The effect of laparoscopic ovarian drilling in patients with anovulatory polycystic ovary syndrome and high serum levels of anti-Müllerian hormone

Female infertility is often associated with anovulatory polycystic ovary syndrome (PCOS), characterized by high serum levels of anti-Müllerian hormone (AMH). Laparoscopic ovarian drilling (LOD) is commonly used to treat PCOS, especially when drug interventions have failed. This study aimed to evaluate the response to LOD intervention in women with PCOS by assessing AMH serum levels and their ability to restore normal physiological menstrual cycle and achieve conception. Seventy-five infertile women (24-41 years old) with body mass index (BMI) ranging from 19.6-35kg/m2 were included in the study. Among them, 57 had primary infertility, and 18 from secondary infertility, with an average duration of 8.6±4.4 years. Baseline levels of follicle-stimulating hormone (FSH), luteinizing hormone (LH), and AMH were measured, and post-LOD levels of LH and AMH were evaluated. Menstrual cycle regularity was evaluated before and after LOD. Baseline FSH serum level before LOD was 5.2-1.6IU/L. Following LOD, the serum levels of LH and AMH significantly decreased from 14.3±4.1 to 7.8±2.8 IU/L and from 13.7±5.9 to 7.7±3.9 IU/L, respectively (p<0.05). LOD significantly (p<0.05) decreased the menstrual cycles irregularity, such as oligomenorrhea and amenorrhea, from 55 (73.3%) to 22 (29.3%) women and from 2 (2.7%) to 0 (0%) women respectively. Moreover, regular menstrual cycles significantly (p<0.05) increased from 18 (24%) to 53 (70.7%) women. Importantly, 68% of LOD-treated women showed a significant increase in pregnancy rates, with 52.9%, 35.3%, and 11.8% achieving pregnancy within 3, 6, and 9 months after LOD, respectively (p<0.05). Moreover, spontaneous ovulation was observed in 7/75 (9.3%) women within 90 days after LOD, and 71.4% achieved pregnancy. These findings highlight the success of laparoscopic ovarian drilling as an intervention for PCOS, with AMH serving as a reliable test to assess the response to LOD treatment.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Transvaginal needle versus laparoscopic ovarian drilling in hormonal profile and pregnancy outcomes of polycystic ovary syndrome: a systematic review and meta-analysis

BACKGROUND

Polycystic ovary syndrome (PCOS) is a prevalent hormonal disorder distinguished by a persistent absence of ovulation. Ovarian drilling is a recognized therapeutic approach for PCOS patients who are unresponsive to medication and can be performed through invasive laparoscopic access or less-invasive transvaginal access. The aim of this systematic review and meta-analysis was to assess the efficacy of transvaginal ultrasound -guided ovarian needle drilling with conventional laparoscopic ovarian drilling (LOD) in patients with PCOS.

METHODS

PUBMED, Scopus, and Cochrane databases were systematically searched for eligible randomized controlled trials (RCTs) from articles published from inception to January 2023. We include RCTs of PCOS that compared transvaginal ovarian drilling and LOD and reported on ovulation and pregnancy rates as the main outcome variable. We evaluated study quality using the Cochrane Risk of bias 2 tool. A random-effects meta-analysis was performed and the certainty of the evidence was assessed according to the GRADE approach. We registered the protocol prospectively in PROSPERO (CRD42023397481).

RESULTS

Six RCTs including 899 women with PCOS met the inclusion criteria. LOD was found to significantly reduce anti-Mullerian hormone (AMH) (SMD: -0.22; 95% CI: -0.38, -0.05; I² = 39.85%) and antral follicle count (AFC) (SMD: -1.22; 95% CI: -2.26, -0.19; I² = 97.55%) compared to transvaginal ovarian drilling. Our findings also indicated that LOD significantly increased the ovulation rate by 25% compared to transvaginal ovarian drilling (RR: 1.25; 95% CI: 1.02, 1.54; I2 = 64.58%). However, we found no significant difference between the two groups in terms of follicle stimulating hormone (SMD: 0.04; 95% CI: -0.26, 0.33; I2 = 61.53%), luteinizing hormone (SMD: -0.07; 95% CI: -0.90, 0.77; I2 = 94.92%), and pregnancy rate (RR: 1.37; 95% CI: 0.94, 1.98; I2 = 50.49%).

