Ovarian surgery for symptom relief in women with polycystic ovary syndrome

Sam Lepine; Junyoung Jo; Mostafa Metwally; Ying C Cheong

doi:10.1002/14651858.CD009526.pub2

Cochrane Database of Systematic Reviews

Cirugía ovárica para el alivio de síntomas en las pacientes con síndrome de ovario poliquístico

Información

DOI:

https://doi.org/10.1002/14651858.CD009526.pub2 Copiar DOI

Base de datos:

Cochrane Database of Systematic Reviews

Versión publicada:

10 noviembre 2017see what's new

Tipo:

Intervention

Etapa:

Review

Grupo Editorial Cochrane:

Grupo Cochrane de Ginecología y fertilidad

Copyright:

Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Contraer

Autores

Sam Lepine

Department of Obstetrics and Gynaecology, Capital and Coast District Health Board, Wellington, New Zealand
Junyoung Jo

Department of Korean Obstetrics and Gynecology, Conmaul Hospital of Korean Medicine, Seoul, Korea, South
Mostafa Metwally

The Jessop Wing and Royal Hallamshire Hospital, Sheffield Teaching Hospitals, Sheffield, UK
Ying C Cheong

Correspondencia a: Department of Obstetrics and Gynaecology, University of Southampton, Southampton, UK

[email protected]

[email protected]

Contributions of authors

SL, JJ and YC performed the analysis and SL was the lead author in the writing of the review.
YC wrote the review and contributed to the methodology and content of the review.
MM contributed to the content and acted as a moderator.

Sources of support

Internal sources

None, Other.

External sources

Support from the Cochrane Gynaecology and Fertility Group, New Zealand.

Help with searches, editorial feedback gratefully acknowledged

Declarations of interest

SL, JJ, MM and YC have no interests to declare.

Acknowledgements

We thank the Cochrane Gynaecology and Fertility Group for providing us with the search strategy and for proof‐reading the review.
We thank Dr Yvonne Obura and Dr Bindiya Jhamb for their contributions to this review.

Version history

Published

Title

Stage

Authors

Version

2017 Nov 10

Ovarian surgery for symptom relief in women with polycystic ovary syndrome

Review

Sam Lepine, Junyoung Jo, Mostafa Metwally, Ying C Cheong

https://doi.org/10.1002/14651858.CD009526.pub2

2011 Dec 07

Ovarian surgery for symptom relief in women with polycystic ovary syndrome

Protocol

Ying C Cheong, Mostafa Metwally, Norman Shreeve, Khaled Sadek, Cindy Farquhar

https://doi.org/10.1002/14651858.CD009526

Differences between protocol and review

We have edited the review's Methods to bring them up to current Cochrane standards. These include: addition of a PRISMA flow chart to document our search and addition of 'Summary of findings' tables in accordance with the now mandatory MECIR standards C74 and C75. We have clarified that menstrual regularity is reported as binary data. There has been a change in the author team between protocol and review, so four review authors shared in selecting studies. We have added an I² percentage for clarification. We planned to use a random‐effects model where data were heterogenous; these analyses using random‐effects model are now sensitivity analyses. The background sections have been updated in the lay and non‐lay sections. We planned to stratify comparisons by some specified characteristics of interventions and planned subgroups by hormone profiles and different surgical techniques; we did not do this because with hindsight the data were not reported in a format applicable to this analysis.

Keywords

MeSH

Medical Subject Headings (MeSH) Keywords

Medical Subject Headings Check Words

Female; Humans;

PICO

Population

Intervention

Comparison

Outcome

El uso y la enseñanza del modelo PICO están muy extendidos en el ámbito de la atención sanitaria basada en la evidencia para formular preguntas y estrategias de búsqueda y para caracterizar estudios o metanálisis clínicos. PICO son las siglas en inglés de cuatro posibles componentes de una pregunta de investigación: paciente, población o problema; intervención; comparación; desenlace (outcome).

Para saber más sobre el uso del modelo PICO, puede consultar el Manual Cochrane.

