Using an electrocautery strategy or recombinant follicle stimulating hormone to induce ovulation in polycystic ovary syndrome: randomised controlled trial

Does laparoscopic ovarian diathermy change clomiphene-resistant PCOS into clomiphene-sensitive?

PURPOSE

To test the role of laparoscopic ovarian diathermy (LOD) in improving the ovarian response to clomiphene citrate (CC) in clomiphene-resistant polycystic ovary syndrome (PCOS) patients.

METHODS

The study comprised of 234 CC-resistant PCOS women who were treated with LOD. Eighty-four patients that remained anovulatory after LOD received 100-150 mg CC for 5 days starting from day 3 of induced menstruation for 1-3 cycles. Outcome measures were; ovulation, pregnancy, miscarriage and live birth rates.

RESULTS

Ovulation occurred in 80/162 cycles (49.4%) and in 30/84 patients (35.7%). Pregnancy occurred in 13/84 patients (15.5%) and in 13/80 cycles (16.2%). Miscarriage and live birth rates were 23.1 and 76.9%, respectively. Ovulatory women showed significantly lower baseline BMI (P < 0.001), Ferriman-Gallwey score (P = 0.02), testosterone (P = 0.03), higher sex hormone binding globulin and lower free androgen index (P < 0.001) compared with anovulatory women. The baseline fasting insulin was statistically significantly lower and fasting glucose:insulin ratio was statistically significantly higher (P = 0.003, 0.002) in ovulatory compared with anovulatory patients.

CONCLUSIONS

LOD improves the ovarian response to CC in at least one-third of CC-resistant patients who remained anovulatory following LOD especially in women who are less hyperandrogenic and less insulin resistant.

Report of the international symposium: polycystic ovary syndrome: first Latin-American consensus

During the last years, numerous consensuses have been held in different countries in order to review the data concerning diagnosis and treatment and their relationship with the ethnic origin, social status and lifestyle of women with Polycystic Ovary Syndrome (PCOS). This study describes the conclusions concerning diagnostic criteria and the appropriate treatment of women with PCOS reached during the International Symposium Polycystic Ovary Syndrome, First Latin-American Consensus held in Buenos Aires, Argentina on 4th and 5th May 2009 to be applied in South American.

Aromatase inhibitors for ovulation induction and ovarian stimulation

Aromatase inhibitors (AIs) were originally developed for the treatment of advanced breast cancer in postmenopausal women. Their use in reproductive medicine has been extensively studied in the past decade. We reviewed the current strategies for ovulation induction for anovulatory women, mostly women with polycystic ovarian syndrome (PCOS), and the scientific basis for use of AIs in reproductive medicine. The AI, letrozole, is effective in ovulation induction in women with PCOS resistant to clomifene citrate and ovarian stimulation for intrauterine insemination and in vitro fertilization (IVF). Letrozole is an attractive option with its oral route of administration, cost, safety profile and effectiveness in ovulation induction and ovarian stimulation. Letrozole has the potential to be the first-line treatment option for ovulation induction in PCOS women, while its use in ovarian stimulation for IVF deserves further study.

Does Adding Dexamethasone to Clomiphene Citrate Improve Ovulation in PCOS Patients? A Triple - Blind Randomized Clinical Trial Study

BACKGROUND

A common cause of anovulation is polycystic ovarian syndrome (PCOS). Clomiphene citrate (CC) is the first line of treatment in PCOS patients however approximately 25% of patients may be CC-resistant. This study aimed to evaluate the efficacy of adding dexamethasone (dex) to CC in CC-resistant PCOS patients with the intent to improve ovulation.

MATERIALS AND METHODS

This randomized controlled trial study was performed on 60 infertile PCOS patients referred to our infertility research center from 2007 to 2009. Patients were randomly divided in two groups and stimulation performed with dex+CC or CC+placebo. Rates of ovulation, pregnancy and number of mature follicles were evaluated.

RESULTS

Ovulation rate in the dex+CC group was 21 out of 30 (70%) and in the CC+placebo group it was 17 out of 30 (56.7%). The pregnancy rate was 5 (16.7%) in the dex+CC group and 3 (10%) in the CC+placebo group. There was no significant difference between rates of ovulation and pregnancy in both groups, but the number of follicles ≥18 mm were significant in the dex+CC group (p<0.05).

CONCLUSION

Our results showed that addition of dex to cc significantly increased the number of matured follicles, however the ovulation and pregnancy rates were comparable between the two groups (Registeration Number: IRCT 138807041760 N2).

