Anovulation is a very important component of polycystic ovarian syndrome and it is this that majorly contributes to infertility in these women. Besides lifestyle changes and medical methods for ovulation induction, one still fails to achieve an ideal scenario at times and that is a single, good quality follicle. Because of high costs of IVF which uses gonadotropins, and also multifetal pregnancies, it may be advisable to widen the net and use minor surgical methods like ovarian diathermy.

1. What is the status o
of surgic
of pol
cal interv
p
patients
ovarian
lycystic
ventions
syndrom
s for infe
me?
ertility in

2. Apollo Medicine 2012 September
Volume 9, Number 3; pp. 202e205 Review Article
What is the status of surgical interventions for infertility in patients
of polycystic ovarian syndrome?
Geeta Chadha
ABSTRACT
Anovulation is a very important component of polycystic ovarian syndrome and it is this that majorly contributes to
infertility in these women.
Besides lifestyle changes and medical methods for ovulation induction, one still fails to achieve an ideal scenario at
times and that is a single, good quality follicle.
Because of high costs of IVF which uses gonadotropins, and also multifetal pregnancies, it may be advisable to widen
the net and use minor surgical methods like ovarian diathermy.
Copyright © 2012, Indraprastha Medical Corporation Ltd. All rights reserved.
Keywords: Infertility, PCOS, Bariatic surgery, Laparotomy
INTRODUCTION
Surgical treatment in the form of ovarian wedge resection
by laparotomy was first proposed for the treatment of infer-tility
in women with polycystic ovary syndrome (PCOS) by
Stein and Leventhal in 1935.1 However, this procedure was
later largely abandoned, despite promising outcomes of
initial series, owing to the risk of postoperative adhesions
and substantial loss of ovarian tissue, and was supplanted
by the use of medical ovulation induction agents such as
clomifene citrate and gonadotropins.2
However, surgical approaches to ovulation induction
have continued to play a part in the management of infer-tility
associated with PCOS both in the form of laparo-scopic
ovarian diathermy, essentially a less traumatic
modern version of ovarian wedge resection, and bariatric
surgery. Surgical approaches to infertility are largely
restricted to cases of anovulation, usually associated with
PCOS, and include laparoscopic ovarian drilling/diathermy
(LOD) and bariatric surgery for morbid obesity and
infertility.
LAPAROSCOPIC OVARIAN DRILLING
LOD, a less invasive modification of ovarian wedge resection,
was first described in women with PCOS by Gjønæss in 1984
who reported ovulation and pregnancy rates as 92 and 58%,
respectively.3 Since this time, LOD using both electrocautery
(diathermy) and laser vaporization has been performed to
create multiple (four to ten) puncture holes in the ovarian
cortex and stroma; the mechanism of action is poorly under-stood
but is believed to be similar to that of ovarian wedge
resection with destruction of ovarian androgen-producing
thecal cells, leading to local (conversion of androgenic intrafol-licular
environment to an estrogenic one) and systemic (reduc-tion
in serum levels of androgens and luteinizing hormone
together with an increase in follicle-stimulating hormone
levels) endocrine changes that are thought to promote follicular
recruitment, maturation and subsequent ovulation.4 In a narra-tive
review reporting on the efficacy of LOD based predomi-nately
on observational studies, the spontaneous ovulation
and pregnancy rates ranged from 54 to 76% and 28 to 56%
at 6 months, and 33 to 88% and 54 to 70% at 12 months.
Senior Consultant, Obstetrics & Gynaecology, Indraprastha Apollo Hospitals, New Delhi 110076, India.
