Laparoscopic drilling by diathermy or laser for ovulation induction in anovulatory polycystic ovary syndrome

 

Abstract

Background

Surgical ovarian wedge resection was the first established treatment for women with anovulatory polycystic ovary syndrome (PCOS) but was largely abandoned due to the risk of postsurgical adhesions and the introduction of medical ovulation induction with clomiphene and gonadotrophins. However, women with PCOS who are treated with gonadotrophins often have an over-production of follicles which may result in ovarian hyperstimulation syndrome (OHSS) and multiple pregnancies. Moreover, gonadotrophins, though effective, are costly and time-consuming requiring intensive monitoring. Surgical therapy with laparoscopic ovarian 'drilling' (LOD) may avoid or reduce the need for gonadotrophins or may facilitate their usefulness. The procedure can be done on an outpatient basis with less trauma and fewer postoperative adhesions than with traditional surgical approaches. Many uncontrolled observational studies have claimed that ovarian drilling is followed, at least temporarily, by a high rate of spontaneous ovulation and conception or that subsequent medical ovulation induction becomes easier.

Objectives

To determine the effectiveness and safety of laparoscopic ovarian drilling compared with ovulation induction for subfertile women with clomiphene-resistant PCOS.

Search methods

We used the search strategy of the Menstrual Disorders and Subfertility Group.

Selection criteria

We included randomised controlled trials of subfertile women with clomiphene-resistant PCOS who undertook laparoscopic ovarian drilling in order to induce ovulation.

Data collection and analysis

Sixteen trials were identified and nine 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.

Main results

There was no evidence of a difference in live birth or clinical pregnancy rate between LOD and gonadotrophins and the pooled odds ratios (OR) (all studies) were 1.04 (95% CI 0.59 to 1.85) and 1.08 (95% CI 0.69 to 1.71) respectively. Multiple pregnancy rates were lower with ovarian drilling than with gonadotrophins (1% versus 16%; OR 0.13, 95% CI 0.03 to 0.52). There was no evidence of a difference in miscarriage rates between the two groups (OR 0.81, 95% 0.36 to 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.

 

Plain language summary

Laparoscopic 'drilling' by diathermy or laser for ovulation induction in anovulatory polycystic ovary syndrome

Ovarian surgery in women with clomiphene-resistant polycystic ovarian syndrome reduces the risk of multiple pregnancy without decreasing the pregnancy rate. Women with polycystic ovary syndrome (PCOS) have trouble ovulating. Gonadotrophins are hormones produced by the pituitary gland. Women with PCOS may be treated with gonadotrophins (either from urinary sources or recombinant techniques) but gonadotrophins can overstimulate the ovary and cause multiple pregnancy. An alternative is a minor surgical procedure called laparoscopic ovarian drilling where a long telescope is passed through a small cut in the umbilicus. The ovaries are then surgically treated by drilling using either heat or laser. This review of trials found that ovarian drilling followed by clomiphene or gonadotrophins, if necessary, was as effective as gonadotrophin therapy alone in inducing ovulation, but the risk of multiple pregnancies was lower in the group who had laparoscopic ovarian drilling. Approximately 50% of women will have a live birth and 16% will have a miscarriage with either procedure.

 

摘要

背景

在無排卵的多囊性卵巢症候群之婦女，利用腹腔鏡電燒或雷射 ‘鑽孔’ 來誘發排卵

針對患有無排卵的多囊性卵巢症候群(PCOS)之婦女而言，手術型的卵巢楔狀切除術是最早為了她們而發展出來的治療方法，但是因為手術後沾黏所帶來的風險，以及可以使用 clomiphene與促性腺激素來誘導排卵，所以大多數人已經捨棄了這樣的治療方法。然而，對於患有多囊性卵巢症候群的婦女們來說，只要是接受過促性腺激素治療之後，通常都會產生過多的卵泡，而這些卵泡可能會造成卵巢過度刺激症候群(OHSS)及懷多胞胎的現象。除此之外，儘管促性腺激素很有效，但是這些激素卻是要價不斐，而且還需要花費很多的時間來進行密集的監控。採用腹腔鏡卵巢「鑽孔」(LOD)的手術治療，也許能夠避免或減少對於促性腺激素類的需求量，甚至能提高它們的功用。基本上，腹腔鏡卵巢鑽孔手術屬於門診手術，跟傳統的手術相比所造成的傷害較少，手術後沾黏的程度也較輕微。許多未加對照的觀察性研究已經指出，卵巢鑽孔後會使得自發性排卵的比率變得比較高，而且至少在短時間來看，有較高的自然排卵率與受孕率，或在後續藥物誘導排卵時較易成功。

