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Slouha E, Segal J, White C, Pallotta T, Ghosh S, Clunes LA, Kollias TF. Ovarian Reserve and Hormone Alteration Following Laparoscopic Ovarian Drilling for Polycystic Ovarian Syndrome: A Systematic Review. Cureus 2024; 16:e62092. [PMID: 38989366 PMCID: PMC11236422 DOI: 10.7759/cureus.62092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2024] [Indexed: 07/12/2024] Open
Abstract
We aimed to conduct a systematic review of the data in the literature on ovarian reserve and ovarian hormone following laparoscopic ovarian drilling (LOD). The PubMed, ScienceDirect, and ProQuest databases were comprehensively searched using a combination of keywords such as "ovarian reserve", "laparoscopic ovarian drilling", "luteinizing hormone", "follicle-stimulating hormone", "inhibin", "LH/FSH ratio", "ovulation", and "testosterone". All studies involving females of reproductive age who were officially diagnosed with polycystic ovarian syndrome (PCOS) and had undergone LOD with reported data concerning at least one of the following parameters were considered for inclusion: ovarian reserve, anti-Mullerian hormone (AMH), inhibin, follicle-stimulating hormone (FSH), luteinizing hormone (LH), LH/FSH ratio, and testosterone. All the included studies were evaluated by the GRADE scale for bias and their findings were synthesized by four independent coauthors. A total of 38 studies involving 3118 female patients were included. Based on our findings, a significant number of participants experienced spontaneous ovulation along with a significant decrease in ovarian reserve, and a significant decrease in AMH, LH, and testosterone, with no significant changes in FSH and inhibin B. With the end goal of LOD being to improve fertility and pregnancy rates among females with PCOS, it is important to look at the first few steps that enable this. As expected, there was a significant improvement in ovulation while the ovarian reserve decreased. Along with the decrease in ovarian reserve, there was a significant normalization in AMH, LH, and testosterone levels. LOD may exert its main effects through the manipulation of the ovarian reserves.
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Affiliation(s)
- Ethan Slouha
- Pharmacology, St. George's University School of Medicine, True Blue, GRD
| | - Jeremy Segal
- Pharmacology, St. George's University School of Medicine, True Blue, GRD
| | - Colton White
- Pharmacology, St. George's University School of Medicine, True Blue, GRD
| | - Theresa Pallotta
- Pharmacology, St. George's University School of Medicine, True Blue, GRD
| | - Shanalyn Ghosh
- Pharmacology, St. George's University School of Medicine, True Blue, GRD
| | - Lucy A Clunes
- Pharmacology, St. George's University School of Medicine, True Blue, GRD
| | - Theofanis F Kollias
- Microbiology, Immunology, and Pharmacology, St. George's University School of Medicine, True Blue, GRD
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Henry L, Berek JS, Diaz I, Feldberg D, Mocanu E, Niederberger CC, Ohlander S, Purandare N, Rosenwaks Z, Tulandi T, Wasson M, Wilailak S, Malhotra J. FIGO statement: Fertility preservation. Int J Gynaecol Obstet 2023; 163:790-794. [PMID: 37807831 DOI: 10.1002/ijgo.15187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
Fertility preservation is a growing field in reproductive medicine that may raise ethical questions. Preservation of fertility must be discussed with the patient if gonadotoxic treatment is required, whether in the case of benign or malignant pathology, or in the management of transgender identity. As a result, surgery or chemotherapy that has fewer adverse impacts on fertility should be proposed if this does not alter the prognosis of the disease. If the risk of infertility persists, then fertility cryopreservation should be proposed for children and adults of reproductive age. Sperm, oocytes, and gonadal tissue can be cryopreserved for many years. FIGO wishes to emphasize the importance of fertility preservation in the medical and surgical management of patients, and the importance of a specialized, multidisciplinary approach.
