Gonadotropin Outcomes Cumulative live birth rates are similar when gonadotropins are compared to clomiphene for ovulation induction when the goal is monofollicular ovulation and a maximum of six ovulatory cycles is similarly recommended (141). When compared to other anovulatory patients, PCOS patients using gonadotropins are at higher risk for multiple gestations (36%), ovarian hyperstimulation syndrome (4.6%), and cycle cancellation (10%) because of their high numbers of baseline antral follicles (141,180, 181). Cancellation should be strongly considered in patients who reach E2 levels 1,000 to 2,500 pg/mL, have three or more follicles 16 mm or larger, or two or more follicles 16 mm or larger plus two or more follicles 14 mm or larger (141). Sequential use of gonadotropins and either clomiphene or aromatase inhibitors has been associated with lower gonadotropin requirements and lower cancellation rates and treatment duration without compromising pregnancy rates. The addition of aromatase inhibitors is associated with a lower number of dominant follicles and lower maximum E2 levels (182–184).
Table 32.8 Different Types of Available Gonadotropin Preparations
FSH, follicle-stimulating hormone; LH, luteinizing hormone; hMG, human menopausal gonatropin; IM, intramuscularly; SC, subcutaneously; N/A, not applicable.
Table 32.9 Contraindications to Gonadotropins for the Treatment of Infertility in Women 1.
Primary ovarian failure with elevated follicle-stimulating hormone levels 2.
3.
An organic intracranial lesion such as a pituitary tumor 4.
5.
6.
Prior hypersensitivity to the particular gonadotropin 7.
Sex hormone–dependent tumors of the reproductive tract and accessory organs 8.
From Physicians desk reference. Micromedex (R) Healthcare Series Vol. 107. Thompson PRD and Micromedex Inc., 1974–2004, with permission.
Surgical Treatment For clomiphene-resistant patients, surgical ovarian drilling has been performed as an alternative to the outdated ovarian wedge resection in an effort to decrease ovarian androgen-producing tissue and to promote ovulation without the risk of multiple pregnancy seen with gonadotropin administration (141,185). Drilling 3 to 15 puncture sites per ovary is typically performed via laparoscopy using electrocautery and diathermy or laser, although transvaginal ultrasound-guided and vaginal hydro-laparoscopy procedures have been reported (186–195). Successful drilling has been performed with the harmonic scalpel (190). Within 12 months after ovarian drilling, cumulative ovulation, clinical pregnancy, and live birth rates are 52%, 26% to 48%, and 13% to 32%, respectively. These outcomes are similar to those using gonadotropins, but ovarian drilling carries a lower multiple gestation rate. Outcomes are not significantly different when diathermy or laser are used for drilling, but they are compromised with patient age greater than 35 years or basal FSH greater than 10 mIU/mL (185,187). The risks of ovarian drilling include surgical complications, adhesions, recurrence of anovulation, and a theoretical risk of ovarian failure (185,196).