Surgically induced ovulation in the polycystic ovary syndrome: wedge resection revisited in the age of laparoscopy

The polycystic ovary syndrome: the first 150 years of study

The communities of reproductive medicine and reproductive sciences have been witness to an enormous acceleration of interest in polycystic ovary syndrome (PCO) since the mid-19th century. Although progress has been increasingly palpable, the fundamentals of the etiology and pathophysiology of PCO remain as elusive as ever. Particularly lacking is a requisite understanding of events at the cellular and molecular levels. As we cross the millennial divide, it appears appropriate that an interim progress report be crafted. This treatise is attempting to meet this objective. What follows traces the chronology of the recorded history of PCO in 4 parts.

Ovulation induction techniques in women with polycystic ovary syndrome

Anovulation is very common and has several different clinical manifestations, including amenorrhea, oligomenorrhea and abnormal uterine bleeding. Various mechanisms can cause anovulation. The clinical consequences and commonest chronic anovulatory disorder, polycystic ovary syndrome (PCOS), has a prevalence that ranges between 6 to 10% of the global population. While multiple causes can eventually result in PCOS, various methods have been described in the literature for its management, often without ascertaining the underlying cause. Ovulation Induction (OI) is a group of techniques that is used in women with PCOS who are looking to conceive and are unbale to do so with natural means. This narrative review presents a summary of the current evidence and available techniques for OI in women with PCOS, highlighting their performance and applicability.

Ultrasound Shear Wave Velocity Varies Across Anatomical Region in Ex Vivo Bovine Ovaries

The physical properties of the ovarian extracellular matrix (ECM) regulate the function of ovarian cells, specifically the ability of the ovary to maintain a quiescent primordial follicle pool while allowing a subset of follicles to grow and mature in the estrous cycle. Design of a long-term, cycling artificial ovary has been hindered by the limited information regarding the mechanical properties of the ovary. In particular, differences in the mechanical properties of the two ovarian compartments, the cortex and medulla, have never been quantified. Shear wave (SW) ultrasound elastography is an imaging modality that enables assessment of material properties, such as the mechanical properties, based on the velocity of SWs, and visualization of internal anatomy, when coupled with B-mode ultrasound. We used SW ultrasound elastography to assess whole, ex vivo bovine ovaries. We demonstrated, for the first time, a difference in mechanical properties, as inferred from SW velocity, between the cortex and medulla, as measured along the length (cortex: 2.57 ± 0.53 m/s, medulla: 2.87 ± 0.77 m/s, p < 0.0001) and width (cortex: 2.99 ± 0.81 m/s, medulla: 3.24 ± 0.97 m/s, p < 0.05) and that the spatial distribution and magnitude of SW velocity vary between these two anatomical planes. This work contributes to a larger body of literature assessing the mechanical properties of the ovary and related cells and specialized ECMs and will enable the rational design of biomimetic tissue engineered models and durable bioprostheses. Impact Statement Shear wave (SW) ultrasound elastography can be used to simultaneously assess the material properties and tissue structures when accompanied with B-mode ultrasound. We report a quantitative difference in mechanical properties, as inferred from SW velocity, between the cortex and medulla, with SW velocity being 11.4% and 8.4% higher in the medulla than the cortex when measured along the length and width, respectively. This investigation into the spatial and temporal variation in SW velocity in bovine ovaries will encourage and improve design of more biomimetic scaffolds for ovarian tissue engineering.

Ovarian Innervation Coupling With Vascularity: The Role of Electro-Acupuncture in Follicular Maturation in a Rat Model of Polycystic Ovary Syndrome

Low-frequency electro-acupuncture (EA) has been shown to restore ovulation in patients with polycystic ovary syndrome (PCOS), and previous animal experiments showed that EA improves ovarian blood flow and angiogenesis. We performed EA for 4 weeks in dihydrotestosterone (DHT)-induced PCOS-like rats and investigated the three-dimensional (3D) ovarian innervation to determine the role of innervation in folliculogenesis and vascularity. Ovarian tissues were made transparent following the CUBIC 3D tissue-clearing protocol and were immunostained using antibodies against platelet endothelial cell adhesion molecule-1 and tyrosine hydroxylase to visualize the ovarian vasculature and innervation, respectively. This was followed by 3D imaging using lightsheet microscopy and analysis using the Imaris software. In control rats, ovarian innervation increased with age, and the neuronal branching started from the ovarian hilum and reached the individual follicles at different follicle stages. At the individual follicle level, each follicle was mainly innervated by one neuronal fiber. Compared with control rats, ovaries from DHT-treated PCOS-like rats had more antral follicles and fewer preovulatory follicles and corpora lutea. Furthermore, PCOS ovaries showed decreased innervation of blood vessels near the hilum and the surrounding individual antral follicles. EA in PCOS-like rats led to increased numbers of preovulatory follicles and corpora lutea together with increased innervation of blood vessels near the hilum. To determine the role of ovarian innervation, we further performed unilateral sectioning of the superior ovarian nerve (SON) in PCOS + EA rats and found that the left sectioned ovary had fewer preovulatory follicles and corpora lutea compared with those in the right non-sectioned ovary. In conclusion, ovarian innervation likely played an important role in folliculogenesis, and EA might restore PCOS pathophysiology by regulating ovarian innervation, at least partially mediated through the SON.

