Surgical Ovulation Induction in Women with Polycystic Ovary Syndrome: A Systematic Review

Background: Currently clomiphene citrate is the first-line treatment to induce ovulation in women with polycystic ovarian syndrome (PCOS). Surgical therapy with laparoscopic ovarian drilling (LOD) may avoid or reduce the need for gonadotropins. Objective: To determine the effectiveness and safety of LOD compared with ovulation induction in subfertile women with clomiphene-resistant PCOS. Search Strategy: A systematic search was performed on PubMed (1966 to August 2007), the Ovid database (1966 to August 2007), and EMBASE (1974-2007). The search terms included: infertility, menstrual disorder, hirsutism, PCOS, surgical intervention, electrocautery, electrocoagulation, diathermy, drilling, and laparoscopic ovarian drilling, ovulation, pregnancy rate, post operation adhesions and ovarian blood flow. Selection Criteria: Randomized controlled trials of women with clomiphene-resistant PCOS who were treated with LOD to induce ovulation were included. Data Collection and Analysis: 3141 patients from 35 trials preformed in different geographic settings were included. All trials were assessed for quality criteria. We included those trials which followed hormonal changes, ovulation, and pregnancy rates after LOD. The primary outcomes measured were hormonal changes, ovulation, and pregnancy rates as well as ovarian artery blood flow, and the secondary outcome was rate of pelvic organ adhesion. Main Results: The overall ovulation rate after LOD was 79.2% (74.9%-83.5% 95% CI). Of all women who ovulated only 66.6% (60.8%-72.4% 95% CI) conceived. The mean peri-adnexal adhesion rate was 22.7% (21.4%-24% 95% CI). Conclusion: Compared with medical therapy, LOD has many advantages including: to be done once, no need for intensive monitoring, no chance of multiple pregnancy or ovarian hyperstimulation syndrome. LOD effectively decreases ovarian androgens and improves folliculogenesis and increases chance of ovulation and pregnancy rate. Finally, in vitro fertilisation should be considered as the last resort.