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Affiliation(s)
- Laurie Henry
- ART Center of the Department of Obstetrics and Gynecology, CHU of Liège-Citadelle Site, University of Liège, Liège, Belgium
| | - Jonathan S Berek
- Stanford Women's Cancer Center, Stanford Cancer Institute, Stanford University School of Medicine, Stanford, California, USA
| | - Ivonne Diaz
- Nueva Granada and Unisanitas University, Bogotá, Colombia
| | - Dov Feldberg
- Infertility and IVF Unit, Helen Schneider Hospital for Women, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel
| | - Edgar Mocanu
- RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - C Craig Niederberger
- Department of Urology, University of Illinois at Chicago College of Medicine, Chicago, Illinois, USA
- Department of Bioengineering, University of Illinois at Chicago College of Engineering, Chicago, Illinois, USA
| | - Samuel Ohlander
- Department of Urology, University of Illinois at Chicago College of Medicine, Chicago, Illinois, USA
| | - Nikhil Purandare
- Department of Obstetrics and Gynecology, Galway University Hospital, Galway, Ireland
| | - Zev Rosenwaks
- The Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Togas Tulandi
- Department of Obstetrics and Gynecology, McGill University, Montréal, Quebec, Canada
| | - Megan Wasson
- Department of Medical and Surgical Gynecology, Mayo Clinic, Phoenix, Arizona, USA
| | - Sarikapan Wilailak
- Department of Obstetrics and Gynecology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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The Evolution of Surgery for Infertility. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 41 Suppl 2:S327-S329. [PMID: 31785687 DOI: 10.1016/j.jogc.2019.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Tulandi T. Évolution des interventions chirurgicales pour traiter l'infertilité. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 41 Suppl 2:S330-S333. [DOI: 10.1016/j.jogc.2019.09.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Hirshberg B, Rheinboldt M. Multimodality imaging of acute locoregional and systemic complications in the setting of assisted reproduction. Emerg Radiol 2019; 26:205-219. [PMID: 30631995 DOI: 10.1007/s10140-018-01665-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 12/13/2018] [Indexed: 02/02/2023]
Abstract
Over the past 40 years since the first in vitro fertilization was performed, both the role of assisted reproductive technology (ART) in establishing viable pregnancy as well as the available treatment options have expanded enormously. Annually in the USA, nearly 2% of pregnancies now employ some form of ART assistance, with in vitro fertilization (IVF) being the most commonly utilized methodology. Both maternal and fetal risks are elevated in ART pregnancies, the latter including adverse outcome due to both increased gestational number as well as advanced maternal age. Maternal risks may be divided into locoregional and systemic complications. Adverse pelvic complications include those relating to gamete harvesting and transfer, ovarian hyperstimulation, the sequela of ectopic and heterotopic pregnancies, as well as ovarian torsion, all of which are elevated in the ART cohort. Ovarian hyperstimulation syndrome is the most commonly encountered complication, with both systemic and pelvic features relating to increased vascular permeability, hemoconcentration, and ascites. While life-threatening cases are relatively rare, moderate and severe manifestations may occur in up to 10% of ART cycles and, as such, are a not infrequent cause for ER visitation. Familiarity with the clinical and imaging manifestations of ART complications as well as their prognostic implications will facilitate a timely diagnosis and assist the interpreting radiologist in best expediting appropriate clinical care. In this article, we will briefly discuss the current methodology of ART then present an imaging-based multimodality review of the potentially encountered adverse maternal sequela, highlighting key diagnostic features and differential considerations as well as potential prognostic implications.
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Abstract
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. Laparoscopic ovarian drilling (LOD) is an alternative method to induce ovulation in PCOS patients with clomiphene citrate resistance instead of gonadotropins. Surgical therapy with LOD may avoid or reduce the need for gonadotropins or may facilitate their use. However, the procedure, though effective, can be traumatic on the ovaries, which may cause postoperative adhesions and/or diminished ovarian reserve. In over-enthusiastic hands, this day-care procedure might lead to iatrogenic premature ovarian failure in young women. Some trials have compared LOD with gonadotropins, but, because of variations in study design and small sample size, the results are inconsistent and definitive conclusions about the relative efficacy of LOD and gonadotropins cannot be extracted from the individual studies. Today, evidence-based reviews conclude that there is 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 is the only pro-LOD argument. However, there are ongoing serious concerns about the long-term effects of LOD on ovarian function.
