Success of laparoscopic ovarian wedge resection is related to obesity, lipid profile, and insulin levels

Clinical Phenotypes of PCOS: a Cross-Sectional Study

This cross-sectional study examines the Doi-Alshoumer PCOS clinical phenotype classification in relation to measured clinical and biochemical characteristics of women with polycystic ovary syndrome (PCOS). Two cohorts of women (Kuwait and Rotterdam) diagnosed with PCOS (FAI > 4.5%) were examined. These phenotypes were created using neuroendocrine dysfunction (IRMA LH/FSH ratio > 1 or LH > 6 IU/L) and menstrual cycle status (oligo/amenorrhea) to create three phenotypes: (A) neuroendocrine dysfunction and oligo/amenorrhea, (B) without neuroendocrine dysfunction but with oligo/amenorrhea, and (C) without neuroendocrine dysfunction and with regular cycles. These phenotypes were compared in terms of hormonal, biochemical, and anthropometric measures. The three suggested phenotypes (A, B, and C) were shown to be sufficiently distinct in terms of hormonal, biochemical, and anthropometric measures. Patients who were classified as phenotype A had neuroendocrine dysfunction, excess LH (and LH/FSH ratio), irregular cycles, excess A4, infertility, excess T, highest FAI and E2, and excess 17αOHPG when compared to the other phenotypes. Patients classified as phenotype B had irregular cycles, no neuroendocrine dysfunction, obesity, acanthosis nigricans, and insulin resistance. Lastly, patients classified as phenotype C had regular cycles, acne, hirsutism, excess P4, and the highest P4 to E2 molar ratio. The differences across phenotypes suggested distinct phenotypic expression of this syndrome, and the biochemical and clinical correlates of each phenotype are likely to be useful in the management of women with PCOS. These phenotypic criteria are distinct from criteria used for diagnosis.

Is There Still a Place for Surgery in Patients with PCOS? A Review

OBJECTIVE

The surgical management of polycystic ovary syndrome (PCOS) represents an unclear option compared to medical therapy, and it is necessary to deepen the role of minimally invasive surgery, represented by laparoscopic ovarian drilling (LOD) and transvaginal hydrolaparoscopy (THL), for the treatment of PCOS in infertile women resistant to drug therapy and to establish its success in terms of ovulation and pregnancy rates.

METHODS

A search was performed in the main electronic databases (MEDLINE, EMBASE, Web of Science, PubMed, and the Cochrane Library) from 1994 to October 2022 in order to evaluate the role of surgery in patients with PCOS resistant to pharmacological treatment. Only original scientific articles in English were included.

RESULTS

Seventeen studies were analyzed in this review. In all analyzed studies, more than 50% of the population underwent spontaneous ovulation after surgical treatment without great differences between the two surgical techniques (LOD and THL). More than 40% of patients delivered, with a higher rate after LOD, although eight ectopic pregnancies and sixty-three miscarriages were reported. A lower risk of adhesion formation after THL has been reported. No clear data regarding the effect of surgery on the regularization of the menstrual cycle has been described. A reduction in LH and AMH serum levels as well as the LH/FSH ratio compared to preoperative levels for both surgical techniques has been described.

CONCLUSIONS

Despite the scarcity and heterogeneity of data, surgical therapy could be considered an effective and safe approach in the management of PCOS patients with resistance to pharmacological treatment who desire to become pregnant.

Tumor necrosis factor alpha versus LH and androstendione as a reliable predictor of spontaneous ovulation after laparoscopic ovarian drilling for women with clomiphene citrate resistance polycystic ovarian disease

OBJECTIVE

Laparoscopic ovarian drilling (LOD) is still a controversial decision; due to the long term hazards; so short and long term predictors after the procedure should be taken in consideration. The aim of this work was to investigate the role of the serum level of tumor necrosis factor alpha (TNF-α) and other polycystic ovarian disease (PCOD) relevant clinical and biochemical factors as a predictor of spontaneous ovulation after laparoscopic ovarian drilling (LOD) in women with clomiphene citrate resistant polycystic ovarian disease (CCR-PCOD).

METHODS

It was a prospective research work, where 150 infertile women with CCR-PCOD had been recruited. TNF-α serum level, which is an inflammatory biomarker, was investigated in addition to other PCOD relevant clinical and biochemical parameters as possible predictors of successful spontaneous ovulation and subsequent pregnancy after LOD.