Clinical outcomes of ovulation induction with metformin, clomiphene citrate and human menopausal gonadotrophin in polycystic ovary syndrome

This pilot study evaluated the effects of coadministration of metformin with clomiphene citrate (CC) and human menopausal gonadotrophin (HMG) in women with CC-resistant polycystic ovary syndrome (PCOS). Sixty women with PCOS were randomly assigned to receive 3 months' treatment with metformin or placebo together with CC and HMG. Transvaginal ultrasound was used to monitor follicular development and ovulation was induced by human chorionic gonadotrophin (HCG). The number of dominant follicles, the oestradiol level on the day HCG was given and the amount of HMG required were significantly lower in the metformin group than in the placebo group, whereas the mono-ovulatory rate and pregnancy rate in the third cycle were significantly higher. The cumulative pregnancy rate in the metformin group (43.3%) was higher than in the placebo group (20.0%), but this difference did not reach statistical significance. In conclusion, coadministration of metformin with CC and HMG reduced the amount of HMG required and increased the mono-ovulatory rate and pregnancy rate.

Letrozole versus laparoscopic ovarian diathermy for ovulation induction in clomiphene-resistant women with polycystic ovary syndrome: a randomized controlled trial

PURPOSE

To compare the effect of letrozole with laparoscopic ovarian diathermy (LOD) for ovulation induction in clomiphene citrate (CC) resistant women with polycystic ovary syndrome (PCOS).

METHODS

Two hundred and sixty anovulatory women with CC-resistant PCOS were selected in this randomized controlled trial. Group A (n = 128) received 2.5 mg letrozole daily for 5 days for up to six cycles. Group B (n = 132) underwent LOD with 6 months follow-up. Outcome measures were ovulation rate, midcycle endometrial thickness, pregnancy, miscarriage and live birth rates.

RESULTS

Ovulation occurred in 335/512 cycles (65.4%) in letrozole group and 364/525 cycles (69.3%) in LOD group without significant difference between both groups. Resumption of regular menstruation was similar in both treatment groups. A significant increase in midcycle endometrial thickness was observed in letrozole group (8.8 ± 1.1 mm vs. 7.9 ± 1.2 mm) (P < 0.05). Pregnancy rate was similar in both groups (15.6 vs. 17.5%). There were no statistical significant differences as regards miscarriage and live birth rates between both groups. No multiple pregnancy or ovarian hyperstimulation occurred in either group.

CONCLUSION

Letrozole and LOD are equally effective for inducing ovulation and achieving pregnancy in CC-resistant PCOS patients.

Laparoscopic ovarian diathermy vs clomiphene citrate plus metformin as second-line strategy for infertile anovulatory patients with polycystic ovary syndrome: a randomized controlled trial

OBJECTIVE

The purpose of this study was to compare the effectiveness of laparoscopic ovarian diathermy (LOD) vs clomiphene citrate (CC) plus metformin in infertile patients with CC-resistant polycystic ovary syndrome (PCOS).

STUDY DESIGN

Fifty primary infertile patients with CC-resistant PCOS were assigned randomly to receive LOD followed by a 6-month observation (group A) or 6-cycle course of CC plus metformin (group B). Reproductive and safety outcomes were analyzed.

RESULTS

No significant difference between 2 groups in pregnancy (15/92 women [16.3%] vs 14/107 women [13.1%]; P = .521) and live-birth (13/92 women [14.1%] vs 12/107 women [11.2%]; P = .536) rates per cycle was observed. With the use of a Cox regression analysis, patients under medical treatment, compared with patients who received surgical treatment, had a relative risk of pregnancy of 1.2 (95% confidence interval, 0.61-2.44; P = .582) and a relative risk of live-birth of 1.4 (95% confidence interval, 0.63-2.96; P = .425).

CONCLUSION

LOD and CC plus metformin seem to be 2 effective approaches to treat infertility in patients with CC-resistant PCOS.

Pregnancy outcome in women with polycystic ovary syndrome comparing the effects of laparoscopic ovarian drilling and clomiphene citrate stimulation in women pre-treated with metformin: a retrospective study

BACKGROUND

Ovarian stimulation in women with polycystic ovary syndrome (PCOS) increases the risk for perinatal complications. Ovulation induction by laparoscopic ovarian drilling (LOD) might improve the overall pregnancy outcomes. The aim of our study was to assess the adverse events or effects on pregnancy of LOD and clomiphene citrate (CC) stimulation in patients who received metformin.

SETTING

Academic research institution. We retrospectively analyzed the courses of 40 spontaneous pregnancies after LOD for CC-resistance, 40 pregnancies after CC stimulation, and 40 pregnancies after metformin treatment alone. Patients in the LOD and the CC groups had been pre-treated with Metformin. Primary outcome parameters were: the rate of multiple pregnancies; the rate of early pregnancy losses/miscarriages; the development of gestational diabetes, pregnancy-induced hypertension, and preeclampsia/HELLP-syndrome; premature delivery; and birth weight.

RESULTS

The rate of twin pregnancies did not differ between the CC group (12.5%), the LOD group (7.5%), and the metformin only group (2.5%, p=0.239). Seventeen women suffered an early miscarriage. There were no differences with regard to the rates of gestational diabetes, pregnancy-induced hypertension, preeclampsia, and preterm delivery. By analyzing all pregnancy complications together, the overall pregnancy complication rate was highest in the CC group (70.0%, 28/40), followed by the LOD group (45.0%, 18/40), and the metformin only group (47.5%, 19/40; p=0.047).