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Ozdemir O, Sari ME, Kalkan D, Koc EM, Ozdemir S, Atalay CR. Comprasion of ovarian stromal blood flow measured by color Doppler ultrasonography in polycystic ovary syndrome patients and healthy women with ultrasonographic evidence of polycystic. Gynecol Endocrinol 2015; 31:322-6. [PMID: 25558942 DOI: 10.3109/09513590.2014.995617] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To compare ovarian stromal artery blood flows measured by Doppler ultrasonography of polycystic ovary syndrome (PCOS) patients and healthy women with polycystic ovarian image in ultrasonography. METHODS Forty-two patients diagnosed with PCOS according to the criteria of 2003 Rotterdam Concencus Conferance on PCOS and 38 healthy volunteers with polycystic ovarian image in ultrasonography were included in the study. Ovarian volumes and ovarian stromal artery blood flows were measured by 3-dimensional (3-D) ultrasonography and Doppler ultrasonography in all patients. RESULTS In patients with PCOS, ovarian stromal artery pulsatility index (PI) and resistivity index (RI) were found significantly different from healthy women with polycystic ovarian image in ultrasonography (p < 0.05). 3-D ovarian volumes were found significantly higher in patients with PCOS (p < 0.05), and a negative correlation was also obtained between ovarian volumes and ovarian stromal artery resistivity indices. CONCLUSION Ovarian stromal artery Doppler examination could have an importance to explain the pathophysiology of PCOS, but there are few publications in the literature about PCOS and the details of ovarian stromal artery Doppler parameters in patients with polycystic ovarian image only. We conclude that Doppler ultrasonography findings of PCOS patients might be helpful in understanding the clinical follow-up and etiology of the disease.
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Affiliation(s)
- Ozhan Ozdemir
- Department of Obstetrics and Gynecology, Ankara Numune Education and Research Hospital , Ankara , Turkey
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Therapeutic effects of metformin and laparoscopic ovarian drilling in treatment of clomiphene and insulin-resistant polycystic ovary syndrome. Arch Gynecol Obstet 2014; 291:1089-94. [PMID: 25304269 DOI: 10.1007/s00404-014-3486-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2014] [Accepted: 09/17/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To compare the therapeutic effects of metformin (Met) and laparoscopic ovarian drilling (LOD) in clomiphene and insulin-resistant patients with polycystic ovary syndrome (CIRPCOS). METHODS A total of 110 patients were randomly divided into two groups. One group was administered Met (n = 55), while the other group underwent LOD (n = 55). Rates of ovulation, pregnancy, and abortion were compared between both groups. RESULTS Rates of normal menstruation, ovulation, and pregnancy in the LOD group were higher than in the Met group: 76.4% (42/55) vs. 58.2% (32/55), P < 0.04; 50.8% (11/258) vs. 33.5% (94/281), P < 0.001; 38.2% (21/55) vs. 20.0% (11/55), P < 0.03. The difference in the early abortion rate between both groups was not statistically significant. CONCLUSIONS Although Met can significantly improve a patient's insulin resistance, we found that in patients diagnosed with CIRCPOS, LOD can be much more effective in improving rates of normal menstruation, ovulation, and pregnancy.
