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Postoperative endocrine alterations and clinical outcome of infertile women with polycystic ovary syndrome after transvaginal hydrolaparoscopic ovarian drilling

2006; Elsevier BV; Volume: 85; Issue: 1 Linguagem: Inglês

10.1016/j.fertnstert.2005.07.1284

1556-5653

Hiroaki Shibahara, Yuki Hirano, Kumiko Kikuchi, Tatsuya Suzuki, Satoru Takamizawa, Mitsuaki Suzuki,

Endometriosis Research and Treatment

Transvaginal hydrolaparoscopic ovarian drilling (THLOD) appears to be an effective minimally invasive procedure to induce ovulation in women with polycystic ovary syndrome (PCOS). Postoperative endocrinological alterations following THLOD show significant decrease of serum LH and testosterone concentrations. Transvaginal hydrolaparoscopic ovarian drilling (THLOD) appears to be an effective minimally invasive procedure to induce ovulation in women with polycystic ovary syndrome (PCOS). Postoperative endocrinological alterations following THLOD show significant decrease of serum LH and testosterone concentrations. Polycystic ovary syndrome (PCOS) is a syndrome of ovarian dysfunction showing cardinal features of hyperandrogenism and polycystic ovarian morphology (1The Rotterdam ESHRE/ASRM-sponsored PCOS consensus workshop groupRevised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome (PCOS).Hum Reprod. 2004; 19: 41-47Crossref PubMed Scopus (4414) Google Scholar). It is one of the most common reproductive endocrine disorders in young adult women, showing clinical signs of menstrual disorder, anovulation, hirsutism, acne, and obesity. Approximately 15% of patients with PCOS remain anovulatory despite treatment with clomiphene citrate (CC), and half of the patients with PCOS who became ovulatory on this treatment fail to conceive (2Nugent D. Vandekerckhove P. Hughes E. Arnot M. Lilford R. Gonadotrophin therapy for ovulation induction in subfertility associated with polycystic ovary syndrome.Cochrane Database Syst Rev. 2000; 4 (CD000410)PubMed Google Scholar). Gonadotropin stimulation is often the next step for the treatment of CC-resistant infertile women with PCOS. Following unsuccessful medical induction of ovulation, ovarian surgery has been selected to induce ovulation. Ovarian surgery for the treatment of PCOS has also been indicated in women who hyperrespond to gonadotropin therapy to avoid such complications as ovarian hyperstimulation syndrome (OHSS) or multiple gestations. Although the effectiveness of bilateral ovarian wedge resection for patients with PCOS has been established since the first report by Stein and Leventhal (3Stein I.F. Leventhal M.L. Amenorrhea associated with bilateral polycystic ovaries.Am J Obstet Gynecol. 1935; 29: 181-191Crossref Google Scholar), laparoscopic procedures to induce ovulation have been recognized as more useful because of their lower invasiveness. Postoperative adhesions are more common after laparotomy than after laparoscopy; the cumulative pregnancy rate after ovarian surgery for PCOS is approximately 55%, which is similar to that obtained by medical induction of ovulation (4Donesky B.W. Adashi E.Y. Surgically induced ovulation in the polycystic ovary syndrome wedge resection revisited in the age of laparoscopy.Fertil Steril. 1995; 63: 439-463Abstract Full Text PDF PubMed Google Scholar, 5Felemban A. Lin Tan S. Tulandi T. Laparoscopic treatment of polycystic ovaries with insulated needle cavitery a reappraisal.Fertil Steril. 2000; 73: 266-269Abstract Full Text Full Text PDF PubMed Scopus (92) Google Scholar). To date, several techniques of laparoscopic surgery have been described, including ovarian biopsy (6Neuwirth R.S. A method of bilateral ovarian biopsy at laparoscopy in infertility and chronic anovulation.Fertil Steril. 1972; 23: 361-366Crossref PubMed Scopus (16) Google Scholar), electrocautery (7Gjonnaess H. Polycystic ovarian syndrome treated by ovarian electrocautery through the laparoscope.Fertil Steril. 1984; 41: 20-25Crossref PubMed Scopus (283) Google Scholar), and laser technology (8Daniell J.F. Miller W. Polycystic ovaries treated by laparoscopic laser vaporization.Fertil Steril. 1989; 51: 232-236Abstract Full Text PDF PubMed Scopus (104) Google Scholar). Most have involved formation of multiple holes on the surface of the ovary using a laser. This procedure is known as laparoscopic ovarian drilling. Recently, transvaginal hydrolaparoscopy (THL) was introduced as the first-line procedure in the exploration of the adnexal structures in infertile women (9Gordts S. Campo R. Rombauts L. Brosens I. Transvaginal hydrolaparoscopy as an outpatient procedure for infertility investigation.Hum Reprod. 