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).
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- 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