Laparoscopic Surgery in Polycystic Ovary Syndrome: Reproductive and Metabolic Effects

Kok-Min Seow; Chi-Chang Juan; Jiann-Loung Hwang; Low-Tone Ho

doi:10.1055/s-2007-992930

Seminars in Reproductive Medicine, Table of Contents

Semin Reprod Med 2008; 26(1): 101-110
DOI: 10.1055/s-2007-992930

Laparoscopic Surgery in Polycystic Ovary Syndrome: Reproductive and Metabolic Effects

Kok-Min Seow¹ ^, ² , Chi-Chang Juan³ ^, ⁴ ^, ⁵ , Jiann-Loung Hwang¹ ^, ² ^, ⁷ , Low-Tone Ho³ ^, ⁴ ^, ⁵ ^, ⁶

¹Department of Obstetrics and Gynecology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
²School of Medicine, Fu-Jen Catholic University, Hsinchuang, Taipei Hsien, Taiwan
³Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
⁴Institute of Physiology, National Yang-Ming University, Taipei, Taiwan
⁵Department of Medical Research & Education, Taipei Veterans General Hospital, Taipei, Taiwan
⁶Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
⁷Department of Obstetrics and Gynecology, Taipei Medical University, Taipei, Taiwan

Abstract

ABSTRACT

Polycystic ovary syndrome (PCOS) is the most common cause of chronic anovulation. Clomiphene citrate (CC) is the first-line treatment for ovulation induction for infertile women with PCOS. In CC-resistant women, a particular surgical method, laparoscopic ovarian drilling (LOD), has been proposed in recent years as an alternative treatment. LOD produces overall spontaneous ovulation and pregnancy rates of 30 to 90% and 13 to 88%, respectively, for CC-resistant PCOS women. The mechanism of LOD is still unknown. The reduction of serum androgen level is believed to be the possible mechanism of LOD to improve spontaneous ovulation and promote fertility in women with PCOS. In addition, LOD may cause a significant reduction in serum luteinizing hormone and insulin levels. However, it should be kept in mind that postoperative adhesion is the most common adverse effect of LOD, and more punctures may be responsible for premature ovarian failure.

KEYWORDS

Polycystic ovary syndrome - laparoscopic ovarian drilling - clomiphene citrate-resistant - pregnancy rate - ovulation rate