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Elgafor el sharkwy IA. Metformin versus laparoscopic unilateral ovarian drilling in clomiphene resistant women with polycystic ovary syndrome. MIDDLE EAST FERTILITY SOCIETY JOURNAL 2013. [DOI: 10.1016/j.mefs.2012.12.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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Hamed HO. Role of adiponectin and its receptor in prediction of reproductive outcome of metformin treatment in patients with polycystic ovarian syndrome. J Obstet Gynaecol Res 2013; 39:1596-603. [PMID: 23875783 DOI: 10.1111/jog.12101] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Accepted: 02/12/2013] [Indexed: 11/30/2022]
Abstract
AIMS The aim of this study was to examine the effect of metformin on serum adiponectin and adiponectin receptor-1 (AdipoR1) and evaluate their role in prediction of ovulation in patients with polycystic ovarian syndrome (PCOS). MATERIAL AND METHODS The study cohort included 68 PCOS patients with clomiphene citrate resistance (group 1) and 28 healthy women as controls (group 2). Baseline serum adiponectin, AdipoR1, total testosterone (T), and homeostasis model of insulin resistance (HOMA-IR) were measured in all participants. Group 1 received metformin (1500 mg/day) for 6 months followed by second blood sampling. RESULTS Group 1 had significantly lower baseline adiponectin and AdipoR1 (P = 0.001) compared to group 2. During treatment, metformin resulted in conception in 5/68 (7%), ovulation in 33/68 (48%) and regular cycles in 41/68 (60%) patients. Group 1 showed post-metformin higher adiponectin and AdipoR1 (P = 0.01) and lower HOMA-IR (P = 0.006) and T (P = 0.001) compared to pre-treatment levels. Post-metformin ovulatory patients had higher adiponectin and AdipoR1 and lower HOMA-IR and T compared to anovulatory patients. Multivariate regression analysis in group 1 showed that only T and HOMA-IR were significant independent factors for predicting ovulatory cycles during metformin treatment (P = 0.04 and P = 0.05, respectively). CONCLUSIONS Metformin treatment enhances both adiponectin activity and insulin sensitivity, resulting in a less hyperandrogenic state in patients with PCOS. Serum adiponectin and AdipoR1 are poor predictors of ovulatory outcome during treatment.
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Affiliation(s)
- Hossam O Hamed
- Department of Obstetrics and Gynecology, Qassim University, Buraidah City, Saudi Arabia; Women's Health Center, Assiut University, Assiut, Egypt
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Abu Hashim H, Al-Inany H, De Vos M, Tournaye H. Three decades after Gjönnaess’s laparoscopic ovarian drilling for treatment of PCOS; what do we know? An evidence-based approach. Arch Gynecol Obstet 2013; 288:409-22. [DOI: 10.1007/s00404-013-2808-x] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2012] [Accepted: 03/12/2013] [Indexed: 10/27/2022]
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El Behery MM, Diab AE, Mowafy H, Ebrahiem MA, Shehata AE. Effect of laparoscopic ovarian drilling on vascular endothelial growth factor and ovarian stromal blood flow using 3-dimensional power Doppler. Int J Gynaecol Obstet 2011; 112:119-21. [PMID: 21144516 DOI: 10.1016/j.ijgo.2010.08.018] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2010] [Revised: 08/12/2010] [Accepted: 10/27/2010] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To determine, by using 3-dimensional power Doppler ultrasonography, the effect of laparoscopic ovarian drilling (LOD) on the serum level of vascular endothelial growth factor (VEGF) and ovarian stromal blood flow changes in polycystic ovary syndrome (PCOS). METHODS A prospective controlled clinical study was conducted on 26 clomiphene-resistant women with PCOS who were scheduled for LOD and a control group of 22 fertile regularly menstruating women. VEGF and 3 ovarian Doppler indices-vascularization index, flow index, and vascularization flow index-were measured and compared between the 2 groups, and before and after LOD in the PCOS group. RESULTS Serum VEGF and the Doppler indices of ovarian stromal blood flow were significantly higher in the PCOS group than in the control group. Serum VEGF and the ovarian stromal blood flow Doppler indices were significantly reduced in the PCOS group after LOD. CONCLUSION Increased vascularity in PCOS demonstrated by Doppler blood flow measurements might be explained by the high level of VEGF. LOD reduced ovarian vascularization and serum VEGF.
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Affiliation(s)
- Manal M El Behery
- Department of Obstetrics and Gynecology, Faculty of Medicine, Zagazig University, Egypt.