Figure 1

Study flow diagram

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Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Figure 4

Forest plot of comparison: 1 LOD vs medical interventions, outcome: 1.1 Menstrual regularity.

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Figure 5

Forest plot of comparison: 1 LOD vs medical interventions, outcome: 1.2 Menstrual regularity.

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Figure 6

Forest plot of comparison: 2 LOD vs other surgical interventions, outcome: 2.1 Menstrual regularity.

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Figure 7

Forest plot of comparison: 3 LOD 4 ‐ 5 vs 2 or fewer punctures, outcome: 3.1 Menstrual regularity.

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Figure 8

Forest plot of comparison: 4 LOD vs LOD variable energy, outcome: 4.1 Menstrual regularity.

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Analysis 1.1

Comparison 1 LOD vs medical interventions, Outcome 1 Menstrual regularity.

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Analysis 1.2

Comparison 1 LOD vs medical interventions, Outcome 2 Menstrual regularity.

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Analysis 1.3

Comparison 1 LOD vs medical interventions, Outcome 3 Improvement in androgenic symptoms (hirsutism/acne).

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Analysis 1.4

Comparison 1 LOD vs medical interventions, Outcome 4 Harms.

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Analysis 1.5

Comparison 1 LOD vs medical interventions, Outcome 5 BMI.

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Analysis 1.6

Comparison 1 LOD vs medical interventions, Outcome 6 Testosterone and free androgen index.

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Analysis 1.7

Comparison 1 LOD vs medical interventions, Outcome 7 Fasting Glucose:Insulin.

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Analysis 2.1

Comparison 2 LOD vs other surgical interventions, Outcome 1 Menstrual regularity.

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Analysis 2.2

Comparison 2 LOD vs other surgical interventions, Outcome 2 Improvement in androgenic symptoms (hirsutism/acne).

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Analysis 2.3

Comparison 2 LOD vs other surgical interventions, Outcome 3 Harms: Adhesions.

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Analysis 2.4

Comparison 2 LOD vs other surgical interventions, Outcome 4 Testosterone and free androgen index.

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Analysis 3.1

Comparison 3 LOD 4 ‐ 5 vs 2 or fewer punctures, Outcome 1 Menstrual regularity.

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Analysis 3.2

Comparison 3 LOD 4 ‐ 5 vs 2 or fewer punctures, Outcome 2 Testosterone and free androgen index.

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Analysis 4.1

Comparison 4 LOD vs LOD variable energy, Outcome 1 Menstrual regularity.

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Analysis 4.2

Comparison 4 LOD vs LOD variable energy, Outcome 2 Harms.

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Analysis 4.3

Comparison 4 LOD vs LOD variable energy, Outcome 3 BMI.

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Analysis 4.4

Comparison 4 LOD vs LOD variable energy, Outcome 4 Testosterone and free androgen index.

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Analysis 4.5

Comparison 4 LOD vs LOD variable energy, Outcome 5 Metabolic measures.

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Summary of findings for the main comparison. LOD compared to medical interventions for symptom relief in women with polycystic ovary syndrome