Full Text

References

REFERENCES

1 Rotterdam ESHRE/ASRM-sponsored PCOS Consensus Workshop Group . Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome (PCOS). Hum Reprod. 2004; 19 41-47
2 Dunaif A. Insulin resistance and the polycystic ovary syndrome: mechanism and implications for pathogenesis. Endocr Rev. 1997; 18 774-800
3 Diamanti-Kandarakis E, Kouli C R, Bergiele A T et al.. A survey of the polycystic ovary syndrome in the Greek island of Lesbos: hormonal and metabolic profile. J Clin Endocrinol Metab. 1999; 84 4006-4011
4 Asuncion M, Calvo R M, San Millan J L, Sancho J, Avila S, Escobar-Morreale H F. A prospective study of the prevalence of the polycystic ovary syndrome in unselected Caucasian women from Spain. J Clin Endocrinol Metab. 2000; 85 2434-2438
5 Ehrmann D A, Barnes R B, Rosenfield R L, Cavaghan M K, Imperial J. Prevalence of impaired glucose tolerance and diabetes in women with polycystic ovary syndrome. Diabetes Care. 1999; 22 141-146
6 Legro R S, Kunselman A R, Dodson W C, Dunaif A. Prevalence and predictors of risk for type 2 diabetes mellitus and impaired glucose tolerance in polycystic ovary syndrome: a prospective, controlled study in 254 affected women. J Clin Endocrinol Metab. 1999; 84 165-169
7 Dunaif A. Polycystic ovary syndrome and obesity. In Bjorntorp P, Brodoff BN Obesity. Philadelphia, PA; JB Lippincott 1992: 594-605
8 Kousta E, White D M, Franks S. Modern use of clomiphene citrate in induction of ovulation. Hum Reprod Update. 1997; 3 359-365
9 Hughes E, Colins J, Vandekerckhove P. Clomiphene citrate for ovulation induction in women with oligo-amenorrhea. Cochrane Database Syst Rev. 2000; 2 CD000056
10 Li T C, Saravelos H, Chow M S, Chisabingo R, Cooke I D. Factors affecting the outcome of laparoscopic ovarian drilling for polycystic ovary syndrome in women with anovulatory infertility. Br J Obstet Gynaecol. 1998; 105 338-344
11 Duleba A J, Banaszewska B, Spaczynski R Z, Pawelczyk L. Success of laparoscopic ovarian wedge resection is related to obesity, lipid profile, and insulin levels. Fertil Steril. 2003; 79 1008-1014
12 Gjonnaess H. Polycystic ovarian syndrome treated by ovarian electrocautery through the laparoscope. Fertil Steril. 1984; 41 20-25
13 Daniell J F, Miller W. Polycystic ovaries treated by laparoscopic laser vaporization. Fertil Steril. 1989; 51 232-236
14 Rossmanith W G, Kechstein J, Spatzier K, Lauritzen C. The impact of ovarian laser surgery on the gonadotrophin secretion in women with polycystic ovarian disease. Clin Endocrinol (Oxf). 1991; 34 223-230
15 Utsunomiya T, Sumioki H, Taniguchi I. Hormonal and clinical effects of multifollicular puncture and resection on the ovaries of polycystic ovary syndrome. Horm Res. 1990; 33(Suppl 2) 35-39
16 Stein I F, Leventhal M L. Amenorrhea associated with bilateral polycystic ovaries. Am J Obstet Gynecol. 1935; 29 181-191
17 Campo S, Felli A, Lamanna M A, Barini A, Garcea N. Endocrine changes and clinical outcome after laparoscopic ovarian resection in women with polycystic ovaries. Hum Reprod. 1993; 8 359-363
18 Amer S A, Banu Z, Li T C, Cooke I D. Long-term follow-up of patients with polycystic ovary syndrome after laparoscopic ovarian drilling: endocrine and ultrasonographic outcomes. Hum Reprod. 2002; 17 2851-2857
19 Stein I F. Wedge resection of the ovaries: the Stein-Leventhal syndrome. In: Greenblatt RB Ovulation: Stimulation, Suppression, Detection. Philadelphia, PA; JB Lippincott 1966: 150-157
