4. Surgery and ovulation induction

#### 4.1. Use of ovarian drilling to induce ovulation

Laparoscopic ovarian drilling has been demonstrated to induce ovulation in women with PCOS. This method of ovulation induction is used for clomiphene-resistant and FSH-resistant PCOS. The mechanism involved in the ovarian diathermy is that it leads to the correction of hypersecretion of LH brought about by modification of the ovarian pituitary feedback. The practice is to drill into both ovaries. However, unilateral drilling has been found to bring about ovulation in either ovaries as well [1, 15, 26]. A net meta-analysis comparing its use as an ovulation induction agent did not find it superior to placebo or no treatment. It had no significantly higher chance at pregnancy or higher pregnancy rates in women with PCOS [6]. In patients with clomiphene resistance where it is being advocated, LOD was found to reduce testosterone and Luteinising hormone levels and associated with more regular cycles, higher ovulation and pregnancy rates compared to metformin alone even though metformin results in more attenuation of luteinizing hormone [28]. Emerging evidence shows that unilateral ovarian drilling has similar effects as bilateral ovarian drilling in bringing about ovulation, pregnancy rates, and life birth rates. Reported pregnancy rates are lower than in treatment with HMG [24]. The seeming comparative advantage of LOD is in its one-off therapy, especially in patients with clomiphene citrate resistance, sustained reversal of the pathology, high ovulation and pregnancy rates, reduced risk of multiple pregnancy, and ovarian hyperstimulation syndrome as well as patient's acceptability [26]. LOD with elecrocautery was found to be superior in treating anovulation compared to laser drilling or use of gonadotropins in clomiphene-resistant PCOS patients. The major side effects of LOD are the fact that it is a theater procedure and requires anesthesia; it may reduce ovarian reserve and has been associated with peri-ovarian adhesions [29, 30]. When ranked according to efficacy of ovulation induction, the systemic review found out that the clomiphene citrate in combination with metformin was the most efficacious followed by follicle-stimulating hormone, letrozole, metformin, clomiphene, tamoxifen, laparoscopic ovarian drilling, and placebo or no treatment in that order. This when ranked in percentage efficacy of effectiveness showed 90, 82, 80, 50, 46, 27, 22 and 3%, respectively [6].

The controversy with the method of treating anovulatory infertility in women with PCOS will continue for some time. The systemic review found out that the clomiphene citrate in combination with metformin was the most efficacious followed by follicle-stimulating hormone, letrozole, metformin, clomiphene, tamoxifen, laparoscopic ovarian drilling, and placebo or no treatment in that order. However, when the ranking in terms of live birth rate was done, letrozole, follicle-stimulating hormone, clomiphene-metformin, tamoxifen, clomiphene citrate, metformin, placebo or no treatment was noted. It will therefore seem reasonable to include letrozole, clomiphene citrate and the combination of clomiphene citrate with metformin as possible first-line drugs in the treatment of anovulatory infertility in women with PCOS. While the gonadotropins is reserved as a second-line drug for these women, ovarian drilling is recommended after failure with the gonadotropins or whenever laparoscopy is indicated for any other reason in these women with failed clomiphene resistance. It will be advisable to refer patients that fail to achieve pregnancy using the methods above for assisted reproductive

Ovulation Induction in Women with Polycystic Ovary Syndrome: What is the Optimal Option?

http://dx.doi.org/10.5772/intechopen.70812

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University of Port Harcourt and University of Port Harcourt Teaching Hospital, Port Harcourt,

[1] Sirmans SM, Pate KA. Epidemiology, diagnosis, and management of polycystic ovary

[2] Broekmans FJ, Knauff EA, Valkenburg O, et al. PCOS a clomiphene citrate ording to the Rotterdam consensus criteria: Change in prevalence among WHO-II anovulation and association with metabolic factors. British Journal of Obstetrics and Gynaecology.

[3] ESHRE Capri Workshop Group. Health and fertility in World Health Organization group 2 anovulatory women. Human Reproduction Update. 2012;18:586-599. DOI: 10.1093/

[4] Goodman NF, Cobin RH, Futterweit W, Glueck JS, Legro RS, Carmine E, et al. American Association of Clinical Endocrinologists, American College of Endocrinology, and Androgen Excess and PCOS Society Disease State clinical review: Guide to the best practices in the evaluation and treatment of polycystic ovary syndrome – Part 1. Endo-

syndrome. Clinical Epidemiology. 2014;6:1-13. DOI: 10.2147/CLEP.S37559

2006;113(10):1210-1217. DOI: 10.1111/j.1471-0528.2006.01008.x

crine Practice. 2015;21(11):1291-1300. DOI: 10.4158/EP15748.DSC

therapy for the treatment of their anovulatory infertility.

Vaduneme K. Oriji\* and Kennedy Nyengidiki

\*Address all correspondence to: vadoriji@yahoo.com

Author details

Nigeria

References

humupd/dms019

#### 4.2. Use of bariatric surgery to induce ovulation

Bariatric surgery has been used for weight reduction among highly obese women who had bariatric surgery for just weight reduction. The bariatric surgery in obese PCOS patient also resulted in weight loss, spontaneous ovulation, and pregnancy.

#### 5. Conclusion

However, when the ranking in terms of live birth rate was done, letrozole (81%) gave the best result, followed by follicle-stimulating hormone (74%), clomiphene-metformin (71%), tamoxifen (48%), clomiphene citrate (36%), metformin (30%), placebo or no treatment (10%).

Women with PCOS should undergo pre-conception counseling before any treatment for infertility. The importance of life-style modification, especially weight loss and exercise, should be emphasized and encouraged in overweight women, and smoking and alcohol consumption should be discouraged [24]. More randomized trial to determine the effect of weight loss to ovulation should be undertaken to elucidate clearly the place of weight loss as a means of ovulation of induction considering its affordability and acceptability as a means of treatment.

The controversy with the method of treating anovulatory infertility in women with PCOS will continue for some time. The systemic review found out that the clomiphene citrate in combination with metformin was the most efficacious followed by follicle-stimulating hormone, letrozole, metformin, clomiphene, tamoxifen, laparoscopic ovarian drilling, and placebo or no treatment in that order. However, when the ranking in terms of live birth rate was done, letrozole, follicle-stimulating hormone, clomiphene-metformin, tamoxifen, clomiphene citrate, metformin, placebo or no treatment was noted. It will therefore seem reasonable to include letrozole, clomiphene citrate and the combination of clomiphene citrate with metformin as possible first-line drugs in the treatment of anovulatory infertility in women with PCOS. While the gonadotropins is reserved as a second-line drug for these women, ovarian drilling is recommended after failure with the gonadotropins or whenever laparoscopy is indicated for any other reason in these women with failed clomiphene resistance. It will be advisable to refer patients that fail to achieve pregnancy using the methods above for assisted reproductive therapy for the treatment of their anovulatory infertility.