目標

對於患有多囊性卵巢症候群、又對clomiphene有抗藥性，而且無法正常生育的婦女們而言，要確認腹腔鏡卵巢鑽孔，跟誘導排卵比較起來的功效與安全性。

搜尋策略

採用的搜尋策略為Menstrual Disorders以及Subfertility Group。

選擇標準

針對患有多囊性卵巢症候群、又對clomiphene有抗藥性，而且無法正常生育的婦女們，我們收集與她們相關的隨機對照試驗，這些文獻都在比較接受腹腔鏡卵巢鑽孔來誘導排卵。

資料收集與分析

在本篇文獻回顧當中，共確認了16項試驗，並收集了其中的9項。所有的試驗都有經過品質標準評估。主要的預後為產下活胎、排卵，以及懷孕率，至於次要的預後則為流產率、多胞胎率、卵巢過度刺激症候群的比率，以及醫療花費。

主要結論

在腹腔鏡的卵巢鑽孔與促性腺激素之間，就產下活胎或是臨床上的懷孕比率方面而言，並沒有實證醫學證據的差別，而且總合勝算比(OR)(所有的研究)分別為1.04(95% CI 0.59到1.85)以及1.08(95% CI 0.69到1.71)。就懷有多胞胎的比率來看，採取卵巢鑽孔跟使用了促性腺激素的對象比較起來，前者的比率會變得比較低(1% 相較於16% ；OR 0.13，95% CI 0.03到0.52)。在這二個組別之間，並沒有證據能夠支持在流產比率方面會有什麼差異存在(OR 0.81，95% 0.36到1.86)。

作者結論

對於患有多囊性卵巢症候群、又對clomiphene有抗藥性的婦女們而言，跟促性腺激素比較起來，當她們接受了腹腔鏡的卵巢鑽孔之後，就產下活胎或是臨床上的懷孕比率方面來看，並沒有證據能夠支持當中會有什麼差異存在。對於接受了腹腔鏡的卵巢鑽孔的婦女們而言，因為懷有多胞胎的比率下降了，所以使得這樣的選項變得具有吸引力。然而，對於卵巢的功能而言，腹腔鏡的卵巢鑽孔是否會帶來長期方面的影響，仍然有所疑慮。

翻譯人

此翻譯計畫由臺灣國家衛生研究院 (National Health Research Institutes, Taiwan) 統籌。

總結

對於患有多囊性卵巢症候群、又對clomiphene有抗藥性的婦女們而言，在她們身上進行的卵巢手術可以降低多胞胎的風險，並且不會降低懷孕率。患有多囊性卵巢症候群(PCOS)的婦女們，都會有排卵方面的問題。促性腺激素是由腦下垂體所產生的荷爾蒙。患有多囊性卵巢症候群的婦女們或許會接受促性腺激素類的治療(不論是取自於泌尿系統的來源或是重組技術)，但是促性腺激素類卻可能會對卵巢造成過度刺激，並導致多胞胎。另一種選擇是較小型的手術，名稱為腹腔鏡卵巢鑽孔術，這種方法會在肚臍部位劃一道小型的切口，然後置入內視鏡。手術方式是使用熱源或是雷射，來進行卵巢鑽孔手術。本篇試驗的回顧發現，在卵巢鑽孔之後，如果有必要而使用了 clomiphene或是促性腺激素類，在誘導排卵方面來看，效果跟單獨使用gonadotrophin療法是相同的，但是在接受腹腔鏡卵巢鑽孔術這組之中，懷多胞胎的風險是較低的。大約有50% 的婦女將會產下活胎，而不論採用的是哪一種程序，有16% 的婦女會發生流產。