20 Malkawi H Y, Qublan H S. Laparoscopic ovarian drilling in the treatment of polycystic ovary syndrome: how many punctures per ovary are needed to improve the reproductive outcome?. J Obstet Gynaecol Res. 2005; 31 115-119
21 Tulandi T, Watkin K, Tan S L. Reproductive performance and three-dimensional ultrasound volume determination of polycystic ovaries following laparoscopic ovarian drilling. Int J Fertil Womens Med. 1997; 42 436-440
22 Weise H C, Naether O, Fischer R, Berger-Bispink S, Delfs T. Behandlungsergebnisse mit der oberflachenkuaterisierung polyzystischer Ovarien bei Sterilitatspatientinnen. Gebrutshilfe Frauenheilkd. 1991; 51 920-924
23 Armar N A, McGarrigle H H, Honour J, Holownia P, Jacobs H S, Lachelin G C. Laparoscopic ovarian diathermy in the management of anovulatory infertility in women with polycystic ovaries: endocrine changes and clinical outcome. Fertil Steril. 1990; 53 45-49
24 Dabirashrafi H. Complications of laparoscopic ovarian cauterization. Fertil Steril. 1989; 52 878-879
25 Am S AK, Li T C, Cooke I D. A prospective dose-finding study of the amount of thermal energy required for laparoscopic ovarian diathermy. Hum Reprod. 2003; 18 1693-1698
26 McNatty K P, Smith D M, Makris A et al.. The intraovarian sites of androgen and estrogen formation in women with normal and hyperandrogenic ovaries as judged by in vitro experiments. J Clin Endocrinol Metab. 1980; 50 755-763
27 Kovacs G, Buckler H, Bangah M et al.. Treatment of anovulation due to polycystic ovarian syndrome by laparoscopic ovarian cautery. Br J Obstet Gynaecol. 1991; 98 30-35
28 Seow K M, Juan C C, Hsu Y P, Hwang J L, Huang L W, Ho L W. Amelioration of insulin resistance in women with PCOS via reduced insulin receptor substrate-1 Ser³¹² phosphorylation following laparoscopic ovarian electrocautery. Hum Reprod. 2007; 22 1003-1010
29 Seow K M, Juan C C, Ho L W et al.. Adipocyte resistin mRNA levels are downregulated by laparoscopic ovarian electrocautery in both obese and lean women with polycystic ovary syndrome. Hum Reprod. 2007; 22 1100-1106
30 Saleh A M, Khalil H S. Review of nonsurgical and surgical treatment and the role on insulin-sensitizing agents in the management of infertile women with polycystic ovary syndrome. Acta Obstet Gynecol Scand. 2004; 83 614-621
31 Chang R J, Nakamura R M, Judd H L, Kaplan S A. Insulin resistance in nonobese patients with polycystic ovarian disease. J Clin Endocrinol Metab. 1983; 57 356-359
32 Shoupe D, Kumar D D, Lobo R A. Insulin resistance in polycystic ovary syndrome. Am J Obstet Gynecol. 1983; 147 588-592
33 Shepard M K, Balmaceda J P, Leika C G. Relationship of weight to successful induction of ovulation with clomiphene citrate. Fertil Steril. 1979; 32 641-645
34 Lobo R A, Gysler M, March C M, Goebelsmann U, Mishell Jr D R. Clinical and laboratory predictors of clomiphene response. Fertil Steril. 1982; 37 168-174
35 Nestler J E, Jakubowicz D J, Evans W S, Pasquali R. Effective metformin on spontaneous and clomiphene-induced ovulation in the polycystic ovary syndrome. N Engl J Med. 1998; 338 1876-1880
36 Hasegawa I, Murakawa H, Suzuki M, Yamamoto Y, Kurabayashi T, Tanaka K. Effect of troglitazone on endocrine and ovulatory performance in women with insulin resistance-related polycystic ovary syndrome. Fertil Steril. 1999; 71 323-327
37 Vandermolen D T, Ratts V S, Evans W S, Stovall D W, Kauma S W, Nestler J E. Metformin increases the ovulatory rate and pregnancy rate from clomiphene citrate in patients with polycystic ovary syndrome who are resistant to clomiphene citrate alone. Fertil Steril. 2001; 75 310-315
