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IN THE NAME OF GOD
In women resistant to clomiphene citrate, or metformin combined with clomiphene, the next step has been gonadotropin therapy. While this treatment causes ovulation in most women, it has several potential problems:
●It can be very difficult to titrate the dose of gonadotropins to achieve monofollicular ovulation.●The high frequency of multifollicular ovulation results in multiple gestations in 30 percent or more of women [4].●The risk of ovarian hyperstimulation syndrome (OHSS) during gonadotropin administration is substantial, necessitating careful monitoring during treatment.●The costs of therapy are high, especially considering that only one ovulatory event will occur with each course of treatment.●For those women who do become pregnant, the frequency of spontaneous abortion appears to be higher than when conception occurs after spontaneous ovulation
The literature now contains reports of over 1000 women in whom partial ovarian resection or ablation was done via a laparoscopic approach in the hope of restoring some
ovulatory function .
Pregnancy has occurred in approximately 55 percent of women undergoing this procedure, a figure that compares favorably with conception rates after three to six cycles of gonadotropin therapy
After laparoscopic surgery to restore ovulation, serum androstenedione concentrations fall transiently and serum LH, testosterone, and inhibin concentrations fall more
permanently .
Conversely, serum FSH concentrations rise.
The net effect is normalization of some of the endocrine abnormalities associated with the polycystic ovary syndrome
The more popular method at this time is the use of a unipolar needle electrode that is insulated proximal to the distal 1 or 2 centimeters.
Four to six punctures of each ovary can produce substantial thermal damage to the stromal compartment while, in theory, producing minimal surface damage, and a minimal amount of
adhesion formation .
Of 15 women who underwent a second-look laparoscopy, 11 women were found to be free of adhesions. Four women had periadnexal adhesions that were filmy, minimal, and found on the ovarian surface only.
important considerations for laparoscopic surgery include:
●Patients should be of normal weight, because the procedure is often unsuccessful in obese women (body mass index >30 kg/m2 body surface area)
●Women should have no additional infertility factors. When PCOS is the only cause of infertility, 80 to 87 percent become pregnant after surgery .In contrast, the pregnancy rates are only 14 to 29 percent in women who also have an additional tubal factor, endometriosis, or an oligospermic male partner .
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Laparoscopic ovarian drilling
Gonadotropin ovulation induction
Advantages One-time, minimally invasive procedureNormalizes endocrinologic and ultrasonographic abnormalitiesRestores ovulatory cycles for many yearsPregnancy and live birth rates are comparable to gonadotropin ovulation induction with no increase in multiple pregnancy or OHSSImproves response to gonadotropin superovulation for IVFMay improve acne and hirsutism
Comparable pregnancy and live birth rates to ovarian drilling without surgery
Widespread availability
Comparison between laparoscopic ovulation induction and gonadotropin ovulation induction
Disadvantages
Surgical risks inherent with laparoscopy
Postoperative adhesions
Diminished reserve ovarian
Few clinicians in the United States offer it
Significantly higher risk for multiple pregnancy
Higher risk of OHSS
Greater cost compared with ovarian drilling
High patient inconvenience due to daily injections and frequent visits for monitoring
No benefit beyond the treatment cycle