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Treatment of WHO 2: Laparoscopic Electrocautery of the Ovaries
Introduction
Polycystic ovary syndrome (PCOS) is the most frequent cause of WHO II anovulation affecting ~10% of women of reproductive age. In 1935, Stein and Leventhal were the first to describe the association between polycystic ovaries (seen at laparotomy) and menstrual irregularities, sterility, hirsutism, and obesity. They performed laparotomies on a group of these patients to obtain ovarian biopsies for diagnostic purposes. Unexpectedly, they observed postoperative resumption of regular menses and fertility in most of their patients. Surgical ovarian wedge resection (OWR) was therefore established as the first effective treatment for anovulatory PCOS patients with high success rates (80% resumption of regular menses and ~60% conception). In the 1960s, OWR was largely abandoned (due to its associated morbidity) in favor of the newly introduced clomiphene citrate, which became the standard first-line ovulation induction therapy in PCOS. In the late 1960s and with the development of minimal invasive surgery, there was a renewed interest in surgical ovulation induction carried out laparoscopically. In 1967, Palmer and De Brux in France and Steptoe in Great Britain were the first to describe laparoscopic ovarian biopsy in PCOS women. However, this new approach did not find its way to clinical practice possibly due to the limited number of centers performing laparoscopic surgery, which was still in its early days. In 1984, Gjönnaess published the first study on laparoscopic electrocautery of the ovary (LEO) reporting very encouraging success rates (91% ovulation rate). Following this publication, LEO gained much popularity worldwide, and a plethora of studies has since been published confirming its efficacy and safety. The underlying mechanisms of LEO actions remain largely uncertain. Several hypotheses have been postulated, such as removal of a mechanical barrier to ovulation or decreased ovarian androgen synthesis due to thermal tissue destruction. Whatever the mechanism may be, it is evident that a small amount of damage to ovarian tissue seems to restore the ovulatory cycle in a high proportion of patients.
Overview of Existing Evidence
This review presents the available evidence for LEO in anovulatory PCOS patients focusing mainly on the following clinically important issues:
• The current role of LEO
• Techniques of LEO
• The optimum number of punctures during LEO
• The optimal depth of needle insertion into the ovary
• Long-term effects and safety of LEO
The Current Role of LEO
As clomiphene citrate (CC) is a relatively cheap, simple, effective, and safe treatment, it is widely regarded as the standard first-line treatment for ovulation induction in anovulatory PCOS women (LOE 2). When LEO was compared in an RCT to CC as a first-line treatment in anovulatory PCOS, it was not found to offer any advantages over CC. It was therefore concluded that LEO should not be offered as a first-line treatment in PCOS (LOE 1b) (1).
In PCOS women with CC resistance, defined as failure to ovulate on the maximum dose (150 mg/day) or failure to conceive despite regular ovulation, the choice is between LEO and gonadotrophin therapy. Both these modalities are equally effective in inducing ovulation and generating pregnancies (LOE 1a) (2,3). A recent Cochrane systematic review compared the outcome of LEO with various medical agents used for ovulation induction in PCOS women, including clomiphene citrate (CC) alone or CC plus tamoxifen, gonadotrophins, and aromatase inhibitors. The review found no significant differences in live birth rates between LEO and medical ovulation induction. However, LEO was associated with lower multiple pregnancy rates. Furthermore, the cost per live birth achieved with LEO has been estimated to be 22% lower than that achieved with gonadotrophin therapy (LOE 1b). A long-term economic evaluation study reported a saving of €3,220 (~20%) per live birth when a strategy starting with LEO before gonadotrophins was adopted (4). LEO should therefore be considered the second-line treatment of choice in preference to gonadotrophin therapy in CC-resistant PCOS women (LOE 1a) (2). LEO has also been recommended in gonadotrophin-over-respondent PCOS women (LOE 2).
Techniques of LEO
Numerous techniques of laparoscopic ovarian surgery to induce ovulation in PCOS women have been developed over the years. Most of the techniques involve either taking ovarian biopsies or making multiple punctures on the surface of the ovary using monopolar or bipolar electrocoagulation or laser. Comparing these three energy modalities, bipolar electrocoagulation seems to result in more destruction per burn when applied to fresh bovine ovaries (LOE 2). More recently, there have been several attempts to use a transvaginal route to perform the ovarian surgery, utilizing either a fertiloscopy or an ultrasound-guided approach.
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