Article

Long-term follow-up of patients with polycystic ovary syndrome after laparoscopic ovarian drilling: Endocrine and ultrasonographic outcomes

Jessop Wing, Sheffield Teaching Hospitals, University of Sheffield, Tree Root Walk, Sheffield S10 2SF, UK.
Human Reproduction (Impact Factor: 4.57). 11/2002; 17(11):2851-7. DOI: 10.1093/humrep/17.11.2851
Source: PubMed

ABSTRACT

There is considerable controversy as to how long the beneficial effects of laparoscopic ovarian drilling (LOD) last. This follow-up study was undertaken to investigate the long-term effects of LOD.
The study included 116 anovulatory women with polycystic ovary syndrome (PCOS) who underwent LOD between 1991 and 1999 (study group) and 34 anovulatory PCOS women diagnosed during the same period, who had not undergone LOD (comparison group). The hospital records were reviewed and most patients attended for a transvaginal ultrasound scan and blood sampling to measure the serum concentrations of LH, FSH, testosterone, androstenedione and sex hormone-binding globulin. The results before and at different intervals, short- (<1 year), medium- (1-3 years) and long-term (4-9 years), after LOD were compared.
The LH:FSH ratio, mean serum concentrations of LH and testosterone and free androgen index decreased significantly after LOD and remained low during the medium- and long-term follow-up periods. The mean ovarian volume decreased significantly (P < 0.05) from 11 ml before LOD to 8.5 ml at medium-term and remained low (8.4 ml) at long-term follow-up.
The beneficial endocrinological and morphological effects of LOD appear to be sustained for up to 9 years in most patients with PCOS.