Gonadal soma controls ovarian follicle proliferation through Gsdf in zebrafish

BACKGROUND

Aberrant signaling between germ cells and somatic cells can lead to reproductive disease and depends on diffusible signals, including transforming growth factor-beta (TGFB) -family proteins. The TGFB-family protein Gsdf (gonadal soma derived factor) controls sex determination in some fish and is a candidate for mediating germ cell/soma signaling.

RESULTS

Zebrafish expressed gsdf in somatic cells of bipotential gonads and expression continued in ovarian granulosa cells and testicular Sertoli cells. Homozygous gsdf knockout mutants delayed leaving the bipotential gonad state, but then became a male or a female. Mutant females ovulated a few oocytes, then became sterile, accumulating immature follicles. Female mutants stored excess lipid and down-regulated aromatase, gata4, insulin receptor, estrogen receptor, and genes for lipid metabolism, vitellogenin, and steroid biosynthesis. Mutant females contained less estrogen and more androgen than wild-types. Mutant males were fertile. Genomic analysis suggests that Gsdf, Bmp15, and Gdf9, originated as paralogs in vertebrate genome duplication events.

CONCLUSIONS

In zebrafish, gsdf regulates ovarian follicle maturation and expression of genes for steroid biosynthesis, obesity, diabetes, and female fertility, leading to ovarian and extra-ovarian phenotypes that mimic human polycystic ovarian syndrome (PCOS), suggesting a role for a related TGFB signaling molecule in the etiology of PCOS. Developmental Dynamics 246:925-945, 2017. © 2017 Wiley Periodicals, Inc.

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.

Polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) affects 5-20% of women of reproductive age worldwide. The condition is characterized by hyperandrogenism, ovulatory dysfunction and polycystic ovarian morphology (PCOM) - with excessive androgen production by the ovaries being a key feature of PCOS. Metabolic dysfunction characterized by insulin resistance and compensatory hyperinsulinaemia is evident in the vast majority of affected individuals. PCOS increases the risk for type 2 diabetes mellitus, gestational diabetes and other pregnancy-related complications, venous thromboembolism, cerebrovascular and cardiovascular events and endometrial cancer. PCOS is a diagnosis of exclusion, based primarily on the presence of hyperandrogenism, ovulatory dysfunction and PCOM. Treatment should be tailored to the complaints and needs of the patient and involves targeting metabolic abnormalities through lifestyle changes, medication and potentially surgery for the prevention and management of excess weight, androgen suppression and/or blockade, endometrial protection, reproductive therapy and the detection and treatment of psychological features. This Primer summarizes the current state of knowledge regarding the epidemiology, mechanisms and pathophysiology, diagnosis, screening and prevention, management and future investigational directions of the disorder.

Stein and Leventhal: 80 years on

Eighty years ago a publication in the Journal proved to be seminal and transformative. The report by Irving Freiler Stein and Michael Leventhal titled, "Amenorrhea associated with polycystic ovaries," has proven to be a remarkably lasting and influential publication. The growth in related literature has been increasing exponentially: the 50 years between 1950 and 2000 saw a little more than 8000 publications on the topic, whereas the 15 year period between 2001 and 2015 (so far) has seen more than 20,000 related publications, a greater than 8-fold increase in the publication rate after 2000. As we commemorate the 80th anniversary year of the publication of the report by Stein and Leventhal, it is important to ask ourselves, "Was this publication truly as seminal as it is generally assumed to be? And why did it gain such a strong foothold on the medical psyche?" To the first question, a review of the antecedent medical literature makes it clear that the report of Drs Stein and Leventhal in 1935, although not flawless, was both seminal and transformative. In fact, it was the first report to describe a series of patients, rather than isolated cases, who demonstrated the triad of polycystic ovaries, hirsutism, and oligo/amenorrhea, connecting what had previously been disparate features of polycystic ovaries and menorrhagia, and hirsutism and oligo/amenorrhea. Second, the facts that Dr Stein and his collaborators were relatively prolific writers, consistent and clear in their message and descriptions; that a possible therapy (bilateral ovarian wedge resection) had been conveniently included in the report; and that the disorder was (is) relatively prevalent, permitted what would eventually be called the Stein-Leventhal syndrome to gain a strong foothold in contemporary medical practice. Overall, we in the field of medicine have much to celebrate, as we commemorate the 80th anniversary of the publication of the report by Stein and Leventhal in 1935, for a new disorder was described, one that we know today affects, in its various forms, 1 in every 7-17 women worldwide.

Adequacy of ovarian diathermy under ultrasound control: an experimental model

Background

To develop a minimally invasive ovarian cauterization technique under transvaginal ultrasound control and evaluate the safety and feasability of monopolar cauterization to cause ovarian injury using female cattle of reproductive age as an experimental model.

Method

Experimental study in a university research center was performed. Eleven female bovines of reproductive age were submitted to monopolar transvaginal ovarian cauterization. The right ovary (RO) was punctured at four sites and 40 W was applied for 5 s at each point, resulting in a total of 800 J (Joules) of thermal energy. In the left ovary (LO), the procedure was similar, with the same time and 80 W, resulting in a thermal energy of 1600 J. Macroscopic and microscopic lesions were assessed.

Results

Of 22 ovaries punctured, 20 were cauterized and exhibited macroscopic and typical microscopic lesions. No lesions could be found in the needle path. The measures of the areas of microscopic electrocautery lesions calculated estimating a cylindrical volume showed a median of 1.12% in the right ovary and 1.65% in the left ovary. When the estimate was calculated by spherical shape, the medians were 1.77% in the right ovary and 3.06% in the left ovary. There was a statistically significant difference in these two estimates (sphere, p = 0.008; cylinder, p = 0.021).

