PubMed1993
Women with PCOS often present with anovulatory infertility. In these women, attempts at ovulation induction should be initiated with clomiphene citrate. However, 10 to 15% of women will not ovulate in response to clomiphene citrate, and in those who do, half will not conceive. Ovulation induction in these patients may involve the administration of hMG or pure FSH, with or without prior pituitary desensitization by GnRH agonists. However, gonadotrophin therapy is expensive, requires extensive monitoring, is not available at all centres and is associated with a significant incidence of ovarian hyperstimulation syndrome, multiple pregnancy and pregnancy loss. Furthermore, the chance of conception is limited to the treatment cycle. For women who fail to respond to clomiphene citrate therapy, and for whom gonadotrophin therapy is unsuccessful or unavailable, surgical therapy should be considered. There is a very limited role, if any, for OWR in the treatment of anovulation due to PCOS. Although effective in inducing ovulation in approximately 80% of women, with pregnancy rates approximating 60%, OWR requires major surgery and is associated with significant adhesion formation. Newer, less invasive techniques are emerging for the anovulatory woman who fails medical management. These include laparoscopic ovarian cautery and laparoscopic ovarian laser vaporization. These surgical techniques can be performed as outpatient procedures and may be combined with a diagnostic laparoscopy. Knowledge of the long-term effects of these techniques is still limited, but results appear promising, with spontaneous ovulation being initiated in 70 to 90% of women. Of the patients who remain anovulatory or oligo-ovulatory after these procedures, most will have been rendered sensitive to clomiphene citrate. Conception rates approximate 60%. The mechanism of action remains uncertain, but is likely to involve alteration of the intraovarian steroid environment and, in turn, the feedback to the hypothalamic-pituitary axis. The overall result is normalization of gonadotrophin drive and follicular microenvironment, allowing follicular recruitment and development to proceed to ovulation. Future clinical studies with long-term follow-up will be required to determine relapse rate and fecundity rates following these procedures. The risk of postoperative adhesion formation and the role of second-look laparoscopy in the prevention of this undesirable complication remains uncertain. Until more complete, long-term information is known, caution must be exercised and complete information provided to the patient with respect to the possible adverse affects.