email: geeta_chadha@hotmail.com
Received: 22.5.2012; Accepted: 2.7.2012; Available online: 7.7.2012
Copyright 2012, Indraprastha Medical Corporation Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.apme.2012.07.004

3. The status of surgical interventions for infertility in patients of polycystic ovarian syndrome Review Article 203
The most current systematic review and meta-analysis of
randomized controlled trials (RCTs) examining all RCTs of
infertile clomiphene citrate-resistant (CCR) women with
PCOSundergoingLODdid not identify any RCTs comparing
LOD with placebo/no treatment. However, there were five
RCTs (338 CCR randomized patients) comparing LOD
(6e12 months of follow-up) versus gonadotropin ovulation
induction (three to six treatment cycles), and meta-analysis
showed no difference in live-birth rate per patient, ongoing
pregnancy rate per patient, ovulation rate per patient, miscar-riage
rate per pregnancy or quality of life between the two
interventions, but there was a reduction in multiple pregnancy
rate per ongoing pregnancy (1 vs17%, respectively; odds ratio
[OR]: 0.13; 95% CI: 0.03e0.59) with LOD in CCR PCOS
patients. There were also less direct costs withLODcompared
with gonadotropins.4
Therefore, LOD has been recommended by an expert
International Consensus Group as second-line therapy in
CCR PCOS.5 A subsequent RCT, also supporting this
recommendation, has therapy in CCR PCOS.5 A subse-quent
RCT, also supporting this recommendation, has
demonstrated no difference between LOD and up to six
cycles of clomifene citrate in terms of live birth, pregnancy,
ovulation and miscarriage rates in therapy-naive women
with PCOS.6
Two RCTs with conflicting results have compared met-formin
to LOD in CCR PCOS.7,8 The first of the RCTs to
be published compared metformin to LOD in 120 over-weight
(BMI 25e30 kg/m2) CCR women with PCOS
with follow-up over 6 months and found no difference in
ovulation rate per cycle (55 vs 53%; p 0.05) or clinical
pregnancy rate per patient (72 vs 56%; relative risk [RR]:
1.28 with 95% CI: 0.99e1.70 favoring metformin) but
a reduced miscarriage rate per pregnancy (15.4 vs 29%;
p 0.05), higher live-birth rate per patient (59 vs 36%;
RR: 1.63 with 95% CI: 1.08e2.46) and lower costs (50
vs V1050; p 0.05) with metformin.8,9
The later RCT to be published compared metformin with
LOD in 110 CCR PCOS patients with a mean BMI of
36 kg/m2 who were also insulin resistant, with follow-up
over 6 months or 30 weeks (whichever occurred first). In
this study, metformin was less efficacious than LOD with
a reduced ovulation rate per cycle (33 vs 51%; RR: 2.05
with 95% CI: 1.4e2.9; p ¼ 0.001), pregnancy rate per cycle
(4 vs 8%; RR: 2.19 with 95% CI: 1.03e4.63; p ¼ 0.03),
and cumulative pregnancy rate per patient (20 vs 38%;
RR: 2.47 with 95% CI: 1.05e5.81; p ¼ 0.03) in conjunc-tion
with a higher proportion of patients who never ovu-lated
(33 vs 14%; RR: 2.85 with 95% CI: 1.11e7.29;
p ¼ 0.02) but no difference in first trimester miscarriage
rate per pregnancy (18 vs 19%; RR: 1.05 with 95% CI:
0.16e6.9; p ¼ 0.09).7
The same group of researchers who published the first of
the RCTs comparing metformin with LOD subsequently
conducted an RCT comparing metformin combined with
clomifene citrate with LOD, and reported a higher ovula-tion
rate per cycle (72 vs 56%, respectively; p ¼ 0.023)
and lower cost of treatment (119.6 vs US$316.8, respec-tively;
p 0.001) but no difference in cumulative preg-nancy
rate (61 vs 62%, respectively; p ¼ 1.0),
miscarriage rate per pregnancy (17 vs 13%, respectively;
p ¼ 1.0) or cumulative live-birth rate (52 vs 54%, respec-tively;
p ¼ 1.0) in 55 randomized CCR PCOS patients
with a mean BMI of 30 kg/m2 (all had a BMI 35 kg/
m2) over 6 months follow-up.10
Despite a risk of postoperative adhesions following
LOD,5 a single RCT has shown that a second-look laparo-scopic
adhesiolysis performed 3 months following LOD in
CCRwomen with PCOS has no benefit in terms of pregnancy
or miscarriage rates per patient over 6 months follow-up.11
In summary, LOD is recommended as a second-line
therapy in CCR PCOS patients and is an alternative to
gonadotropin therapy with equal efficacy but lower risk
of multiple pregnancy and cost. There is conflicting
evidence as to whether metformin alone or LOD is more
beneficial in terms of reproductive outcome. Based on
a single small RCT with a primary end point of live-birth
rate and sample size defined arbitrarily,10 there was no
evidence of a difference in pregnancy or live-birth rate
between 6-months treatment with either clomifene citrate
combined with metformin or LOD.
