Hello hzeer-ga!
I?m sorry to hear of your wife?s difficulties. I?m sure that this must
be a difficult time for you both, especially considering the various
treatments she has already undergone. I found some information that
answers your question, and I hope that it helps as you are
experiencing what must be a difficult challenge in your lives right
now. I?ll begin by explaining briefly about PCOS and its common signs
and symptoms, although I recognize that you are probably aware of
these. Then I will get to the specifics of your questions.
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PCOS AND INFERTILITY
PCOS (Polycystic Ovarian Syndrome) is a condition that affects as many
as 10% of all women, or more. While researchers have been able to
define a fairly consistent set of symptoms for PCOS, they have not
found a singe cause, as of yet. It is a leading cause of infertility,
and no cure has yet been found. The most common symptoms include:
* Irregular menstrual cycles, or even the lack of cycles
* Multiple ovarian cysts in many cases
* Elevated blood pressure
* Acne
* Insulin resistance, or even diabetes
* Infertility
* Increased body and facial hair, along with alopecia (loss of hair)
* Weight problems
(From the Polycystic Ovarian Syndrome Association
http://www.pcosupport.org/medical/whatis.php)
Other conditions that a physician may consider are ?Cushing?s disease
(overactive adrenal gland), thyroid problems, congenital adrenal
hyperplasia or increased prolactin production by the pituitary gland.?
Blood tests ordered may include thyroid functions, prolactin levels,
17-hydroxyprogesterone, and a dexamethasone suppression test. In many
cases PCOS sufferers will have elevated androgen (male hormone) levels
so these hormones will be tested as well. Insulin resistance is also a
problem so a two-hour glucose tolerance test will probably be
performed. Women with PCOS also have a number of cardiac complications
so tests such as cholesterol, homocysteine, CRP, and PAI-1 levels may
be obtained to assess their cardiac risk factors.
(From the Georgia Reproductive Specialists, http://www.ivf.com/pcostreat.html)
Both of these sites have information regarding basic treatments for
PCOS as well as brief introductions into various reproductive
technologies. Since you have asked about a few things in particular, I
will focus my detailed explanation on these three.
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OVARIAN DRILLING
Ovarian drilling is a laparoscopic procedure, where instruments are
introduced through very small incisions in the abdomen, and the
surgeon uses a camera to guide him or her. A small needle punctures
the cyst in the ovary, and then an electrical current is used to
destroy part of the cyst. At Pregnancy-info.net, they state that
success rates are less than 50%, but they do not specify what outcomes
determine ?success? in their opinions. At any rate, side effects, such
as scarring, could further impact the ability to become pregnant in
the long run.
http://www.pregnancy-info.net/infertility_PCOS.html
A study published in the British Journal of Obstetrics and Gynaecology
in March 1998 discusses success rates in achieving pregnancy after
ovarian drilling. The study enrolled 118 women with documented cases
of PCOS and then performed the procedure on them over a five-year
period. The total conception rate within the first 12 months after the
procedure was 54%. Women who successfully conceived had had ?a shorter
duration of infertility, were treated with diathermy (rather than
laser), had higher pre-operative luteinising hormone [LH] levels, were
younger and were more likely to have ultrasonographic evidence of
polycystic ovarian disease.? When considering only women who had been
infertile for 3 years or less prior to the procedure, the success rate
increases to 79%.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9532997&dopt=Abstract
In March 2005 a study regarding laparoscopic ovarian drilling (LOD)
was published in the European Journal of Obstetrics, Gynecology, and
Reproductive Biology. In this study 45 women who had been
unsuccessfully treated with clomiphene (Clomid) were selected to
undergo LOD. ?Serum testosterone (T), follicle stimulating hormone
(FSH) and luteinizing hormone (LH), fasting insulin and glucose
levels, body mass indexes, modified Ferriman Gallwey (FG) hirsutism
scores of the subjects are recorded before and after the procedure.?
After LOD, 93.3% of the women reported normal menstrual cycles, and
64.4% achieved pregnancy spontaneously. ?The serum levels of T, free
T, LH, LH:FSH ratio, insulin and FG scores were significantly reduced
after LOD, although glucose levels and glucose/insulin ratio remained
unchanged.?