1998; 13: 99-103Crossref PubMed Scopus (182) Google Scholar). Because of the advantages of THL, including accurate inspection of adnexal structures without manipulation, it became clear that THL is a less traumatic and more suitable outpatient procedure than diagnostic laparoscopy (10Shibahara H. Fujiwara H. Hirano Y. Suzuki T. Obara H. Takamizawa S. et al.Usefulness of transvaginal hydrolaparoscopy in investigating infertile women with Chlamydia trachomatis infection.Hum Reprod. 2001; 16: 1690-1693Crossref PubMed Scopus (43) Google Scholar, 11Fujiwara H. Shibahara H. Hirano Y. Suzuki T. Takamizawa S. Sato I. Usefulness and prognostic value of transvaginal hydrolaparoscopy in infertile women.Fertil Steril. 2003; 79: 186-189Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar). The risks of a general anesthetic are avoided, and there is less chance of trauma to major vessels. Therefore, we have been performing THL as a diagnostic laparoscopy on infertile women based on any of the following four indications: 1Tubal obstruction or peritubal adhesion are suggested by the hysterosalpingography2Serum antibody against Chlamydia trachomatis is positive3Diagnosis of early stage endometriosis4Uunexplained infertility (10Shibahara H. Fujiwara H. Hirano Y. Suzuki T. Obara H. Takamizawa S. et al.Usefulness of transvaginal hydrolaparoscopy in investigating infertile women with Chlamydia trachomatis infection.Hum Reprod. 2001; 16: 1690-1693Crossref PubMed Scopus (43) Google Scholar, 11Fujiwara H. Shibahara H. Hirano Y. Suzuki T. Takamizawa S. Sato I. Usefulness and prognostic value of transvaginal hydrolaparoscopy in infertile women.Fertil Steril. 2003; 79: 186-189Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar) Fernandez et al. (12Fernandez H. Alby J.-D. Gervaise A. de Tayrac R. Frydman R. Operative transvaginal hydrolaparoscopy for treatment of polycystic ovary syndrome a new minimally invasive surgery.Fertil Steril. 2001; 75: 607-611Abstract Full Text Full Text PDF PubMed Scopus (91) Google Scholar, 13Fernandez H. Watrelot A. Alby J.D. Kadoch J. Gervaise A. de Tayrac R. et al.Fertility after ovarian drilling by transvaginal fertiliscopy for treatment of polycystic ovary syndrome.J Am Assoc Gynecol Laparosc. 2004; 11: 374-378Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar) have recently reported the feasibility of ovarian drilling by THL for PCOS. Based on our preliminary study (14Hirano Y. Shibahara H. Takamizawa S. Suzuki I. Yamanaka S. Suzuki T. et al.Application of transvaginal hydrolaparoscopy for ovarian drilling using Nd AG laser in infertile women with polycystic ovary syndrome.Reprod Med Biol. 2003; 2: 37-40Crossref Google Scholar), we investigated postoperative endocrine alterations and clinical outcome of infertile women with PCOS after transvaginal hydrolaparoscopic ovarian drilling (THLOD) using a laser was investigated to clarify the usefulness of this new technique. Between April 2002 and June 2004, seven infertile women with PCOS were enrolled to this study. Five women with CC-resistant PCOS and two women with the risk of developing OHSS underwent THLOD. The mean age and body mass index (BMI) of patients were 27.3 ± 1.9 years old and 24.7 ± 8.9, respectively. The procedure for THLOD was followed as we previously described (14Hirano Y. Shibahara H. Takamizawa S. Suzuki I. Yamanaka S. Suzuki T. et al.Application of transvaginal hydrolaparoscopy for ovarian drilling using Nd AG laser in infertile women with polycystic ovary syndrome.Reprod Med Biol. 2003; 2: 37-40Crossref Google Scholar). In brief, THLOD was performed under general anesthesia in the lithotomy position. After disinfections, a Hys-cath (Sumitomo Bakelite Co. Ltd., Tokyo, Japan) was inserted into the uterine cavity for chromotubation. Tubo-ovarian structures and tubal passage were carefully investigated using THL (Circon ACMI, Stamford, CT). Subsequently, ovarian drilling was performed using an Nd:YAG laser (STAGE MY-100; Solar Laser Systems, Minsk, Republic of Belarus) or Holmium laser (VersaPulse; Boston Scientific, Boston, MA) to ablate the portions of the ovarian cortex. A sterile quartz glass fiber measuring 1 mm in core diameter was passed through the operating channel of the laparoscope using a special laser fiber steering device