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Metformin versus laparoscopic ovarian drilling in clomiphene- and insulin-resistant women with polycystic ovary syndrome. Int J Gynaecol Obstet 2009; 108:143-7. [DOI: 10.1016/j.ijgo.2009.08.033] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2009] [Revised: 08/12/2009] [Accepted: 09/23/2009] [Indexed: 12/13/2022]
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Teede HJ, Hutchison SK, Zoungas S. The management of insulin resistance in polycystic ovary syndrome. Trends Endocrinol Metab 2007; 18:273-9. [PMID: 17698366 DOI: 10.1016/j.tem.2007.08.001] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2007] [Revised: 06/25/2007] [Accepted: 08/03/2007] [Indexed: 10/22/2022]
Abstract
Polycystic ovary syndrome (PCOS) has reproductive and metabolic implications. Insulin resistance (IR), secondary to genetic and lifestyle factors, is integral in the pathogenesis, metabolic, clinical features and the long-term sequelae in the majority of people with PCOS. Therapeutic strategies targeting IR in PCOS ameliorate clinical features and might reduce long-term sequelae including diabetes. The mainstay for improving IR is lifestyle change; however, feasibility and sustainability remain concerns. In PCOS, metformin reduces IR, improves ovarian function, regulates cycles, lowers androgens, improves clinical hyperandrogenism and potentially improves fertility. Metformin is also likely to delay diabetes onset and has a role in PCOS in those at high risk of diabetes; however, further research is needed to clarify specific target subgroups and clinical indications.
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Affiliation(s)
- Helena J Teede
- Jean Hailes Research Unit, Monash Institute of Health Services Research, Monash University, Melbourne, Australia.
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Abstract
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.
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Affiliation(s)
- Cihat Unlu
- Department of Obstetrics and Gynecology, Ankara University School of Medicine, Dikimevi-Ankara, Turkey.
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Palomba S, Falbo A, Orio F, Russo T, Sbano F, D'Alessandro P, Cariati F, Tolino A, Colao A, Zullo F. Efficacy of laparoscopic ovarian diathermy in clomiphene citrate-resistant women with polycystic ovary syndrome: relationships with chronological and ovarian age. Gynecol Endocrinol 2006; 22:329-35. [PMID: 16785158 DOI: 10.1080/09513590600645700] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
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.
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Affiliation(s)
- Stefano Palomba
- Department of Obstetrics & Gynecology, University 'Magna Graecia' of Catanzaro, Catanzaro, Italy.
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Kurabayashi T, Suzuki M, Fujita K, Murakawa H, Hasegawa I, Tanaka K. Prognostic factors for ovulatory response with clomiphene citrate in polycystic ovary syndrome. Eur J Obstet Gynecol Reprod Biol 2006; 126:201-5. [PMID: 16337728 DOI: 10.1016/j.ejogrb.2005.11.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2004] [Revised: 11/06/2005] [Accepted: 11/08/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To evaluate prospectively the prognostic factors for ovulatory responses following clomiphene citrate (CC) administration in polycystic ovary syndrome (PCOS). STUDY DESIGN Fifty-nine infertile patients with a diagnosis of PCOS were recruited. Ovulation was induced using 100 mg/day CC administered daily from days 5 to 9 of the cycle. Endocrine and metabolic parameters between responder and non-responder groups were analyzed. RESULTS For a 75-g fasting glucose load (75-g OGTT), blood glucose levels at 60 and 120 min, the area under the curve (AUC) and blood insulin levels at 120 min in the non-responder group (n=25) were significantly higher than those in the responder group (n=34), although the measurements of fasting blood glucose and insulin were not significantly different between the two groups. In the receiver operating characteristic curves, the most appropriate cutoff point was 120 mg/dl for the blood glucose level at 120 min and 9000 for the blood glucose x insulin level at 120 min. There were no significant differences in the clinical characteristics or in the endocrine and metabolic parameters between conceived (n=9) and non-conceived groups (n=21). CONCLUSION The levels of blood glucose and blood glucose x insulin at 120 min after 75-g OGTT could be good biochemical markers of CC resistance in PCOS. No predictors of conception following CC therapy were identified by this study.