RESULTS

Recruited women with higher preoperative levels of TNF-α, LH, and androstenedione had significantly higher rates of spontaneous ovulation within the first three months follow up after LOD, in contrast to obese women with BMI ≥ 25 kg/m2, long duration of infertility ≥3 years, marked biochemical hyperandrogenism (testosterone levels ≥4.5 nmol/L, free androgen index ≥15), and high insulin resistance (IR). Ninty five (95 = 63.3%) women in between women regularly menstruated (105 = 70%) had spontaneous ovulation, and of those spontaneously ovulated, 35(36.8%) women got pregnant spontaneously during the first 3 months follow up. Extended follow up for 12 months period revealed that 61 women got pregnant, with cumulative pregnancy rate of 58%. Logistic regression showed that the best cut-off values for spontaneous ovulation after LOD were 65.1 pg/ml, 11.5 IU/l, and 3.1 ng/ml and with a sensitivity of 91%, 88%, 55%, and with a specificity of 85%, 79%, 78%, for TNF-α, LH, androstenedione serum level respectively.

CONCLUSION

TNF-α, LH, and Androstenedione could be considered as reliable predictors to depend on for recruiting the ideal women candidates with CCR-PCOD; to have the maximum benefits after LOD treatment option.

Biological effects of combined resveratrol and vitamin D3 on ovarian tissue

BACKGROUND

Resveratrol (3,5,4'-trihydroxy-trans-stilbene) is a natural antioxidant polyphenol able to exert a wide range of biological effect on several tissues. Despite its important beneficial properties, it has a low water solubility, which limits its therapeutic applications in humans. Resveratrol also acts as a phytoestrogen that modulates estrogen receptor (ER)-mediated transcription. In addition, it has been shown that ovarian tissues benefit greatly from vitamin D3, which exerts its beneficial effects through VDR receptors. The aim was to evaluate the cooperative effects of resveratrol combined with vitamin D3 on ovarian cells and tissues and some other organs as well. Moreover, the modulation of specific intracellular pathways involving ER and VDR receptors has been studied.

METHODS

The experiments were performed both in vitro and in vivo, to analyze cell viability, radical oxygen species production, signal transductions through Western Blot, and resveratrol quantification by HPLC.

RESULTS

Cell viability, radical oxygen species production, and intracellular pathways have been studied on CHO-K1 cells. Also, the relative mechanism activated following oral intake in female Wistar rats as animal model was investigated, evaluating bioavailability, biodistribution and signal transduction in heart, kidney, liver and ovarian tissues. Both in in vitro and in vivo experiments, resveratrol exerts more evident effects when administered in combination with vitD in ovarian cells, showing a common biphasic cooperative effect: The role of vitamin D3 in maintaining and supporting the biological activity of resveratrol has been clearly observed. Moreover, resveratrol plus vitamin D3 blood concentrations showed a biphasic absorption rate.

CONCLUSIONS

Such results could be used as a fundamental data for the development of new therapies for gynecological conditions, such as hot-flashes.

Laparoscopic ovarian drilling: An alternative but not the ultimate in the management of polycystic ovary syndrome

Since its introduction in 1984, laparoscopic ovarian drilling has evolved into a safe and effective surgical treatment for anovulatory, infertile women with polycystic ovary syndrome (PCOS), unresponsive to clomiphene citrate. It is as effective as gonadotropins in terms of pregnancy and live birth rates, but without the risks of ovarian hyperstimulation syndrome and multiple pregnancies. It improves ovarian responsiveness to successive ovulation induction agents. Its favorable reproductive and endocrinal effects are sustained long. Despite its advantages, its use in unselected cases of PCOS or for non-fertility indications is not prudent owing to the potential risks of iatrogenic adhesions and ovarian insufficiency.

Women with clomiphene citrate resistant polycystic ovarian disease: predictors of spontaneous ovulation after laparoscopic ovarian drilling

OBJECTIVE

To evaluate the role of different clinical, biochemical and sonographic factors as predictors of spontaneous ovulation after laparoscopic ovarian drilling (LOD) in women with clomiphene citrate resistant polycystic ovarian disease (CCR-PCOD).

STUDY DESIGN

This prospective study recruited 251 infertile women with CCR-PCOD. Several clinical, biochemical and sonographic criteria were tested as possible predictors of spontaneous ovulation after LOD using multivariate analysis.