Conclusion

The experimental animal model described for transvaginal ultrasound-guided ovarian needle cauterization seems to be feasible. The ovaries were successfully cauterized without injuries in needle path and more energy resulted in significantly more thermal lesion. The safety and effectiveness of this technique, theoretically less invasive than current ovarian drilling methods, could be tested in anovulatory women with PCOS.

The role of TGF-β in polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a common endocrine disorder characterized by chronic oligoanovulation and hyperandrogenism and associated with insulin resistance, type 2 diabetes, and cardiovascular risk. In recent years, genetic studies have linked PCOS to a dinucleotide marker D19S884 in the fibrillin 3 gene. Fibrillins make up the major component of microfibrils in the extracellular matrix (ECM) and interact with molecules in the ECM to regulate transforming growth factor β (TGF-β) signaling. Therefore, variations in fibrillin 3 and subsequent dysregulation of TGF-β may contribute to the pathogenesis of PCOS. Here, we review the evidence from genetic studies supporting the role of TGF-β in PCOS and describe how TGF-β dysregulation may contribute to (1) the fetal origins of PCOS, (2) reproductive abnormalities in PCOS, and (3) cardiovascular and metabolic abnormalities in PCOS.

Convergence of multiple mechanisms of steroid hormone action

Steroid hormones modulate a wide array of physiological processes including development, metabolism, and reproduction in various species. It is generally believed that these biological effects are predominantly mediated by their binding to specific intracellular receptors resulting in conformational change, dimerization, and recruitment of coregulators for transcription-dependent genomic actions (classical mechanism). In addition, to their cognate ligands, intracellular steroid receptors can also be activated in a "ligand-independent" manner by other factors including neurotransmitters. Recent studies indicate that rapid, nonclassical steroid effects involve extranuclear steroid receptors located at the membrane, which interact with cytoplasmic kinase signaling molecules and G-proteins. The current review deals with various mechanisms that function together in an integrated manner to promote hormone-dependent actions on the central and sympathetic nervous systems.

Transvaginal ultrasound ovarian diathermy: sheep as an experimental model

BACKGROUND

Some techniques of transvaginal ovarian drilling have been previously described. Nevertheless a monopolar transvaginal ovarian cauterization, that use the expertise and safety of transvaginal puncture for oocyte captation seems to be an easier and feasible approach. The aim of this study was to develop a minimally invasive ovarian cauterization technique under transvaginal ultrasound control, and to evaluate the safety of the transvaginal ovarian monopolar cauterization, female sheep at reproductive age were used as an experimental model.

FINDINGS

An experimental study was performed in a university research center. Seventeen female sheep (15 Corriedale e 2 Suffolk) in reproductive age were submitted to transvaginal ovarian cauterization with a monopolar Valleylab Force 2 electrocautery. Macroscopic and microscopic lesions were assessed. Ovarian size were 1.31 cm2 ± 0,43 (Corriedale) and 3.41 cm2 ± 0,64 (Suffolk). From 30 ovaries from Corriedale sheep punctured, only 3 were cauterized, presenting macroscopic and typical microscopic lesion. In the Suffolk sheep group, only one ovary was cauterized. No lesion could be found in the needle path.

CONCLUSIONS

This is the first experimental animal model described for ovarian cauterization needle guided by transvaginal ultrasound. The sheep does not seem to be the ideal animal model to study this technique. Another animal model, whose ovaries are better identified by transvaginal ultrasound should be sought for this technique, theoretically less invasive, before it could be offered safely to women with polycystic ovary syndrome.

[Postoperative abdominal adhesions and their prevention in gynaecological surgery: I. What should you know?]

Adhesions are the most frequent complications of abdominopelvic surgery, causing important short- and long-term problems, including infertility, chronic pelvic pain and a lifetime risk of small bowel obstruction. They also complicate future surgery with increased morbidity and mortality risk. They pose serious quality of life issues for many patients with associated social and healthcare costs. Despite advances in surgical techniques, including laparoscopy, the healthcare burden of adhesion-related complications has not changed in recent years. Adhesiolysis remains the main treatment although adhesions reform in many patients. The extent of the problem of adhesions has been underestimated by surgeons and the health authorities. There is rising evidence however that surgeons can take important steps to reduce the impact of adhesions. As well as improvements in surgical technique, developments in adhesion-reduction strategies and new agents offer a realistic possibility of reducing adhesion formation and improving outcomes for patients. This paper is the first of a two-part publication providing a comprehensive overview of the evidence on adhesions to allow gynaecological surgeons to be best informed on adhesions, their development, impact on patients, health systems and surgical outcomes. In the second paper we review the various strategies to reduce the impact of adhesions and improve surgical outcomes to assist fellow surgeons in France to consider the adoption of adhesion reduction strategies in their own practice.

Surgical Approach for Polycystic Ovarian Syndrome in Management of Infertility

BACKGROUND

In patients with Polycystic Ovarian Syndrome (PCOS), resolution of infertility is an important goal of treatment. Wedge resection of the ovaries described as a means to achieve this was practiced in the middle of twentieth century. With the advent of endoscopic surgery, surgical approach for the same condition has been modified. Multi point biopsy, multiple needle puncture, electofulguration and laser fulguration are being tried in the context of PCOS. This project was taken up to evaluate the scope of electo fulguration in clomiphene resistant PCOS.