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=15734089&dopt=Abstract
A smaller study was performed in 2002 at the Ayub Medical College in
Abbottabad and the Khyber Medical College in Peshawar, both in
Pakistan. Sixteen women with PCOS were selected to undergo LOD. They
all had a full infertility workup before the procedure, including a
6-month trial of clomiphene. After the procedure 14 (87.5%) women had
regular menstrual cycles and 11 (68.8%) achieved pregnancy.
http://www.ayubmed.edu.pk/JAMC/PAST/15-4/Azizun.htm
In a study published in 2004 in Human Reproduction, they list factors
related to pregnancy success after LOD. They state that, ?marked
obesity, marked hyperandrogenism and/or long duration of infertility
in women with PCOS seem to predict resistance to LOD. High LH levels
in LOD responders appear to predict higher probability of pregnancy.?
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15178663&query_hl=6&itool=pubmed_docsum
A study reviewed in the Cochrane Database in 2006 shows no significant
difference in pregnancy rates after LOD versus treatment with
gonadotropins (LH, FSH, HMG, etc.). About 50% of women will have a
live birth and about 16% will have a miscarriage after achieving
pregnancy. There were fewer multiple births associated with LOD,
however.
http://www.cochrane.org/reviews/en/ab001122.html
A 2003 review article in Reproductive Biology and Endocrinology
discusses various treatment options for infertility and PCOS. The
authors reviewed multiple studies and compiled the data to determine
overall success rates. They report that 82% of women in the studies
experienced ovulation following LOD and 63% achieved pregnancy. This
data compares favorably with a similar Cochrane review. The authors
also state that if ovulation has not been achieved spontaneously after
2-3 months following LOD, adding an ovulation stimulator (like
clomiphene) is more successful at this point than it would have been
before LOD.
http://www.pubmedcentral.gov/articlerender.fcgi?tool=pubmed&pubmedid=14617367
Other patient information sites seem to report the same 50% success
rate for LOD (although I did see rates as high as 75% after 3 years).
For the most part, it looks as though they are using birth rate rather
than pregnancy rate to determine this success. This is the statistic
that will be most important to patients.
http://www.womens-health.co.uk/infertility6.asp
http://www.ivf-infertility.com/infertility/treatment/ovarian11.php
http://www.conceivingconcepts.com/medical/askthedoc/polycystic_ovaries/
http://health.ivillage.com/gyno/gynoovaries/0,,677r,00.html
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HUMAN MENOPAUSAL GONADOTROPIN (HMG) vs. FSH
HMG is a combination of Luteinizing Hormone (LH) and
Follicle-stimulating Hormone (FSH) obtained from the urine of
menopausal females. LH and FSH are the hormones responsible for the
maturation of an egg and its release from the ovary. HMG is an
extremely potent ovulation drug. It is administered as a series of
injections starting about 3 days after a period starts. It is then
given for 7 to 12 days.
http://adam.about.com/reports/000022_7.htm
General information puts the overall ovulatory success rate with HMG
at about 75-85% in ?appropriately selected women.? Its risk of
multiple pregnancies is about 20% per treatment cycle. About one-third
of those cases are triplets or more. Similar risks are cited for FSH.
http://www.ivf-infertility.com/infertility/treatment/ovarian4.php
http://www.ivf-infertility.com/infertility/treatment/ovarian5.php
In the August 2003 Fertility & Sterility, there was an article
discussing HMG and FSH in the treatment of infertility. Fifty women
with unexplained fertility were assigned to either receive HMG or FSH
along with Intrauterine Insemination (IUI), a technique whereby semen
is deposited directly into the uterus, closer to the fallopian tubes
where fertilization occurs. Pregnancy occurred in 15-20% of all women,
regardless of grouping. The length of time necessary to induce
ovulation was less with the HMG group. This, along with the fact that
HMG is less expensive than FSH, means that treatment with HMG is
potentially more cost-effective.
http://www.medscape.com/viewarticle/461801
A Cochrane review comparing HMG to FSH in in-vitro fertilization found
that the success rates were essentially identical, both in terms of
total pregnancies and live births.