with a deflectable tip. The power used ranged up to 10 W. The focused laser beam was used from a distance of 1.5–3.0 mm to create approximately 40 holes on the surface of each ovary. Serum hormonal profiles obtained before and after THLOD were compared. Preoperative serum LH, FSH, LH/FSH, and testosterone concentrations were 13.6 ± 1.8 mIU/mL, 8.9 ± 3.7 mIU/mL, 1.9 ± 1.1, and 59.0 ± 44.6 ng/dL, respectively. Those values after THLOD were 7.2 ± 3.0 mIU/mL, 7.5 ± 2.4 mIU/mL, 1.0 ± 0.5, and 39.8 ± 21.3 ng/dL, respectively. The serum LH and testosterone concentrations significantly decreased after THLOD (P<.01 and P=.01, respectively), whereas that of FSH and LH/FSH did not. However, the LH/FSH values normalized in five patients. Except for one patient who dropped out of this study, six patients recovered and had regular ovulatory cycles without developing OHSS. In four (67%) of six patients, pregnancies were established: one by timed intercourse during the spontaneous cycle, two by intrauterine insemination (IUI) following clomiphene-FSH-HCG treatment, and one by IVF-ET. The pregnancy courses in these patients have been uneventful to this point. There were no intra- or postoperative complications of THLOD. In the present study, endocrine alterations and the clinical outcome of infertile women with PCOS after THLOD were investigated to clarify the usefulness of this new technique. Although lasers include CO2, argon, KTP, Nd-YAG, and Holmium, the technique and success rates have been similar to that of electrocautery (15Farquhar C. Vandekerckhove P. Arnot M. Lilford R. Laparoscopic “drilling” by diathermy or laser for ovulation induction in anovulatory polycystic ovary syndrome.Cochrane Database Syst Rev. 2000; : CD001122PubMed Google Scholar). Fernandez et al. reported the usefulness of THL for the treatment of PCOS by ovarian drilling (12Fernandez H. Alby J.-D. Gervaise A. de Tayrac R. Frydman R. Operative transvaginal hydrolaparoscopy for treatment of polycystic ovary syndrome a new minimally invasive surgery.Fertil Steril. 2001; 75: 607-611Abstract Full Text Full Text PDF PubMed Scopus (91) Google Scholar, 13Fernandez H. Watrelot A. Alby J.D. Kadoch J. Gervaise A. de Tayrac R. et al.Fertility after ovarian drilling by transvaginal fertiliscopy for treatment of polycystic ovary syndrome.J Am Assoc Gynecol Laparosc. 2004; 11: 374-378Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar). They performed ovarian drilling using bipolar electrosurgery by THL in 80 CC-resistant anovulatory women with PCOS. During a mean follow-up of 18.1 months, 73 (91%) patients recovered regular ovulatory cycles. The cumulative pregnancy rate was 60% for spontaneous and stimulated cycles, with 40% imputed to drilling alone (13Fernandez H. Watrelot A. Alby J.D. Kadoch J. Gervaise A. de Tayrac R. et al.Fertility after ovarian drilling by transvaginal fertiliscopy for treatment of polycystic ovary syndrome.J Am Assoc Gynecol Laparosc. 2004; 11: 374-378Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar). The present study demonstrated the same effectiveness for THLOD. No complications occurred; however, they did not describe endocrine alterations following THLOD. On the basis of our study, serum LH and testosterone concentrations significantly decreased after THLOD, whereas those of FSH and LH/FSH did not (Fig. 1). In a recent review (4Donesky B.W. Adashi E.Y. Surgically induced ovulation in the polycystic ovary syndrome wedge resection revisited in the age of laparoscopy.Fertil Steril. 1995; 63: 439-463Abstract Full Text PDF PubMed Google Scholar), it was demonstrated that the immunoreactive LH level was significantly decreased after a transient increase immediately after classic laparoscopic surgery. Moreover, most studies reported a postoperative decrease of testosterone levels. As for the serum FSH concentration, most reports did not show a significant decrease. Therefore, the present data by THLOD also supported their conclusions. These hormonal changes are of considerable interest; however, the significance of these postoperative endocrine alterations is not yet clear (4Donesky B.W. Adashi E.Y. Surgically induced ovulation in the polycystic ovary syndrome wedge resection revisited in the age of laparoscopy.Fertil Steril. 1995; 63: 439-463Abstract Full Text PDF PubMed Google Scholar). In conclusion, THLOD appears to be an alternative minimally invasive surgery in PCOS patients, facilitating appropriate endocrine alterations.