Laparoscopic 'drilling' by diathermy or laser for ovulation induction in anovulatory polycystic ovary syndrome

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. Some treatment schedules with medical ovulation induction 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, using either heat or laser. This review of trials found that ovarian drilling without or with ovulation induction, if necessary, was as effective as medical ovulation induction alone in inducing ovulation, but the risk of multiple pregnancies was lower in the group of women who had laparoscopic ovarian drilling. Approximately 37% of women will have a live birth and 7% will have a miscarriage with either procedure.

Authors' conclusions: 

There was no evidence of a significant difference in rates of clinical pregnancy, live birth or miscarriage in women with clomiphene-resistant PCOS undergoing LOD compared to other medical treatments. The reduction in multiple pregnancy rates in women undergoing LOD makes this option attractive. However, there are ongoing concerns about the long-term effects of LOD on ovarian function.

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Background: 

Surgical ovarian wedge resection was the first established treatment for women with anovulatory polycystic ovary syndrome (PCOS) but was largely abandoned both due to the risk of postsurgical adhesions and the introduction of medical ovulation induction. However, women with PCOS who are treated with medical ovulation induction, with drugs such as gonadotrophins, often have an over-production of follicles which may result in ovarian hyperstimulation syndrome and multiple pregnancies. Moreover, gonadotrophins, though effective, are costly and time-consuming and their use requires intensive monitoring. Surgical therapy with laparoscopic ovarian 'drilling' (LOD) may avoid or reduce the need for medical ovulation induction, or may facilitate its usefulness. The procedure can be done on an outpatient basis with less trauma and fewer postoperative adhesions than with traditional surgical approaches. Many uncontrolled observational studies have claimed that ovarian drilling is followed, at least temporarily, by a high rate of spontaneous ovulation and conception, 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 strategy: 

We used the search strategy of the Menstrual Disorders and Subfertility Group (MDSG) to search the MDSG Trials Register, CENTRAL, MEDLINE, EMBASE, CINAHL and PsycINFO. The keywords included polycystic ovary syndrome, laparoscopic ovarian drilling, electrocautery and diathermy. Searches were conducted in September 2011, and a further search of the MDSG Trials Register was made on 14 May 2012.

Selection criteria: 

We included randomised controlled trials of subfertile women with clomiphene-resistant PCOS who undertook laparoscopic ovarian drilling in order to induce ovulation.

Data collection and analysis: 

This is an update of a previously updated review. There were nine RCTs in the previous version; an additional 16 trials were added in the current (2012) update. All trials were assessed for quality. The primary outcomes were live birth and multiple pregnancy. The secondary outcomes were rate of miscarriage, ovulation and pregnancy rates, ovarian hyperstimulation syndrome (OHSS), quality of life and cost.

Main results: 

Eight trials, including 1034 women, reported on the primary outcome of live birth rate per couple. Live births were reported in 34% of women in the LOD groups and 40% in other medical treatment groups. There were five different comparisons with LOD and there was no evidence of a difference in live births when compared with clomiphene citrate + tamoxifen (OR 0.81; 95% CI 0.42 to 1.53; P = 0.51, 1 trial, n = 150), gonadotrophins (OR 0.97; 95% CI 0.59 to 1.59; P = 0.89, I2 = 0%, 2 trials, n = 318) or aromatase inhibitors (OR 0.84; 95% CI 0.54 to 1.31; P = 0.44, I2 = 0%, 2 trials, n = 407).There was evidence of significantly fewer live births following LOD compared with clomiphene citrate + metformin (OR 0.44; 95% CI 0.24 to 0.82; P = 0.01, I2 = 78%, 2 trials, n = 159); the high heterogeneity in this subgroup could not be explained by population differences or differences in quality of the trials.

Twelve trials reported on multiple pregnancies (n= 1129 women). There were no multiple pregnancies in either group for clomiphene citrate or aromatase inhibitors compared with LOD. The rate of multiple pregnancies was significantly lower in the LOD group compared with trials using gonadotrophins (OR 0.13; 95% CI 0.03 to 0.52; P=0.004, I2 = 0%, 5 trials, n = 166).

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