38 Neveu N, Granger L, St-Michel P, Lavoie H B. Comparison of clomiphene citrate, metformin, or the combination of both for first-line ovulation induction and achievement of pregnancy in 154 women with polycystic ovary syndrome. Fertil Steril. 2007; 87 113-120
39 Lord J M, Flight I H, Norman R J. Metformin in polycystic ovary syndrome: systematic review and meta-analysis. BMJ. 2003; 327 951-953
40 Kashyap S, Wells G A, Rosenwaks Z. Insulin-sensitizing agents as primary therapy for patients with polycystic ovarian syndrome. Hum Reprod. 2004; 19 2474-2483
41 Malkawi H Y, Qublan H S, Hamaideh A H. Medical vs. surgical treatment for clomiphene citrate-resistant women with polycystic ovary syndrome. J Obstet Gynaecol. 2003; 23 289-293
42 Palomba S, Orio Jr F, Falbo A et al.. Metformin administration and laparoscopic ovarian drilling improve ovarian response to clomiphene citrate (CC) in oligo-anovulatory CC-resistant women with polycystic ovary syndrome. Clin Endocrinol (Oxf). 2005; 63 631-635
43 Farquhar C M, Williamson K, Gudex G, Johnson N P, Garland J, Sadler L. A randomized controlled trial of laparoscopic ovarian diathermy versus gonadotropin therapy for women with clomiphene citrate-resistant polycystic ovary syndrome. Fertil Steril. 2002; 78 404-411
44 Szilágyi A, Hole R, Kechstein J, Rossmanith W G. Effects of ovarian surgery on the dopaminergic and opiodergic control of gonadotropin and prolactin secretion in women with polycystic ovarian disease. Gynecol Endocrinol. 1993; 7 159-166
45 Greenblatt E M, Caper R F. Adhesion formation after laparoscopic ovarian cautery for polycystic ovarian syndrome: lack of correlation with pregnancy rate. Fertil Steril. 1993; 60 766-770
46 Tiitinen A, Tenhunen A, Seppälä M. Ovarian electrocauterization causes LH-regulated but not insulin-regulated endocrine changes. Clin Endocrinol (Oxf). 1993; 39 181-184
47 Sakata M, Tasaka K, Kurahci H, Terakawa N, Miyake A, Tanizawa O. Changes of bioactive luteinizing hormone after laparoscopic ovarian cautery in patients with polycystic ovarian syndrome. Fertil Steril. 1990; 53 610-613
48 Yanagibori A, Kojima E, Ohtaka K, Morita M, Hirakawa S. Nd-YAG laser therapy for infertility with a contact-type probe. J Reprod Med. 1989; 34 456-460
49 Kato M, Kikuchi I, Shimaniki H et al.. Efficacy of laparoscopic ovarian drilling for polycystic ovary syndrome resistant to clomiphene citrate. J Obstet Gynaecol Res. 2007; 33 174-180
50 Palomba S, Falbo A, Orio Jr F et al.. Efficacy of laparoscopic ovarian diathermy in clomiphene citrate-resistant women with polycystic ovary syndrome: relationships with chronological and ovarian age. Gynecol Endocrinol. 2006; 22 329-335
51 van Wely M, Bayram N, van der Veen F, Bossuyt P M. Predictors for treatment failure after laparoscopic electrocautery of the ovaries in women with clomiphene citrate-resistant polycystic ovary syndrome. Hum Reprod. 2005; 20 900-905
52 Gürgan T, Urman B, Aksu T, Yarali H A, Develioglu O, Kisnisci H. The effect of short-interval laparoscopic lysis of adhesions on pregnancy rates following Nd-YAG laser photocoagulation of polycystic ovaries. Obstet Gynecol. 1992; 80 45-47
53 Balen A H, Tan S L, MacDougall J, Jacobs H S. Miscarriage rates following in-vitro fertilization are increased in women with polycystic ovaries and reduced by pituitary desensitization with buserelin. Hum Reprod. 1993; 8 959-964
54 Homburg R, Armar N A, Eshel A, Adams J, Jacobs H S. Influence of serum luteinising hormone concentrations on ovulation, conception, and early pregnancy loss in polycystic ovary syndrome. BMJ. 1988; 297 1024-1026
