Maternity and Child Healthcare Hospital, Shen-Zhen, People s Republic of China

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1 Transvaginal ultrasound-guided ovarian interstitial laser treatment in anovulatory women with polycystic ovary syndrome: a randomized clinical trial on the effect of laser dose used on the outcome Wenjie Zhu, M.M., a Zhihong Fu, M.D., a Xiumin Chen, M.M., a Xuemei Li, M.B., a Zhen Tang, M.M., b Yonghong Zhou, M.B., c and Qian Geng, M.M. c a Department of Reproductive Health; b Department of Gynecology; and c Department of Centre Laboratory, Shen-Zhen City Maternity and Child Healthcare Hospital, Shen-Zhen, People s Republic of China Objective: To explore an optimal laser dose of transvaginal ultrasound guided ovarian interstitial laser coagulation in management of anovulation in patients with polycystic ovary syndrome (PCOS). Design: Randomized, controlled trial. Setting: A reproductive medical center. Patient(s): Eighty women with PCOS and clomiphene citrate resistant infertility underwent ultrasound-guided transvaginal ovarian interstitial yttrium aluminum garnet laser treatment. All subjects were divided randomly into four groups of A, B, C, and D. Intervention(s): Group A, one coagulation point per ovary; group B, two points; group C, three points; group D, four to five points. Main Outcome Measure(s): Postoperative ovulation rate, pregnancy rate, and some biochemical parameters. Result(s): The rates of ovulation in groups C (75.00%, 95% confidence interval [CI]: 51% 91%) and D (80.00%, 95% CI: 56% 94%) within 6 postoperative months were significantly higher than in groups A (5.00%, 95% CI: 0% 25%) and B (15.00%, 95% CI: 3% 38%). The pregnancy rates in groups C (45.00%, 95% CI: 23% 69%) and D (40.00%, 95% CI: 19% 64%) also were significantly higher than in groups A (5.00%, 95% CI: 0 25%) and B (10.00%, 95% CI: 1% 32%). The mean serum T levels were significantly lower in groups C ( nmol/l) and D ( nmol/l) compared with groups A ( nmol/l) and B ( nmol/l). Conclusion(s): One and two intraovarian laser coagulation points per ovary are associated with poor outcomes. Three points per ovary seem to represent the plateau of effective dose for the ovarian interstitial laser treatment in PCOS. (Fertil Steril Ò 2010;94: Ó2010 by American Society for Reproductive Medicine.) Key Words: Anovulation, dose laser, ovarian interstitial, polycystic ovary syndrome, transvaginal, ultrasoundguided In 2005, we designed and evaluated the effectiveness of the transvaginal ultrasound guided ovarian interstitial laser treatment in 23 anovulatory women with clomiphene citrate (CC) resistant polycystic ovary syndrome (PCOS) as a new method of ovulation induction in infertile women with PCOS, with a >80% ovulation rate and 36% pregnancy rate during 6 postoperative months (1). However, just as the technique of laparoscopic ovarian diathermy or drilling applied in the management of anovulatory women with CC-resistant PCOS, in which a satisfactory treatment result usually associates with the appropriate number of punctures made, Received February 6, 2009; revised February 27, 2009; accepted March 3, 2009; published online May 5, W.Z. has nothing to disclose. Z.F. has nothing to disclose. X.C. has nothing to disclose. X.L. has nothing to disclose. Z.T. has nothing to disclose. Y.Z. has nothing to disclose. Q.G. has nothing to disclose. Supported by a grant for scientific research from the Shenzhen Bureau of Science and Technology (No ). Reprint requests: Wenjie Zhu, M.D., No. 3012, Fu-Qiang Road, Shen- Zhen, , Guang-Dong, People s Republic of China (FAX: ; zhuwenjie542004@yahoo.com.cn). power setting, and duration of each puncture (2 6), an optimal outcome of ovarian interstitial laser treatment also depends on the appropriate number of intraovarian laser coagulation points. What is an optimal laser dosage applied to the ovarian interstitial laser treatment? To explore an optimal laser dose for this new treatment protocol, we designed the present randomized clinical trial to compare the effectiveness among women treated with different laser doses (number of ovarian interstitial coagulation points) and to try to determine what is the optimal laser dose for women with PCOS accepted for transvaginal ultrasound guided ovarian interstitial laser treatment. MATERIALS AND METHODS Study Design This was a randomized clinical trial involving patients with CC-resistant PCOS undergoing transvaginal ultrasound guided ovarian interstitial laser treatment at our Reproductive Medical Center. The subjects were recruited and studied for 268 Fertility and Sterility â Vol. 94, No. 1, June /$36.00 Copyright ª2010 American Society for Reproductive Medicine, Published by Elsevier Inc. doi: /j.fertnstert