LOD compared to medical interventions for symptom relief in women with polycystic ovary syndrome
Patient or population: Women with symptoms of PCOS Setting: Clinic or hospital Intervention: Laparoscopic ovarian drilling (LOD) Comparison: medical interventions
Outcomes	Relative effect (95% CI)	*Anticipated absolute effects^ (95% CI)**			Quality of the evidence (GRADE)	What happens
Outcomes	Relative effect (95% CI)	Without LOD	With LOD	Difference	Quality of the evidence (GRADE)	What happens
Menstrual regularity at 6 months LOD vs metformin N of participants: 236 (2 RCTs) LOD vs metformin + clomiphene N of participants: 332 (2 RCTs) LOD vs gonadotropins N of participants: 35 (1 RCT) LOD vs letrozole N of participants: 260 (1 RCT) LOD vs metformin + letrozole N of participants: 146 (1 RCT)	Findings inconsistent and data unsuitable for pooling	Not calculable			⊕⊝⊝⊝ VERY LOW ^{1, 2, 3}
	OR 1.02 (0.64 to 1.64)	70.6%	71.0% (60.5 to 79.7)	0.4% more (10 fewer to 9.2 more)	⊕⊕⊝⊝ LOW ^{1, 3}
	OR 19.20 (3.17 to 116.45)	11.1%	70.6% (28.4 to 93.6)	59.5% more (17.3 more to 82.5 more)	⊕⊕⊝⊝ LOW ^{1, 3}
	OR 1.08 (0.64 to 1.84)	68.8%	70.4% (58.5 to 80.2)	1.6% more (10.3 fewer to 11.4 more)	⊕⊕⊝⊝ LOW ^{1, 3}
	OR 0.95 (0.49 to 1.81)	52.1%	50.8% (34.7 to 66.3)	1.3% fewer (17.3 fewer to 14.2 more)	⊕⊕⊝⊝ LOW ^{1, 3}
Improvement in androgenic symptoms at 6 months (hirsutism/acne) ‐ LOD vs metformin N of participants: 126 (1 RCT)	OR 1.00 (0.42 to 2.37)	79.4%	79.4% (61.8 to 90.1)	0.0% fewer (17.6 fewer to 10.7 more)	⊕⊕⊝⊝ LOW ^{1, 3}
Improvement in androgenic symptoms at 6 months (hirsutism/acne) ‐ LOD vs gonadotrophins N of participants: 50 (1 RCT)	Acne: OR 3.20 (0.33 to 30.94) Hirsutism: OR 2.31, (0.22 to 23.89)	See comments			⊕⊝⊝⊝VERY LOW ^{1, 4}	Acne: 4/29 without LOD, 1/21 with LOD Hirsutism: 3/29 without LOD, 1/21 with LOD
Harms: GI Upset at 6 months ‐ LOD vs metformin + clomiphene N of participants: 332 (2 RCTs) Harms: OHSS rates at 6 months ‐ LOD vs gonadotrophins N of participants: 33 (1 RCT)	OR 0.05 (0.01 to 0.36)	10.4%	0.6% (0.1 to 4.0)	9.9% fewer (10.3 fewer to 6.4 fewer)	⊕⊕⊕⊝ MODERATE ¹
	OR 0.08 (0.00 to 1.61)	25.0%	2.6% (0.0 to 34.9)	22.4% fewer (25 fewer to 9.9 more)	⊕⊕⊝⊝ LOW ^{1, 3}
*The risk in the intervention group (and its 95% confidence interval) is based on the mean risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; OR: Odds ratio; OHSS: ovarian hyperstimulation syndrome
GRADE Working Group grades of evidence High quality: We are very confident that the true effect lies close to that of the estimate of the effect Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect
¹Downgraded one level for serious risk of bias: Included studies not double‐blinded, and in some cases methods of randomization unclear. ²Downgraded two levels for very serious and unexplained heterogeneity: I² = 85%, direction of effect inconsistent ³Downgraded one level for serious imprecision. ⁴Downgraded two levels for very serious imprecision: Broad confidence interval, very few events.

Summary of findings for the main comparison. LOD compared to medical interventions for symptom relief in women with polycystic ovary syndrome

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Summary of findings 2. LOD compared to other surgical interventions for symptom relief in women with polycystic ovary syndrome