CONCLUSIONS

CC, but not LOD, increases the complication rate in pregnant patients who received metformin.

A prospective randomized trial comparing the clinical and endocrinological outcome with rosiglitazone versus laparoscopic ovarian drilling in patients with polycystic ovarian disease resistant to ovulation induction with clomiphene citrate

OBJECTIVES

Rosiglitazone, an insulin sensitizing agent is used currently in women with clomiphene citrate (CC) resistant polycystic ovarian syndrome (PCOS). Our study proposed to compare the efficacy of rosiglitazone and CC with laparoscopic ovarian drilling (LOD) and CC in terms of biochemical effects, ovulation rate and pregnancy rate in patients of PCOS resistant to CC.

METHODS

This prospective randomised trial included 43 patients of PCOS resistant to CC. Twenty-two women were assigned to the rosiglitazone (4 mg twice daily) and CC group and other 21 patients underwent unilateral LOD and then received CC and multivitamins. The treatment continued for six cycles in both the groups. The biochemical response, ovulation rate and pregnancy rate over a follow up period of 6 months were compared.

RESULTS

Treatment with rosiglitazone and CC or LOD and CC resulted in increased ovulation (80.8 vs. 81.5%) and pregnancy (50 vs. 42.8%), respectively. There was no statistical difference between the two groups in terms of biochemical response, ovulation rate and pregnancy rate.

CONCLUSION

To avoid the risk of adverse effects of LOD preference may be given to the use of rosiglitazone and CC therapy in patients of PCOS resistant to CC.

Randomized controlled trial comparing laparoscopic ovarian diathermy with clomiphene citrate as a first-line method of ovulation induction in women with polycystic ovary syndrome

BACKGROUND

Laparoscopic ovarian diathermy (LOD) is currently accepted as a successful second-line treatment for ovulation induction (OI) in clomiphene citrate (CC)-resistant women with polycystic ovary syndrome (PCOS). The aim of this study was to test the hypothesis that LOD may be superior to CC as a first-line treatment.

METHODS

The study included 72 anovulatory women with PCOS who were randomized to LOD (n = 36) or CC (n = 36). Women who remained anovulatory after LOD were offered CC. Similarly, women receiving CC who failed to ovulate or conceive were offered LOD. Pregnancy rates were compared between the two groups using chi(2) and odds ratio with 95% confidence interval (OR, 95% CI).

RESULTS

After randomization, six women conceived before starting treatment and another patient postponed treatment. The remaining 65 women received the treatment (33 underwent LOD and 32 received CC). After the primary treatment, more pregnancies (44%) occurred in women receiving CC than in those undergoing LOD (27%), although the difference did not reach statistical significance [P = 0.13, OR 2.1 (0.7 - 5.8)]. After adding the second treatment, the pregnancy rate was still higher, but to a less extent, in the CC group [63% versus 52%, P = 0.2, OR 1.6 (0.6 - 4.2)].

CONCLUSIONS

LOD is not superior to CC as a first-line method of OI in women with PCOS. The trial is registered with ClinicalTrials.gov with an identifier number NCT00220545.

Le syndrome des ovaires polykystiques (SOPK)

Polycystic ovaries syndrome (PCOS) is one of the most common female hormonal disorders. Its multiple components--reproductive, metabolic, neoplasic and cardiovascular--have a major impact on the public health. Androgen excess and resistance to insulin, probably from genetic origin, are responsible for most of the clinical symptomatology. Resistance to insulin seems to be accompanied by a greater risk of glucose intolerance, type 2 diabetes, lipidic anomalies and can involve the development of cardiovascular diseases. In addition, sleep apnea syndrome is more progressively described in PCOS. Infertility, menses disorders and hirsutism often push these patients to consult their physician. A better understanding of the physiopathological mechanisms led to the emergence of new therapeutic options increasing the sensitivity to insulin. Besides the pregnancy wishes, cares aim to attenuate the marks of the hyper-androgenism (hormonal treatment and cosmetic) and to correct cardiovascular, respiratory and gynaecological risk factors. In case of infertility by anovulation, cares must be performed by trained experts to minimize the risk of ovarian hyper-stimulation syndrome and multiple pregnancies. A gradation from loose weight to clomiphene citrate ovulation induction, ovarian drilling, low dose gonadotropin, in vitro fertilisation, or in vitro maturation of oocytes should bring back good reproduction potential.