2 a period of 30 months between January 2006 and June The study was approved by the Ethics Committee of Shen- Zhen Maternity and Child Healthcare Hospital and the Institutional Review Board of Shen-Zhen Bureau of Science and Technology of China. Subjects all signed an informed consent form. Sample Size In a rough estimate before the study, the ovulation rates were about 10% to 20% for the laser dose of one or two points per ovary and 60% to 80% for three to five points. Therefore, the sample size of 15 to 20 per group is the result calculated from the comparison of multiple sample rates (a ¼ 0.05, b ¼ 0.10). According to the guideline made by the Institutional Review Board of Shen-Zhen Bureau of Science and Technology, the study had to be accomplished within 3 years. We calculated that, in our center, a sample size of 80 to 90 subjects would need to be recruited over approximately a 30-month period. We ended up with 80 patients in this study. Subject Selection Eighty patients with PCOS were enrolled by our clinicians from our infertility treatment clinic between 2005 and All women presented with oligomenorrhea or amenorrhea and anovulation for at least 2 years and were seeking pregnancy. The mean ( SD) age was years, and the mean duration of infertility years. The mean body mass index was kg/m 2. All subjects had polycystic ovaries on transvaginal ultrasound scan (Aloka-1000, UST-985, 5 MHz transvaginal probe; Aloka Co. Ltd, Tokyo, Japan), and the diagnosis of PCOS was made referring to the Rotterdam criteria (7). Serum concentrations of FSH ( IU/L), LH ( IU/L), and T ( nmol/l) were assessed at the third day of P-induced bleeding (natural P injection; Guangzhou Minxin Pharmaceutical Company, Guang-Zhou, China). Transvaginal ultrasound scan examination revealed bilateral ovarian enlargement and 10 to 30 subcapsular follicles of 2 to 8 mm in diameter in a unilateral ovary with stromal hypertrophy. All patients had received incremental CC doses (50, 100, and 150 mg), after which ovulation failed. A normal hysterosalpingography or laparoscopy had to have been recorded in the past 3 years before ovarian interstitial laser treatment. Any contraindications to surgery, previous treatment with laparoscopic ovarian diathermy, and the presence of tubal or male factors for infertility were considered as exclusion criteria. The selection and enrollment for each subject were decided by three clinicians together. All subjects were informed that this procedure was a new technique and that the optimal laser dose has not been confirmed, although previously some patients were treated by this technique for the same purpose with a good outcome. During the selection procedure, five eligible subjects opted not to participate when counseled about the possible risk, and three other subjects who declined randomization were excluded. Finally, 80 eligible patients were enrolled. Randomization First, 80 random numbers generated by means of computer were divided randomly into four groups: A, B, C, and D. Then, all subjects enrolled were arranged in an enrolled date order, and at this time, the sequence of random numbers became the sequence of all subjects. Therefore, 80 subjects were divided randomly into groups A, B, C, and D. The random allocation sequence was concealed in a closed, dark-colored envelope until the surgeries were assigned, and specifically just before entering the operating room. Randomization occurred after patients agreed to participate in the study. After randomization, women who were allocated in same group were given the same laser dosage during ovarian interstitial laser treatment. For each group of A, B, C, and D, the number of laser coagulation points made in their ovaries was as follows: group A, one coagulation point per ovary; group B, two points; group C, three points; group D, four or five points. To each point, the size of the laser coagulation zone was nearly 10 mm in diameter (a light spot of 10-mm diameter on the ovarian plane monitored by transvaginal ultrasound). Each patient underwent the ovarian interstitial laser treatment performed by same experienced operator, who assessed