Trial Information

Transvaginal Ultrasound-Guided Ovarian Interstitial Laser Treatment in Anovulatory Women With Polycystic Ovarian Syndrome: A Randomized Prospective Study on the Effect of Laser Dose Used on the Outcome

Materials and methods Subject selection Fifty-six patients with anovulatory infertility due
to PCOS were included in the study between January 2005 and December 2007. All women
presented with oligo-/amenorrhea and anovulation for at least 2 years and were seeking
pregnancy. The mean (± SD) age was 29.1 ± 3.1 years and the mean duration of infertility 3.3
± 2.0 years. The mean body mass index (BMI) was 22.9 ± 3.5 kg/m2. All subjects had
polycystic ovaries on transvaginal ultrasound scan (TVS) (Aloka-1000, UST-985, 5 MHz
transvaginal probe, Aloka Co. Ltd, Tokyo, Japan), and the diagnosis of PCOS was made
according to criteria of The Rotterdam (The Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus
Workshop Group, 2003). Serum concentrations of FSH (5.4±2.3 IU/L), LH (11.8±3.2IU/L) and T
(3.79±1.54nmol/L) were assessed at the third day of progesterone-induced bleeding (natural
progesterone injection; Guangzhou Minxing pharmaceutical company, Guang-Zhou, China). TVS
examination revealed bilateral ovarian enlargement and 10-30 subcapsular follicles of 2-8 mm
in diameter in unilateral ovary with a stromal hypertrophy. All cases have received
incremental clomifene citrate (CC) doses (50, 100, and 150mg), to which they failed to
respond. A normal hysterosalpingography or laparoscopy had to have been recorded in the past
three years prior to ovarian interstitial laser treatment. Any contraindications to surgery,
previous treatment with LOD and the presence of tubal or male factors for infertility were
considered as exclusion criteria. 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.

Protocol Study design This was a prospective, randomized study. Fifty-six subjects meeting
the enrolled criteria were randomly divided into four groups of A、B、C、D according to a
computer-generated random list. Randomization occurred after patients agreed to inclusion in
the study (Figure 1). After randomization, women who were allocated in same group were
intervened with same laser dosage during ovarian interstitial laser treatment. For each
group of A、B、C、D, the number of laser coagulation points made in their ovaries as follows:
group A, one coagulation point per ovary; group B, two points; group C, three points; group
D, four to five points. To each point, the size of laser coagulation zone was 10 mm in
diameter (a light spot of diameter 10 mm on the ovarian plane monitored by transvaginal
ultrasound).

Techniques of ovarian interstitial laser treatment The procedure of transvaginal
ultrasound-guided ovarian interstitial laser treatment has been detailed in previous data
(Zhu et al., 2006). All participants were treated on the third day after
progesterone-induced menstruation period. An intramuscular injection of 50-100mg of
Pethidine (Pethidine Hydrochloride Injection, Shenyang First Pharmaceutical, NEPG,
Shen-Yang, China) was administered to each women about 30 minutes before starting the
operation. After emptying their bladder, the women were placed in lithotomy. They were then
prepared using an aseptic vulva and vaginal douche. TVS was performed and the widest ovarian
plane was found. 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 three to five laser coagulation points have be made in unilateral
ovary. For each treatment point, a fibre optic cable of 400 um in diameter was sent to
intraovarian point by means of a 17-gauge, 35-cm-long needle (K-OPS-1035-Cook IVF; Brisbane,
Australia) and the electrical laser (XH-YAG-100 Laser; Wuhan Xinghua Photoelectricity Co.
Ltd, Wu-Han, China) was activated persistently for two to five minutes with a power of 3-5 W
and current of 8-10 A, until a 10-mm light spot appeared on the ovarian plane. In group A,
only one laser treatment point was made per ovary; and group B, two points; group C, three
points; group D, four to five points. The women stayed in bed for two to three hours after
the surgery, after which they were re-examined with TVS in order to rule out intra-abdominal
haemorrhage prior to discharge.

Postoperative Monitoring Serum hormone concentrations At the second, fourth and sixth month
after the operation, a blood sample was taken on day three of menstrual cycle for
measurement of serum levels of LH, FSH, testosterone, prolactin (PRL), estradiol (E2) and
progesterone if the women had a regular ovulation and menstrual cycle. If not, the blood
sample was taken on day three of progesterone-induced withdrawal bleeding. Another blood
sample was taken on day 21 of the same cycle in order to measure the serum concentration of
progesterone when ovulation could not be diagnosed by TVS.

Follicle development and ovulation Follicular growth and ovulation was monitored monthly by
TVS at four to five days intervals after the operation. The scanning was repeated after two
to three days when the leading follicle reached diameter of 12 mm. When the dominant
follicles reached a diameter of 16 mm. LH surge was detected by urinalysis. Combined this
result with TVS, ovulation and the timing of sexual intercourse could be confirmed. If the
ovulation intervals during the six postoperative months were within a range of 21-35 days,
the woman was documented as a responder having regular ovulation. If spontaneous ovulation
and menstruation did not occur during six 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 16-19 days following ovulation. The pregnancy rate was calculated based
on the women who conceived. Miscarriage would be considered, if gestational sac without
cardiac action or previous cardiac action stopped, although a urine pregnancy test was
positive.

Adverse effects Adverse effects, including intra-abdominal haemorrhage, infection, injuries
of internal organs and failure of ovarian function, were recorded.

Analysis of the data Women were divided into four groups according to the number of laser
coagulation points made in their ovarian interstitial as follows: group A (n=14) treated
with one laser coagulation point per ovary, group B (n=14) two points, group C (n=14) three
points, group D (n=14) four to five points. 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, testosterone, PRL, progesterone, E2 levels. Analysis of variance was used for
statistical analysis. The ovulation rate and pregnancy rate were calculated based on the
cases of postoperative spontaneous ovulation and pregnancy. Contingency table analysis was
used to compare success rates, with P<0.05 considered statistically significant.