55 Regan L, Owen E J, Jacobs H S. Hypersecretion of luteinizing hormone, infertility, and miscarriage. Lancet. 1990; 336 1141-1144
56 Sagle M, Bishop K, Ridley N et al.. Recurrent early miscarriage and polycystic ovaries. BMJ. 1988; 297 1027-1028
57 Abdel Gadir A, Mowafi R S, Alnaser H M, Alrashid A H, Alonezi O M, Shaw R W. Ovarian electrocautery versus human menopausal gonadotrophins and pure follicle stimulating hormone therapy in the treatment of patients with polycystic ovarian disease. Clin Endocrinol (Oxf). 1990; 33 585-592
58 Rimington M R, Walker S M, Shaw R W. The use of laparoscopic ovarian electrocautery in preventing cancellation of in-vitro fertilization treatment cycles due to risk of ovarian hyperstimulation syndrome in women with polycystic ovaries. Hum Reprod. 1997; 12 1443-1447
59 Farquhar C, Vandekerckhove P, Arnot M, Likford R. Laparoscopic “drilling” by diathermy or laser for ovulation induction in anovulatory polycystic ovary syndrome. Cochrane Database Syst Rev. 2000; CD001122
60 Greenblatt E, Casper R F. Endocrine changes after laparoscopic ovarian cautery in polycystic ovarian syndrome. Am J Obstet Gynecol. 1987; 156 279-285
61 Gjönnaess H, Norman N. Endocrine effects of the ovarian electrocautery in patients with polycystic ovarian disease. Br J Obstet Gynaecol. 1987; 94 779-783
62 Aakvaag A, Gjönnaess H. Hormonal response to electrocautery of the ovary in patients with polycystic ovarian disease. Br J Obstet Gynaecol. 1985; 92 1258-1264
63 Balen A H, Jacobs H S. A prospective study comparing unilateral and bilateral laparoscopic ovarian diathermy in women with the polycystic ovary syndrome. Fertil Steril. 1994; 62 921-925
64 Balen A H, Tan S L, Jacobs H S. Hypersecretion of luteinizing hormone: a significant cause of infertility and miscarriage. Br J Obstet Gynaecol. 1993; 100 1082-1089
65 Stanger J D, Yovich J L. Reduced in-vitro fertilization of human oocyte from patients with raised basal luteinising hormone levels during the follicular phase. Br J Obstet Gynaecol. 1985; 92 385-393
66 Smitz J, Ron-EL R, Tarlatzis B C. The use of gonadotrophin releasing hormone agonists for in vitro fertilization and other assisted procreation techniques: experience from three centres. Hum Reprod. 1992; 7(Suppl 1) 49-66
67 Am S AK, Li T C, Ledger W L. Ovulation induction using laparoscopic ovarian drilling in women with polycystic ovary syndrome: predictors of success. Hum Reprod. 2004; 19 1719-1724
68 Hamori M, Zwirner M, Clédon P, Tinneberg H R. Androgen response in polycystic ovary syndrome to FSH treatment after LHRH agonist suppression. Int J Fertil. 1992; 37 171-175
69 Lemieux S, Lewis G F, Ben-Chetrit A, Steiner G, Greenblatt E M. Correction of hyperandrogenemia by laparoscopic ovarian cautery in women with polycystic ovarian syndrome is not accompanied by improved insulin sensitivity or lipid-lipoprotein levels. J Clin Endocrinol Metab. 1999; 84 4278-4282
70 Saleh A, Morris D, Tan L S, Tulandi T. Effects of laparoscopic ovarian drilling on adrenal steroids in polycystic ovary syndrome patients with and without hyperinsulinemia. Fertil Steril. 2001; 75 501-504
71 Api M, Gorgan H, Cetin A. Laparoscopic ovarian drilling in polycystic ovary syndrome. Eur J Obstet Gynecol Reprod Biol. 2005; 119 76-81
72 Buttram V C, Vaquero Jr C. Post-ovarian wedge resection adhesive disease. Fertil Steril. 1975; 26 874-876
73 Luciano A A, Maier D B, Koch E L, Nulsen J C, Whitman G F. A comparative study of postoperative adhesions following laser surgery by laparoscopy versus laparotomy in the rabbit model. Obstet Gynecol. 1989; 74 220-224