RESULTS

Women with higher preoperative levels of LH, FSH and/or androstenedione had significantly higher rates of spontaneous ovulation within the first eight weeks after LOD, but only FSH and androstenedione were found to be independent predictors. Other factors including age, BMI, type of infertility, duration of infertility, menstrual pattern, testosterone level, ovarian volume and SHBG were insignificant predictors. Receiver-operating characteristic (ROC) curves derived from FSH, LH, androstenedione, and a logistic regression model showed that the best cut-off values were 4.1IU/l, 7.8IU/l, 1.2ng/ml, and 0.4897, respectively, with sensitivity of 91.18%, 100%, 73.53%, and 88.24% and specificity of 69.57%, 69.57%, 65.22%, and 73.91% for FSH, LH, androstenedione, and logistic regression model respectively. An extended follow up (9 months after LOD) was conducted for the anovulatory and the non-pregnant ovulatory women, who were treated individually according to their clinical situation. Of these women, 53.5% (69/129) got pregnant, resulting in a cumulative pregnancy rate of 48% (82/171). Of these pregnancies, 16/82 (19.5%) were spontaneous while 35.4% (29/82) and 45.1% (37/82) occurred after ovulation induction by CC and gonadotropins, respectively.

CONCLUSION

This study supports the use of androstenedione, LH and FSH as a simple reliable tool in triaging patients with CCR-PCOD to select the ideal candidates for LOD.

Lysyl oxidase interacts with AGE signalling to modulate collagen synthesis in polycystic ovarian tissue

Connective tissue components – collagen types I, III and IV – surrounding the ovarian follicles undergo drastic changes during ovulation. Abnormal collagen synthesis and increased volume and density of ovarian stroma characterize the polycystic ovary syndrome (PCOS). During the ovulatory process, collagen synthesis is regulated by prolyl hydroxylase and lysyl oxidase (LOX) activity in ovarian follicles. LOX catalyzes collagen and elastin cross-linking and plays essential role in coordinating the control of ovarian extracellular matrix (ECM) during follicular development. We have recently shown accumulation of advanced glycation end products (AGEs), molecules that stimulate ECM production and abnormal collagen cross-linking, in ovarian tissue. However, the possible link between LOX and AGEs-induced signalling in collagen production and stroma formation in ovarian tissue from PCOS remains elusive. The present study investigates the hypothesis of AGE signalling pathway interaction with LOX gene activity in polycystic ovarian (PCO) tissue. We show an increased distribution and co-localization of LOX, collagen type IV and AGE molecules in the PCO tissue compared to control, as well as augmented expression of AGE signalling mediators/effectors, phospho(p)-ERK, phospho(p)-c-Jun and nuclear factor κB (NF-κB) in pathological tissue. Moreover, we demonstrate binding of AGE-induced transcription factors, NF-κB and activator protein-1 (AP-1) on LOX promoter, indicating a possible involvement of AGEs in LOX gene regulation, which may account for the documented increase in LOX mRNA and protein levels compared to control. These findings suggest that deposition of excess collagen in PCO tissue that induces cystogenesis may, in part, be due to AGE-mediated stimulation of LOX activity.

Effects of resveratrol on proliferation and apoptosis in rat ovarian theca-interstitial cells

Polycystic ovary syndrome (PCOS) is characterized by ovarian dysfunction and associated with ovarian theca-interstitial (T-I) cell hyperplasia, hyperinsulinemia, systemic inflammation and oxidative stress. This in vitro study tested whether rat T-I cell growth with or without insulin can be altered by resveratrol, a natural polyphenol with anti-carcinogenic, anti-inflammatory, anti-proliferative and antioxidant properties. Rat T-I cells were cultured with and without resveratrol and/or insulin, and the effects on DNA synthesis, number of viable cells and markers of apoptosis were evaluated. Resveratrol alone induced a potent concentration-dependent inhibition of cell growth by inhibiting DNA synthesis, decreasing the number of viable cells and increasing the activity of executioner caspases 3 and 7; these effects of resveratrol counteracted the pro-proliferative and anti-apoptotic effects of insulin. Immunofluorescence analysis of cells incubated with resveratrol showed concentration- and time-dependent morphological changes consistent with apoptosis. The present findings indicate that resveratrol promotes apoptosis to reduce rat T-I cell growth in vitro as well as inhibiting insulin-induced rat T-I cell growth. This suggests a possibility that resveratrol and/or mechanisms mediating its effect may be relevant to the development of novel treatments for PCOS, which is characterized by both excessive ovarian mesenchyma growth and hyperinsulinemia.