BARIATRIC SURGERY
Bariatric or weight-loss surgery in the general population
results in approximately 15e30% weight loss that is sus-tained
in the long term.12 A Cochrane review of bariatric
surgery in the general population found that such surgery
resulted in greater weight loss than conventional treatment
in obesity (BMI 30 kg/m2) and a reduction in comorbid-ities
such as diabetes and hypertension based on three RCTs
and three prospective cohort studies.13 However, this
review did not assess fertility outcomes and reproductive
outcomes and reported that caseecontrol and cohort studies
show improved fertility and a reduction in obstetrical
complications such as gestational diabetes, macrosomia
and hypertensive disorders of pregnancy, but the incidence
of intra-uterine growth restriction appears to be increased.
No conclusions could be drawn regarding the risk of
preterm labor and miscarriage.14 Another systematic review
of bariatric surgery in the general population assessed.
A recent review on the treatment of obesity in PCOS pub-lished
by an expert International Panel of PCOS Researchers

4. 204 Apollo Medicine 2012 September; Vol. 9, No. 3 Chadha
appointed by the Androgen Excess and PCOS Society identi-fied
two uncontrolled observational studies in morbidly obese
and overweight PCOS women who have reported improve-ment
in menstrual cyclicity, ovulation and natural concep-tion.
15 This same review also reported that while bariatric
surgery is a potential future treatment option for obese
PCOS women, the criteria for performing such bariatric
surgery are still largely debatable and more scientific research
is required. However, a consensus was reached in the British
Fertility Society guidelines that fertility treatment should be
deferred in the general population of women who are
morbidly obese until they have lost weight to below a BMI
of 35 kg/m2.16 The results of pregnancies achieved after bari-atric
surgery have recently been reviewed.17 The review
supports the conclusion that the risk of adverse maternal
and neonatal outcome could be reduced in women who are
morbidly obese with PCOS by bariatric surgery before preg-nancy.
However, the review also identifies the lack of high-quality
information. Further studies are recommended.
SUMMARY
Laparoscopic ovarian drilling
d Laparoscopic ovarian drilling (LOD) is a second-line
therapy in clomifene citrate-resistant (CCR) women
with PCOS that is equally effective as three to six treat-ment
cycles of gonadotropin ovulation induction in
terms of fertility outcome, but with a lower risk of
multiple pregnancy and less direct costs.
d There is a conflicting randomized controlled trial (RCT)
evidence as to whether metformin alone or LOD is more
beneficial in terms of reproductive outcome.
Bariatric surgery
d There is a lack of published RCTs on bariatric surgery in
PCOS and further research, both observational studies
and RCTs, are recommended.
CONFLICTS OF INTEREST
The author has none to declare.
ACKNOWLEDGMENTS
The author would like to acknowledge Medscape, CREI;
Women Health Education, Michael F. Costello, MBBS,
FRANZCOG, William L. Ledger, MBBS, for the material
presented here.
REFERENCES
1. Stein IF, Leventhal ML. Amenorrhea associated with bilateral
polycystic ovaries. Am J Obstet Gynecol. 1935;29:181e191.
2. Unlu C, Atabekoglu CS. Surgical treatment in polycystic
ovary syndrome. Curr Opin Obstet Gynecol. 2006;18(3):
286e292.
3. Gjønæss H. Polycystic ovarian syndrome treated by ovarian
electrocautery through the laparoscope. Fertil Steril.
1984;41(1):20e25.
4. Farquhar C, Lilford RJ, Marjoribanks J, Vandekerckhove P.
Laparoscopic ‘drilling’ by diathermy or laser for ovulation
induction in anovulatory polycystic ovary syndrome.