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Available from: Saad Amer, Dec 25, 2013
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    • "LOD has been proven to significantly reduce circulating AMH levels [26], with values remaining significantly reduced up to 6 months after the procedure [16]. The mechanic effect of LOD on polycystic ovaries may reside in destruction of small antral and pre-antral follicles, besides stroma, resulting in a relatively long term impact on circulating levels of AMH, LH, and total and free testosterone [27]. As a result of these changes, increased ovulation and pregnancy rates have been documented after LOD in patients with PCOS. "
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    ABSTRACT: To examine whether ovarian puncture for immature oocyte retrieval and in-vitro maturation (IVM) has an effect on the endocrine profile of patients with polycystic ovary syndrome (PCOS). Twenty-two consecutive patients with PCOS undergoing IVM treatment were included. Serum anti-Mullerian hormone (AMH), sex hormone-binding globulin (SHBG), total testosterone (TT) and luteinized hormone (LH) levels were analyzed at the start of the cycle, on the day of immature oocyte retrieval (OR) and at fixed intervals thereafter, for up to three months after OR. Five days after OR circulating AMH, TT, calculated free testosterone (FTc), and LH levels were significantly reduced and circulating SHBG was significantly increased. Two weeks after OR, TT, FTc and LH remained reduced, whereas circulating AMH and SHBG levels recovered to pre-puncture values. Three months after OR, all circulating hormone levels had recovered to baseline values. Ovarian puncture for the retrieval of immature oocytes and IVM in patients with PCOS has a significant impact on the ovarian endocrine profile, but this impact is brief and transient.
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    • "The basic rule for all of these methods in PCOS is to use the lowest possible dose of a drug or of energy to induce unifollicular ovulation (Balen, 2006). The advantage of LOD over IVF is that it induces unifollicular ovulation without the risk of ovarian hyperstimulation syndrome or high-order multiple pregnancies (Balen, 2006), and its beneficial effects can last for up to 9 years (Amer et al., 2002). The success of either unilateral (ULOD) or bilateral LOD (BLOD) depends on how much tissue is destroyed. "
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    ABSTRACT: Does unilateral volume-adjusted laparoscopic diathermy increase the chances of ovulation in women with polycystic ovary syndrome (PCOS)? Although unilateral laparoscopic ovarian drilling (ULOD) using adjusted thermal doses was more efficient than bilateral laparoscopic ovarian drilling (BLOD) using fixed doses, the chances of ovulation were improved in patients irrespective of the technique used. The adjustment of the thermal dose to ovarian volume in BLOD increases ovulation and pregnancy rates compared with fixed-dose treatment, but BLOD causes the formation of adhesions, particularly on the left ovary, and increases the risk of damage to ovarian tissue. In contrast, ULOD with a fixed thermal dose minimizes the risk of ovarian tissue damage, and can increase the activity in both right and left ovaries, although this varies in humans and in other species. This prospective, longitudinal, study, between September 2009 and January 2013, included 96 infertile women with PCOS who were unresponsive to clomiphene citrate treatment and had underwent either ULOD or BLOD. After surgery, the groups were followed up for 6 months to assess ovulatory response. Patients were assigned to two groups; one group underwent laparoscopic ovarian drilling of the right ovary alone, while both ovaries were treated in the second group. The ULOD group (n = 49) received thermal doses adjusted to the volume of the right ovary (60 J/cm(3)). The BLOD group (n = 47) received fixed doses of 600 J per ovary, regardless of its volume. The two treatment groups were matched by the number of participants, age and baseline parameters. The ovulation rate during the first menstrual cycle after LOD was significantly higher in the ULOD group than in the BLOD group [73 versus 49%; absolute risk reduction (ARR), -0.25; 95% confidence interval (CI), -0.44 to -0.03; P = 0.014]. Treatment with ULOD on the right ovary significantly increased the chances of ovulation in patients with a larger right ovary compared with those who had a smaller right ovary (100 versus 36%; ARR, -0.64; 95% CI, -0.84 to -0.37; P = 0.004). Interestingly, the chances of ovulation were also significantly higher in patients in the BLOD group who had a larger right ovary compared with those who had a smaller right ovary (88 versus 33%; ARR, -0.55; 95% CI, -0.73 to -0.28; P = 0.002). The pregnancy rate was also significantly higher in patients with a larger right ovary compared with those with a smaller right ovary, regardless of the treatment group. The 6-month follow-up was too short to demonstrate any long-term differences in the ovulation rates. Future research should therefore extend the follow-up beyond 6 months. Another limitation is that ULOD was used to treat only the right ovary. Future studies should investigate whether ULOD treatment of the larger ovary, whether left or right, would significantly increase the ovulation rate. This study represents an advance in the determination of the optimal laparoscopic treatment for women with PCOS, as it was shown that improved results can be achieved using less thermal energy in volume-adjusted ULOD. The study was not funded. The authors declare no conflicting interests. NCT01833949 (ClinicalTrials.gov.).
    Full-text · Article · Jul 2013 · Human Reproduction
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    • "LOD is an effective procedure in properly selected cases, because drilling appears to be equally effective with lesser chances of multiple pregnancies [45, 46]. In LOD treatment, high success pregnancy rates of around 60 % are expected after treatment within 6 months of time with a low risk of adverse effects in PCOS, and peak pregnancy rate is seen around 6–9 months after surgery [47]. "
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    ABSTRACT: Polycystic ovary syndrome (PCOS) is the most frequent endocrine disorder in women of reproductive age. In 2006 the Japanese Society of Obstetrics and Gynecology (JSOG) proposed new, revised diagnostic criteria that in the future could also be valued internationally. Based on the new diagnostic criteria, the JSOG has also proposed the revised treatment criteria in 2008. In PCOS obese patients desiring children, weight loss and exercise is recommended. Nonobese patients, or those obese women who do not ovulate after lifestyle changes, are submitted to ovulation-induction therapy with clomiphene citrate (CC). Obese CC-resistant patients who have impaired glucose tolerance or insulin resistance are treated with a combination of metformin and CC. If these treatments options are unsuccessful, ovulation induction with exogenous gonadotropin therapy or laparoscopic ovarian drilling (LOD) is recommended. A low-dose step-up regimen is recommended with careful monitoring in order to reduce the risk of ovarian hyperstimulation syndrome (OHSS) and multiple pregnancies. Alternatively, with LOD high successful pregnancy rates of around 60 % are expected with a low risk of multiple pregnancies. If ovulation induction is unsuccessful, IVF-ET treatment is indicated. In high OHSS-risk patients, systematic embryo freezing and subsequent frozen embryo transfer cycles are recommended. In nonobese, anovulatory PCOS patients not desiring children, pharmacological treatments such as Holmström, Kaufmann regimens or low-dose oral anticonceptives are used to induce regular withdrawal bleeding. These treatments are especially important for preventing endometrial hyperplasia and endometrial cancer. These new diagnostic and treatment criteria hopefully will contribute to an improved care of PCOS patients in Japan.
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