Skip to main content Accessibility help

We use cookies to distinguish you from other users and to provide you with a better experience on our websites. Close this message to accept cookies or find out how to manage your cookie settings.

Close cookie message
×
Hostname: page-component-76fb5796d-r6qrq Total loading time: 0 Render date: 2024-04-30T03:45:32.179Z Has data issue: false hasContentIssue false

31 - Surgical Management of Polycystic Ovary Syndrome

from PART II - INFERTILITY EVALUATION AND TREATMENT

Published online by Cambridge University Press:  04 August 2010

By
Hakan Yarali ,
Gurkan Bozdag  and
Ibrahim Esinler
Edited by
Botros R. M. B. Rizk ,
Juan A. Garcia-Velasco ,
Hassan N. Sallam  and
Antonis Makrigiannakis
Botros R. M. B. Rizk
Affiliation:
University of South Alabama
Juan A. Garcia-Velasco
Affiliation:
Rey Juan Carlos University School of Medicine,
Hassan N. Sallam
Affiliation:
University of Alexandria School of Medicine
Antonis Makrigiannakis
Affiliation:
University of Crete
Get access

Summary

INTRODUCTION

Polycystic ovarian syndrome (PCOS) is a common and illunderstood endocrine disorder with multisystem sequelae. Clinical presentation is variable. It is characterized clinically by oligoamenorrhoea, signs of androgen excess such as hirsutism, acne, alopecia, obesity, and infertility, biochemically by elevation of serum androgens, luteinizing hormone (LH), and LH/follicular-stimulating hormone (FSH) ratio and not infrequently by insulin resistance (1). Morphologically, the ovaries are enlarged and have thick shiny capsules with peripherally placed multiple intermediate sized (2–8 mm in diameter) follicles. However, not all patients with clinically or endocrinologically defined PCOS demonstrate polycystic ovaries, nor do all women with polycystic ovaries have PCOS. Among 257 “normal volunteers,” 23 percent were found to have polycystic ovaries, and of the patients with polycystic ovaries, only about 50 percent had PCOS (2). Alternatively, of those women with PCOS, approximately, 70 percent have polycystic ovaries on ultrasonographic examination (3).

The diagnostic criteria of PCOS have been recently revised after a joint meeting of the European Society for Human Reproduction (ESHRE) and American Society for Reproductive Medicine (ASRM) in Rotterdam in May 2003 (4). It was agreed that the diagnosis of PCOS required the presence of at least two of the following three criteria: 1) oligo- and/or anovulation, 2) hyperandrogenism (clinical and/or biochemical), and 3) ultrasonographic appearance of polycystic ovaries, after the exclusion of other etiological factors (4).

Keywords

clomiphene citrategonadotrophin treatmenthyperandrogenismlaparoscopic ovarian drillingpolycystic ovary syndromemetformin
Type
Chapter
Information
Infertility and Assisted Reproduction , pp. 294 - 301
Publisher: Cambridge University Press
Print publication year: 2008

