Surgical management of infertility due to polycystic ovarian syndrome after failure of medical management

ObjectivesTo evaluate surgical management and fertility and pregnancy outcome in women with polycystic ovarian syndrome (PCOS).Study designRetrospective file review and follow-up of 74 consecutive women with PCOS resistant to citrate clomiphene (CC) who underwent ovarian drilling by fertiloscopy with bipolar energy, together with hysteroscopic surgery when indicated (Canadian TASK FORCE II-2).ResultsOf 77 files, only 3 women were lost to follow-up. Mean age was 30.2 years (SD 5.3) [29.0–31.4 CI 95%], and mean BMI 25.6 kg/m2 (SD 6.2) [24.2–27.0 CI 95%]. Pregnancy occurred after drilling in 47 cases (63%), spontaneously in 20 (27%), after ovarian stimulation in 5 (6.7%) and after in vitro fertilization in 22 (29.7%). Laparoscopic conversion was required in 5 cases (6.7%), due to failure to visualize the adnexa (n = 3), or pelvic adhesions (n = 1), or uterine hemorrhage (n = 1). Hysteroscopy detected and simultaneously treated a uterine anomaly in 18 of 74 patients: uterine septum (n = 10, 13%), T-shaped uterine cavity (n = 3, 4%), endometrial polyp (n = 2, 2.7%), endometrial hypertrophy (n = 2, 2.7%), and synechiae (n = 1, 1.3%).The mean overall delay to pregnancy was 11.1 months (SD 8.5) [8.7–13.5 CI 95%] and to spontaneous pregnancy, 7 months (SD 7.6) [3.7–10.3 CI 95%]. The mean follow-up was 23.4 months (SD 16.5) [18.1–28.7 CI 95%]. After multivariate analysis, the likelihood of pregnancy was significantly associated with previous ovarian stimulation by FSH (OR = 2.28, 95% CI = 1.08–4.83) and initial FSH level (OR = 0.52, 95% CI = 0.29–0.93).ConclusionOvarian drilling by hydrolaparoscopy is an effective treatment for CC-resistant PCOS. The high rate of associated uterine anomalies justifies simultaneous hysteroscopic surgery.