The position of diagnostic laparoscopy in current fertility practice

In everyday clinical practice, it is not always clear if and when exactly in the fertility work-up a diagnostic laparoscopy should be offered. The aim of this review is to analyse the available evidence with respect to alternative diagnostic methods for detecting tuboperitoneal infertility and with respect to the position of diagnostic laparoscopy in women with infertility. A literature search of the National Library of Medicine and the National Institutes of Health (PubMed) was performed using the key words 'diagnostic laparoscopy and infertility'. The study methodology was carefully considered in an effort to present conclusions preferably based on randomized controlled trials (RCTs). The routine use of diagnostic laparoscopy for the evaluation of all cases of female infertility is currently under debate. According to data published in retrospective non-controlled studies, diagnostic laparoscopy after several failed cycles of ovulation induction enables the detection of a significant proportion of pelvic pathology amenable to treatment. A Cochrane review has shown that laparoscopic ovarian diathermy in clomiphene-resistant polycystic ovarian syndrome is at least as effective as gonadotrophin treatment, and results in a lower multiple pregnancy rate. The role of laparoscopy before the start of treatment with intrauterine insemination is controversial, according to one RCT. In women with bilateral ultrasonically visible hydrosalpinges, two RCTs have demonstrated increased implantation and pregnancy rates in IVF cycles after salpingectomy. Although RCTs which have studied the benefit of laparoscopic surgery in moderate or severe endometriosis are still lacking, its value has generally been accepted. In conclusion, some specific clinical settings, solid evidence is available to recommend the use of diagnostic laparoscopy in current fertility practice. There is however a need for more RCTs to answer remaining questions regarding its value in the diagnosis and treatment of some patients with infertility.

Routine Chlamydia antibody testing is of limited use in subfertile women with anovulation

The Chlamydia antibody titre (CAT) is a test used to identify subfertile couples at increased risk for tubal pathology. The usefulness of the routine performance of CAT was evaluated in a multicentre prospective cohort study, in women without regular ovulation. Consecutive couples presenting with subfertility due to an irregular menstrual cycle or amenorrhoea were included. A total of 711 women were studied, all of whom underwent CAT. Tubal status was verified in 190 of these women. Two-sided tubal pathology was found in 5% of these women, and one-sided occlusion in 10%. Of all the women in the study group, 33 (4.6%) had an abnormal CAT, of which 21 underwent further tubal testing. Tubal pathology was found in two (10%) of these 21 patients. The sensitivity and specificity of CAT were respectively 20% and 89%. Correction for verification bias increased the specificity to 96% with a drop of the sensitivity to 9%. In subfertile couples with anovulation, the performance of CAT is not useful. It is proposed that testing for tubal disease in these women is delayed until treatment with clomiphene citrate has failed.

ART: iatrogenic multiple pregnancy?

Assisted reproductive technologies (ART) are now widely accepted as effective treatment for most causes of infertility. With improving success rates, attention has turned to the problem of multiple pregnancies, which are associated with a poor perinatal outcome, maternal complications and significant financial consequences. The challenge is to reduce multigestational pregnancies while maintaining good treatment outcomes. Methods to prevent multiple pregnancy include restrictive use of ART in couples with a good chance of spontaneous pregnancy, cautious use of gonadotrophins, and increased use of natural-cycle intra-uterine insemination and elective single embryo transfer in in-vitro fertilization and intracytoplasmic sperm injection. The aim of this article is to review the contribution of fertility treatment to multiple pregnancies and strategies for reducing multiples in ART.

Surgical treatment in polycystic ovary syndrome

PURPOSE OF REVIEW

The purpose of this review is to provide a critical summary of current knowledge on the role and effectiveness of ovarian surgery in the treatment of polycystic ovary syndrome.

RECENT FINDINGS

Clomiphene citrate is used as a first-line treatment for ovulation induction in infertile anovulatory patients with polycystic ovary syndrome. In clomiphene citrate-resistant women, other treatment modalities such as laparoscopic electrocautery or ovulation induction with gonadotropins have been proposed as alternative therapies. Although gonadotropin treatment and laparoscopic ovarian drilling have demonstrated similar reproductive outcomes, laparoscopic ovarian drilling has some advantages over gonadotropin treatment such as lower cost per pregnancy, improvement in menstrual regularity, and better long-term reproductive performance. On the other hand, knowledge about the pathogenesis of polycystic ovary syndrome has been growing and insulin-sensitizing drugs have gained popularity as a new treatment option.

SUMMARY

According to current data, metformin has gained popularity as first-line management in clomiphene citrate-resistant women with polycystic ovary syndrome. If ovulation does not occur within several months after treatment with metformin, after the evaluation of all pros and cons related to each treatment, laparoscopic ovarian drilling or gonadotropins may be considered as an effective option according to patient choice.

Infertility in polycystic ovary syndrome: focus on low-dose gonadotropin treatment

Polycystic ovary syndrome accounts for more than 75% of cases of anovulatory infertility. The mechanism of anovulation is uncertain but there is evidence that arrested antral follicle development is associated with the abnormal endocrine profile, in particular the interaction of insulin and LH on granulosa cell differentiation. In terms of management, induction of ovulation can be achieved in most cases by the use of antiestrogens. Treatment of clomiphene-resistant subjects is difficult; conventional doses of gonadotropins are associated with high rates of ovarian hyperstimulation syndrome and multiple pregnancy. On the other hand, low-dose gonadotropin therapy has proven effective in inducing unifollicular ovulation and, in this review, we present, in detail, a recent analysis the results from this center. The cumulative conception rate after six cycles was more than 50% and, importantly, the multiple pregnancy rate was only 3%. Weight reduction in obese subjects with PCOS not only increases the chance of fertility but may also improve the long-term prognosis with regard to development of diabetes. Insulin-sensitizing drugs such as metformin may also have a place in treatment of PCOS.