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Yildiz, BO, Yarali, H, Oguz, H, Bayraktar, M. Glucose intolerance, insulin resistance, and hyperandrogenemia in first degree relatives of women with polycystic ovary syndrome. J Clin Endocrinol Metab 2003;88:2031–6.CrossRefGoogle ScholarPubMed
Polson, DW, Adams, J, Wadsworth, J, Franks, S. Polycystic ovaries— a common finding in normal women. Lancet 1988;1:870–2.CrossRefGoogle ScholarPubMed
Carmina, E, Ditkoff, EC, Malizia, G, Vijod, AG, Janni, A, Lobo, RA. Increased circulating levels of immunoreactive beta-endorphin in polycystic ovary syndrome is not caused by increased pituitary secretion. Am J Obstet Gynecol 1992;167:1819–24.CrossRefGoogle Scholar
The 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;19:41–7.
Balen, AH, Laven, JS, Tan, SL, Dewailly, D. Ultrasound assessment of the polycystic ovary: international consensus definitions. Hum Reprod Update 2003;9:505–14.CrossRefGoogle ScholarPubMed
Geisthovel, F. A comment on the European Society of Human Reproduction and Embryology/American Society for Reproductive Medicine consensus of the polycystic ovarian syndrome. Reprod Biomed Online 2003;7:602–5.CrossRefGoogle ScholarPubMed
Leventhal, ML. The Stein-Leventhal syndrome. Am J Obstet Gynecol 1958;76:825–38.CrossRefGoogle ScholarPubMed
Stein, IF, Cohen, MR. Surgical treatment of bilateral polycystic ovaries. Am J Obstet Gynecol 1939;38:465–73.CrossRefGoogle Scholar
Stein, IF. Duration of fertility following ovarian wedge resection— Stein-Leventhal syndrome. Obstet Gynecol Surv 1965;20:124–7.CrossRefGoogle Scholar
Adashi, EY, Rock, JA, Guzick, D, Wentz, AC, Jones, GS, Jones, HW Jr. Fertility following bilateral ovarian wedge resection: a critical analysis of 90 consecutive cases of the polycystic ovary syndrome. Fertil Steril 1981;36:320–5.CrossRefGoogle ScholarPubMed
Portuondo, JA, Melchor, JC, Neyro, JL, Alegre, A. Periovarian adhesions following ovarian wedge resection or laparoscopic biopsy. Endoscopy 1984;16:143–5.CrossRefGoogle ScholarPubMed
Gomel, V. [Reasons for surgical treatment of polycystic ovary syndrome]. J Gynecol Obstet Biol Reprod (Paris) 2003;32:S46–9.Google ScholarPubMed
Gjonnaess, H. Polycystic ovarian syndrome treated by ovarian electrocautery through the laparoscope. Fertil Steril 1984;41:20–5.CrossRefGoogle ScholarPubMed
Lord, JM, Flight, IH, Norman, RJ. Insulin-sensitising drugs (metformin, troglitazone, rosiglitazone, pioglitazone, D-chiro-inositol) for polycystic ovary syndrome. Cochrane Database Syst Rev 2003;CD003053.Google ScholarPubMed
Mitwally, MF, Casper, RF. Aromatase inhibitors for the treatment of infertility. Expert Opin Investig Drugs 2003;12:353–71.CrossRefGoogle ScholarPubMed
Gomel, V, Taylor, PJ. Diagnostic and operative gynecologic laparoscopy. Vol. 198. 1995, St. LouisMosby.Google Scholar
Saleh, AM, Khalil, HS. Review of nonsurgical and surgical treatment and the role of insulin-sensitizing agents in the management of infertile women with polycystic ovary syndrome. Acta Obstet Gynecol Scand 2004;83:614–21.CrossRefGoogle ScholarPubMed
Felemban, A, Tan, SL, Tulandi, T. Laparoscopic treatment of polycystic ovaries with insulated needle cautery: a reappraisal. Fertil Steril 2000;73:266–9.CrossRefGoogle ScholarPubMed
Gurgan, T, Urman, B, Aksu, T, Yarali, H, Develioglu, O, Kisnisci, HA. The effect of short-interval laparoscopic lysis of adhesions on pregnancy rates following Nd-YAG laser photocoagulation of polycystic ovaries. Obstet Gynecol 1992;80:45–7.Google ScholarPubMed
Malkawi, HY, Qublan, HS. 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;31:115–9.CrossRefGoogle ScholarPubMed
Amer, SA, Li, TC, Cooke, ID. A prospective dose-finding study of the amount of thermal energy required for laparoscopic ovarian diathermy. Hum Reprod 2003;18:1693–8.CrossRefGoogle ScholarPubMed