the size of each coagulation point and the operation condition. The treating sequence of subjects was as same as the sequence enrolled. The study was not double-blinded, because the clinicians were aware of the treatment group. Techniques of Ovarian Interstitial Laser Treatment The procedure of transvaginal ultrasound guided ovarian interstitial laser treatment has been detailed previously (1). All participants were treated on the third day after P-induced bleeding. An intramuscular injection of 50 to 100 mg of pethidine (pethidine hydrochloride injection; Shenyang First Pharmaceutical, NEPG, Shen-Yang, China) was administered to each woman about 30 minutes before starting the operation. After emptying their bladder, the women were placed in lithotomy position. They were then prepared with use of an aseptic vulva and vaginal douche. The procedure proceeded in the following four steps; 1. Location and puncture: The transvaginal probe was moved from side to side to find the largest or the second largest ovarian plane. The operator then punctured the predetermined intraovarian point with the long 17- gauge, 35-cm-long needle (K-OPS-1035-Cook IVF; Brisbane, Australia). These points were always at least 10 mm distance from the surface of the ovary and 5 mm from each other. If intraovarian coagulation occurred at a spot 10 mm (actually a near sphere) in diameter away from the ovarian surface, the coagulation was contained to at least a 5-mm distance from the surface so that there was minimal damage to the ovarian surface. Usually, one to three intraovarian points can be predetermined in the widest ovarian plane; in other words, one to three laser coagulation points can be accomplished on the widest ovarian plane. If not, the next largest ovarian plane was chosen as the next option until some setting Fertility and Sterility â 269

3 TABLE 1 Characteristics of 80 anovulatory women with PCOS who underwent ovarian interstitial laser treatment for infertility: comparison between women treated with different laser doses (number of ovarian interstitial coagulation points). All patients (N [ 80) Group A (n [ 20) Group B (n [ 20) Group C (n [ 20) Group D (n [ 20) Age (y) 29.1 (3.1) 28.2 (3.2) 29.7 (3.4) 30.2 (2.5) 28.3 (3.4) Body mass index (kg/m 2 ) 22.9 (3.5) 21.9 (2.9) 22.4 (3.9) 23.8 (2.7) 23.4 (3.6) Duration of infertility (y) 3.3 (2.0) 3.7 (2.3) 3.6 (1.7) 3.5 (1.8) 3.6 (2.0) Serum LH (IU/L) 13.7 (4.6) 12.9 (3.7) 13.7 (4.7) 13.5 (4.5) 14.3 (5.3) Serum FSH (IU/L) 6.5 (1.4) 5.9 (1.3) 6.6 (2.0) 6.8 (1.6) 6.7 (1.7) Serum LH/FSH ratio 2.1 (0.7) 2.2 (0.9) 2.1 (0.6) 2.0 (0.6) 2.1 (0.8) Serum T (nmol/l) 2.9 (0.7) 3.3 (0.8) 2.8 (0.6) 2.7 (0.7) 3.0 (0.7) Dimensions of ovary (mm) a 28.7 (3.6) 28.2 (3.3) 28.5 (3.5) 29.1 (4.0) 28.4 (3.6) Menstrual cycle pattern Regular, n (%) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) Oligomenorrhea, n (%) 30 (38) 9 (43) 8 (43) 6 (29) 7 (36) Amenorrhea, n (%) 50 (62) 11 (57) 12 (57) 14 (71) 13 (64) Hirsutism/acne Yes, n (%) 24 (30) 6 (29) 9 (43) 4 (21) 6 (29) No, n (%) 56 (70) 14 (71) 11 (57) 16 (79) 14 (71) Infertility Primary, n (%) 58 (73) 13 (64) 16 (79) 14 (71) 16 (79) Secondary, n (%) 22 (27) 7 (36) 4 (21) 6 (29) 4 (21) Note: Values are given as mean (SD) and number of observations as n (%). The results shown are those obtained before the operation. a The values are given as average of two dimensions of ovary. laser coagulation points had been made in the unilateral ovary. 2. The fiberoptic cable passes through the needle: After aspiration of the fluid (blood or follicular fluid) present inside the long needle, an assistant cut the soft tube connected to the long needle, and a fiberoptic cable of 400 mm in diameter was inserted into the long needle up to the marked point. The tip of the fiberoptic cable had to reach the tip of the long needle, so the operator could draw the long needle back about 10 mm until the bare fiber was out of the tip of the long needle. 3. Laser coagulation: The electrical laser (XH-YAG-100 Laser; Wuhan Xinghua Photoelectricty Co. Ltd., Wu-Han, China) was activated persistently for 2 to 5 minutes with a power of 3 to 5 W and current of 8 to 10 A, until a 10-mm light spot appeared on the ovarian plane. 