CONCLUSION

LOD significantly lowers circulating AMH and AFC and significantly increases ovulation rate in PCOS patients compared to transvaginal ovarian drilling. As transvaginal ovarian drillingremains a less-invasive, more cost-effective, and simpler alternative, further studies are warranted to compare these two techniques in large cohorts, with a particular focus on ovarian reserve and pregnancy outcomes.

Molecular Mechanisms of Laparoscopic Ovarian Drilling and Its Therapeutic Effects in Polycystic Ovary Syndrome

Polycystic ovary syndrome (PCOS) is a common endocrinopathy, characterized by chronic anovulation, hyperandrogenism, and multiple small subcapsular cystic follicles in the ovary during ultrasonography, and affects 5–10% of women of reproductive age. PCOS is frequently associated with insulin resistance (IR) accompanied by compensatory hyperinsulinemia and, therefore, presents an increased risk of type 2 diabetes mellitus (DM). The pathophysiology of PCOS is unclear, and many hypotheses have been proposed. Among these hypotheses, IR and hyperandrogenism may be the two key factors. The first line of treatment in PCOS includes lifestyle changes and body weight reduction. Achieving a 5–15% body weight reduction may improve IR and PCOS-associated hormonal abnormalities. For women who desire pregnancy, clomiphene citrate (CC) is the front-line treatment for ovulation induction. Twenty five percent of women may fail to ovulate spontaneously after three cycles of CC treatment, which is called CC-resistant PCOS. For CC-resistant PCOS women, there are many strategies to improve ovulation rate, including medical treatment and surgical approaches. Among the various surgical approaches, one particular surgical method, called laparoscopic ovarian drilling (LOD), has been proposed as an alternative treatment. LOD results in an overall spontaneous ovulation rate of 30–90% and final pregnancy rates of 13–88%. These benefits are more significant for women with CC-resistant PCOS. Although the intra- and post-operative complications and sequelae are always important, we believe that a better understanding of the pathophysiological changes and/or molecular mechanisms after LOD may provide a rationale for this procedure. LOD, mediated mainly by thermal effects, produces a series of morphological and biochemical changes. These changes include the formation of artificial holes in the very thick cortical wall, loosening of the dense and hard cortical wall, destruction of ovarian follicles with a subsequently decreased amount of theca and/or granulosa cells, destruction of ovarian stromal tissue with the subsequent development of transient but purulent and acute inflammatory reactions to initiate the immune response, and the continuing leakage or drainage of “toxic” follicular fluid in these immature and growth-ceased pre-antral follicles. All these factors contribute to decreasing local and systemic androgen levels, the following apoptosis process with these pre-antral follicles to atresia; the re-starting of normal follicular recruitment, development, and maturation, and finally, the normalization of the “hypothalamus–pituitary–ovary” axis and subsequent spontaneous ovulation. The detailed local and systematic changes in PCOS women after LOD are comprehensively reviewed in the current article.

Laparoscopic Ovarian Drilling Reduces Testosterone and Luteinizing Hormone/Follicle-Stimulating Hormone Ratio and Improves Clinical Outcome in Women with Polycystic Ovary Syndrome

Background:

Laparoscopic ovarian drilling (LOD) is one of the common modes of treatment for women with polycystic ovary syndrome (PCOS) who are resistant to clomiphene citrate. The data related to the effect of LOD on sex hormones are limited.

Aim:

The objective of the study was to investigate the effect of LOD on hormonal parameters and clinical outcomes in women with PCOS.

Settings and Design:

This study was conducted in a tertiary care hospital.

Materials and Methods:

Fifty PCOS patients who were admitted for LOD were enrolled in the study. Serum testosterone, luteinizing hormone (LH), and follicle-stimulating hormone (FSH) levels were estimated in all the patients before and after LOD.

