Farquhar C, Lilford R J, Marjoribanks J, Vandekerckhove P
Department of Obstetrics & Gynaecology, University of Auckland, PO Box 92019, Auckland, New Zealand, 1003.
Cochrane Database Syst Rev. 2005 Jul 20(3):CD001122. doi: 10.1002/14651858.CD001122.pub2.
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 due to the risk of post-surgical adhesions and the introduction of medical ovulation induction with clomiphene and gonadotrophins. However patients with PCOS treated with gonadotrophins often have an over-production of follicles and are exposed to the risks of ovarian hyperstimulation syndrome (OHSS) and multiple pregnancy. Moreover ovulation induction with gonadotrophins, though effective, is an expensive, inconvenient and time-consuming treatment requiring intensive monitoring. Surgical therapy with laparoscopic ovarian "drilling" (LOD) may avoid or reduce the need for gonadotrophins or may facilitate their use. The procedure can be done on an outpatient basis with less trauma and fewer postoperative adhesions. Many uncontrolled observational studies have claimed that ovarian drilling is followed, at least temporarily, by a high rate of spontaneous ovulation and conception, and/or that subsequent medical ovulation induction becomes easier.
To determine the effectiveness and safety of laparoscopic ovarian drilling compared with ovulation induction for subfertile women with clomiphene-resistant PCOS.
We used the search strategy of the Menstrual Disorders and Subfertility Group.
We included randomised controlled trials of subfertile women with clomiphene-resistant PCOS that undertook laparoscopic ovarian drilling in order to induce ovulation.
Fifteen trials were identified and six 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.
There was no evidence of a difference in live births or ongoing pregnancies between LOD and gonadotrophins and the pooled Odds Ratio (OR) (all studies) was 1.04 (95% CI 0.74, 1.99) and 1.16 (95% CI 0.72, 1.86) respectively. Multiple pregnancy rates were lower with ovarian drilling than with gonadotrophins (1% vs 16%, OR: 0.13, 95% CI: 0.03 to 0.59). There was no evidence of a difference in miscarriage rates between the two groups (OR 0.81, 955% 0.36, 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.
多囊卵巢综合征（PCOS）女性诱导排卵及无排卵（不排卵）问题已广为人知。手术性卵巢楔形切除术是最早确立的针对无排卵性PCOS患者的治疗方法，但因术后粘连风险以及克罗米芬和促性腺激素药物诱导排卵方法的出现而基本被弃用。然而，接受促性腺激素治疗的PCOS患者常有卵泡过度生成情况，并面临卵巢过度刺激综合征（OHSS）和多胎妊娠风险。此外，促性腺激素诱导排卵虽有效，但费用高昂、不便且耗时，需要密切监测。腹腔镜卵巢“打孔”（LOD）手术治疗或许可避免或减少促性腺激素的使用，或便于其使用。该手术可在门诊进行，创伤小且术后粘连少。许多非对照观察性研究称，卵巢打孔后至少短期内自发排卵和受孕率较高，和/或后续药物诱导排卵会更容易。
确定与药物诱导排卵相比，腹腔镜卵巢打孔术对克罗米芬抵抗性PCOS不孕女性的有效性和安全性。
我们采用了月经紊乱与不孕组的检索策略。
我们纳入了针对克罗米芬抵抗性PCOS不孕女性进行腹腔镜卵巢打孔以诱导排卵的随机对照试验。
共识别出15项试验，其中6项纳入本综述。所有试验均根据质量标准进行评估。主要结局为活产、排卵及妊娠率，次要结局为流产率、多胎妊娠率、卵巢过度刺激综合征发生率及费用。
未发现LOD组与促性腺激素组在活产或持续妊娠方面存在差异，合并优势比（OR）（所有研究）分别为1.04（95%CI 0.74，1.99）和1.16（95%CI 0.72，1.86）。卵巢打孔组的多胎妊娠率低于促性腺激素组（1%对16%，OR：0.13，95%CI：0.03至0.59）。两组间流产率无差异（OR 0.81，95%CI 0.36，1.86）。
与促性腺激素治疗相比，未发现接受LOD治疗的克罗米芬抵抗性PCOS女性在活产率和流产率方面存在差异。LOD治疗女性多胎妊娠率降低，使该方法颇具吸引力。然而，人们仍持续关注LOD对卵巢功能的长期影响。