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Affiliation(s)
- Takumi Kurabayashi
- Department of Obstetrics and Gynecology, Niigata University School of Medicine, Niigata, Japan.
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La Marca A, Artensio AC, Stabile G, Volpe A. Metformin treatment of PCOS during adolescence and the reproductive period. Eur J Obstet Gynecol Reprod Biol 2005; 121:3-7. [PMID: 15941616 DOI: 10.1016/j.ejogrb.2004.09.015] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2004] [Revised: 07/22/2004] [Accepted: 09/29/2004] [Indexed: 11/30/2022]
Abstract
Insulin resistance is a common feature of PCOS. Hyperinsulinemia has been causally linked with all features of the syndrome, such as hyperandrogenism, reproductive disorders, and metabolic disturbances. Several insulin-sensitizing agents have been tested in the management of PCOS. Metformin is the only drug currently in widespread clinical use for PCOS. In a high percentage of patients, treatment with metformin is followed by regularization of the menstrual cycle, less pronounced hyperandrogenism and cardiovascular risk factors, and some improvement in the response to therapies aimed at induction of ovulation. In adolescent girls who are anovulatory and moderately obese, metformin administration can have a normalizing effect on multiple aberrations within the endocrine-metabolic status. During the reproductive period, metformin administration can improve reproductive function and the establishment of pregnancy. A role of metformin in prevention of gestational diabetes and hypertensive complications of pregnancy has yet to be shown. Finally, any real benefit of insulin-lowering treatment in terms of lesser cardiovascular risk in women with PCOS women remains to be demonstrated.
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Affiliation(s)
- Antonio La Marca
- Institute of Obstetrics and Gynecology, University of Modena and Reggio Emilia, Policlinico of Modena, Italy.
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Teede HJ, Meyer C, Norman RJ. Insulin-sensitisers in the treatment of polycystic ovary syndrome. Expert Opin Pharmacother 2005; 6:2419-27. [PMID: 16259573 DOI: 10.1517/14656566.6.14.2419] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Polycystic ovary syndrome (PCOS) is a common endocrine condition with reproductive and metabolic implications. In the current setting there is an evolving, yet inadequate, understanding of the pathophysiology, long-term health implications and ideal therapies for women with PCOS. Insulin resistance, secondary to both genetic and lifestyle factors, is integrally involved in the pathogenesis, the metabolic and clinical features and the long-term sequelae of PCOS in a majority of patients. Therapeutic strategies targeting insulin resistance ameliorate clinical features and may reduce long-term sequelae of PCOS, including diabetes. The main benefit of improved insulin resistance is to improve fertility and potentially to improve clinical features of hyperandrogenism and lower androgen levels. Insulin sensitisers also have the potential to delay the development of diabetes and cardiovascular disease in PCOS. Lifestyle therapy is indicated as the first intervention; however, metformin as an insulin sensitising agent has a role in first-line medical therapy in women with PCOS. Further research is needed to define the role of insulin sensitisers in PCOS and to determine the long-term risks and benefits of these therapies.
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Affiliation(s)
- Helena J Teede
- Jean Hailes Foundation, Monash Institute of Health Services Research, Monash Medical Centre, Level 1 Block E, Locked Bag 29 Clayton VIC 3168, Australia.
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Nakhuda GS, Sauer MV. Addressing the growing problem of multiple gestations created by assisted reproductive therapies. Semin Perinatol 2005; 29:355-62. [PMID: 16360495 DOI: 10.1053/j.semperi.2005.08.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Iatrogenic multiple pregnancy is the most significant complication of assisted reproductive technology (ART). Approximately half of all children born subsequent to ART result from a plural gestation. Furthermore, the majority of triplets and higher order births are the product of ART. The risks for multiple pregnancy vary with practice patterns and the techniques used to achieve pregnancy. Recognizing the potential for serious morbidity associated with multiple pregnancies, infertility specialists have developed strategies to reduce the complication of multiple pregnancies while maintaining acceptable pregnancy rates. Implementation of these refined practices has led to a reduction in the incidence of higher order multiple births, although the incidence of twins has yet to be minimized. Further reduction in the incidence of multiple births after ART necessitates a redefinition of success to emphasize the healthy singleton birth rate, rather than crude pregnancy rates.