4. The fiberoptic cable withdrawal and relocation: The fiberoptic cable then was withdrawn carefully from the long needle with care taken not to pull the needle out of the ovary while withdrawing it toward the surface. The next point was then located and punctured with repetition of the procedure as listed in steps 2 to 4. This procedure continued until some treatment points on the unilateral ovary were completed. The needle was then withdrawn. This procedure was repeated on the contralateral ovary as well. Ideally, there should only be one puncture site on the surface of each ovary, and care should be taken to minimize surface damage to the ovaries. In group A, only one laser treatment point was made per ovary; group B, two points; group C, three points; and group D, four or five points. The women stayed in bed for 2 to 3 hours after the surgery, after which they were reexamined with a transvaginal ultrasound scan to rule out intra-abdominal hemorrhage before discharge. Postoperative Monitoring Serum hormone concentrations At the second, fourth, and sixth month after the operation, a blood sample was taken on day 3 of the menstrual cycle for measurement of serum levels of LH, FSH, T, PRL, E 2, and P if the women had a regular ovulation and menstrual cycle. If not, the blood sample was taken on day 3 of P-induced withdrawal bleeding. Another blood sample was taken on day 21 of the same cycle to measure the serum concentration of P when ovulation could not be diagnosed by transvaginal ultrasound scan. Follicle development and ovulation Follicular growth and ovulation was monitored monthly by transvaginal ultrasound 270 Zhu et al. Ovarian interstitial laser in PCOS Vol. 94, No. 1, June 2010

4 FIGURE 1 Rates of spontaneous ovulation, conception, and conversion of oligomenorrhea or amenorrhea to regular cycles in women with PCOS after ovarian interstitial laser coagulation treatment with use of different laser doses (number of ovarian interstitial coagulation points). (A) Spontaneous ovulation rates during 6 postoperative months (P<.001). (B) Conception rates during 6 postoperative months (P<.01). (C) Rate of conversion to regular cycles after operation (P<.01). A scan at 4- to 5-day intervals after the operation. The scanning was repeated after 2 to 3 days when the leading follicle reached a diameter of 12 mm. When the dominant follicles reached a diameter of 16 mm, LH surge was detected by urinalysis. Combining this result with transvaginal ultrasound scan, ovulation and the timing of sexual intercourse could be confirmed. If the ovulation intervals during the 6 postoperative months were within a range of 21 to 35 days, the woman was documented as a responder having regular ovulation. If spontaneous ovulation and menstruation did not occur during 6 postoperative months, the woman was categorized as a nonresponder. The women whose status was between both would be categorized as having irregular ovulation. Pregnancy and miscarriage A urine pregnancy test was performed if spontaneous menstruation did not occur during 16 to 19 days after ovulation. The pregnancy rate was calculated on the basis of the women who conceived. Miscarriage would be considered if a gestational sac of 7 to 8 pregnant weeks was without cardiac action or previous cardiac action stopped, although a urine pregnancy test was positive. Adverse effects Adverse effects, including intra-abdominal hemorrhage, infection, injuries of internal organs, and failure of ovarian function, were recorded. B C Analysis of the Data The means SD of the baseline and postoperative second, fourth, and sixth month values among the four groups were calculated for the serum LH, FSH, T, PRL, P, and E 2 levels. Analysis of variance to do an overall comparison between groups (ANOVA) (Newman-Keuls method of q-test was used to compare individual groups) and a linear test for trend (linear regression) were used to see by how much the mean of the outcome increased or decreased per dose. The ovulation and pregnancy rates were calculated on the basis of the cases of postoperative spontaneous ovulation and pregnancy. A c 2 test for trend (or a linear-by-linear association test) was used to compare the ovulation and conception proportions among four groups (a fourfold table was used to compare individual groups and P values would be corrected when 1%theoretical frequency [T]<5), and a logistic regression was used to give an odds ratio for each increase in dosage with 95% confidence intervals. The Statistical Package for the Social Sciences (SPSS 13.0; SPSS Inc., Chicago, IL) was used for statistical analyses. Statistical significance was set at P<.05. RESULTS The clinical and endocrinologic characteristics of the 80 women are shown in Table 1. Analysis of variance showed no difference among groups A to D in these characteristics. There were no losses to follow up. Ovulation The rates of ovulation from groups A to D, including subjects with regular or irregular ovulation, were 5.00% (1 of 20), Fertility and Sterility â 271