METHODS

Forty patients who did not show sonographic evidence of ovulation with clomiphene citrate (CC) 100mg OD for 05 days in two cycles were subjected to laparoscopy. The patients who did not show any pelvic factor for infertility were alternately assigned to electro - fulguration treatment of ovaries or no fulguration during laparoscopy. These were designated as 'Lap EC' & 'Only CC' group respectively. For 'Only CC' group' stimulation with CC was continued for four cycles with a higher dose 150 mg OD for 05 days. Lap EC group were subjected to CC 100mg OD for 5 days for two cycles in case of non achievement of ovulation in the first two drug free cycles following EC. Folliculometry, HCG administration and Intra Uterine Insemination (IUI) was performed for both groups.

RESULTS

Total percentage of ovulatory cycles were 51.8% in EC group compared to 5.26% in the CC group. Overall pregnancy rate of 30% was achieved in the Lap EC group as compared to only 10% in the CC group (p<0.05).

CONCLUSION

Laparoscopic electrofulguration of ovaries increases the chances of ovulation and conception. This being a cheaper one time procedure as compared to other expensive ovulation inducing agents, should be the preferred mode and the primary procedure wherever polycystic ovaries are encountered while evaluating a case of infertility by laparoscopy.

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.

Effect of N-acetyl-cysteine after ovarian drilling in clomiphene citrate-resistant PCOS women: a pilot study

The aim of this randomized double-blind placebo-controlled pilot study was to evaluate N-acetyl-cysteine (NAC) as an adjunctive therapy following unilateral laparoscopic ovarian drilling (LOD) for clomiphene citrate-resistant women with polycystic ovary syndrome (PCOS). A total of 60 patients with clomiphene citrate-resistant PCOS who underwent unilateral LOD were assigned randomly to receive either NAC 1.2 g/d (group A=30) or placebo (group B=30) for 5 days starting at day 3 of the cycle for 12 consecutive cycles. The primary outcome was pregnancy rate; secondary outcomes were ovulation rates, endometrial thickness and pregnancy outcome. Baseline clinical, endocrine, and sonographic characteristics were similar in the two groups. A significant increase in both ovulation and pregnancy rates was observed in the NAC group, compared with placebo [87% versus 67% (RR 1.3; 95% CI 1.2-2.7) and 77% versus 57% (RR 1.4; 95% CI 1.1-2.7), respectively, P<0.01]. Moreover, miscarriage rates were significantly lower and live birth rates were significantly higher in the NAC group [8.7% versus 23.5% (RR 0.4; 95% CI 0.1-3.7) and 67% versus 40% (RR 1.7; 95% CI 0.3-3.5), respectively, P<0.01]. In conclusion, NAC is a novel adjuvant therapy after unilateral LOD which might help improve overall reproductive outcome.

Cancer risk among infertile women with androgen excess or menstrual disorders (including polycystic ovary syndrome)

OBJECTIVE

To define relationships of androgen excesses to cancer risk.

DESIGN

Retrospective cohort study.

SETTING

Five large infertility practices.

PATIENT(S)

Among 12,193 women evaluated for infertility during 1965-1988 and traced for cancer incidence through 1999, 2,560 had androgen excess or menstrual disorders; among these, 412 met established criteria for polycystic ovary syndrome.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Cancer incidence. Derivation of standardized incidence ratios (SIRs) and 95% confidence intervals (CIs) for cancer risk comparisons with the general population and rate ratios (RRs) for comparisons with other infertility patients.

RESULT(S)

Androgen excess/menstrual disorder patients showed significant SIRs for breast (1.31; 95% CI, 1.05-1.62) and uterine (2.02; 95% CI, 1.13-3.34) cancers and melanoma (1.96; 95% CI, 1.12-3.18). Significant associations for breast and uterine cancers were restricted to primary infertility patients (respective SIRs of 1.53 and 3.48). After adjustment for other cancer predictors, the only excess risk was for uterine cancer among primary infertility patients. Compared with women with secondary infertility and no androgen excess/menstrual disorder, those with primary infertility and a disorder had an RR of 1.88 (95% CI, 0.82-4.32). Cancer risks among the women with polycystic ovary syndrome or androgen excess disorders appeared to be similar to those in the more comprehensive group.

CONCLUSION(S)

Previous findings linking androgen excess disorders to elevated uterine cancer risks might largely reflect underlying risk profiles.

The extent of ovarian damage produced by ovarian cauterisation in the human

The object of this study was to assess the extent of ovarian damage produced by ovarian cauterisation. This was a prospective comparative study between four and eight holes using monopolar diathermy comparing the extent of damage of ovarian tissue in the human. The study was carried out in the department of obstetrics and gynaecology, Cairo University. We studied 50 patients aged 40-45 years who were scheduled for abdominal hysterectomy with bilateral salpingo-oophorectomy for benign gynaecological disease. One ovary was subjected to unipolar diathermy with four holes (group I) and the contralateral ovary involved eight holes (group II). The main outcome measured was the extent of ovarian damage produced by the cautery. The percentage area of cautery showed a median of 0.4% and a mean of 0.48% +/- 0.35 in group I, compared to a median of 1% and a mean of 1% +/- 0.31 in group II. The difference between the two groups is statistically significant (P < 0.001). The study suggests that the extent of injury to the ovary produced by cautery might be small, especially when using four holes; however, it is difficult to determine long-term host tissue response.

