Laparoscopic 'drilling' by diathermy or laser for ovulation induction in anovulatory polycystic ovary syndrome

Farquhar C, Lilford R, Marjoribanks J, Vanderkerchove P

Published Online:

November 10, 2010

Ovarian surgery in women with clomiphene-resistant polycystic ovarian syndrome reduces the risk of multiple pregnancy without decreasing the pregnancy rate. Women with polycystic ovary syndrome (PCOS) have trouble ovulating. Gonadotrophins are hormones produced by the pituitary gland. Women with PCOS may be treated with gonadotrophins (either from urinary sources or recombinant techniques) but gonadotrophins can overstimulate the ovary and cause multiple pregnancy. An alternative is a minor surgical procedure called laparoscopic ovarian drilling where a long telescope is passed through a small cut in the umbilicus. The ovaries are then surgically treated by drilling using either heat or laser. This review of trials found that ovarian drilling followed by clomiphene or gonadotrophins, if necessary, was as effective as gonadotrophin therapy alone in inducing ovulation, but the risk of multiple pregnancies was lower in the group who had laparoscopic ovarian drilling. Approximately 50% of women will have a live birth and 16% will have a miscarriage with either procedure.

Abstract (click to read)

Background:

Surgical ovarian wedge resection was the first established treatment for women with anovulatory polycystic ovary syndrome (PCOS) but was largely abandoned due to the risk of postsurgical adhesions and the introduction of medical ovulation induction with clomiphene and gonadotrophins. However, women with PCOS who are treated with gonadotrophins often have an over-production of follicles which may result in ovarian hyperstimulation syndrome (OHSS) and multiple pregnancies. Moreover, gonadotrophins, though effective, are costly and time-consuming requiring intensive monitoring. Surgical therapy with laparoscopic ovarian 'drilling' (LOD) may avoid or reduce the need for gonadotrophins or may facilitate their usefulness. The procedure can be done on an outpatient basis with less trauma and fewer postoperative adhesions than with traditional surgical approaches. Many uncontrolled observational studies have claimed that ovarian drilling is followed, at least temporarily, by a high rate of spontaneous ovulation and conception or that subsequent medical ovulation induction becomes easier.

Objectives:

To determine the effectiveness and safety of laparoscopic ovarian drilling compared with ovulation induction for subfertile women with clomiphene-resistant PCOS.

Search strategy:

We used the search strategy of the Menstrual Disorders and Subfertility Group.

Selection criteria:

We included randomised controlled trials of subfertile women with clomiphene-resistant PCOS who undertook laparoscopic ovarian drilling in order to induce ovulation.

Data collection and analysis:

Sixteen trials were identified and nine were included in the review. All trials were assessed for quality criteria. The primary outcomes were live birth, ovulation and pregnancy rates and the secondary outcomes were rates of miscarriage, multiple pregnancy, ovarian hyperstimulation syndrome and cost.

Main results:

There was no evidence of a difference in live birth or clinical pregnancy rate between LOD and gonadotrophins and the pooled odds ratios (OR) (all studies) were 1.04 (95% CI 0.59 to 1.85) and 1.08 (95% CI 0.69 to 1.71) respectively. Multiple pregnancy rates were lower with ovarian drilling than with gonadotrophins (1% versus 16%; OR 0.13, 95% CI 0.03 to 0.52). There was no evidence of a difference in miscarriage rates between the two groups (OR 0.81, 95% 0.36 to 1.86).

Authors' conclusions:

There was no evidence of a difference in the live birth rate and miscarriage rate in women with clomiphene-resistant PCOS undergoing LOD compared to gonadotrophin treatment. The reduction in multiple pregnancy rates in women undergoing LOD makes this option attractive. However, there are ongoing concerns about long-term effects of LOD on ovarian function.

This record should be cited as:

Farquhar C, Lilford R, Marjoribanks J, Vanderkerchove P. Laparoscopic drilling by diathermy or laser for ovulation induction in anovulatory polycystic ovary syndrome. Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD001122. DOI: 10.1002/14651858.CD001122.pub3

Assessed as up to date:

July 31, 2007

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Primary Review Group:

Menstrual Disorders and Subfertility Group

Health topics:

Gynaecology > Subfertility > Female: associated with other medical conditions

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

Laparoscopic 'drilling' by diathermy or laser for ovulation induction in anovulatory polycystic ovary syndrome

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