• Jing Zhang, Liulin Tang, Linglingli Kong, Taixiang Wu, Liangzhi Xu, Xin Pan, and Guan J Liu.
• Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China.
• Cochrane Db Syst Rev. 2019 Jul 31; 7 (7): CD008583CD008583.

BackgroundOvulatory disturbance is a key diagnostic feature of polycystic ovarian syndrome (PCOS), leading to infertility and correspondingly heavy disease burden. Many therapeutic strategies have been used to induce ovulation for women with PCOS who are infertile. Ultrasound-guided transvaginal ovarian needle drilling (UTND) is a novel surgical method used to induce ovulation for women with clomiphene-resistant PCOS at the outpatients clinic. Nevertheless, the quality in most of the studies seemed low, and the safety and efficacy of UTND is still uncertain.ObjectivesTo evaluate the efficacy and safety of UTND for subfertile women with clomiphene-resistant PCOS.Search MethodsWe searched the Cochrane Gynaecology and Fertility Group (CGFG) Specialised Register, CENTRAL, MEDLINE, Embase, and six other databases to November 2018. We checked conference abstracts from the 2018 ESHRE, reference lists, and clinical trials registries. We contacted experts and specialists in the field.Selection CriteriaWe included randomised controlled trials (RCTs) comparing UTND to laparoscopic ovarian drilling (LOD), and UTND combined with gonadotropins to gonadotropins alone for women of reproductive age with clomiphene-resistant PCOS and infertility.Data Collection And AnalysisTwo review authors independently screened appropriate trials for inclusion, assessed methodological quality and risk of bias, and extracted data. The primary outcomes were live birth rate and incidence of surgical complications (bleeding and infection). We included ovarian hyperstimulation syndrome (OHSS) as a secondary outcome. Meta-analyses could only be conducted for the secondary outcomes pregnancy rate and ovulation rate in the comparison of UTND versus LOD using a random-effect model. We calculated odds ratios (OR) with 95% confidence intervals (CI) for dichotomous data. We assessed the overall quality of the evidence by applying GRADE criteria.Main ResultsWe included five trials involving 639 clomiphene-resistant women with PCOS. Three studies compared UTND with LOD, and two compared UTND combined with gonadotropins with gonadotropins alone. The evidence was of low to very low quality. The main limitations were serious risk of bias due to poor reporting of methods, inconsistency resulting from heterogeneity, imprecision induced by limited sample size, and lack of reporting of clinically relevant outcomes such as live birth and surgical complications.UTND versus LODNo studies reported on the main outcome live birth. One study reported on surgical complications; however, the evidence for this outcome was of very low quality because it was based on one study with small sample size and there were no events in either arm. Thus, we are uncertain whether there is any difference in surgical complications between UTND and LOD.We are also uncertain whether there is any difference in pregnancy rate when comparing UTND with LOD (OR 0.54, 95% CI 0.28 to 1.03; I2 = 56%; 3 RCTs, n = 473; very-low quality evidence). UTND may lead to a slight decrease in ovulation rate when compared to LOD (OR 0.66, 95% CI 0.45 to 0.97; I2 = 0%; 3 RCTs, n = 473; low-quality evidence). This suggests that among clomiphene-resistant women with PCOS using LOD with an expected ovulation rate of 69.5%, the ovulation rate among women using UTND may be between 50.6% and 68.8%No studies reported on the outcomes OHSS and multiple pregnancy. There was also insufficient evidence to reach a conclusion regarding miscarriage as there was only one study of very low quality.UTND combined with gonadotropins versus gonadotropins aloneNo studies reported on the main outcomes live birth and incidence of surgical complications. The evidence for the outcomes OHSS, pregnancy, ovulation, miscarriage, and multiple pregnancy in this comparison was of very low quality. Thus, we are uncertain whether there is any difference in these outcomes for women with clomiphene-resistant PCOS using UTND combined with gonadotropins as compared with gonadotropins.Authors' ConclusionsBased on very low-quality evidence, It is uncertain whether there is any difference in pregnancy rate, incidence of surgical complications, and miscarriage rate between UTND and LOD in women with clomiphene-resistant PCOS. UTND may lead to a slight decrease in ovulation rate when compared to LOD. No studies reported on the outcomes live birth rate, incidence of OHSS, and multiple pregnancy rate. No studies reported on the main outcomes live birth and surgical complications for the comparison UTND combined with gonadotrophins versus gonadotrophins alone. The evidence for the outcomes OHSS, pregnancy, ovulation, miscarriage, and multiple pregnancy in this comparison was of very low quality. Thus, it is unclear if there is a difference in any of the outcomes between UTND combined with gonadotrophins versus gonadotrophins alone.

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