Anovulation and ovulation induction

Conventional treatment of normogonadotropic anovulatory infertility is ovulation induction using the antiestrogen clomiphene citrate, followed by follicle-stimulating hormone. Multiple follicle development, associated with ovarian hyperstimulation, and multiple pregnancy remain the major complications. Cumulative singleton and multiple pregnancy rate data after different induction treatments are needed. Newer ovulation induction interventions, such as insulin-sensitizing drugs, aromatase inhibitors and laparoscopic ovarian electrocoagulation, should be compared with conventional treatments. Ovulation induction efficiency might improve if patient subgroups with altered chances for success or complications with new or conventional techniques could be identified, using multivariate prediction models based on initial screening characteristics. This would make ovulation induction more cost-effective, safe and convenient, enabling doctors to advise patients on the most effective and patient-tailored treatment strategy.

Ovulation induction in women with polycystic ovary syndrome

To date, clomiphene citrate (CC) remains the first therapeutical step for inducing ovulation in anovulatory PCOS patients. Metformin alone or combined with CC is a valid second step approach, whereas the laparoscopic ovarian diathermy can be useful only in selected cases.

Polycystic ovarian syndrome--prognosis and outcomes

Polycystic ovarian syndrome (PCOS) is a condition that is present in 5-6% of women of reproductive age. It has potentially profound implications for women with regard to anovulatory infertility and symptoms related to elevated androgen levels. In addition, in later life women are prone to significant health problems related to hyperinsulinaemia, with an excess risk for diabetes and cardiovascular risk factors. Evidence suggests that the adverse features of PCOS can be ameliorated with lifestyle intervention, such as diet and exercise, while further short-term benefits related to ovulation and cardiac risk factors may be derived from medication with metformin. Evidence for the long-term use of metformin to protect against adverse cardiovascular outcomes and for the use of metformin throughout pregnancy to reduce the risk of miscarriage, gestational diabetes, pre-eclampsia and fetal macrosomia is still lacking.

Surgical treatment of polycystic ovary syndrome

Laparoscopic ovarian surgery for the induction of ovulation in women with polycystic ovary syndrome provides a single-treatment option with a good rate of unifollicular ovulation, thereby minimizing the need for extensive ultrasound monitoring because of a low risk of multiple pregnancy. The cumulative conception rates after 6 months are lower than those with gonadotropin therapy, but after 12 months the pregnancy rates are similar. The risks, albeit low, are those of laparoscopic surgery, general anaesthesia and ovarian damage.

Ovulation induction in normogonadotropic anovulation (PCOS)

Treatment of normogonadotropic anovulatory infertility (World Health Organization class 2, or WHO2) is by induction of ovulation using clomiphene citrate (CC), followed by follicle-stimulating hormone (FSH) in cases of treatment failure. Not all patients will become ovulatory or will conceive with this treatment. Others, exhibiting multifollicular instead of monofollicular development, may encounter complications such as ovarian hyperstimulation and multiple pregnancy. Recently introduced alternative treatment interventions-such as insulin-sensitizing drugs, aromatase inhibitors, or laparoscopic electrocautery of the ovaries-may offer the possibility of improving the efficacy of the classical ovulation induction algorithm. Based on initial patient characteristics, it may be possible to identify specific patient subgroups with altered chances of success or complications while using one of these interventions. Regarding CC and FSH ovulation induction, this has been performed using multivariate prediction models. This approach may enable us to improve safety, cost-effectiveness, and patient convenience in future ovulation induction.

Preoperative luteinizing hormone levels predict the ovulatory response to laparoscopic ovarian drilling in patients with clomiphene citrate-resistant polycystic ovary syndrome

OBJECTIVE

Laparoscopic ovarian drilling (LOD) is a treatment option for women with clomiphene citrate (CC)-resistant polycystic ovary syndrome (PCOS), but appropriate indications for this procedure are lacking. The aim of this study was to analyze preoperative factors affecting the efficacy of LOD in producing ovulation in CC-resistant PCOS patients.

DESIGN

Retrospective cohort study.

PATIENTS AND METHODS

We studied 40 infertile Japanese women with CC-resistant PCOS who received LOD using argon-beam electrocoagulation. These patients satisfied the diagnostic criteria of the revised European Society of Human Reproduction and Embryology/American Society for Reproductive Medicine PCOS consensus.

RESULTS

After LOD, ovulation occurred in 33 (83%) patients; pregnancy occurred in 22 patients (55%). Preoperative serum luteinizing hormone (LH) levels were significantly higher in women who ovulated after LOD than in those who did not ovulate. The area under the receiver operator characteristic curve for ovulation using preoperative LH levels was 0.81 (95% confidence interval: 0.67-0.96). After LOD, follicle-stimulating hormone levels increased significantly in the non-ovulating group but were unchanged in the ovulating group.