Polycystic ovary syndrome: a follow-up study on diabetes mellitus, cardiovascular disease and malignancy 15-25 years after ovarian wedge resection

The aim of the present study was to examine the occurrence of possibly associated diseases in 149 women with polycystic ovary syndrome (PCOS) 15-25 years after ovarian wedge resection. Diabetes mellitus was the only associated disease which showed a significantly increased occurrence. No significant change in cancers specific for the female gender was seen. Likewise, the relative risk of cardiovascular disease was not affected. However, the power of the statistical test was low. This long-term study indicates increased risk of diabetes mellitus in PCOS patients. The study group is too small to give any conclusions about other possibly associated diseases. Family histories, however, revealed that associated diseases are related to genetic disposition rather than to PCOS per se.

[Polycystic ovary syndrome. Prototype of a cardio-metabolic syndrome]

Polycystic ovary syndrome (PCOS) is a common endocrine disorder affecting women in the reproductive age and is a major cause of anovulation, hyperandrogenism and infertility. Since obesity and insulin resistance are predominant features of women with PCOS, a variety of metabolic disturbances are associated. There is a marked increase in the risk of developing type-2 diabetes in these patients and a majority of women with PCOS will subsequently harbour an enhanced cardiovascular risk.

Effects of simvastatin and oral contraceptive agent on polycystic ovary syndrome: prospective, randomized, crossover trial

CONTEXT

Polycystic ovary syndrome (PCOS) is associated with hyperandrogenism and cardiovascular risks including dyslipidemia and systemic inflammation. In vitro, statins decrease proliferation and steroidogenesis of ovarian theca-interstitial cells.

OBJECTIVE

The study objective was to compare effects of two treatments of PCOS: simvastatin plus oral contraceptive pill (OCP) vs. OCP alone.

DESIGN

In a prospective, crossover trial, 48 women with PCOS were randomized to either simvastatin plus OCP for 12 wk followed by OCP alone for an additional 12 wk, or to OCP alone for 12 wk and, subsequently, simvastatin plus OCP for an additional 12 wk. Evaluations were performed at baseline, after 12 wk (crossover), and after 24 wk. Data were analyzed using a random effects model.

SETTING

The study was conducted in an academic medical center.

PRIMARY OUTCOME

Serum total testosterone was the primary outcome measure.

RESULTS

Total testosterone decreased by 38% after Statin + OCP, whereas OCP alone led to a 26% decrease; the statin-attributable effect was significant (P < 0.004). Free testosterone declined by 58% after Statin + OCP, significantly more than the 35% decline after OCP alone (P = 0.006). Hirsutism decreased by 8.1% after Statin + OCP, a greater effect than the 4.7% decrease after OCP alone (P = 0.02). Statin decreased LH, but not FSH or prolactin. Statin + OCP decreased total and low-density lipoprotein cholesterol by 7.5% and 20%, respectively. OCP alone led to a 5% increase of total cholesterol without effect on low-density lipoprotein cholesterol. Statin prevented OCP induced increase of triglycerides. C-reactive protein decreased by 45% after Statin + OCP, a significantly different effect (P = 0.006) than a 6% increase after OCP alone. Soluble vascular cell adhesion molecule 1 decreased by 18% after Statin + OCP, a greater decline than the 10% decrease after OCP alone (P = 0.01).

CONCLUSIONS

Simvastatin improved endocrine/clinical aspects of PCOS and had beneficial effects on lipid profile and markers of systemic inflammation.

Immunohistochemical localization of advanced glycation end-products (AGEs) and their receptor (RAGE) in polycystic and normal ovaries