Cochrane Database Syst Rev. 2007;3:CD001122 [Cochrane
systematic review of ovarian drilling. A thorough summary
up to 2006].
5. Thessaloniki ESHRE/ASRM-Sponsored PCOS Consensus
Workshop Group. Consensus on infertility treatment related
to polycystic ovary syndrome. Hum Reprod. 2008;23(3):
462e477.
6. Amer SA, Li TC, Metwally M, Emarh M, Ledger WL.
Randomized controlled trial comparing laparoscopic ovarian
diathermy with clomiphene citrate as a first-line method of
ovulation induction in women with polycystic ovary
syndrome. Hum Reprod. 2009;24(1):219e225.
7. Hamed HO, Hasan AF, Ahmed OG, Ahmed MA. Metformin
versus laparoscopic ovarian drilling in clomiphene- and
insulin-resistant women with polycystic ovary syndrome. Int
J Gynaecol Obstet. 2010;108(2):143e147.
8. Palomba S, Orio F Jr, Nardo LG, et al. Metformin administration
versus laparoscopic ovarian diathermy in clomiphene citrate-resistant
women with polycystic ovary syndrome: a prospective
parallel randomized double-blind placebo-controlled trial.
J Clin Endocrinol Metab. 2004;89(10):4801e4809.
9. Moll E, Van Der Veen F, Van Wely M. The role of metformin
in polycystic ovary syndrome: a systematic review. Hum
Reprod Update. 2007;13(6):527e537.
10. Palomba S, Falbo A, Battista L, et al. Laparoscopic ovarian
diathermy vs clomiphene citrate plus metformin as second-line
strategy for infertile anovulatory patients with polycystic
ovary syndrome: a randomized controlled trial. Am J Obstet
Gynecol. 2010;202(6):E571eE578 [Most recent randomized
controlled trial of ovarian drilling versus medical treatment
of polycystic ovary syndrome anovulation].
11. Gurgan T, Urman B, Aksu T, Yarali H, Develioglu O,
Kisnisci HA. The effect of short-interval laparoscopic lysis
of adhesions on pregnancy rates following Nd-YAG laser
photocoagulation of polycystic ovaries. Obstet Gynecol.
1992;80(1):45e47.
12. Buchwald H, Williams SE. Bariatric surgery worldwide 2003.
Obes Surg. 2004;14(9):1157e1164.

5. The status of surgical interventions for infertility in patients of polycystic ovarian syndrome Review Article 205
13. Colquitt JL, Picot J, Loveman E, Clegg AJ. Surgery for
obesity. Cochrane Database Syst Rev. 2009;2:CD003641
[Cochrane systematic review of bariatric surgery. Useful
general knowledge but not focussed on the management of
anovulation].
14. Guelinckx I, Devlieger R, Vansant G. Reproductive outcome
after bariatric surgery: a critical review. Hum Reprod Update.
2009;15(2):189e201 [Up to date review of the use of bariatric
surgery for treatment of obesity-related infertility that is well
referenced].
15. Moran LJ, Pasquali R, Teede HJ, Hoeger KM, Norman RJ.
Treatment of obesity in polycystic ovary syndrome: a position
statement of the Androgen Excess and Polycystic Ovary
Syndrome Society. Fertil Steril. 2009;92(6):1966e1982.
16. Balen AH, Anderson RA. Impact of obesity on female repro-ductive
health: British fertility society, policy and practice
guidelines. Hum Fertil (Camb). 2007;10(4):195e206.
17. Maggard MA, Yermilov I, Li Z, et al. Pregnancy and fertility
following bariatric surgery: a systematic review. JAMA.
2008;300(19):2286e2296.

6. Apollo hospitals: http://www.apollohospitals.com/
Twitter: https://twitter.com/HospitalsApollo
Youtube: http://www.youtube.com/apollohospitalsindia
Facebook: http://www.facebook.com/TheApolloHospitals
Slideshare: http://www.slideshare.net/Apollo_Hospitals
Linkedin: http://www.linkedin.com/company/apollo-hospitals
BBlloogg:: http://www.letstalkhealth.in/