FOR WOMEN WHO HAVE PCOS
In laparoscopic ovarian drilling, an insulated needle unipolar electrode is inserted in the ovary perpendicular to the surface to create 6 to 12 evenly spaced punctures using 40 watts of coagulating current for 2 seconds at each point. The mechanism of action is unclear, but it is thought that the destruction of androgen-producing stroma is responsible for the reduction in testosterone level, increase in follicle-stimulating hormone (FSH), and return to FSH cyclicity in 80% of cases.
- Among obese women who have oligo-ovulation, ovarian drilling (FIGURE) is generally reserved for patients who have not responded to clomiphene or gonadotropins. This procedure has proved to be as effective as clomiphene administration, with the advantage that it does not increase the risk of multiple gestation and leads to longstanding improvement in one third of patients.5 Ovarian drilling is a modification of ovarian wedge resection for women who have PCOS. The mechanism of action is not clear, but it is thought that destruction of adrogen-producing stroma causes an immediate reduction in testosterone, an increase in follicle-stimulating hormone (FSH), and a return to FSH cyclicity in 80% of cases. These effects can persist for several years, and a pregnancy rate of approximately 60% can be attained in less than 6 months. Clomiphene-resistant women may be more responsive to the drug after ovarian drilling, and the risk of ovarian hyperstimulation appears to be reduced. Ovarian drilling is less effective in obese women than in women of normal weight. Complications include adhesions around the ovary and reduced ovarian reserve.
- Assisted reproductive technology (ART) is sometimes used in this population, but it is less likely to lead to pregnancy and live birth, for unknown reasons.2,3 We inform obese women that a BMI below 30 is desirable before ART.
WHAT THIS EVIDENCE MEANS FOR PRACTICE
Overall, the management of infertility in obese women is extremely challenging because of its multiple causes—many of which are still not well understood. However, the profound implications of obesity for all aspects of reproduction make it imperative that we pay more attention to identification and treatment of obesity in the infertile population.
IVF is cited by Nobel Committee for its “benefit to mankind”
On December 10, 2010, Robert Edwards, PhD, was awarded the Nobel Prize in Physiology or Medicine for his innovative and pioneering work to create IVF. In presenting the award, the Committee noted that Professor Edwards’ work “represents a monumental medical advance that can truly be said to confer the greatest benefit to mankind.”
Professor Edwards is the embryologist who performed the basic science and laboratory work, along with Dr. Patrick Steptoe, who provided clinical care, which led to the birth of the world’s first IVF baby, Louise Brown, on July 25, 1978. Since then, IVF has become the most successful treatment for infertility and is available in more than 100 countries. The delivery rate for each single IVF attempt is about 25% globally; it more than doubles in selected patients who have a good prognosis. In some countries, almost 5% of all births arise from IVF; in the United States, that figure is about 1%. The International Committee Monitoring ART (ICMART) estimates that more than 4 million babies have been born from IVF around the world.
Prof. Robert Edwards (left) holds the infant Louise Brown
Early road was rocky
Despite the broad and significant success of IVF, Professor Edwards struggled for years against scientific and social opposition. His research was opposed by some on ethical and religious grounds, and the United Kingdom refused to fund some of his early work. The initial lack of support for IVF has transformed into acceptance as infertility has been recognized as a disease by many governments and the World Health Organization (WHO). In addition, the Centers for Disease Control and Prevention (CDC) has recognized infertility as a public health issue.
Nevertheless, most insurers still provide inadequate IVF coverage because of misperceptions about infertility and lack of recognition that it is a disease that globally affects 9% of all women of reproductive age, with male-partner sperm problems contributing to the problem in about 50% of cases.
IVF technologies achieve many goals
Over the past 32 years, IVF has revolutionized reproductive medicine and the treatment of infertility and brought an entirely new science to human reproduction. Specific IVF technologies that have changed the face of medicine include:
- intracytoplasmic sperm injection (ICSI) to treat male factor infertility
- cryopreservation or vitrification of sperm, eggs, and embryos to allow optimal results from IVF and to help cancer patients have babies after treatment
- preimplantation genetic diagnosis (PGD) to prevent major genetic diseases. (For more on PGD, see the January 2009 “Update on Prenatal Counseling” in our archive at www.obgmanagement.com.)