Dabirashrafi, H. Complications of laparoscopic ovarian cauterization. Fertil Steril 1989;52:878–9.Google ScholarPubMed
Fernandez, H, Alby, JD, Gervaise, A, Tayrac, R, Frydman, R. Operative transvaginal hydrolaparoscopy for treatment of polycystic ovary syndrome: a new minimally invasive surgery. Fertil Steril 2001;75:607–11.CrossRefGoogle ScholarPubMed
Branigan, EF, Estes, A, Walker, K, Rothgeb, J. Thorough sonographic oocyte retrieval during in vitro fertilization produces results similar to ovarian wedge resection in patients with clomiphene citrate-resistant polycystic ovarian syndrome. Am J Obstet Gynecol 2006;194:1696–700; discussion 1700–1.CrossRefGoogle ScholarPubMed
Rossmanith, WG, Keckstein, J, Spatzier Klauritzen, C. The impact of ovarian laser surgery on the gonadotrophin secretion in women with polycystic ovarian disease. Clin Endocrinol (Oxf) 1991;34:223–30.CrossRefGoogle ScholarPubMed
Keckstein, J. Laparoscopic treatment of polycystic ovarian syndrome. Baillieres Clin Obstet Gynaecol 1989;3:563–81.CrossRefGoogle ScholarPubMed
Liguori, G, Tolino, A, Moccia, G, Scognamiglio, G, Nappi, C. Laparoscopic ovarian treatment in infertile patients with polycystic ovarian syndrome (PCOS): endocrine changes and clinical outcome. Gynecol Endocrinol 1996;10:257–64.CrossRefGoogle ScholarPubMed
Alborzi, S, Khodaee, R, Parsanejad, ME. Ovarian size and response to laparoscopic ovarian electro-cauterization in polycystic ovarian disease. Int J Gynaecol Obstet 2001;74:269–74.CrossRefGoogle ScholarPubMed
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;50:567–72.CrossRefGoogle ScholarPubMed
Lockwood, GM, Muttukrishna, S, Groome, NP, Matthews, DR, Ledger, WL. Mid-follicular phase pulses of inhibin B are absent in polycystic ovarian syndrome and are initiated by successful laparoscopic ovarian diathermy: a possible mechanism regulating emergence of the dominant follicle. J Clin Endocrinol Metab 1998;83:1730–5.CrossRefGoogle ScholarPubMed
Armar, NA, McGarrigle, HH, Honour, J, Holownia, P, Jacobs, HS, Lachelin, GC. Laparoscopic ovarian diathermy in the management of anovulatory infertility in women with polycystic ovaries: endocrine changes and clinical outcome. Fertil Steril 1990;53: 45–9.CrossRefGoogle ScholarPubMed
Amer, SA, Gopalan, V, Li, TC, Ledger, WL, Cooke, ID. Long term follow-up of patients with polycystic ovarian syndrome after laparoscopic ovarian drilling: clinical outcome. Hum Reprod 2002;17:2035–42.CrossRefGoogle ScholarPubMed
Naether, OG, 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;9:2342–9.CrossRefGoogle ScholarPubMed
Aakvaag, A, Gjonnaess, H. Hormonal response to electrocautery of the ovary in patients with polycystic ovarian disease. Br J Obstet Gynaecol 1985;92:1258–64.CrossRefGoogle ScholarPubMed
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. 2:35–9.CrossRefGoogle ScholarPubMed
Campo, S, Felli, A, Lamanna, MA, Barini, A, Garcea, N. Endocrine changes and clinical outcome after laparoscopic ovarian resection in women with polycystic ovaries. Hum Reprod 1993;8:359–63.CrossRefGoogle ScholarPubMed
Kriplani, A, Manchanda, R, Agarwal, N, Nayar, B. Laparoscopic ovarian drilling in clomiphene citrate-resistant women with polycystic ovary syndrome. J Am Assoc Gynecol Laparosc 2001; 8:511–8.CrossRefGoogle ScholarPubMed
Heylen, SM, Puttemans, PJ, Brosens, IA. Polycystic ovarian disease treated by laparoscopic argon laser capsule drilling: comparison of vaporization versus perforation technique. Hum Reprod 1994;9:1038–42.CrossRefGoogle ScholarPubMed
Li, TC, Saravelos, H, Chow, MS, Chisabingo, R, Cooke, ID. Factors affecting the outcome of laparoscopic ovarian drilling for polycystic ovarian syndrome in women with anovulatory infertility. Br J Obstet Gynaecol 1998;105:338–44.CrossRefGoogle ScholarPubMed