Statistical Analysis:

Paired t-test was used to assess the differences in hormonal parameters before and after LOD.

Results:

LOD reduces testosterone (P < 0.001), LH (P < 0.001), and LH/FSH ratio (P < 0.001), increases FSH (P < 0.001) levels, and improves the rate of ovulation (38/50) and clinical pregnancy (21/50) in PCOS. When subgroup analysis was done, LOD significantly reduced testosterone and LH/FSH ratio in ovulatory and conceived groups. Furthermore, the menstrual cycle became regular, and hirsutism and acne were reduced after LOD in women with PCOS.

Conclusions:

LOD reduces testosterone and LH/FSH ratio and improves clinical outcome in PCOS.

Changes in ovarian reserve and ovarian blood flow in patients with polycystic ovary syndrome following laparoscopic ovarian drilling

This prospective cohort study was conducted on 80 patients with clomiphene citrate (CC)-resistant polycystic ovary syndrome undergoing laparoscopic ovarian drilling (LOD). Pre- and post-LOD ovarian reserve parameters (anti-Mullerian hormone: AMH, ovarian volume: OV, and antral follicle count: AFC) and ovarian stromal blood flow indices (Vascularization index: VI, flow index: FI, and vascularization flow index: VFI) were measured to explore the effect of LOD and to find out the correlation between serum AMH and different clinical, hormonal, and ultrasonic variables. There was a highly significant reduction of the serum AMH (p < .001) after LOD with significant reduction in OV, AFC and vascular indices (VI, FI and VFI) of the right and left ovaries (p < .05). LOD significantly reduced ovarian reserve parameters (AMH, OV and AFC) and ovarian stromal blood flow indices (VI, FI and VFI) with no observed correlation between AMH levels and Doppler indices.

Serum anti-Mullerian hormone levels after ovarian drilling for the second-line treatment of polycystic ovary syndrome: a pilot-randomized study comparing laparoscopy and transvaginal hydrolaparoscopy

Aim of the study was to asses and compare serum anti-Mullerian harmone (AMH) levels after laparoscopic ovarian drilling (LOD) and transvaginal hydrolaparoscopy (THL) ovarian drilling in clomifene citrate (CC)-resistant polycystic ovary syndrome (PCOS) patients; secondary outcome was to evaluate postoperative pain to estimate the acceptability of procedures. A total of 246 patients with CC-resistant PCOS were randomized into two groups: 123 underwent LOD and 123 underwent THL ovarian drilling. AMH serum levels were evaluated before and after the procedure; moreover, women were asked to rate pain on a visual analog scale (VAS) from 0 (no pain, perfectly acceptable) to 10 (unbearable pain, completely unacceptable). In both groups, postoperative serum AMH levels were significantly reduced compared to preoperative levels (6.06 ± 1.18 and 5.84 ± 1.16 versus 5.00 ± 1.29 and 4.83 ± 1.10; p < 0.0001). Comparing postoperative serum AMH levels, no statistically significant difference was observed between the two surgical technique. After the procedure, mean pain VAS score was significantly higher for women who underwent LOD ovarian drilling in comparison to THL (3.26 ± 1.1 versus 1.11 ± 0.5; p < 0.0001). In conclusion, THL ovarian drilling is comparable to the LOD in terms of reduction in AMH, but it is preferred by patients in terms of acceptability. These results could support to use of THL ovarian drilling in the treatment of patients with CC- resistant PCOS.

Impact of laparoscopic ovarian drilling on serum anti-mullerian hormone levels in patients with anovulatory Polycystic Ovarian syndrome

OBJECTIVES

Anti-mullerian hormone (AMH) is a marker of the activity of recruitable ovarian follicles. It is useful in the prediction of ovarian reserve. Women with polycystic ovarian syndrome (PCOS) have elevated circulating and intrafollicular AMH levels. Laparoscopic ovarian drilling (LOD) in patients with PCOS destroys ovarian androgen-producing tissue and reduces their peripheral conversion to estrogens. Identifying factors that determine the response of patients with PCOS to LOD will help in selecting the patients who would likely benefit from this treatment. AMH is one such marker that can predict the response to LOD. To evaluate the effect of LOD on serum AMH levels among PCOS responders and non-responders and the usefulness of AMH as a tool in predicting the response to LOD, and to whether there was loss of ovarian function after LOD.