Ultrasound-guided transvaginal ovarian needle drilling (UTND) for treatment of polycystic ovary syndrome: a randomized controlled trial

OBJECTIVE

To evaluate the outcome of ovarian needle drilling using transvaginal ultrasound guidance as an alternative to the traditional laparoscopic electrosurgical drilling for patients with polycystic ovary syndrome (PCOS).

DESIGN

A randomized controlled study.

SETTING

University teaching hospital and private practice setting.

PATIENT(S)

The study comprised 163 patients with clomiphene-resistant PCOS.

INTERVENTION(S)

Patients were randomly allocated to either treatment with ultrasound-guided transvaginal needle ovarian drilling (UTND; n = 82) or laparoscopic electrosurgery ovarian drilling (n = 81).

MAIN OUTCOME MEASURE(S)

Hormonal changes (FSH, LH, T), ovulation and pregnancy.

RESULT(S)

There were no significant differences between the two groups with regard to body mass index, hormonal profiles, clinical manifestations, and ultrasound findings of PCOS. The duration of UTND was 15.3 +/- 5.61 minutes (10.5-22.3 minutes), while it was 25.6 +/- 8.2 minutes (20.3-38.1 minutes) in laparoscopic drilling, with a statistically significant difference between the two groups. There were no significant differences between the two groups with regard to resumption of normal menstruation, hirsutism, acne, ovulation, and pregnancy. UTND resulted in significant improvement in the ovulation, pregnancy, hirsutism, and acne. There were significant decreases in the serum LH and T levels but not in the FSH or LH/FSH levels after UTND as well.

CONCLUSION(S)

UTND can be adopted as an outpatient office procedure. The ease of scheduling, reduced costs, and rapid recovery suggest it as a first-line treatment for PCOS cases resistant to clomiphene citrate.

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.

Symptoms and treatments of polycystic ovary syndrome

Up to 10% of women may suffer from polycystic ovary syndrome (PCOS). The clinical symptoms may vary, so the biochemical profile and ultrasonography are used to predict an accurate diagnosis. Many studies have indicated that a relationship may exist between hyperinsulineamia and hyperandrogenism but the exact pathogenesis remains obscure. PCOS is treated by a combination of surgery or pharmacological management. Treatment is not always successful therefore women in these cases require support and care from nursing staff to help overcome the disappointment of treatment failure. To support women with PCOS, nurses need to be knowledgeable about the condition and its clinical manifestations and available treatment options. This article aims to examine the current aetiology, clinical manifestations, pathophysiology, diagnosis and treatment options available to women with a diagnosis of PCOS.

Increase of multiple pregnancies caused by ovulation induction with gonadotropin in combination with metformin in infertile women with polycystic ovary syndrome

Metformin appears to be an effective medicine to induce ovulation in women with polycystic ovary syndrome and insulin resistance. After the introduction of metformin treatment for such cases, the use of gonadotropin in combination with metformin significantly increased the incidence of multiple pregnancies.

Ovarian reserve in women with polycystic ovary syndrome who underwent laparoscopic ovarian drilling

OBJECTIVE

To evaluate ovarian reserve assessed by hormones and sonography in women with polycystic ovary syndrome (PCOS) undergoing laparoscopic ovarian drilling (LOD).

METHODS

This was a cross-sectional study. Twenty-one PCOS women undergoing LOD were enrolled in the study (the LOD group). Their day-3 anti-Müllerian hormone (AMH), inhibin B, follicle-stimulating hormone (FSH) levels, antral follicles count (AFC) and summed ovarian volume representing ovarian reserve were compared with those of PCOS women who did not undergo LOD (the PCOS group) and those of normal ovulatory women (the control group).

RESULTS

There were no differences in age and body mass index between groups. AMH levels seemed to be lower in the LOD (4.60 +/- 3.16 ng/ml) than in the PCOS (5.99 +/- 3.36 ng/ml) groups, but did not reach statistical significance. Day-3 FSH levels were significantly higher and AFC was significantly lower in the LOD than in the PCOS group. AMH levels, AFC and summed ovarian volume were significantly greater, but FSH was significantly lower, in the PCOS group compared with the control group. There were no differences in inhibin B levels between groups.

CONCLUSION

This study showed that ovarian reserve assessed by hormonal levels and sonography seems to be lower in the LOD than in the PCOS group. The PCOS women both with and without LOD had significantly greater ovarian reserve than the age-matched controls having normal ovulatory menstruation.

Ovarian interstitial YAG-laser: an effective new method to manage anovulation in women with polycystic ovary syndrome

OBJECTIVE

This study was undertaken to assess the effectiveness of transvaginal ultrasound-guided ovarian interstitial laser-coagulation treatment in anovulatory women with polycystic ovary syndrome (PCOS).

STUDY DESIGN

Nineteen anovulatory women with clomiphene citrate-resistant PCOS underwent ultrasound-guided transvaginal ovarian interstitial YAG-laser treatment. In this study, serum hormonal level, spontaneous ovulation rate, and pregnancy rate were assessed.

RESULTS

With a spontaneous ovulation rate of 84.2%, 16 of 19 cases ovulated regularly during the 6-month postoperative period. The mean serums luteinizing hormone and serum testosterone levels in the second, fourth, and sixth postoperative months were significantly lower than preoperative levels: 5.87 +/- 2.04 IU/L versus 13.17 +/- 3.03 IU/L (P < .001) and 2.98 +/- 1.79 nmol/L versus 5.49 +/- 3.23 nmol/L (P < .001), respectively. The mean luteinizing hormone/follicle-stimulating hormone ratio was also significantly lower postoperatively at 1.09 +/- 0.30 compared with the preoperative 2.85 +/- 1.14 (P < .001). There was a cumulative pregnancy rate at 6 months of 32.3% (6/19) among the subjects. No significant operative complications were encountered.