The aim of the present study was to investigate the localization/immunohistochemical distribution of AGEs and RAGE, as well as their putative signalling mediator NF-kappaB in ovaries of women with polycystic ovary syndrome (PCOS) compared to normal. Archival ovarian-tissue samples from biopsies of six women with PCOS and from six healthy of similar age women, were examined immunohistochemically with monoclonal anti-AGEs, anti-RAGE and anti-NF-kappaB(p50/p65) specific antibodies. In healthy women, AGE immunoreactivity was observed in follicular cell layers (granulosa and theca) and luteinized cells, but not in endothelial cells. PCOS specimens displayed AGE immunoexpression in theca interna and granulosa cells as well as in endothelial cells, but staining of granulosa cells was stronger than in that of normal ovaries. RAGE was highly expressed in normal and PCOS tissues. Normal tissue exhibited no staining differences between granulosa cell layer and theca interna. However, in PCOS ovaries, granulosa cells displayed stronger RAGE expression compared to theca interna cells in comparison to controls. NF-kappaB(p50/p65) was expressed in the cytoplasm of theca interna and granulosa cells of both normal and PCOS ovaries; whereas the NF-kappaB p65 subunit was only observed in granulosa cells nuclei in PCOS tissue. In conclusion, these findings demonstrate for the first time that RAGE and AGE-modified proteins with activated NF-kappaB are expressed in human ovarian tissue. Furthermore, a differential qualitative distribution of AGE, RAGE and NF-kappaB p65 subunit was observed in women with PCOS compared to healthy controls, where a stronger localization of both AGE and RAGE was observed in the granulosa cell layer of PCOS ovaries.

Why does ovarian surgery in PCOS help? Insight into the endocrine implications of ovarian surgery for ovulation induction in polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a complex disorder with heterogeneity of clinical and endocrine features. Ovarian surgery for ovulation induction has been used in the management of clomiphene citrate-resistant anovulatory women with PCOS. Various types of ovarian surgery have been employed (wedge resection, electrocautery, laser vaporization, multiple ovarian biopsies and others) and all procedures result in an altered endocrine profile after surgery. The mechanism behind the reversal of endocrinological dysfunction in PCOS after ovarian surgery remains incompletely understood. This review scans the literature systematically to identify the endocrine changes after ovarian surgery in PCOS, in order to glean some knowledge of the mechanism involved. After ovarian surgery in PCOS, a rapid reduction in serum levels of all ovarian hormones is seen, in combination with increased serum levels of pituitary hormones. Folliculogenesis is then initiated and ovarian hormone production increases, synchronically with a reduction of pituitary hormones. Continuation of follicle growth in subsequent cycles after ovarian surgery occurs in an environment with less androgens and lower LH and FSH levels compared with pretreatment levels. The endocrine changes found after ovarian surgery in PCOS women seem to be governed by the ovaries themselves. Rapid reduced secretion of all ovarian hormones restores feedback to the hypothalamus and pituitary, resulting in appropriate gonadotrophin secretion. Initiation of follicular development seems to be induced by increasing FSH levels following a reduction of the follicle excess and (intra-ovarian) androgen levels. Additionally, anti-Müllerian hormone and gonadotrophin surge attenuating factor probably have a role in the endocrine changes.

Efficacy of laparoscopic ovarian diathermy in clomiphene citrate-resistant women with polycystic ovary syndrome: relationships with chronological and ovarian age

BACKGROUND

Laparoscopic ovarian diathermy (LOD) has been used successfully as a first-, second- and third-line treatment for ovulation induction in women with polycystic ovary syndrome (PCOS). However, little is known about the predictors for LOD efficacy. The aim of the present study was to evaluate reproductive outcomes in clomiphene citrate (CC)-resistant PCOS patients treated with LOD according to ovarian and chronological age.

METHOD

A total of 60 non-obese, primary infertile, CC-resistant women with PCOS were enrolled and treated with LOD. During the following 6 months, all patients underwent ovulation monitoring and timed intercourse. If spontaneous ovulation did not occur within 3 months from surgery, CC (100 mg/day) was administered for 5 days from day 3 of the remaining cycles. The ovulation, abortion and pregnancy rates were assessed and analyzed with patients categorized according to chronological age (group A, <25 years; group B, 25-30 years; group C, 30-35 years; group D, >35 years) and ovarian age (group 1, follicle stimulating hormone (FSH) < 10 mIU/ml; group 2, FSH > 10 mIU/ml).

RESULTS

At the end of the study, total ovulation, pregnancy and abortion rates were 57.1, 13.0 and 18.2%, respectively. No difference in all reproductive outcomes was observed between groups A, B and C, whereas the efficacy of LOD was significantly lower in group D. A significant difference in all clinical endpoints was detected between groups 1 and 2.

CONCLUSIONS

Our data show that chronological age >35 years and basal FSH value > 10 mIU/ml are related to poor reproductive prognosis in CC-resistant PCOS patients treated with LOD.

