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

BACKGROUND

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 because 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.

OBJECTIVES

To determine the effectiveness and safety of laparoscopic ovarian drilling with ovulation induction for subfertile women with clomiphene resistant polycystic ovarian syndrome.

SEARCH STRATEGY

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.

SELECTION CRITERIA

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.

DATA COLLECTION AND ANALYSIS

Fifteen trials were identified; six were included in the review all of which 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.

MAIN RESULTS

The ongoing pregnancy rate following ovarian drilling compared with gonadotrophins differed according to the length of follow up. Overall, the pooled OR (all studies) was not statistically significant (OR 1.27, 95% CI 0.77, 1.98). Multiple pregnancy rates were reduced in the ovarian drilling arms of the four trials where there was a direct comparison with gonadotrophins (OR 0.16, 95%CI 0.03,0.98). There was no difference in miscarriage rates in the drilling group when compared with gonadotrophin in these trials (OR 0.61, 955% 0.17, 2.16).

REVIEWER'S CONCLUSIONS: There is insufficient evidence of a difference in cumulative ongoing pregnancy rates between laparoscopic ovarian drilling after 6-12 months follow up and 3-6 cycles of ovulation induction with gonadotrophins as a primary treatment for subfertile patients with anovulation (failure to ovulate) and polycystic ovarian syndrome (PCOS). Multiple pregnancy rates are considerably reduced in those women who conceive following laparoscopic drilling.