5 TABLE 2 Endocrine changes after ovarian interstitial laser treatment in 80 women with anovulatory infertility due to PCOS: comparison among women treated with different laser doses (number of ovarian interstitial coagulation points). Group A (n [ 20, c [ 59) Group B (n [ 20, c [ 52) Group C (n [ 20, c [ 39) Group D (n [ 20, c [ 41) P value (ANOVA) LH (IU/L) 11.6 (3.9) (4.9) 6.9 (2.0) a 7.5 (4.5) a <.001 FSH (IU/L) 6.1 (0.6) 6.6 (0.9) 6.6 (1.0) 7.0 (1.1).466 LH/FSH ratio 1.9 (0.7) 2.1 (0.8) 1.1 (0.3) a 1.1 (0.6) a <.001 T (nmol/l) 3.1 (0.6) 3.0 (0.6) 2.1 (0.6) a 2.1 (0.4)a <.001 Note: Values are given as mean (SD) of the postoperative second, fourth, and sixth month. c ¼ cycle; n ¼ number of subjects. a P<.01 vs. groups A and B % (3 of 20), 75.00% (15 of 20), and 80.00% (16 of 20), respectively. A c 2 test for trend analysis showed a statistically significant difference in incidences of ovulation among the four groups of A through D (linear-by-linear association test, P<.001) (see Fig. 1A). The rates of groups C and D were significantly higher than of groups A (P<.001; P<.001) and B (P<.001; P<.001). With a logistic regression model analysis to see the effect of dosage on ovulation, the odds ratio values from group A to D were 1.000, 3.353, 7.550, and 4.234, respectively. These results are listed in Table 2. Conception The conception rates for 6 postoperative months in groups A, B, C, and D were 5.00% (1 of 20), 10.00% (2 of 20), 45.00% (9 of 20), and 40.00% (8 of 20), respectively. Contingency table c 2 test showed a statistically significant difference among the four groups (linear-by-linear association test, P<.001). The conception rates were significantly higher in groups C and D than in groups A or B (Fisher s exact test or linearby-linear association test, P<.05; P<.05) (see Fig. 1B). Via a logistic regression model, the relationship between the dosage and pregnancy odds ratio from groups A to D was 1.000, 2.111, 3.943, and 2.233, respectively. These results are listed in Table 2. One subject in group D decided to postpone pregnancy because of a family dispute, and the other woman in group B had a miscarriage at pregnancy week 9. Menstrual Pattern All women in this study had oligomenorrhea or amenorrhea before the treatment. After ovarian interstitial laser coagulation treatment, one woman in group C conceived before having the next menstrual cycle. A c 2 test showed that the frequencies of regular menstrual cycles were significantly different among the four groups (A through D) (P<.01). The frequencies of regular menstrual cycles were significantly higher in groups C (11 of 20, 55.00%) and D (10 of 20, 50.00%) than in groups A (1 of 20, 5.00%) (P<.01; P<.01) and B (2 of 20, 10.00%) (P<.01, P<.01) (see Fig. 1C). Endocrine Changes The postoperative endocrine values changed over time. The trend of hormone levels is depicted in Figure 2. The serum LH level, T level, and LH/FSH ratio reduced significantly at 2, 4, and 6 months after ovarian interstitial laser treatment (see Fig. 2A, C, and D). The mean level of the postoperative endocrine values is presented in Table 3. An ANOVA showed that the mean postoperative LH and T levels, as well as the LH/FSH ratio, were statistically significantly different among the four groups (P<.001; P<.001; P<.001). The mean serum T levels were significantly lower in groups C ( nmol/l) and D ( nmol/l) compared with groups A ( nmol/l) (P<.001; P<.001) and B ( nmol/l) (P<.001; P<.001). The mean LH value and LH/FSH ratio in groups C and D also were significantly lower than in groups A and B. See Table 3. A linear test for trend (linear regression) shows that there was a linear regression relationship between the changes of several hormones (independent variable) and increase of laser dose (dependent variable). Each increase of dose with one point would decrease the mean LH level IU/L (y ¼ x, R 2 ¼ 0.918), the mean serum T level nmol/l (y ¼ x, R 2 ¼ 0.925), and LH/FSH ratio value (y ¼ x, R 2 ¼ 0.834). Adverse Effects All of the women finished their surgical procedure of ovarian interstitial laser treatment, and there were no adverse events. The surgical procedure lasted approximately 35 to 40 minutes. DISCUSSION In this randomized clinical trial, we evaluated the effect of the laser dose applied at ovarian interstitial laser coagulation treatment on the clinical and biochemical outcome in 80 women with PCOS. To the best of our knowledge, this is the first series to report on the laser dose-response relationship of ovarian interstitial laser treatment. 272 Zhu et al. Ovarian interstitial laser in PCOS Vol. 94, No. 1, June 2010

