KatCarney

Controversies in Infertility and Assisted Reproduction

April 24-27, 2003; Berlin, Germany

from Medscape Ob/Gyn & Women's Health
Posted 05/13/2003
Peter Kovacs, MD

from Medscape Ob/Gyn & Women's Health

Polycystic Ovary Syndrome (PCOS)
L Mettler, MD (Germany),[15] was asked to talk about a rather controversial area, surgical treatment of PCOS. PCOS was described decades ago, but still the exact etiology is not known. Part of the problem is that the disease is heterogeneous, with a rather mixed clinical picture. Initially, PCOS was treated surgically by the resecting part of the ovary and subsequently by drilling holes into it. During the past decade, more and more evidence has pointed to a metabolic defect -- insulin resistance -- as a crucial factor in the pathophysiology of PCOS. Various medical treatment options can be used to treat hirsutism, hyperandrogenism, infertility, or irregular cycles, depending on the presenting complaint.

Dr. Mettler advocated the laparoscopic treatment for PCOS patients, as it is a single procedure that has lasting effects (1-2 years) and is associated with a fairly high rate of spontaneous pregnancies (about 70% after 1 year of follow-up). She made the point that PCOS should be evaluated through a multidisciplinary approach (eg, endocrinology, internal medicine, and gynecology). She said that she would recommend initial treatment with CC or insulin-sensitizing medications. Although this point was not stressed, and actually was only mentioned during the discussion, to my mind this is the most important message. PCOS is a metabolic problem, and the metabolic abnormality should be treated if we want to avoid all the possible complications (short-term, long-term) that are associated with it. Laparoscopic drilling will restore cyclic ovarian function in up to 80% of the cases, but it will not affect hyperinsulinemia and the metabolic consequences. Therefore, it is ineffective in preventing the long-term cardiovascular complications. In addition, study results are always better than results achieved by general practitioners because of the surgical expertise of those performing the trials.

One also should not forget that more than 50% of PCOS patients are obese and are therefore at a higher risk for complications during anesthesia and laparoscopic surgery. Further, how many times should we operate on a woman with PCOS? What do we do with those who are not "cured" by the first surgery and then present with the same problem? How can we avoid fertility-compromising adhesion formation after surgery? How do we affect ovarian function/reserve when we destroy part of the primordial follicle pool? These questions all need to be answered. Therefore, surgical treatment should be reserved as a last option, after the currently available medical options have all failed.

source: http://www.medscape.com/viewarticle/453587_5

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