Stegmann, BJ, Craig, HR, Bay, RC, Coonrod, DV, Brady, MJ, Garbaciak, JA Jr. Characteristics predictive of response to ovarian diathermy in women with polycystic ovarian syndrome. Am J Obstet Gynecol 2003;188:1171–3.CrossRefGoogle ScholarPubMed
Duleba, AJ, Banaszewska, B, Spaczynski, RZ, Pawelczyk, L. Success of laparoscopic ovarian wedge resection is related to obesity, lipid profile, and insulin levels. Fertil Steril 2003;79:1008–14.CrossRefGoogle ScholarPubMed
Gomel, V, Yarali, H. Surgical treatment of polycystic ovary syndrome associated with infertility. Reprod Biomed Online 2004;9: 35–42.CrossRefGoogle ScholarPubMed
Gjonnaess, H. Ovarian electrocautery in the treatment of women with polycystic ovary syndrome (PCOS). Factors affecting the results. Acta Obstet Gynecol Scand 1994;73:407–12.CrossRefGoogle ScholarPubMed
Tozer, AJ, Al-Shawaf, T, Zosmer, A, et al. Does laparoscopic ovarian diathermy affect the outcome of IVF-embryo transfer in women with polycystic ovarian syndrome? A retrospective comparative study. Hum Reprod 2001;16:91–5.CrossRefGoogle ScholarPubMed
Rimington, MR, Walker, SM, Shaw, RW. 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;12:1443–7.CrossRefGoogle ScholarPubMed
Farhi, J, Soule, S, Jacobs, HS. Effect of laparoscopic ovarian electrocautery on ovarian response and outcome of treatment with gonadotropins in clomiphene citrate-resistant patients with polycystic ovary syndrome. Fertil Steril 1995;64:930–5.CrossRefGoogle ScholarPubMed
Colacurci, N, Zullo, F, Franciscis, P, Mollo, A, Placido, G. In vitro fertilization following laparoscopic ovarian diathermy in patients with polycystic ovarian syndrome. Acta Obstet Gynecol Scand 1997;76:555–8.CrossRefGoogle ScholarPubMed
Amin, AF, Abd el-Aal, , Darwish, AM, Meki, AR. 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;79:938–41.CrossRefGoogle ScholarPubMed
Abdel Gadir, A, Mowafi, RS, Alnaser, HM, Alrashid, AH, Alonezi, OM, Shaw, RW. 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;33:585–92.CrossRefGoogle ScholarPubMed
Farquhar, C, Vandekerckhove, P, Lilford, R. Laparoscopic “drilling” by diathermy or laser for ovulation induction in anovulatory polycystic ovary syndrome. The Cochrane Library, 2002.Google Scholar
Homburg, R, Howles, CM. Low-dose FSH therapy for anovulatory infertility associated with polycystic ovary syndrome: rationale, results, reflections and refinements. Hum Reprod Update 1999;5:493–9.CrossRefGoogle ScholarPubMed
Bayram, N, Wely, M, Kaaijk, EM, Bossuyt, PM, 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.CrossRefGoogle ScholarPubMed
Vicino, M, Loverro, G, Bettocchi, S, Simonetti, S, Mei, L, Selvaggi, L. Predictive value of serum androstenedione basal levels on the choice of gonadotropin or laparoscopic ovarian electrocautery as ovulation induction in clomiphene citrate-resistant patients with polycystic ovary syndrome. Gynecol Endocrinol 2000;14:42–9.CrossRefGoogle ScholarPubMed
Farquhar, CM, Williamson, K, Gudex, G, Johnson, NP, 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;78:404–11.CrossRefGoogle ScholarPubMed
Farquhar, CM, Williamson, K, Brown, PM, Garland, J. An economic evaluation of laparoscopic ovarian diathermy versus gonadotrophin therapy for women with clomiphene citrate resistant polycystic ovary syndrome. Hum Reprod 2004;19: 1110–5.CrossRefGoogle ScholarPubMed
Gjonnaess, H. Late endocrine effects of ovarian electrocautery in women with polycystic ovary syndrome. Fertil Steril 1998;69:697–701.CrossRefGoogle ScholarPubMed
Pirwany, I, Tulandi, T. Laparoscopic treatment of polycystic ovaries: is it time to relinquish the procedure?Fertil Steril 2003;80: 241–51.CrossRefGoogle ScholarPubMed