CONCLUSIONS

Preoperative serum LH levels may be a good predictor of LOD efficacy in patients with PCOS. Therefore, eligibility criteria for LOD should be strictly applied, since LOD for patients with inadequate LH levels is not only ineffective, but also may impair ovarian reserve.

Patient-tailored conventional ovulation induction algorithms in anovulatory infertility

Conventional treatment of normogonadotropic anovulatory infertility is ovulation induction using the antiestrogen clomiphene citrate, followed by follicle-stimulating hormone. Multiple follicle development, associated with ovarian hyperstimulation, and multiple pregnancy remain the major complications. Cumulative singleton and multiple pregnancy rate data after different induction treatments are needed. Newer ovulation induction interventions, such as insulin-sensitizing drugs, aromatase inhibitors and laparoscopic ovarian electrocoagulation, should be compared with conventional strategies. Ovulation induction efficiency might improve if patient subgroups with altered chances for success or complications with new or conventional techniques could be identified, using multivariate prediction models based on initial screening characteristics. This would make ovulation induction more cost-effective, safe and convenient, enabling doctors to advise patients on the most effective and patient-tailored treatment strategy.

An economic evaluation of laparoscopic ovarian diathermy versus gonadotrophin therapy for women with clomiphene citrate-resistant polycystic ovarian syndrome

PURPOSE OF REVIEW

Women with polycystic ovarian syndrome are typically anovulatory and require ovulation induction. Ovarian wedge resection was the first treatment for anovulation but was eventually abandoned because of the increased risk of postsurgical adhesions and as medical ovulation induction with clomiphene and gonadotrophins was introduced. However, with the advent of laparoscopy, there has been a return to surgical approaches. The potential advantages of laparoscopic surgery include avoidance of hyperstimulation and the lowered costs make ovarian surgery an attractive alternative to gonadotrophins.

RECENT FINDINGS

Clinical trials in New Zealand and the Netherlands have compared costs of laparoscopic ovarian drilling with gonadotrophins. The total cost of treatment in the Netherlands study for the ovarian drilling group was euro 4664 and for the gonadotrophins group was euro 5418. Without the cost of monitoring and the diagnostic laparoscopy then the difference was euro 2110 in favour of ovarian drilling. It was estimated that the cost per term pregnancy would be euro 14,489 for gonadotrophin and euro 11,301 for ovarian drilling (22% lower). The higher rates of multiple pregnancy in the gonadotrophin group were considered to be responsible for the increased costs. In the New Zealand trial the costs of a live birth were one-third lower in the group that underwent laparoscopic ovarian diathermy compared with those women who received gonadotrophins (NZ$19,640 and 29,836, respectively).

SUMMARY

Treating women with clomiphene-resistant polycystic ovarian syndrome with laparoscopic ovarian diathermy results in reduced direct and indirect costs. The reduction in multiple pregnancies makes the alternative of surgery particularly attractive.

Treatment preferences and trade-offs for ovulation induction in clomiphene citrate–resistant patients with polycystic ovary syndrome

OBJECTIVE

To investigate patient preferences and trade-offs for laparoscopic electrocautery of the ovaries relative to ovulation induction with recombinant FSH (rFSH) in patients with clomiphene citrate (CC)-resistant polycystic ovary syndrome (PCOS).

DESIGN

Assessment of preferences and trade-offs in a randomized controlled trial.

SETTING

Academic hospital.

PATIENT(S)

Thirty-two CC-resistant patients with PCOS who had been randomly assigned to either laparoscopic electrocautery of the ovaries or ovulation induction with rFSH and 32 control patients with PCOS under treatment with CC.

INTERVENTION(S)

Preference for laparoscopic electrocautery relative to rFSH was established during an interview. Trade-offs between treatment burden and effectiveness were evaluated by varying hypothetical pregnancy rates after laparoscopic electrocautery until patients switched in their initial preference.

MAIN OUTCOME MEASURE(S)

Preference for laparoscopic electrocautery of the ovaries; trade-off between burden and effectiveness of treatment.

RESULT(S)

The majority of the patients would prefer electrocautery of the ovaries over ovulation induction with rFSH if both treatment strategies resulted in similar pregnancy rates. However, most patients were willing to trade off their preference for increased effectiveness: the percentage of patients who preferred electrocautery over rFSH sharply declined when the difference in hypothetical pregnancy rates was more than 5% in favor of rFSH.

CONCLUSION(S)

Patients with polycystic ovary syndrome are well able to express an informed preference for laparoscopic electrocautery of the ovaries or ovulation induction with rFHS. Preferences are guided by features of the respective treatments but seem to be dominated by their effectiveness and safety.