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Affiliation(s)
- Gary S Nakhuda
- Division of Reproductive Endocrinology and Infertility, College of Physicians & Surgeons, Columbia University, New York, NY 10032, USA.
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Kaya H, Sezik M, Ozkaya O. Evaluation of a new surgical approach for the treatment of clomiphene citrate-resistant infertility in polycystic ovary syndrome: Laparoscopic ovarian multi-needle intervention. J Minim Invasive Gynecol 2005; 12:355-8. [PMID: 16036198 DOI: 10.1016/j.jmig.2005.05.017] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2004] [Accepted: 03/25/2004] [Indexed: 11/22/2022]
Abstract
Laparoscopic ovarian drilling (LOD) is the accepted second-line treatment for clomiphene citrate-resistant anovulatory infertility in polycystic ovary syndrome (PCOS). Although multiple pregnancy rates are reduced with ovarian drilling procedures, postoperative adhesion formation is a potential complication in up to 85% of the women subjected to laparoscopic destructive ovarian procedures. Our objective was to determine the effectiveness of a new, specially designed laparoscopic device and technique that might enable treatment for patients with anovulatory PCOS with less trauma and fewer postoperative adhesions. Thirty-five infertile clomiphene citrate-resistant women with PCOS were included. Seventeen women underwent laparoscopic ovarian multi-needle intervention (LOMNI), and 18 women received step-up ovulation induction treatment with recombinant follicle-stimulating hormone followed by intrauterine insemination for three cycles. Patients were followed for a period of 6 months after either laparoscopic surgery or the initiation of ovulation induction therapy. Outcome measures were cycle regularity, pregnancy rate, safety, postoperative adhesion formation, and cost effectiveness. There were no significant differences between the two groups in terms of age, body-mass index, duration of infertility, and basal cycle-day 2 hormone levels. Significant improvement in cycle regularity (p <.01) was found after LOMNI. Cumulative pregnancy rates (35.3% in the LOMNI group vs 33.3% in the ovulation induction group) did not differ between the groups. No adverse events following surgery were noted. Moderate ovarian hyperstimulation syndrome and multiple pregnancies occurred in four and two patients, respectively, in the ovulation induction group. Eight nonpregnant women in the LOMNI group underwent repeat laparoscopy at the end of the follow-up period. No adhesion formation attributable to LOMNI was observed in any of those eight women. The cost of LOMNI was significantly (p <.001) lower than the ovulation induction treatment. In conclusion, LOMNI may be a safe, inexpensive, and effective procedure for the treatment of CC-resistant infertility in patients with PCOS. It seems to preserve the beneficial effects and probably omits unwanted effects (such as adhesion formation) of LOD.
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Affiliation(s)
- Hakan Kaya
- Department of Obstetrics and Gynecology, Suleyman Demirel University, School of Medicine, Isparta, Turkey.
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Abstract
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.
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Affiliation(s)
- Ioannis E Messinis
- Department of Obstetrics and Gynaecology, University of Thessalia, Medical School, Larissa, Greece.