CONCLUSION

The ultrasound-guided transvaginal ovarian interstitial laser treatment may be an effective new method to manage anovulation in PCOS patients.

Transvaginal, ultrasound-guided, ovarian, interstitial laser treatment in anovulatory women with clomifene-citrate-resistant polycystic ovary syndrome

OBJECTIVE

To assess the effectiveness of transvaginal, ultrasound-guided, ovarian, interstitial laser coagulation treatment in anovulatory women with polycystic ovary syndrome (PCOS).

DESIGN

A pilot study.

SETTING

Assisted reproductive technology unit.

SAMPLE

Twenty-three anovulatory women with clomifene-citrate-resistant PCOS.

METHODS

Ultrasound-guided, transvaginal, ovarian, interstitial yttrium-aluminium-garnet laser treatment.

MAIN OUTCOME MEASURES

Serum luteinizing hormone (LH), follicle-stimulating hormone (FSH), testosterone, prolactin and estradiol levels, spontaneous ovulation rate and pregnancy rate were measured over 6 months of follow up.

RESULTS

Regular ovulation occurred in 19 out of 22 (86.4%) women in the 6 months following ovarian treatment (one woman was lost to follow up). On the postoperative second, fourth and sixth month, the mean serum LH levels were 4.54 SD 1.21 iu/l, 4.90 SD 2.18 iu/l and 4.42 SD 1.03 iu/l, significantly (P < 0.001, P < 0.001, P < 0.001) lower than the preoperative level of 13.89 +/- 3.62 iu/l; the mean serum testosterone levels were 2.69 SD 1.83 nmol/l, 2.42 SD 1.11 nmol/l and 2.28 SD 1.96 nmol/l and significantly (P < 0.001, P < 0.001, P < 0.001) lower than the preoperative baseline value of 5.37 SD 3.09 nmol/l; the mean LH/FSH ratios of 0.93 SD 0.26, 0.88 SD 0.17 and 0.81 SD 0.14 were also significantly lower than the preoperative value of 2.78 SD 1.21 (P < 0.001). Pregnancy occurred in eight women and there was a cumulative pregnancy rate at 6 months of 36% (8/22) among the subjects. There were no significant operative complications.

CONCLUSION

Ultrasound-guided, transvaginal, ovarian, interstitial laser treatment appears effective in improving hormonal profiles and inducing ovulation and successful pregnancy in women with clomifene-resistant PCOS.

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.

Postoperative endocrine alterations and clinical outcome of infertile women with polycystic ovary syndrome after transvaginal hydrolaparoscopic ovarian drilling

Transvaginal hydrolaparoscopic ovarian drilling (THLOD) appears to be an effective minimally invasive procedure to induce ovulation in women with polycystic ovary syndrome (PCOS). Postoperative endocrinological alterations following THLOD show significant decrease of serum LH and testosterone concentrations.

Effect of exercise on ovarian morphology and expression of nerve growth factor and alpha(1)- and beta(2)-adrenergic receptors in rats with steroid-induced polycystic ovaries

Oestadiol valerate (EV)-induced polycystic ovaries (PCO) in rats cause anovulation and cystic ovarian morphology. Denervation of ovarian sympathetic nerves restores ovulatory disruption. In the present study, we determined whether 5 weeks of voluntary exercise influence ovarian morphology and the expression of sympathetic markers in the EV-induced PCO rat model. The effect of exercise on (i) ovarian morphology; (ii) mRNA and protein expression of nerve growth factor (NGF); and (iii) mRNA and number of ovarian-expressing cells for the NGF receptor (p75 neurotrophin receptor) and the alpha(1a)-, alpha(1b)-, alpha(1d)- and beta(2)-adrenergic receptors (ARs) in rats with EV-induced PCO was evaluated. PCO was induced by a single i.m. injection of EV, and controls were injected with oil alone in adult cycling rats. The rats were divided into four groups: (i) control (oil); (ii) exercise group (oil + exercise); (iii) a PCO group (EV); and (iv) a PCO exercise group (EV + exercise). The exercise and PCO exercise groups ran voluntarily for 5 weeks in computer-monitored wheels placed in the cages where they were housed. The results obtained indicated that ovarian morphology was almost normalised in the PCO exercise group; NGF mRNA and protein concentrations were normalised in the PCO exercise group; high numbers of NGF receptor expressing cells in PCO ovaries were lowered by exercise; and the number of immunopositive cells of the different AR subtypes were all reduced after exercise in the PCO group, except for the alpha(1b)- and beta(2)-AR whereas the mRNA levels were unaffected, indicating transcriptional regulation. In conclusion, our data indicate a beneficial effect of regular exercise, as a modulator of ovarian sympathetic innervation, in the prevention and treatment of human PCOS.

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.

Pregnancy following ovarian drilling in a woman with polycystic ovary syndrome and nine previous first trimester miscarriages

CASE REPORT

We report a woman with a history of polycystic ovary syndrome (PCOS) and nine first-trimester miscarriages following ovulation induction and in vitro fertilization. The majority of these attempts were associated with ovarian hyperstimulation syndrome. No causes of recurrent miscarriages other than PCOS were found. Following laparoscopic ovarian drilling (LOD) she delivered a live neonate at 30 weeks of gestation.