LOD compared to other surgical interventions for symptom relief in women with polycystic ovary syndrome
Patient or population: Women with symptoms of PCOS Setting: Clinic or hospital Intervention: LOD Comparison: other surgical interventions
Outcomes	Relative effect (95% CI)	*Anticipated absolute effects^ (95% CI)**			Quality of the evidence (GRADE)	What happens
Outcomes	Relative effect (95% CI)	Without LOD	With LOD	Difference	Quality of the evidence (GRADE)	What happens
Menstrual regularity ‐ LOD vs unilateral LOD N of participants: 104 (2 RCTs)	OR 1.51 (0.62 to 3.71)	71.2%	78.8% (60.5 to 90.1)	7.7% more (10.7 fewer to 19 more)	⊕⊕⊕⊝ MODERATE ¹	1 study follow‐up at 3 months. 1 study follow‐up at 12 months
Menstrual regularity at 6 months ‐ LOD vs ultrasound‐guided transvaginal ovarian drilling N of participants: 147 (1 RCT)	OR 1.23 (0.64 to 2.37)	54.7%	59.7% (43.6 to 74.1)	5.1% more (11.1 fewer to 19.4 more)	⊕⊕⊝⊝ LOW ^{1 2}
Menstrual regularity at 12 months Laser LOD vs harmonic scalpel N of participants: 34 (1 RCT)	OR 2.13 (0.17 to 26.03)	88.2%	94.1% (56.0 to 99.5)	5.9% more (32.2 fewer to 11.3 more)	⊕⊕⊝⊝ LOW ^{1, 3}	Note control group is NdYAG Laser
Improvement in androgenic symptoms at 6 months (Acne) ‐ LOD vs USS guided N of participants:31 (1 RCT)	OR 0.84 (0.20 to 3.5)	47.1%	42.7% (15.1 to 75.7)	4.3% fewer (32 fewer to 28.6 more)	⊕⊕⊝⊝ LOW ^{1, 2}
Improvement in androgenic symptoms at 6 months (Hirsutism) ‐ LOD vs USS‐guided N of participants: 39 (1 RCT)	OR 1.09 (0.30 to 3.91)	40.0%	42.1% (16.7 to 72.3)	2.1% more (23.3 fewer to 32.3 more)	⊕⊕⊝⊝ LOW ^{1, 2}
Harms: Adhesions at 6 months ‐ LOD vs THL N of participants: 246 (1 RCT)	OR 0.10 (0.05 to 0.18)	59.3%	12.7% (6.8 to 20.8)	46.6% fewer (52.5 fewer to 38.5 fewer)	⊕⊝⊝⊝ VERY LOW ^{1, 4}
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; OR: Odds ratio; THL: transvaginal hydrolaparoscopy
GRADE Working Group grades of evidence High quality: We are very confident that the true effect lies close to that of the estimate of the effect Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect
¹Downgraded one level for serious risk of bias: Included studies not double‐blinded or unclear allocation concealment or unclear randomization method. ²Downgraded one level for serious imprecision. ³Single study, narrow confidence interval. ⁴Downgraded two levels for very serious imprecision: Broad confidence interval, very few events.

Summary of findings 2. LOD compared to other surgical interventions for symptom relief in women with polycystic ovary syndrome

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Summary of findings 3. LOD 4‐5 compared to 2 or fewer punctures for symptom relief in women with polycystic ovary syndrome

LOD 4 ‐ 5 punctures compared to 2 or fewer punctures for symptom relief in women with polycystic ovary syndrome
Patient or population: Women with symptoms of PCOS Setting: Clinic or hospital Intervention: LOD 4 ‐ 5 punctures Comparison: 2 or fewer punctures
Outcomes	Relative effect (95% CI)	*Anticipated absolute effects^ (95% CI)**			Quality of the evidence (GRADE)	What happens
		Without LOD 4‐5	With LOD 4‐5	Difference
Menstrual regularity at 6 months ‐ LOD 4 ‐ 5 coagulation points compared to 2 or fewer N of participants: 73 (2 RCTs)	OR 16.04 (4.19 to 61.34)	13.9%	72.1% (40.3 to 90.8)	58.2% more (26.4 more to 76.9 more)	⊕⊕⊝⊝ LOW ^{1, 2}
Menstrual regularity at 6 months ‐ LOD (4 ‐ 5 laser coagulation points) vs 1 laser coagulation point per ovary N of participants: 40 (1 RCT)	OR 19.00 (2.12 to 170.38)	5.0%	50.0% (10.0 to 90.0)	45.0% more (5 more to 85 more)	⊕⊕⊝⊝ LOW ^{1, 2}
Menstrual regularity at 6 months ‐ LOD 4 punctures vs 2 punctures per ovary N of participants: 33 (1 RCT)	OR 14.00 (2.60 to 75.41)	25.0%	82.4% (46.4 to 96.2)	57.4% more (21.4 more to 71.2 more)	⊕⊕⊝⊝ LOW ^{1, 2}
Improvement in androgenic symptoms	No data available
Harms LOD 4 ‐ 5 versus fewer punctures	No data available
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; OR: Odds ratio;
GRADE Working Group grades of evidence High quality: We are very confident that the true effect lies close to that of the estimate of the effect Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect
¹Downgraded one level for serious risk of bias: Included studies not double‐blinded or methods of randomization unclear. ²Downgraded one level for serious imprecision.