Individualized cost-effective conventional ovulation induction treatment in normogonadotrophic anovulatory infertility (WHO group 2)

BACKGROUND

Conventional treatment in normogonadotrophic anovulatory infertility (WHO 2) consists of clomiphene citrate (CC), followed by exogenous gonadotrophins (FSH) and IVF. Response to these treatments may be predicted on the basis of individual patient characteristics. We aimed to devise a patient-tailored, cost-effective treatment algorithm involving the above-mentioned treatment modalities, based on individual patient characteristics.

METHODS

Sixteen prognostic groups are defined, according to the presence or absence of: age >30 years, amenorrhea, elevated androgen levels and obesity. The chances of response with each of the three treatments were calculated using prediction models. Treatment costs were based on the data of 240 patients visiting a specialist academic fertility unit. Outcome was an ongoing pregnancy within 12 months after initiation of treatment. The costs per pregnancy of three different strategies were compared, with a threshold for cost-effectiveness of 10 000.

RESULTS

The strategy CC + FSH + IVF compared with FSH + IVF generated more pregnancies against lower costs. Compared with CC + IVF, it also produced more pregnancies, but at higher costs. For <30 years of age with normal androgen levels, costs per pregnancy were less than 10 000. For women >30 years old, costs per pregnancy were 25 000 and over 200 000, when presenting with normal or elevated androgen levels, respectively.

CONCLUSIONS

The conventional treatment protocol is efficient for women aged <30 years with normal androgen levels. For women >30 years old with elevated androgen levels, FSH may be skipped.

Ovulation induction: a mini review

Ovulation induction is the method for treating anovulatory infertility. For patients with hypogonadotrophic hypogonadism, the treatment involves administration of both FSH and LH, while HCG is injected for follicle rupture. Pulsatile GnRH has the same effectiveness as gonadotrophins and the advantage of the low multiple pregnancy rate. In polycystic ovary syndrome (PCOS), the first treatment choice is clomiphene citrate. With this drug, in properly selected patients, the cumulative pregnancy rate approaches that of normal women. Low-dose protocols of FSH are the second line of treatment, effective in inducing monofollicular development. Laparoscopic ovarian drilling can be an alternative but not as a first choice treatment in clomiphene-resistant patients. Other treatments, such as pulsatile GnRH and GnRH agonists, are hardly used today in PCOS. However, in obese women with PCOS, weight loss and exercise should be recommended as the first line of therapy. Newer agents including aromatase inhibitors and insulin sensitizers, although promising, need further evaluation.

A randomized controlled trial evaluating metformin pre-treatment and co-administration in non-obese insulin-resistant women with polycystic ovary syndrome treated with controlled ovarian stimulation plus timed intercourse or intrauterine insemination

BACKGROUND

There are few data in the literature regarding the utility of metfomin before and during gonadotrophin administration in women with polycystic ovary syndrome (PCOS). The aim of the present study was to assess the effect of the pre-treatment and co-administration of metformin in infertile PCOS women treated with controlled ovarian stimulation (COS) followed by timed intercourse (TI) or intrauterine insemination (IUI).

METHODS

Seventy insulin-resistant primary infertile women with PCOS were randomized to receive metformin cloridrate (850 mg twice daily; group A) or placebo tablets (two tablets daily; group B) for 3 months. Three trials of COS using highly purified urinary FSH (hpFSH) plus TI/IUI were performed. Number of ampoules of gonadotrophin used, duration of the ovarian stimulation, cycle cancellation, ovulation, pregnancy, abortion, live birth, mono-ovulatory cycles, multiple pregnancies and ovarian hyperstimulation syndrome (OHSS) rates were assessed.

RESULTS

No difference between groups was detected in ovulation, cycle cancellation, pregnancy, abortion, live birth, multiple pregnancies and OHSS rates. The mono-ovulatory cycle rates were significantly (P = 0.002) more frequent in group A than in group B, whereas the days of stimulation for non-cancelled cycles and the number of vials of gonadotrophins used were significantly (P < 0.001) higher in group A than in group B.

CONCLUSION

In insulin-resistant women with PCOS, metformin pre-treatment and co-administration with hpFSH increases the mono-ovulatory cycles.

Gonadotrophins in ovulation induction

For anovulatory women who fail to ovulate or conceive with clomiphene citrate, gonadotrophin ovulation induction has been the conventional second-line therapy. The aim of treatment is to achieve monofollicular development and ovulation. This differs fundamentally from the aim of ovarian stimulation for IVF, in which multiple follicular development is the goal. The small therapeutic window of ovulation induction requires a rigorous approach to monitoring, and willingness to cancel the cycle when multiple follicle development occurs. The two most widely used approaches are the low-dose step-up and the step-down protocols. While the latter more closely mimics the normo-ovulatory cycle, outcomes are similar. For safety reasons, the step-down protocol has not been widely adopted. The principle risks of ovulation induction are ovarian hyperstimulation syndrome and multiple pregnancy. There is a need to individualize treatment if outcomes are to be optimized. The role of adjuvant therapies remains unclear. However, prediction models based on initial screening parameters enable the optimal dose of FSH to be determined, and the identification of patients with a poor prognosis for successful treatment.