DISCUSSION

This case describes the difficulties associated with the management of patients with PCOS and recurrent abortions. We believe that LOD has helped prevent miscarriage in this patient. The early application of this technique in such patients needs to be formally assessed by a prospective study.

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.

Combined oral contraceptives in the treatment of polycystic ovary syndrome

Combined oral contraceptives (COC) are the most often used treatment modality for polycystic ovary syndrome (PCOS). Undisputedly, COC suppress androgen production, thus ameliorating skin androgenic symptoms and improving menstrual dysfunction. On the other hand, there are still many unresolved issues concerning their metabolic effects. COC could decrease insulin sensitivity and deteriorate glucose tolerance, although the negative influence on insulin sensitivity is dependent on other factors (especially obesity) and this need not be expressed in non-obese patients. It is probable that the impairment of glucose tolerance is reversible, as the incidence of diabetes is not increased in past COC users. The effects of COC on the lipid spectrum are dependent on the type of gestagen, but lipid levels usually remain within the reference limits. Combination therapy of COC with weight reduction or insulin sensitizers could further suppress androgen levels and improve metabolic parameters. The establishment of COC after laparoscopic ovarian drilling may further decrease androgen levels. The combination of COC and GnRH analogues is not superior to COC therapy alone. Prospective data about the influence of COC on the risk of diabetes mellitus, coronary artery disease and endometrial cancer in PCOS women are lacking.

Polycystic ovarian syndrome: marked differences between endocrinologists and gynaecologists in diagnosis and management

BACKGROUND

Women with polycystic ovarian syndrome (PCOS) commonly consult endocrinologists or gynaecologists and it is not known whether these specialty groups differ in their approach to management.

OBJECTIVE

To compare the investigation, diagnosis and treatment practices of endocrinologists and gynaecologists who treat PCOS.

DESIGN AND SETTING

A mailed questionnaire containing a hypothetical patient's case history with varying presentations--oligomenorrhoea, hirsutism, infertility and obesity--was sent to Australian clinical endocrinologists and gynaecologists in teaching hospitals and private practice.

RESULTS

Evaluable responses were obtained from 138 endocrinologists and 172 gynaecologists. The two specialty groups differed in their choice of essential diagnostic criteria and investigations. Endocrinologists regarded androgenization (81%) and menstrual irregularity (70%) as essential diagnostic criteria, whereas gynaecologists required polycystic ovaries (61%), androgenization (59%), menstrual irregularity (47%) and an elevated LH/FSH ratio (47%) (all P-values < 0.001). In investigation, gynaecologists were more likely to request ovarian ultrasound (91%vs. 44%, P < 0.001) and endocrinologists more likely to measure adrenal androgens (80%vs. 58%, P < 0.001) and lipids (67%vs. 34%, P < 0.001). Gynaecologists were less likely to assess glucose homeostasis but more likely to use a glucose tolerance test to do so. Diet and exercise were chosen by most respondents as first-line treatment for all presentations. However, endocrinologists were more likely to use insulin sensitizers, particularly metformin, for these indications. In particular, for infertility, endocrinologists favoured metformin treatment whereas gynaecologists recommended clomiphene.

CONCLUSIONS

There is a lack of consensus between endocrinologists and gynaecologists in the definition, diagnosis and treatment of PCOS. As a consequence, women may receive a different diagnosis or treatment depending on the type of specialist consulted.

Management of Infertility in Women with Polycystic Ovary Syndrome

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.

Is ovulation induction still a therapeutic problem in patients with polycystic ovary syndrome?

Polycystic ovary syndrome (PCOS) is one of the most common endocrine diseases affecting women of fertile age, and is characterized by hyperandrogenism, chronic anovulatory cycles and oligomenorrhea or amenorrhea. Given the repercussions of chronic anovulation on sterility, PCOS is a heavy social burden. Here we describe the procedures used to induce ovulation in PCOS patients, the surgical approach and medical treatments that are still being experimented.

Effect of electro-acupuncture stimulation of different frequencies and intensities on ovarian blood flow in anaesthetized rats with steroid-induced polycystic ovaries

BACKGROUND

Maintenance of ovarian blood flow (OBF) is suggested to be important for regular ovulation in women with polycystic ovaries (PCO). The purpose of the present study was to investigate whether electro-acupuncture (EA) of different frequencies and intensities can improve the OBF of anaesthetized rat in the animal model of PCO.

METHODS

PCO was experimentally induced by a single intramuscular (i.m.) injection of estradiol valerate (EV) in rats. Control rats were given i.m. injection of oil. The involvement of the two ovarian sympathetic nerves; superior ovarian nerve (SON) and plexus ovarian nerve (OPN), in OBF responses was elucidated by severance of SON and OPN in both control and PCO rats. How systemic circulatory changes affect OBF was evaluated by continuous recording of the blood pressure. OBF was measured on the surface of the ovary-using laser Doppler flowmetry. Acupuncture needles were inserted bilaterally into the abdominal and hind limb muscles and connected to an electrical stimulator. Two frequencies--2 Hz (low) and 80 Hz (high)--with three different intensities--1.5, 3, and 6 mA--were applied for 35 s.