Summary of findings 3. LOD 4‐5 compared to 2 or fewer punctures for symptom relief in women with polycystic ovary syndrome

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Summary of findings 4. LOD compared to LOD variable energy for symptom relief in women with polycystic ovary syndrome

LOD compared to LOD variable energy for symptom relief in women with polycystic ovary syndrome
Patient or population: Women with symptoms of PCOS Setting: Clinic or hospital Intervention: LOD Comparison: LOD variable energy
Outcomes	Relative effect (95% CI)	*Anticipated absolute effects^ (95% CI)**			Quality of the evidence (GRADE)	What happens
		Without LOD	With LOD	Difference
Menstrual regularity at 6 months ‐ LOD vs adjusted thermal dose N of participants: 115 (1 RCT)	OR 0.42 (0.16 to 1.14)	87.9%	75.4% (53.8 to 89.3)	12.6% fewer (34.1 fewer to 1.3 more)	⊕⊝⊝⊝ VERY LOW ^{1, 2}
Menstrual regularity at 3 months ‐ LOD unipolar vs LOD bipolar N of participants: 20 (1 RCT)	OR 1.00 (0.05 to 18.57)	90.0%	90.0% (31.0 to 99.4)	0.0% fewer (59 fewer to 9.4 more)	⊕⊝⊝⊝ VERY LOW ^{1, 2}	Groups had different metabolic characteristics at baseline
Improvement in androgenic symptoms	No data available
Harms: Adhesions at 6 months № of participants: 64 (1 study)	OR 0.96 (0.32 to 2.88)	28.6%	27.7% (11.3 to 53.5)	0.8% fewer (17.2 fewer to 25 more)	⊕⊝⊝⊝ VERY LOW^{1, 2}	Women that remained enrolled for second‐look laparoscopy
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; OR: Odds ratio;
GRADE Working Group grades of evidence High quality: We are very confident that the true effect lies close to that of the estimate of the effect Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect
¹Downgraded one level for serious risk of bias: Included studies not double‐blinded or unclear allocation concealment. ²Downgraded two levels for very serious imprecision: Broad confidence interval, very few events.

Summary of findings 4. LOD compared to LOD variable energy for symptom relief in women with polycystic ovary syndrome

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Comparison 1. LOD vs medical interventions

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Menstrual regularity Show forest plot	2		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected

1.1 LOD vs Metformin alone	2		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
2 Menstrual regularity Show forest plot	5		Odds Ratio (M‐H, Fixed, 95% CI)	Subtotals only

2.1 LOD vs Metformin + Clomiphene	2	332	Odds Ratio (M‐H, Fixed, 95% CI)	1.02 [0.64, 1.64]
2.2 LOD vs Gonadotropins	1	35	Odds Ratio (M‐H, Fixed, 95% CI)	19.2 [3.17, 116.45]
2.3 LOD vs Letrozole	1	260	Odds Ratio (M‐H, Fixed, 95% CI)	1.08 [0.64, 1.84]
2.4 LOD vs Metformin + Letrozole	1	146	Odds Ratio (M‐H, Fixed, 95% CI)	0.95 [0.49, 1.81]
3 Improvement in androgenic symptoms (hirsutism/acne) Show forest plot	2		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected

3.1 LOD vs Metformin	1		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
3.2 LOD vs Gonadotrophins	1		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
4 Harms Show forest plot	3		Odds Ratio (M‐H, Fixed, 95% CI)	Subtotals only

