Farquhar C, Vandekerckhove P, Arnot M, Lilford R
Department of Obstetrics and Gynaecology, National Women's Hospital, Claude Road, Epsom, Auckland, New Zealand, 1003.
Cochrane Database Syst Rev. 2000(2):CD001122. doi: 10.1002/14651858.CD001122.
Problems in inducing ovulation in women with polycystic ovary syndrome (PCOS) and anovulation (failure to ovulate) are well recognised. Surgical ovarian wedge resection was the first established treatment for anovulatory PCOS patients but was largely abandoned of the risk of post-surgical adhesion formation. It was replaced by medical ovulation induction with clomiphene and gonadotrophins. However patients with PCOS treated with gonadotrophins often have a polyfollicular response and are exposed to the risks of ovarian hyperstimulation syndrome (OHSS) and multiple pregnancy. Although effective, it is an expensive, stressful and time consuming form of treatment requiring intensive monitoring. A new surgical therapy, laparoscopic ovarian "drilling", may avoid or reduce the need, or facilitate the use, of gonadotrophins for inducing ovulation. The procedure can be done on an outpatient basis with less trauma and fewer postoperative adhesions. It has been claimed in many uncontrolled observational studies that it is followed, at least temporarily, by a high rate of spontaneous postoperative ovulation and conception, or that subsequent medical ovulation induction becomes easier.
To determine the effectiveness of laparoscopic ovarian drilling for ovulation induction in subfertile women with anovulation (failure to ovulate) and polycystic ovarian syndrome (PCOS).
The search strategy of the Menstrual Disorders and Subfertility Group was used for the identification of randomised controlled trials (RCTS). A computerised MEDLINE search was used to identify non randomised controlled trials.
Trials were eligible for inclusion if treatment consisted of laparoscopic ovarian drilling in order to induce ovulation in subfertile women with PCOS and compared with a concurrent control group.
Fourteen trials were identified; eight were included in the review of which seven were randomised. All trials were assessed for quality criteria. The main studied outcomes were ovulation and pregnancy rates. Miscarriage rate, multiple pregnancy rate, and incidence of overstimulation and ovarian hyperstimulation syndrome rate were secondary outcomes.
With the exception of multiple pregnancy rates no differences were demonstrated for any of the interventions studied but the numbers of patients who have been randomised to controlled studies at this time is insufficient to conclude that laparoscopic ovarian drilling is more effective than gonadotrophin therapy for other outcomes.
REVIEWER'S CONCLUSIONS: The value of laparoscopic ovarian drilling as a primary treatment for subfertile patients with anovulation (failure to ovulate) and polycystic ovarian syndrome (PCOS) is undetermined. There is insufficient evidence to determine a difference in ovulation or pregnancy rates when compared to gonadotrophin therapy as a secondary treatment for clomiphene resistant women. Multiple pregnancy rates are reduced in those women who conceive following laparoscopic drilling. None of the studied modalities of drilling technique had any obvious advantages.
多囊卵巢综合征（PCOS）女性诱导排卵以及无排卵（无法排卵）问题已广为人知。手术卵巢楔形切除术是最早确立的针对无排卵PCOS患者的治疗方法，但由于术后粘连形成的风险，该方法在很大程度上被弃用。它被氯米芬和促性腺激素的药物促排卵治疗所取代。然而，接受促性腺激素治疗的PCOS患者通常会出现多个卵泡反应，并面临卵巢过度刺激综合征（OHSS）和多胎妊娠的风险。虽然有效，但这是一种昂贵、压力大且耗时的治疗方式，需要密切监测。一种新的手术疗法，即腹腔镜卵巢“打孔”术，可能避免或减少使用促性腺激素诱导排卵的需求，或便于使用促性腺激素。该手术可在门诊进行，创伤较小，术后粘连较少。许多非对照观察性研究称，术后至少短期内会有较高的自发排卵和受孕率，或者后续的药物促排卵会变得更容易。
确定腹腔镜卵巢打孔术对无排卵（无法排卵）和多囊卵巢综合征（PCOS）的不育女性诱导排卵的有效性。
采用月经失调与不育症小组的检索策略来识别随机对照试验（RCT）。使用计算机化的MEDLINE检索来识别非随机对照试验。
如果治疗包括腹腔镜卵巢打孔术以诱导PCOS不育女性排卵，并与同期对照组进行比较，则该试验符合纳入标准。
共识别出14项试验；其中8项纳入综述，7项为随机试验。所有试验均根据质量标准进行评估。主要研究结局为排卵率和妊娠率。流产率、多胎妊娠率、过度刺激发生率和卵巢过度刺激综合征发生率为次要结局。
除多胎妊娠率外，所研究的任何干预措施均未显示出差异，但目前随机纳入对照研究的患者数量不足以得出结论，即腹腔镜卵巢打孔术在其他结局方面比促性腺激素治疗更有效。
腹腔镜卵巢打孔术作为无排卵（无法排卵）和多囊卵巢综合征（PCOS）不育患者的主要治疗方法的价值尚未确定。与作为氯米芬抵抗女性二线治疗的促性腺激素治疗相比，没有足够的证据确定在排卵率或妊娠率方面存在差异。腹腔镜打孔术后受孕的女性多胎妊娠率降低。所研究的任何打孔技术方式均无明显优势。
