14 - Surgical management of anovulatory infertility in polycystic ovary syndrome

Summary

Introduction

The management of anovulatory infertility in polycystic ovary syndrome (PCOS) has traditionally involved the use of clomifene citrate and then gonadotrophin therapy or laparoscopic ovarian surgery in those who are clomifene resistant. The principles of therapy are first to optimise health (for example, weight loss for those who are overweight) before commencing therapy and then induce regular unifollicular ovulation, while minimising the risks of ovarian hyperstimulation syndrome and multiple pregnancy. Weight loss improves the endocrine profile and the likelihood of ovulation and a healthy pregnancy.

From the 1930s to the early 1960s, wedge resection of the ovary was the only treatment for PCOS. Wedge resection required a laparotomy and removal of up to 75% of each ovary, and often resulted in extensive pelvic adhesions. The modern-day, minimal access alternative to gonadotrophin therapy for clomifene-resistant PCOS is laparoscopic ovarian surgery, usually employing diathermy or laser. Laparoscopic ovarian surgery has therefore replaced ovarian wedge resection as the surgical treatment for clomifene resistance in women with PCOS. It is free of the risks of multiple pregnancy and ovarian hyperstimulation and does not require intensive ultrasound monitoring. Furthermore, ovarian diathermy is said to be as effective as routine gonadotrophin therapy in the treatment of clomifene-insensitive PCOS, although the evidence for this will be discussed in this chapter.