Wely, M, Bayram, N, Veen, F, Bossuyt, PM. An economic comparison of a laparoscopic electrocautery strategy and ovulation induction with recombinant FSH in women with clomiphene citrate-resistant polycystic ovary syndrome. Hum Reprod 2004;19:1741–5.CrossRefGoogle ScholarPubMed
Malkawi, HY, Qublan, HS, Hamaideh, AH. Medical vs. surgical treatment for clomiphene citrate-resistant women with polycystic ovary syndrome. J Obstet Gynaecol 2003;23:289–93.CrossRefGoogle ScholarPubMed
Palomba, S, Orio, F Jr.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;63:631–5.CrossRefGoogle ScholarPubMed
Kocak, I, Ustun, C. Effects of metformin on insulin resistance, androgen concentration, ovulation and pregnancy rates in women with polycystic ovary syndrome following laparoscopic ovarian drilling. J Obstet Gynaecol Res 2006;32:292–8.CrossRefGoogle ScholarPubMed
Saleh, A, Morris, D, Tan, SL, Tulandi, T. Effects of laparoscopic ovarian drilling on adrenal steroids in polycystic ovary syndrome patients with and without hyperinsulinemia. Fertil Steril 2001;75:501–4.CrossRefGoogle ScholarPubMed
Legro, RS, Finegood, D, Dunaif, A. A fasting glucose to insulin ratio is a useful measure of insulin sensitivity in women with polycystic ovary syndrome. J Clin Endocrinol Metab 1998;83: 2694–8.Google ScholarPubMed
Dunaif, A, Segal, KR, Futterweit, W, Dobrjansky, A. Profound peripheral insulin resistance, independent of obesity, in polycystic ovary syndrome. Diabetes 1989;38:1165–74.CrossRefGoogle ScholarPubMed
Tiitinen, A, Tenhunen, A, Seppala, M. Ovarian electrocauterization causes LH-regulated but not insulin-regulated endocrine changes. Clin Endocrinol (Oxf) 1993;39:181–4.CrossRefGoogle Scholar
Lemieux, S, Lewis, GF, Ben-Chetrit, A, Steiner, G, Greenblatt, EM. 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;84:4278–82.Google ScholarPubMed
Amer, SA, Banu, Z, Li, TC, Cooke, ID. Long-term follow-up of patients with polycystic ovary syndrome after laparoscopic ovarian drilling: endocrine and ultrasonographic outcomes. Hum Reprod 2002;17:2851–7.CrossRefGoogle ScholarPubMed
Lunde, O, Djoseland, O, Grottum, P. Polycystic ovarian syndrome: a follow-up study on fertility and menstrual pattern in 149 patients 15-25 years after ovarian wedge resection. Hum Reprod 2001;16:1479–85.CrossRefGoogle ScholarPubMed
Weise, HC, Naether, O, Fischer, R, Berger-Bispink, S, Delfs, T. Results of treatment with surface cauterization of polycystic ovaries in sterility patients. Geburtshilfe Frauenheilkd 1991;51: 920–4.CrossRefGoogle ScholarPubMed
Corson, SL, Grochmal, SA. Contact laser laparoscopy has distinct advantages over alternatives. Clin Laser Mon 1990;8:7–9.Google ScholarPubMed
Campo, S., Ovulatory cycles, pregnancy outcome and complications after surgical treatment of polycystic ovary syndrome. Obstet Gynecol Surv 1998;53:297–308.CrossRefGoogle ScholarPubMed
Daniell, JF, Miller, W. Polycystic ovaries treated by laparoscopic laser vaporization. Fertil Steril 1989;51:232–6.CrossRefGoogle ScholarPubMed
Rizk, B, Nawar, MG. Laparoscopic ovarian drilling for surgical induction of ovulation in polycystic ovary syndrome. In Allahbadia, G (Ed.) Mumbai: India, Rotunda Medical Technologies (2001), chapter 18, 140–4.Google Scholar
Rizk, B. Prevention of Ovarian Hyperstimulation Syndrome. In Rizk, B (Ed.). Ovarian Hyperstimulation Syndrome. Cambridge: United Kingdom. Cambridge University Press, chapter 7, 130–99.CrossRef

Save book to Kindle

To save this book to your Kindle, first ensure coreplatform@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about saving to your Kindle.

Note you can select to save to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

Available formats
×

Save book to Dropbox

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Dropbox.

Available formats
×

Save book to Google Drive

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Google Drive.

Available formats
×