6 FIGURE 2 Change trend of serum LH, FSH, and T levels and LH/FSH ratio for postoperative second, fourth, and sixth month in groups A, B, C, and D. (A) LH. (B) FSH. (C) LH/FSH ratio. (D) T. A B C D In previous data published, the optimal clinical outcomes of ovarian interstitial laser coagulation treatment to manage the anovulatory women with PCOS-related infertility were achieved by making three to five intraovarian coagulation points per ovary with each point of diameter 10 mm (1). The estimated volume of these three to five treatment points is nearly 2 to 4 ml according to the sphere of diameter of 10 mm per point. In this study, the highest spontaneous ovulation (70% 80%) and pregnancy (40% 45%) rates within 6 postoperative months occurred in groups C (three points per ovary) and D (four to five points), not in groups A (one point) and B (two points). This indicated not only that three to five treatment points per ovary is the optimal laser dose of ovarian interstitial laser treatment but also that the technique described previously was reproducible and valid and need not be changed. In terms of our observation it is difficult to make six or more treatment points per ovary, because there hardly is any clear ovarian plane to be found after five treatment points are made. Laparoscopic ovarian diathermy as a traditional technique has been used to manage anovulation in patients with CC-resistant PCOS infertility for the past 3 decades. The number of punctures have varied markedly between three and 25 per ovary with power settings between 30 and 400 W (2, 6). Such a wide range of puncture points made in an ovary with different outcomes in different studies can be explained by the variation in techniques used in laparoscopic ovarian diathermy, including [1] using different instruments (e.g., needles, scissors, biopsy forceps) to deliver the energy to the ovary; [2] applying a different amount of energy to the ovary (measured in joules, equivalent to power in watts multiplied by the duration of electricity applied in s per puncture); and [3] distribution of the thermal energy, either localized to a few holes or more widely spread over many holes with varying depths of penetration. Therefore, it is important that the comparison between different studies of laparoscopic ovarian diathermy should take into consideration the total amount of thermal energy delivered to each ovary, not just the number of holes made in the ovary. However, in this respect, the ovarian interstitial laser coagulation treatment is different when compared with laparoscopic ovarian diathermy. First, the size of the coagulation zone in the ovarian interstitium is related positively to the thermal energy delivered to ovarian interstitium and can clearly be monitored by transvaginal ultrasound scan as a coagulation zone appearing in an ovarian plane. Different laser doses yielded different sizes of the coagulation zone; in the other words, the different sizes of the coagulation zones represented the different laser doses (the power and persistent time). Second, the power used in ovarian interstitial laser coagulation treatment usually is at 3 to 5 W (1, 8), much lower than the power applied in laparoscopic ovarian diathermy ( W); therefore it is easier to control the size of the coagulation zone in ovarian interstitial laser coagulation treatment than to control the damage range of the hole made in laparoscopic ovarian diathermy. If the coagulation zone is of similar sizes, the different number of coagulation points will represent the different laser doses. Therefore, only by analyzing (or controlling) the effect of number of laser coagulation points made in each ovary on the clinical outcome can we know the dose-response relationship of ovarian interstitial laser coagulation treatment. Fertility and Sterility â 273