4.1 LOD vs Metformin + Clomiphen	2	332	Odds Ratio (M‐H, Fixed, 95% CI)	0.05 [0.01, 0.36]
4.2 LOD vs Gonadotrophins	1	33	Odds Ratio (M‐H, Fixed, 95% CI)	0.08 [0.00, 1.61]
5 BMI Show forest plot	2		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

5.1 LOD vs Metformin	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
5.2 LOD vs Metformin + Letrozole	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
6 Testosterone and free androgen index Show forest plot	5		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

6.1 LOD vs Metformin	2		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
6.2 LOD vs GnRHa + OCP	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
6.3 LOD vs Metformin + Letrozole	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
6.4 LOD versus Rosiglitazone	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
7 Fasting Glucose:Insulin Show forest plot	3		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

7.1 LOD vs Rosiglitazone	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
7.2 LOD vs Metformin	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
7.3 LOD vs Metformin + Letrozole	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]

Comparison 1. LOD vs medical interventions

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Comparison 2. LOD vs other surgical interventions

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Menstrual regularity Show forest plot	4		Odds Ratio (M‐H, Fixed, 95% CI)	Subtotals only

1.1 LOD vs Unilateral LOD	2	104	Odds Ratio (M‐H, Fixed, 95% CI)	1.51 [0.62, 3.71]
1.2 LOD vs Ultrasound guided transvaginal ovarian drilling	1	147	Odds Ratio (M‐H, Fixed, 95% CI)	1.23 [0.64, 2.37]
1.3 Laser LOD vs Harmonic Scalpel	1	34	Odds Ratio (M‐H, Fixed, 95% CI)	2.13 [0.17, 26.03]
2 Improvement in androgenic symptoms (hirsutism/acne) Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected

2.1 Hirsutism	1		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
2.2 Acne	1		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
3 Harms: Adhesions Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected

4 Testosterone and free androgen index Show forest plot	6		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

4.1 LOD vs Ultrasound guided transvaginal ovarian drilling	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
4.2 LOD versus mini laparoscopy with sedation	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
4.3 LOD vs unilateral LOD	3		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
4.4 Laser LOD vs Harmonic Scalpel	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]

Comparison 2. LOD vs other surgical interventions

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Comparison 3. LOD 4 ‐ 5 vs 2 or fewer punctures

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Menstrual regularity Show forest plot	2	73	Odds Ratio (M‐H, Fixed, 95% CI)	16.04 [4.19, 61.34]

1.1 LOD (4‐5 laser coagulation points) vs 1 laser coagulation point per ovary	1	40	Odds Ratio (M‐H, Fixed, 95% CI)	19.0 [2.12, 170.38]
1.2 LOD 4 punctures vs 2 punctures per ovary LOD	1	33	Odds Ratio (M‐H, Fixed, 95% CI)	14.0 [2.60, 75.41]
2 Testosterone and free androgen index Show forest plot	2		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

2.1 LOD 4‐5 punctures vs 2 or fewer punctures (Testosterone)	2	73	Mean Difference (IV, Fixed, 95% CI)	‐0.90 [‐1.12, ‐0.68]
2.2 LOD 4 punctures vs 2 punctures (FAI)	1	33	Mean Difference (IV, Fixed, 95% CI)	‐1.5 [‐3.21, 0.21]

Comparison 3. LOD 4 ‐ 5 vs 2 or fewer punctures

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Comparison 4. LOD vs LOD variable energy

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Menstrual regularity Show forest plot	2		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected

1.1 LOD vs Adjusted thermal dose	1		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.2 LOD unipolar vs LOD bipolar	1		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
2 Harms Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected

3 BMI Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

4 Testosterone and free androgen index Show forest plot	2		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

4.1 LOD vs Adjusted thermal dose	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
4.2 LOD unipolar vs LOD bipolar	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
5 Metabolic measures Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

5.1 LOD (unipolar) vs bipolar	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]

Comparison 4. LOD vs LOD variable energy

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Cirugía ovárica para el alivio de síntomas en las pacientes con síndrome de ovario poliquístico

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