Valproate is associated with new-onset oligoamenorrhea with hyperandrogenism in women with bipolar disorder

BACKGROUND

Preliminary evidence suggests that valproate is associated with isolated features of polycystic ovarian syndrome (PCOS), while contradictory data support an association between epilepsy and PCOS. The development of PCOS features after initiation of valproate was therefore examined in women with bipolar disorder using a standardized definition of PCOS.

METHODS

Three hundred women 18 to 45 years old with bipolar disorder were evaluated for PCOS at 16 Systematic Treatment Enhancement for Bipolar Disorder sites. A comparison was made between the incidence of hyperandrogenism (hirsutism, acne, male-pattern alopecia, elevated androgens) with oligoamenorrhea that developed while taking valproate versus other anticonvulsants (lamotrigine, topiramate, gabapentin, carbamazepine, oxcarbazepine) and lithium. Medication and menstrual cycle histories were obtained, and hyperandrogenism was assessed.

RESULTS

Among 230 women who could be evaluated, oligoamenorrhea with hyperandrogenism developed in 9 (10.5%) of 86 women on valproate and in 2 (1.4%) of 144 women on a nonvalproate anticonvulsant or lithium (relative risk 7.5, 95% confidence interval [CI] 1.7-34.1, p = .002). Oligoamenorrhea always began within 12 months of valproate use.

CONCLUSIONS

Valproate is associated with new-onset oligoamenorrhea with hyperandrogenism. Monitoring for reproductive-endocrine abnormalities is important when starting and using valproate in reproductive-aged women. Prospective studies are needed to elucidate risk factors for development of PCOS on valproate.

Simvastatin improves biochemical parameters in women with polycystic ovary syndrome: results of a prospective, randomized trial

OBJECTIVE

To test the hypothesis that statins improve hyperandrogenemia in women with polycystic ovary syndrome (PCOS).

DESIGN

Prospective, randomized trial.

SETTING

Academic medical center.

PATIENT(S)

Forty-eight women with PCOS.

INTERVENTION(S)

Subjects were randomized to a statin group (simvastatin, 20 mg daily plus oral contraceptive pill [OCP]; n = 24) or an OCP group (OCP alone; n = 24).

MAIN OUTCOME MEASURE(S)

Serum T.

RESULT(S)

Baseline parameters of both groups were comparable. After 12 weeks of treatment, serum T levels declined by 41% in the statin group and by 14% in the OCP group. In the statin group, there was a greater decrease of LH (43% decrease vs. 9% in the OCP group) and a greater decline of LH/FSH ratio (44% vs. 12%). In the statin group, total cholesterol declined by 10% and low-density lipoprotein (LDL) by 24%. In the OCP group, total cholesterol increased by 8%, and LDL was unchanged.

CONCLUSION(S)

This is the first study demonstrating that statin decreases T levels and normalizes gonadotropin levels in women with PCOS. Statin therapy might offer a novel approach, providing endocrine and cardiovascular benefits.

Irregular cycles and steroid hormones in polycystic ovary syndrome

BACKGROUND

This cross-sectional study was undertaken to evaluate the factors that relate to menstrual status (oligo-amenorrhoea versus eumenorrhoea) in polycystic ovary syndrome (PCOS).

METHODS

A total of 234 women with clinical and biochemical features suggestive of PCOS underwent metabolic and hormonal evaluation. A forward stepwise logistic regression model was created based on the results to determine variables related to ovulatory status.

RESULTS

Only follicular phase progesterone and estradiol (E(2)) were retained in the final model. This model correctly classified 80% of PCOS women by ovulatory status. Univariate analysis revealed no difference in progesterone between ovulatory groups but E(2) was higher in anovulatory groups. This suggested interaction between progesterone and E(2) and the single interaction variable (progesterone/E(2)) also classified 80% of women by ovulatory status correctly.

CONCLUSION

The results suggest that a low ratio of progesterone to E(2) is associated with menstrual irregularity and ovulatory status in PCOS.

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.

Laparoscopic ovarian drilling in polycystic ovary syndrome

BACKGROUND AND OBJECTIVE

Patients with polycystic ovary syndrome (PCOS) treated with gonadotrophins often have a polyfollicular response and are exposed to the risks of ovarian hyperstimulation syndrome (OHSS) and multiple pregnancy. The aim of the present study was to evaluate the efficacy of laparoscopic ovarian drilling (LOD) on the endocrinologic, clinical parameters and reproductive outcome of clomiphene-resistant anovulatory infertile patients with PCOS using monopolar diathermy.