7 TABLE 3 Results of c 2 test (linear-by-linear association) and logistic regression in rates of ovulation and pregnancy for groups A, B, C, and D. Ovulation Pregnancy Group Value P Odds ratio (95% CI) Value P Odds ratio (95% CI) Overall ( ) ( ) A vs. B ( ) ( ) A vs. C ( ) ( ) A vs. D ( ) ( ) B vs. C ( ) ( ) B vs. D ( ) ( ) C vs. D ( ) ( ) Note: CI ¼ confidence interval. It should be pointed out that the initial coagulation point with a diameter of 10 mm on an ovarian plane may overrepresent the size of the real coagulation zone, because some fluid or blood yielded during the procedure also appears as strong light on the ovarian plane. The 10-mm diameter of light spot is then possibly a mixture containing coagulation tissue and fluid, and the real range of the coagulation zone is revealed possibly several days after the fluid is absorbed. However, in this study, we ignored this effect, and the size of the coagulation zone used to judge the effect of the number of ovarian laser coagulation points on the outcome, including the clinical and endocrine outcome, was the size shown by transvaginal ultrasound scan at the operation time. In this study, the application of one laser point per ovary in group A was found to produce poor clinical or endocrine change for 6 months after the operation; one treatment point per ovary seems therefore to be an ineffective laser dose for anovulatory patients with PCOS. Two laser points applied per ovary (group B) also resulted in a significantly poorer outcome than the results seen in groups C and D in terms of restoration of menstrual regularity, spontaneous ovulation, and conception rates. The two points per ovary probably does represent the threshold dose (i.e., the lowest dose at which a response could be seen). These clinical results also can be explained in terms of the change in odds ratio values given by logistic regression. The best clinical and endocrine outcome occurred in groups C (three points per ovary) and D (four or five points), in which there was a nearly 80% spontaneous ovulation rate and 40% to 45% pregnancy rate during 6 postoperative months. As such the efficacy of transvaginal ultrasound guided ovarian interstitial laser treatment in the management of anovulatory patients with PCOS is similar to that of the traditional ovarian wedge resection and laparoscopic ovarian diathermy (9, 10). At the same time, we show that three points per ovary is a plateau laser dose of ovarian interstitial treatment, because the result of four or five points per ovary was not significantly different from that achieved with the application of three points. However, because four or five treating points per ovary did not produce irreversible damage to the ovary, it may not be excessive, but then we do not know what an excessive laser dose for this new treatment method is. Postoperative reduction of serum LH, LH/FSH ratio, and T level occurred in three of four groups. In addition, it is of interest to note that the magnitude of the decrease in LH levels and LH/FSH ratio after ovarian interstitial laser treatment seems to be dose dependent, with the higher reduction being achieved in groups C and D (three to five points per ovary). A linear regression test showed a linear regression relationship between the increase of laser dose and decrease of the mean serum LH, T level, and LH/FSH ratio. This may be explained by the greater reduction of serum T concentrations as a result of greater destruction of the androgen-producing ovarian stroma with higher laser dose (more number of laser coagulation points). As the result, the serum estrogen level decrease because of a reduction in androgen levels (androgens aromatize to estrogen) may be responsible for decreased positive feedback on LH and decreased negative feedback on FSH at the level of pituitary. The endocrine change after ovarian interstitial laser treatment is similar to the change of sex hormones occurring after laparoscopic ovarian diathermy described by Amer et al. (9). However, none of the groups of women in our study showed postoperative increase of the serum FSH level, probably because of the limited number of laser points that can be applied. In this respect, the ovarian interstitial laser treatment is different from laparoscopic ovarian diathermy, in which 15 to 25 punctures per ovary can be made (11, 12). Too many treating points potentially may cause excessive ovarian damage and result in an elevated postoperative serum FSH concentration. According to its pathophysiology, PCOS is manifested clinically by both a hyperandrogenism and state of estrogen 274 Zhu et al. Ovarian interstitial laser in PCOS Vol. 94, No. 1, June 2010

