate with metformin (alone or combined with clomiphene), there are still women who are unresponsive. (See "Metformin for treatment of the polycystic ovary syndrome" and "Overview of ovulation induction" and "Ovulation induction with clomiphene citrate".)

In women resistant to clomiphene citrate, or metformin combined with clomiphene, the next step has been gonadotropin therapy. While this treatment causes ovulation in most women, it has several potential problems:

It can be very difficult to titrate the dose of gonadotropins to achieve monofollicular ovulation.

The high frequency of multifollicular ovulation results in multiple gestations in 30 percent or more of women [4].

The risk of ovarian hyperstimulation syndrome (OHSS) during gonadotropin administration is substantial, necessitating careful monitoring during treatment. (See "Pathogenesis of ovarian hyperstimulation syndrome".)

       

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Oct 2014. | This topic last updated: Nov 8, 2013.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2014 UpToDate, Inc.
References
Top
  1. 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.
  2. Garcia J, Jones GS, Wentz AC. The use of clomiphene citrate. Fertil Steril 1977; 28:707.
  3. Nunley WC Jr, Bateman BG, Kitchin JD 3rd. Reproductive performance of patients treated with clomiphene citrate. South Med J 1985; 78:31.
  4. Wang CF, Gemzell C. The use of human gonadotropins for the induction of ovulation in women with polycystic ovarian disease. Fertil Steril 1980; 33:479.
  5. Stein, IF, Leventhal, ML. Amenorrhea associated with bilateral polycystic ovaries. Am J Obstet Gynecol 1935; 29:181.
  6. Portuondo JA, Melchor JC, Neyro JL, Alegre A. Periovarian adhesions following ovarian wedge resection or laparoscopic biopsy. Endoscopy 1984; 16:143.
  7. Luciano AA. Laparotomy versus laparoscopy. Prog Clin Biol Res 1990; 358:35.
  8. Luciano AA, Maier DB, Koch EI, et al. A comparative study of postoperative adhesions following laser surgery by laparoscopy versus laparotomy in the rabbit model. Obstet Gynecol 1989; 74:220.
  9. Donesky BW, Adashi EY. Surgically induced ovulation in the polycystic ovary syndrome: wedge resection revisited in the age of laparoscopy. Fertil Steril 1995; 63:439.
  10. 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.
  11. Bayram N, van Wely M, Kaaijk EM, et al. Using an electrocautery strategy or recombinant follicle stimulating hormone to induce ovulation in polycystic ovary syndrome: randomised controlled trial. BMJ 2004; 328:192.
  12. 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.
  13. Balen AH, Jacobs HS. A prospective study comparing unilateral and bilateral laparoscopic ovarian diathermy in women with the polycystic ovary syndrome. Fertil Steril 1994; 62:921.
  14. 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.
  15. Greenblatt E, Casper RF. Endocrine changes after laparoscopic ovarian cautery in polycystic ovarian syndrome. Am J Obstet Gynecol 1987; 156:279.
  16. Lockwood GM, Muttukrishna S, Groome NP, et al. Mid-follicular phase pulses of inhibin B are absent in polycystic ovarian syndrome and are initiated by successful laparoscopic ovarian diathermy: a possible mechanism regulating emergence of the dominant follicle. J Clin Endocrinol Metab 1998; 83:1730.
  17. Liguori G, Tolino A, Moccia G, et al. Laparoscopic ovarian treatment in infertile patients with polycystic ovarian syndrome (PCOS): endocrine changes and clinical outcome. Gynecol Endocrinol 1996; 10:257.
  18. 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.
  19. 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.
  20. Mio Y, Toda T, Tanikawa M, et al. Transvaginal ultrasound-guided follicular aspiration in the management of anovulatory infertility associated with polycystic ovaries. Fertil Steril 1991; 56:1060.