MATERIALS AND METHODS

This is a prospective cohort study including 30 clomiphene-resistant women with anovulatory PCOS undergoing LOD. Statistical analysis was performed to evaluate the effect of LOD on serum levels of AMH on these women.

RESULTS

A significant fall in the levels of AMH was observed after LOD in both responders and non-responders (p<0.001). Women with AMH >8.3 ng/mL showed a significantly lower ovulation rate (33.3%). LOD was not associated with a risk of diminished ovarian reserve.

CONCLUSION

LOD is an effective first-line treatment for women with PCOS who are clomiphene resistant. LOD has no negative effect on ovarian reserve. AMH is a useful marker in predicting the outcome of LOD.

Impact of unilateral versus bilateral laparoscopic ovarian drilling on ovarian reserve and pregnancy rate: a randomized clinical trial

OBJECTIVE

To assess the impact of unilateral dose adjusted ovarian drilling (ULOD) compared to bilateral ovarian drilling (BLOD) on ovarian reserve and pregnancy rate.

METHODS

This randomized clinical study included 105 patients with polycystic ovary syndrome. Patients were assigned to two groups; group 1 (n = 52) underwent dose adjusted ULOD using 60 Joules/cm(3) applied to the larger ovary, while group 2 (n = 53) underwent BLOD with fixed doses of 1200 J. Ovulation rate, anti-Mullerian hormone (AMH), antral follicle count (AFC), and pregnancy rates were assessed at 3 and 6 months of follow-up.

RESULTS

Ovulation and pregnancy rates at 3 months periods were comparable (p > 0.05), but was significantly higher in BLOD at 6 months period (p < 0.05). There was a highly significant difference between the two groups regarding the AMH level at 3- and 6-month follow-up periods (p < 0.001) with lower levels in the BLOD group. The AFC was comparable in the two groups after 3 months (p > 0.05) but became higher in the ULOD at 6-month follow-up period (p < 0.001).

CONCLUSION

Dose-adjusted ULOD applied to the larger ovary has comparable ovulation and pregnancy rates to fixed dose BLOD at 3-month follow-up periods with decrease in its effectiveness after 6 months.

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

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

Assessment of ovarian reserve after unilateral diathermy with thermal doses adjusted to ovarian volume

Women with polycystic ovary syndrome seem to have a larger ovarian reserve. However, regardless of a greater reserve, diminished ovarian reserve has been reported after laparoscopic diathermy. The aim of this article was to determine whether the doses adjusted unilateral laparoscopic ovarian drilling with diathermy (ULOD) diminishes ovarian reserve to compare with bilateral laparoscopic ovarian drilling with diathermy (BLOD). Ninety-six women were assigned in two groups. One group underwent ULOD receiving thermal doses (0-840 J per ovary) adjusted to volume one ovary. The other group underwent BLOD receiving fixed doses (600 J per ovary). Ovarian reserve markers [anti-Müllerian hormone (AMH); antral follicle count (AFC) and ovarian volume] were measured before and after surgery (1 and 6 months). Both groups showed a decrease in AMH after surgery, but it was significantly more distinct in the BLOD versus ULOD group (2.0 ng/mL versus 1.3 ng/mL; p = 0.018) in the first follow-up month and remained significantly different through the sixth follow-up month (1.9 ng/mL versus 1.15 ng/mL; p = 0.023). In contrast, in the sixth month, the ULOD versus BLOD showed a significantly greater increase AFC (p < 0.001) and volume (p = 0.013). Our findings evidenced that the dose-adjusted unilateral diathermy (60 J/cm(3)) does not have significant and long-term effects on ovarian reserve.