8 excess, which can underlie a disorder of folliculogenesis with increased follicular recruitment, but with an arrest of follicular development at the small antral stage (13). Theoretically, the ovarian interstitial laser treatment should be more effective than laparoscopic ovarian diathermy in management of anovulation in PCOS. This new technique decreased more stroma tissue producing androgens than the laparoscopic ovarian diathermy protocol by intraovarian interstitial laser ablation instead of ovarian surface drilling. However, the ovarian vasculature that distributes mainly in the myeloid tissue possibly will be damaged if intraovarian laser treatment point is performed at the center of the ovary. Therefore, to avoid damage to the ovarian vasculature, intraovarian hemorrhage, and premature ovarian failure, we suggest that the predetermined point of ovarian interstitial treatment had better not be too close to the center of the ovary and the number of treatment points not be many as well. A previous study (14) showed that laparoscopic ovarian diathermy in women with PCOS may result in a decrease in ovarian stromal blood flow velocity. We do not known what the real influence of ovarian interstitial laser, especially of the laser dose (the number of ovarian interstitial laser treatment points), is on the ovarian stromal blood flow. To answer this, a further study is essential. In conclusion, three coagulation points (with diameter of 10 mm per point) per ovary seems to be the plateau dose sufficient to produce an optimal outcome for ovarian interstitial laser treatment in anovulatory women with PCOS. Reducing the laser dose below that level is associated with poorer results and increasing the dose above it does not improve the outcome. REFERENCES 1. Zhu WJ, Li XM, Chen XM, Lin Z, Zhang L. Transvaginal, ultrasoundguided, ovarian, interstitial laser treatment in anovulatory women with clomifene-citrate resistant polycystic ovary syndrome. Br J Obstet Gynaecol 2006;113: Naether OGJ, Fischer R, Weise HC, Geiger-Kotzler L, Delfs T, Rudolf K. Laparoscopic electrocoagulation of the ovarian surface in infertile patients with polycystic ovarian disease. Fertil Steril 1993;60: Merchant RN. Treatment of polycystic ovary disease with laparoscopic low-watt bipolar electrocoagulation of the ovaries. J Am Assoc Gynecol Laparosc 1996;3: Li TC, Saravelos H, Chow MS, Chisabingo R, Coode LD. Factors affecting the outcome of laparoscopic ovarian drilling for polycystic ovarian syndrome in women with anovulatory infertility. Br J Obstet Gynaecol 1998;105: Tulandi T. Laparoscopic treatment of polycystic ovarian syndrome. In: Tulandi T, ed. Atlas of laparoscopic and hysteroscopic techniques for gynecologists. London: Saunders, 1999: Felemban A, Tan SL, Tulandi T. Laparoscopic treatment of polycystic ovaries with insulated needle cautery: a reappraisal. Fertil Steril 2000;73: The Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome. Fertil Steril 2004;81: Beek JF, Kaaijk EM, Van der Veen F, de Boer K, Ankum WM, ten Kate FJ, et al. Interstitial laser treatment of the ovary: an experimental study in goats. Lasers Surg Med 1996;18: Amer SAK, Gopalan V, Li TC, Ledger WL, Cooke ID. Long-term follow-up of patients with polycystic ovarian syndrome after laparoscopic laser: clinical outcome. Hum Reprod 2002;17: Amer SAK, Li TC, Cooke ID. A prospective dose-finding study of the amount of thermal energy required for laparoscopic ovarian diathermy. Hum Reprod 2003;18: Amer SAK, Li TC, Cooke LD. Laparoscopic ovarian diathermy in women with polycystic ovarian syndrome: a retrospective study on the influence of the amount of energy used on the outcome. Hum Reprod 2002;17: Tabrizi NM, Mohammad K, Dabirashrafi H, Nia FI, Salehi P, Dabirashrafi B, et al. Comparison of 5-, 10-, and 15-point laparoscopic ovarian electrocauterization in patients with polycystic ovarian disease: a prospective, randomized study. JSLS 2005;9: Doi SA, Al-Zaid M, Towers PA, Scott CJ, Al-Shoumer KA. Irregular cycles and steroid hormones in polycystic ovary syndrome. Hum Reprod 2005;20: Parsanezhad ME, Bagheri MH, Alborzi S, Schnidt EH. Ovarian stromal blood flow changes after laparoscopic ovarian cauterization in women with polycystic ovary syndrome. Hum Reprod 2003;18: Fertility and Sterility â 275