RESULTS

Low-frequency EA at intensities of 3 and 6 mA elicited significant increases in OBF in the Control group compared to baseline. In the PCO group the increases in OBF were significant only when stimulating with low-frequency EA at 6 mA. After severance of the ovarian sympathetic nerves, the increased response of OBF that had been induced by low-frequency EA in both the Control and PCO group was abolished, indicating that the OBF response is mediated via the ovarian sympathetic nerves. High-frequency EA at 6 mA significantly decreased OBF and mean arterial blood pressure (MAP) in the Control group compared to baseline. In the PCO group, the same stimulation produced similar decreases in MAP, but not in OBF.

CONCLUSION

Low-frequency EA stimulation with a strong intensity (6 mA) increases OBF in rats with steroid-induced PCO whereas less strong intensity (3 mA) induces similar changes in control rats. Severance of the ovarian sympathetic nerves, abolish this OBF increase in both study groups, which suggests that the responses of OBF to EA are mediated via the ovarian sympathetic nerves.

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

OBJECTIVE

To compare the effectiveness of an electrocautery strategy with ovulation induction using recombinant follicle stimulating hormone in patients with polycystic ovary syndrome.

DESIGN

Randomised controlled trial.

SETTING

Secondary and tertiary hospitals in the Netherlands.

PARTICIPANTS

168 patients with clomiphene citrate resistant polycystic ovary syndrome: 83 were allocated electrocautery and 85 were allocated recombinant follicle stimulating hormone.

INTERVENTION

Laparoscopic electrocautery of the ovaries followed by clomiphene citrate and recombinant follicle stimulating hormone if anovulation persisted, or induction of ovulation with recombinant follicle stimulating hormone.

MAIN OUTCOME MEASURE

Ongoing pregnancy within 12 months.

RESULTS

. The cumulative rate of ongoing pregnancy after recombinant follicle stimulating hormone was 67%. With only electrocautery it was 34%, which increased to 49% after clomiphene citrate was given. Subsequent recombinant follicle stimulating hormone increased the rate to 67% at 12 months (rate ratio 1.01, 95% confidence interval 0.81 to 1.24). No complications occurred from electrocautery with or without clomiphene citrate. Patients allocated to electrocautery had a significantly lower risk of multiple pregnancy (0.11, 0.01 to 0.86).

CONCLUSION

The ongoing pregnancy rate from ovulation induction with laparoscopic electrocautery followed by clomiphene citrate and recombinant follicle stimulating hormone if anovulation persisted, or recombinant follicle stimulating hormone, seems equivalent to ovulation induction with recombinant follicle stimulating hormone, but the former procedure carries a lower risk of multiple pregnancy.

Assisted reproduction in the treatment of polycystic ovarian syndrome

Treatment of patients with polycystic ovary syndrome (PCOS) with assisted reproductive techniques is a great challenge for the infertility specialist. Patients with PCOS demonstrate many problems, such as excessive body weight and hyperinsulinaemia, that render management more complex. Prior to treatment with IVF, the PCOS patient should be thoroughly evaluated for disclosure of endometrial neoplasia, hyperinsulinaemia, and other general health related problems. Ovarian stimulation for IVF carries the risks of overstimulation and severe hyperstimulation, which should be avoidable in most cases with preventive measures. The outcome in terms of pregnancy and implantation rates is similar for patients with PCOS when compared with patients undergoing IVF for other indications. There are some questions regarding oocyte and embryo quality in women with PCOS. This manifests itself in lower fertilization rate and decreased embryo quality in some studies. However, increased numbers of oocytes available for insemination or ICSI compensate for decreased fertilization rates and embryo quality. More recent studies suggest higher cumulative conception rates in women with PCOS when compared with controls. In-vitro maturation (IVM) of oocytes retrieved from non-stimulated or minimally stimulated cycles represents a viable option that should be considered seriously when assisted conception is attempted. Results of IVM, however, should be improved further and generalized before the technique can be advocated as the initial treatment approach in these patients.

Prepubertal administration of estradiol valerate disrupts cyclicity and leads to cystic ovarian morphology during adult life in the rat: role of sympathetic innervation

Administration of estradiol valerate (EV) to adult rats leads to anovulation and cystic ovarian morphology. Sympathetic ovarian nerve denervation (SONX) overcomes this disruption. In this study, we determined whether EV administration to juvenile rats prevents achievement of reproductive competence, disrupts cyclicity, and whether this programming is facilitated via activation of the sympathetic nerve input to the ovary. Prepubertal rats were administered 2 mg EV in corn oil or corn oil alone. One half of the animals from each group underwent SONX on d 71 of life. Rats were euthanized on d 91 for determination of serum gonadotropins, progesterone, Delta4 androstenedione, and estradiol concentrations, ovarian norepinephrine (NE), and 3beta-hydroxysteroid dehydrogenase (3beta-HSD) activities and ovarian dynamics. Results revealed that EV administration during juvenile period advanced pubertal onset, suppressed circulating LH, FSH, and Delta4 androstenedione, increased ovarian NE, estradiol, and 3beta-HSD activities, disrupted ovarian dynamics evidenced as absent corpus luteum and presence of ovarian cysts and culminated in anovulation. SONX restored cyclicity in these animals, normalized LH, estradiol, ovarian 3beta-HSD activities, and ovarian dynamics as evidenced by the disappearance of ovarian cysts and appearance of corpus luteum and restored corpus luteum function. These findings provide evidence that EV exposure during juvenile life leads to long-lasting deleterious reproductive consequences via activation of the sympathetic ovarian nerve.