http://www.cochrane.org/reviews/en/ab003973.html
Similar results were obtained in a Cochrane review discussing HMG and
FSH in PCOS patients.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11034687&query_hl=13&itool=pubmed_docsum
A study performed at Al-Azhar University in Cairo enlisted 100 women
with PCOS to undergo various infertility treatments. Ultimately,
pregnancies per patient and per treatment cycle (or each time you
begin taking a medication or undergo a procedure) were listed as
follows:
* HMG plus LHRHa (LH-releasing hormone analog): 55% per patient, 18.3% per cycle
* LOD: 45% per patient, 15% per cycle
* HMG plus HCG (human chorionic gonadotropin): 30% per patient, 10% per cycle
* Clomiphene plus HCG: 20% per patient, 6.6% per cycle
* FSH plus HCG: 15% per patient, 5% per cycle
The authors? conclusions are that the best treatment option in PCOS is
HMG plus LHRHa, followed by LOD.
http://www.obgyn.net/pcos/pcos.asp?page=/infertility/articles/pcos_azizetal
Data reported on InfertilityPhysician.com, a site maintained by
Pennsylvania Infertility specialist Michael D. Birnbaum, M.D., states
that there is a 17% pregnancy rate per cycle of treatment for HMG plus
IUI, versus a 7% pregnancy rate with HMG alone.
http://www.infertilityphysician.com/ovulation/unexplained.html
Success rates for FSH alone are about 10%, and with FSH plus IUI, 15-18%.
http://www.babyzone.com/features/content/display.asp?contentid=1728&scf=1002
A 1991 study published in Fertility & Sterility compared HMG to FSH in
PCOS Patients. Thirty women enrolled in the study and were assigned
randomly to receive either drug. Five single pregnancies occurred in
both groups. Ovulation occurred in 70-90% of women in both groups.
This study concludes that low-dose gonadotropins are the key, rather
than one medication in particular.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=1898891&query_hl=13&itool=pubmed_docsum
In a study published by the Journal of the Pakistan Medical
Association in 2004, IUI was performed along with the administration
of clomiphene, HMG, or a combination of the two in order to stimulate
ovulation. There was also a group that received IUI with natural
ovulation. A total of 209 couples participated, achieving pregnancy
rates of 15%. Induced ovulation was more effective than natural
ovulation, with HMG alone being the most effective ovulation
stimulator.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15552282&query_hl=9&itool=pubmed_docsum
General risks for any type of hormonal fertility treatments include:
* Multiple pregnancies?depending on the source, risks run in the
20-25% range. About one-third of those are triplets or more.
* Ovarian Hyperstimulation Syndrome (OHSS or OHS)?this can lead to
electrolyte imbalances, and endangerment of the kidney and liver. The
risk of blood clots and even death is increased. Some common symptoms
of OHSS are abdominal bloating, nausea, vomiting, and shortness of
breath.
* Ruptured/Bleeding ovarian cysts?overproduction of follicles, when
unchecked, can lead to rupture and bleeding.
* Cancer concerns?most concerns have been theoretical, and studies
seem to indicate that cancer risks end up being the same factors that
contributed to the infertility in most cases. There was one small
study implicating HMC in breast cancer cases in women taking the drug
for more than six months. This was an extremely small study, however
and there have been no larger, corroborating studies as of yet.
http://adam.about.com/reports/000022_7.htm
As you can see from the data available, there doesn?t seem to be a
clear-cut answer to which choice is better between HMG and FSH. Each
has its benefits and risks, and these need to be discussed in detail
with your clinician. Obtaining a second (or third) opinion may also be
a good idea.
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There is a wealth of information available about reproductive
technologies, and this is an exciting area of growth in the medical
community. The decision to have a baby along with the frustrations and
disappointments that come along with difficulties conceiving tend to
arouse a complex set of emotions and feelings. I hope that the
research here has been not only informative, but also comforting as
you explore the many options available. In doing this research, it
becomes apparent that many of the success rates are measured over a
period of 6 months up to a year or more, so there is still time to see
what the effects of your wife?s treatments will be (I recognize that
each passing month seems long when trying to have a baby). I wish you
all the best in your efforts! If you need any further clarification
please let me know how I can help.
Sincerely,
Boquinha-ga
Search strategy:
Online search
Pubmed.com search (ovarian drilling success, hmg success pcos)
Cochrane Database search?www.cochrane.org (ovarian drilling, hmg success)
Search terms:
PCOS
Ovarian drilling ?success rate?
Hmg infertility
Hmg ?success rate?
FSH ?success rate?
hmg pcos pregnancy |