74 Naether O G, Baukloh V, Fischer R, Kowalczyk T. Long term follow up in 206 infertility patients with polycystic ovarian syndrome after laparoscopic electrocautery of the ovarian surface. Hum Reprod. 1994; 9 2342-2349
75 Kucuk M, Kilic-Okman T. Hormone profiles and clinical outcome after laparoscopic ovarian drilling in women with polycystic ovary syndrome. Med Sci Monit. 2005; 11 CR29-CR34
76 Bayram N, van Wely M, Kaajik E M, Bossuyt P M, van der Veen F. Using an electrocautery strategy or recombinant follicle stimulating hormone to induce ovulation in polycystic ovary syndrome: randomised controlled trial. BMJ. 2004; 328 192
77 Cleemann L, Lauszus F F, Trolle B. Laparoscopic ovarian drilling as first line of treatment in infertile women with polycystic ovary syndrome. Gynecol Endocrinol. 2004; 18 138-143
78 Felemban A, Tan S L, Tulandi T. Laparoscopic treatment of polycystic ovaries with insulated needle cautery: a reappraisal. Fertil Steril. 2000; 73 266-269
79 Merchant R N. Treatment of polycystic ovary disease with laparoscopic low-watt bipolar electrocoagulation of the ovaries. J Am Assoc Gynecol Laparosc. 1996; 3 503-508
80 Pelosi 3rd M A, Pelosi M A. Laparoscopic electrosurgical furrowing technique for the treatment of polycystic ovaries. J Am Assoc Gynecol Laparosc. 1996; 4 57-62
81 Wu M H, Huang M F, Tsai S J, Pan H A, Cheng Y C, Lin Y S. Effects of laparoscopic ovarian drilling on young adult women with polycystic ovarian syndrome. J Am Assoc Gynecol Laparosc. 2004; 11 184-190
82 Amin A F, Abd el-Aal D E, Darwish A M, Meki A R. Evaluation of the impact of laparoscopic ovarian drilling on Doppler indices of ovarian stromal blood flow, serum vascular endothelial growth factor, and insulin-like growth factor-1 in women with polycystic ovary syndrome. Fertil Steril. 2003; 79 938-941
83 Am S A, Li T C, Cooke I D. Repeated laparoscopic ovarian diathermy is effective in women with anovulatory infertility due to polycystic ovary syndrome. Fertil Steril. 2003; 79 1211-1215
84 Tulandi T, Saleh A, Morris D, Jacobs H S, Payne N, Tan S L. Effects of laparosocpic ovarian drilling on serum vascular endothelial growth factor (VDGF) and on insulin responses to oral glucose tolerance test. Fertil Steril. 2000; 74 585-588
85 Zullo F, Pellicano M, Zupi E, Guida M, Mastrantonio P, Nappi C. Minilaparoscopic ovarian drilling under local anesthesia in patients with polycystic ovary syndrome. Fertil Steril. 2000; 74 376-379
86 Taskin O, Yalcinoglu A I, Kafkasli A, Burak F, Ozekici U. Comparison of the effects of ovarian cauterization and gonadotropin-releasing hormone agonist and oral contraceptive therapy combination on endocrine changes in women with polycystic ovary disease. Fertil Steril. 1996; 65 1115-1118
87 Tasaka K, Sakata M, Kurachi H, Komura H, Miyake A, Tanizawa O. Electrocautery in polycystic ovary syndrome. Horm Res. 1990; 33 40-42
88 Gadir A A, Khatim M S, Mowafi R S, Alnaser H M, Alzaid H G, Shaw R W. Hormonal changes in patients with polycystic ovarian disease after ovarian electrocautery or pituitary desensitization. Clin Endocrinol (Oxf). 1990; 32 749-754
89 Sumioki H, Utsunomyiya T, Matsuoka K, Korenaga M, Kadota T. The effect of laparoscopic multiple punch resection of the ovary on hypothalamo-pituitary axis in polycystic ovary syndrome. Fertil Steril. 1988; 50 567-572

Low-Tone HoM.D.

Department of Medical Research and Education

Taipei Veterans General Hospital, No. 201, Shih-Pai Road, Taipei, Taiwan

Email: ltho@vghtpe.gov.tw