  21. Gjönnaess H. Polycystic ovarian syndrome treated by ovarian electrocautery through the laparoscope. Fertil Steril 1984; 41:20.
  22. Daniell JF, Miller W. Polycystic ovaries treated by laparoscopic laser vaporization. Fertil Steril 1989; 51:232.
  23. Felemban A, Tan SL, Tulandi T. Laparoscopic treatment of polycystic ovaries with insulated needle cautery: a reappraisal. Fertil Steril 2000; 73:266.
  24. Catenacci M, Goldberg JM. Transvaginal hydrolaparoscopy. Semin Reprod Med 2011; 29:95.
  25. Flyckt RL, Goldberg JM. Laparoscopic ovarian drilling for clomiphene-resistant polycystic ovary syndrome. Semin Reprod Med 2011; 29:138.
  26. Farquhar CM, Williamson K, Brown PM, Garland J. An economic evaluation of laparoscopic ovarian diathermy versus gonadotrophin therapy for women with clomiphene citrate resistant polycystic ovary syndrome. Hum Reprod 2004; 19:1110.
  27. Abdel Gadir A, Mowafi RS, Alnaser HM, et al. Ovarian electrocautery versus human menopausal gonadotrophins and pure follicle stimulating hormone therapy in the treatment of patients with polycystic ovarian disease. Clin Endocrinol (Oxf) 1990; 33:585.
  28. Gadir AA, Alnaser HM, Mowafi RS, Shaw RW. The response of patients with polycystic ovarian disease to human menopausal gonadotropin therapy after ovarian electrocautery or a luteinizing hormone-releasing hormone agonist. Fertil Steril 1992; 57:309.
  29. 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.
  30. Palomba S, Orio F Jr, Nardo LG, et al. Metformin administration versus laparoscopic ovarian diathermy in clomiphene citrate-resistant women with polycystic ovary syndrome: a prospective parallel randomized double-blind placebo-controlled trial. J Clin Endocrinol Metab 2004; 89:4801.
  31. Palomba S, Falbo A, Battista L, et al. Laparoscopic ovarian diathermy vs clomiphene citrate plus metformin as second-line strategy for infertile anovulatory patients with polycystic ovary syndrome: a randomized controlled trial. Am J Obstet Gynecol 2010; 202:577.e1.
  32. Nestler JE, Stovall D, Akhter N, et al. Strategies for the use of insulin-sensitizing drugs to treat infertility in women with polycystic ovary syndrome. Fertil Steril 2002; 77:209.
  33. Pirwany I, Tulandi T. Laparoscopic treatment of polycystic ovaries: is it time to relinquish the procedure? Fertil Steril 2003; 80:241.
  34. Abdellah MS. Reproductive outcome after letrozole versus laparoscopic ovarian drilling for clomiphene-resistant polycystic ovary syndrome. Int J Gynaecol Obstet 2011; 113:218.
  35. Gjønnaess H. The course and outcome of pregnancy after ovarian electrocautery in women with polycystic ovarian syndrome: the influence of body-weight. Br J Obstet Gynaecol 1989; 96:714.
  36. Gjönnaess H. A simple treatment for polycystic ovarian syndrome. World Health Forum 1990; 11:214.
  37. Armar NA, McGarrigle HH, Honour J, et al. Laparoscopic ovarian diathermy in the management of anovulatory infertility in women with polycystic ovaries: endocrine changes and clinical outcome. Fertil Steril 1990; 53:45.
  38. Thessaloniki ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group. Consensus on infertility treatment related to polycystic ovary syndrome. Fertil Steril 2008; 89:505.
  39. Gürgan T, Kişnişçi H, Yarali H, et al. Evaluation of adhesion formation after laparoscopic treatment of polycystic ovarian disease. Fertil Steril 1991; 56:1176.
  40. 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.
  41. Dabirashrafi H. Complications of laparoscopic ovarian cauterization. Fertil Steril 1989; 52:878.
  42. Melica F, Chiodi S, Cristoforoni PM, Ravera GB. Reductive surgery and ovarian function in the human--can reductive ovarian surgery in reproductive age negatively influence fertility and age at onset of menopause? Int J Fertil Menopausal Stud 1995; 40:79.
  43. 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.