MATERIAL AND METHODS

Forty-five clomiphene-resistant anovulatory women with PCOS have participated in the study. Serum testosterone (T), follicle stimulating hormone (FSH) and luteinizing hormone (LH), fasting insulin and glucose levels, body mass indexes, modified Ferriman Gallwey (FG) hirsutism scores of the subjects are recorded before and after the procedure. Endocrinologic and clinical profile and reproductive outcome of the patients were analysed.

RESULTS

Ovarian drilling was successfully employed without any surgical complications and mean +/- S.D. duration of follow-up time was 29.73 +/- 10.64 months. In the follow-up period 93.3% of the subjects were recorded to have regular cycles and 64.4% pregnancy rate was achieved, spontaneously. The serum levels of T, free T, LH, LH:FSH ratio, insulin and FG scores were significantly reduced after LOD, although glucose levels and glucose/insulin ratio remained unchanged.

CONCLUSION

In choosing ovulation induction method in clomiphene resistant PCOS patients, LOD may avoid or reduce the risk of OHSS and multiple pregnancy than gonadotrophins with the same success rate of conception. The high pregnancy rate, and economic aspect of the procedure offer an attractive management for patients with PCOS.

Laparoscopic treatment of polycystic ovaries: is its place diminishing?

PURPOSE OF REVIEW

The purpose of this review is to provide a critical discussion on the place of laparoscopic ovarian drilling and medical treatment with metformin for polycystic ovary syndrome.

RECENT FINDINGS

Laparoscopic ovarian drilling remains popular. It is associated with an ovulation rate of approximately 80% and a pregnancy rate of 50-60% within 1 year of the procedure. The technique results in a decrease in ovarian stromal blood flow. An increasing amount of data, however, suggests that treatment with metformin is equally as effective. The use of metformin in pregnancy appears to be safe; it decreases the miscarriage rate and possibly the incidence of gestational diabetes.

SUMMARY

Laparoscopic ovarian drilling and metformin improve ovulatory dysfunction and pregnancy rate to a similar extent. The advantages of metformin continue beyond conception. It reduces the miscarriage rate and also decreases the likelihood of developing gestational diabetes. A randomized trial comparing the effects of metformin and laparoscopic ovarian drilling in women with polycystic ovary syndrome is recommended.

Screening for and treatment of polycystic ovary syndrome in teenagers

Polycystic ovary syndrome (PCOS) usually arises during puberty and is marked by hyperinsulinemia and hyperandrogenism. Adolescents with PCOS are at an increased risk of developing health problems later on in life such as type 2 diabetes, cardiovascular disease, and infertility. Furthermore, the physical signs of PCOS can be detrimental to a teenage girl's self-image. Early diagnosis and treatment of PCOS in adolescents are essential in ensuring adulthood health and restoring self-esteem. Treatments for an adolescent with PCOS include diet and exercise, metformin, and oral contraceptive pills. Each of these options has been shown to be effective in improving certain aspects of PCOS, and probably the best treatment plan involves some combination of them.

Surgical treatment of polycystic ovary syndrome associated with infertility

Laparoscopic ovarian drilling is a relatively simple procedure performed by minimal access and usually on an outpatient basis. It provides an alternative treatment option for polycystic ovary syndrome (PCOS) patients anovulatory to clomiphene citrate. The mechanism of action of laparoscopic ovarian drilling is unclear; its beneficial effect is apparently due to destruction of the androgen-producing stroma. The procedure appears to have little or no effect on insulin sensitivity and lipoprotein profile. The majority (56-94%) of PCOS patients who are clomiphene citrate resistant ovulate after drilling, and at least half of them go on to achieve a pregnancy. Predictive factors for pregnancy are younger age and lower body mass index. The endocrine changes resulting from ovarian drilling last for an extended period of time. Exogenous gonadotrophin treatment and laparoscopic ovarian drilling appear to yield comparable ovulation and pregnancy rates; however, multiple pregnancy is rare with drilling. There are several complications associated with the procedure, including post-operative periadnexal adhesion formation. Alternative treatment options, including lifestyle modification (diet and exercise) and metformin, may well reduce the need for ovarian drilling in well-selected cases. Progress in understanding of this complex syndrome and effective new treatments will further diminish the need for surgery.