Multiple birth resulting from ovarian stimulation for subfertility treatment

Assisted reproductive technologies (ARTs) aim to increase a woman's chances of becoming pregnant by bringing many female and male gametes into close proximity. Techniques to achieve this objective include ovarian hyperstimulation by maturation of several oocytes, intrauterine insemination (IUI) of concentrated sperm, or in-vitro fertilisation (IVF) by bringing gametes together outside the female body. The very nature of ovarian hyperstimulation--with or without IUI--enhances the risk of multiple pregnancy (eg, two or more babies). In most IVF cycles, more than one embryo is transferred, again resulting in an increased chance of multiple pregnancy. Developed societies have witnessed a large rise in prevalence of twin, triplet, and higher order multiple births, mainly resulting from ARTs. The primary aim of this Review is to increase awareness of the many implications of the present iatrogenic epidemic of multiple births. The background of ovarian hyperstimulation, trends supporting current practice, and strategies to reduce the chance of multiple pregnancy are highlighted.

Predicting ongoing pregnancy following ovulation induction with recombinant FSH in women with polycystic ovary syndrome

BACKGROUND

Ovulation induction with recombinant FSH (rFSH) is common in women with polycystic ovary syndrome (PCOS) not responding to clomiphene citrate treatment, despite the associated risk of multiple pregnancies. We analysed clinical, ultrasonographic and endocrine parameters during initial screening of women with clomiphene citrate-resistant PCOS as predictors of ongoing pregnancy within 12 months of treatment following ovulation induction with rFSH.

METHODS

Eighty-five women were allocated to receive rFSH as part of a multicentre clinical trial. rFSH was administered in a chronic low-dose step-up protocol. The primary end-point was an ongoing pregnancy within 12 months. A logistic model was built using clinical, ultrasonographic and endocrine parameters to predict the response to rFSH treatment, adjusted for the number of cycles performed.

RESULTS

In total, 85 women underwent 272 treatment cycles with rFSH, of which 57 women (67%) achieved an ongoing pregnancy. Oligomenorrhoea, shorter duration of infertility and a lower free androgen index (FAI) were associated with higher chances of an ongoing pregnancy, resulting in a predictive model with a modest discriminative power (area under the curve 0.72, 95% confidence interval 0.64-0.79) that allowed us to distinguish between women with a probability of <5% of attaining an ongoing pregnancy and women with a probability of >25% of doing so.

CONCLUSION

A model consisting of oligo/amenorrhoea, duration of infertility and FAI level allowed a distinction to be made between women with a poor chance and women with a good chance of achieving an ongoing pregnancy.

Predictors for treatment failure after laparoscopic electrocautery of the ovaries in women with clomiphene citrate resistant polycystic ovary syndrome

BACKGROUND

Laparoscopic electrocautery has been put forward as the treatment of choice in women with clomiphene citrate (CC)-resistant polycystic ovary syndrome (PCOS). In order to make an informed treatment decision it would be helpful if we could identify women with PCOS with a high probability of treatment failure following electrocautery of the ovaries.

METHODS

Eighty-three women with CC-resistant PCOS were allocated to receive laparoscopic electrocautery followed by CC when anovulation persisted as part of a randomized controlled trial. Multivariable logistic regression analyses using clinical, ultrasonographic and endocrinological parameters were performed to predict (i) failure to ovulate within 8 weeks after electrocautery, and (ii) failure to reach an ongoing pregnancy after electrocautery with or without CC.

RESULTS

Of the 83 women, 56 (67%) ovulated within 8 weeks after electrocautery. The model for predicting anovulation after electrocautery included LH/FSH rate, year of menarche and glucose level. Women who were younger at menarche, had a lower LH/FSH ratio and a lower glucose level were more likely to have persistent anovulation. The area under the curve was 0.74. After electrocautery and CC, 41 women reached an ongoing pregnancy. No prognostic parameters could be identified to predict failure to reach an ongoing pregnancy after electrocautery followed by CC.

CONCLUSIONS

Persistence of anovulation after electrocautery could be predicted and women with a high risk of persisting anovulation could be distinguished. We were, however, not able to predict treatment failure after electrocautery followed by CC.

Impact of androgens on fertility – physiological, clinical and therapeutic aspects

Ovarian androgen synthesis and regulation are essential to ensure adequate steroidogenesis and folliculogenesis. In primates, there is evidence for a direct impact on the number of small antral follicles and on the process of chronic anovulation. Therefore, serum androgen should be more carefully assessed in infertile women. Accurate measurements of serum androgen are required to better identify patients with androgen excess or deficiency. Medical or surgical interventions are able to decrease ovarian androgen excess and to reduce the risk of hyperstimulation. Conversely, androgen supplementation should be considered in women at risk of low ovarian response to gonadotrophins, related to androgen deficiency. This review supports a specific and broad role of androgen in reproductive physiology.