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Strowitzki T, von Wolff M. Laparoscopic ovarian drilling (LOD) in patients with polycystic ovary syndrome (PCOS): an alternative approach to medical treatment? ACTA ACUST UNITED AC 2005. [DOI: 10.1007/s10397-005-0099-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Abstract
The management of infertility in women with polycystic ovary syndrome (PCOS) centers around options for inducing ovulation. This is an evidence-based review of the management of PCOS, which includes a MEDLINE search of publications between 1986 and May 2005 and a search of the Cochrane Database. Weight loss, exercise, and metformin will induce ovulation in many insulin-resistant women and obese women with PCOS, and should always be the first-line treatment. Ovulation induction has been performed with clomiphene citrate (clomifene) as the first-line treatment, but the use of aromatase inhibitors has been shown to be as successful. The strategies for reducing the risks of gonadotropin therapy such as low-dose follicle-stimulating hormone (FSH) stimulation and the addition of metformin are discussed. Both gonadotropin releasing-hormone agonists and antagonists are equally effective in in vitro fertilization stimulation in conjunction with FSH therapy. Metformin may have a benefit in pregnancy in reducing the risks of miscarriage and diabetes mellitus; however, prospective trials are still lacking.
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Affiliation(s)
- Laurel Stadtmauer
- Department of Obstetrics and Gynecology, The Jones Institute for Reproductive Medicine, Eastern Virginia Medical School, Norfolk, VA 23507, USA.
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Al-Fadhli R, Tulandi T. Laparoscopic treatment of polycystic ovaries: is its place diminishing? Curr Opin Obstet Gynecol 2004; 16:295-8. [PMID: 15232482 DOI: 10.1097/01.gco.0000136495.56958.1a] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Raedah Al-Fadhli
- Department of Obstetrics and Gynecology, McGill University, Canada
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Palomba S, Orio F, Falbo A, Russo T, Lombardi G, Zullo F. Are laparoscopic ovarian diathermy and gonadotropin administration the only therapeutic second-steps in clomiphene-citrate resistant women with polycystic ovary syndrome? Hum Reprod 2004; 19:2682-3; author reply 2683. [PMID: 15496601 DOI: 10.1093/humrep/deh468] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Fernandez H, Watrelot A, Alby JD, Kadoch J, Gervaise A, deTayrac R, Frydman R. Fertility after Ovarian Drilling by Transvaginal Fertiloscopy for Treatment of Polycystic Ovary Syndrome. ACTA ACUST UNITED AC 2004; 11:374-8. [PMID: 15559352 DOI: 10.1016/s1074-3804(05)60054-0] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
STUDY OBJECTIVE To evaluate fertiloscopy ovarian drilling with bipolar energy in women with clomiphene citrate-resistant polycystic ovary syndrome (PCOS). DESIGN Prospective study (Canadian Task Force classification II). SETTING University teaching hospital and private clinic. PATIENTS Eighty women with clomiphene citrate-resistant PCOS. INTERVENTION Operative transvaginal fertiloscopy with a coaxial bipolar electrode. MEASUREMENTS AND MAIN RESULTS During a mean follow-up of 18.1 months (+/- 6.4), 73 women (91%) recovered regular and ovulatory cycles. The cumulative pregnancy rate was 60% (44/73) for spontaneous and stimulated cycles, with 39.7% (29/73) imputed to drilling alone. The mean time to conceive was 3.9 months (range 1-11.8). There were eight miscarriages (18%), and no ectopic pregnancies or multiple pregnancy. No complications occurred. CONCLUSION Ovarian drilling by transvaginal fertiloscopy with bipolar electrosurgery appears to be an effective minimally invasive procedure in patients with PCOS resistant to clomiphene citrate.
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Affiliation(s)
- Hervé Fernandez
- Service de Gynécologie-Obstétrique, Hôpital Antoine Béclère, Assistance Publique-Hôpitaux de Paris, Clamart, France
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Abstract
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.
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Affiliation(s)
- Victor Gomel
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.
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Yoon TK, Youn NY. Female Infertility. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2003. [DOI: 10.5124/jkma.2003.46.9.825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Tae Ki Yoon
- Department of Obstetrics and Gynecology·Infertility Medical Center, Pochun Cha University College of Medicine, Kang-nam Cha Hospital, Korea. ,
| | - Nae Young Youn
- Department of Obstetrics and Gynecology·Infertility Medical Center, Pochun Cha University College of Medicine, Kang-nam Cha Hospital, Korea. ,
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