lod ovarian drilling

البصرى-رحمه القال الحسن

من عمل بغير علم كان ما يفسده أكثر مما يصلحه والعامل بغير علم كالسائر على غير طريق فاطلبوا العلم طلبا ل يضر بالعبادة

بالعلمواطلبوا العبادة طلبا ل يضر

2-12-12 laparoscopic surgery

Background

Polycystic ovarian syndrome (PCOS) is the most

common endocrinopathy encountered in young female population and the most common cause of anovulatory infertility (Hamilton-Fairley and Pearce 1993)

Historically wedge resection of the ovaries was the main therapeutic approach for a long time (Stein and Leventhal 1935)

Background

Clomiphene citrate (CC) remains the first line therapy for anovulatory patients with PCOS Ovulation can be anticipated in 80-85 of cycles half of which will result in pregnancy (Kelly and Adashi 1987)

Unfortunately 15 to 40 of anovulatory subjects are resistant to standared CC regimens (Franks et al 1985 Pritts2002)

Background

The development of operative laparoscopy in the late 1960s led to a revival of surgical treatment of PCOS (Gjnnaess 1984 Gurgan et al 1994)

Operative laparoscopy has many advantages over laparotomy

General advantages of operative laparoscopy

(Garry 1977)

1- More precise surgery because of superior view

2- Superior hemostasis

3- Less tissue handling and drying out

4- Avoids the use of retractors and packs

5- Less pain and analgesic requirement



6-Cosmesis

7-Quicker ambulation

8-Shorter convalescence

9-More rapid return to work and to full activities

10-Reduced costs (Levine 1985)

11-Quality assurance improved documentation can be recorded on video CDor DVD

Indications of LOD

CC resistant PCOS patients (as a 2nd line therapy) especially in patients who live too far away from the hospital and can not attend for intensive monitoring required for gonadotropin therapy

Recurrent miscarriage High LHPrevention of long term morbidity

(metabolic and cardiovascular risks)(Amer et al2007 found no benefit )

Evolution of Surgical management of PCOS

Initially laparoscopic wedge resection Biopsy (celioscopic ovarian resection)

multiple small (punch) biopsies of the ovarian surface (Sumioki 1988)

] Laparoscopic ovarian diathermy (Gjonnaess

1984) Needle point electrode (drilling) (4-10

points (92-69)Laser vaporization or photo-coagulation

(Daniell 1989)


Transvaginal ultrasound follicular

aspiration (Maio et al 1991)Cryocautery ( Ali 1992 )Bipolar diathermy of PCO (Kovacs

1993)Endo coagulation (Amin1994)


Unilateral ovarian drilling (Balen and Jacobs1994 Zakherah et al 2004)Single Puncture Electrocoagulation of Ovarian Stroma SPECOSldquo Shawki1996Transvaginal ultrasound-guided electrocautery (Syritsa1998)Removing one ovary (Kaaijk 1999)Transvaginal hydrolaparoscopy (Gordts et al2009fertil steril)Single port laparoscopic surgery LOD (2010)

Methodology of Ovarian Drilling

Preoperative requirements

1 Documented PCOS (clinical hormonal and sonographic)

2Clomiphene resistance

3Normal prolactin or treated

4Inability or unwilling to undergo gonadotropin therapy

5 Normal endometrial cavity with patent tubes

6Normal semen analysis


Operative requirementsGeneral endotracheal anaesthesiaHigh flow CO2 insufflatorVideo assisted triple puncture laparoscopy Instillation of normal saline (300 ml) into the pouch of

Douglas to enhance ovarian cooling after drilling Unipolar current is advised in a cutting mode to

minimize thermal damage the power is activated just before touching the ovary (Corson needle)

Antimesenteric border The number of cauterization points depends on the

ovarian volume (4-10 punctures) (Zakherah et al 2010)


Traditionally 40 W-4 seconds- 4 puncture points (rule 0f 4)but should be tailored according ovarian volume(Zakherah etal 2011)After diathermy each ovary should be lowered into the pool of salineNo coagulation should be done within 1 cm from the helium may lead to ovarian atrophyAt the end of the procedure both ovaries should be irrigated with Ringers lactate It was concluded that ldquothe solution to pollution is dilutionldquo


Recently Zakherah et al 2010 concluded that adjusted diathermy dose based on ovarian volume for laparoscopic ovarian drilling of polycystic ovary syndrome has a better reproductive outcome compared with fixed thermal dosage

LASER Vs Electrocautery

Electrocautery is superior to LASER in achieving ovulaton and pregnancy ( li et al 1998)

LASER especially CO2 may be associated with a higher risk of adhesion formation

Electrocautery is less costly easier to use and its effect may last longer (Naether et al1994)

linear incision 5-7 mm in depth Laparoscopic ovarian drilling using a harmonic scalpel (Takeuchi et al2002)laparoscopic ovarian multi-needle intervention (LOMNI) (Kaya et al2005)Ultrasound-guided transvaginal ovarian needle drilling (UTND)(Badawy et al2009)

Other techniques of LOS

Mechanisms of Action of Laparoscopic Ovarian Drilling

The mechanisms of action are not understood Placebo effect(Aono et al 1976)Destruction of androgen producing ovarian stromaCorrecting abnormal ovarian pituitary feedback

(Balen and Jacobs 1994)VEGF and IGF-1 which are typically increased in

patients with PCOS(Amin et al2003)Reduction of ovarian inhibin with a resultant rise in

FSH (Amer et al2007 found no change)

Outcomes of Ovarian Drilling

Clinical Outcome of Ovarian Drilling Restoration of regular menstruation in

approximately 80The mean ovulation rate was 70 and the

cumulative pregnancy and live birth rate was 76 and 64 respectively (Bayram et al2004)

Miscarriage rate is similar to general population Reproductive performance seems to last for may

years in about one third of cases (Amer et al2002)


Women with PCOS who conceived after the drilling were at higher risk of GDM and PIH and this risk seemed to be independent of maternal obesity (Al-Ojaimi 2006)

Metformin Low dose aspirin

Outcome of Ovarian Drilling

Hormonal Changes After Ovarian Drilling Decline in the LH levels Decrease in androgens (testosterone and

androstenedione) (Armar etal1990)Increase in serum prolactin Rise in FSH levels (Api 2008=no change )Gjonnaess (1998) concluded that ovarian

electrocautery for PCOS normalizes ovarian function including androgen production and these results seem to be stable for 18-20 years

Predictors of the outcome

Clinical predictorsMarked obesity(BMIge35)History of infertility gt3 years

Biochemical predictors High LH levelsge10IU)Marked hyperandrogenemiaInsulin resistance

(Amer et al2004)

Complications of ovarian drilling

A part from the need of surgery under general anesthesia and the risk of any surgical procedure 1- Pelvic adhesionsAdhesion formation rates following laparoscopic ovarian drilling ranged from zero (Daniell and Miller 1988) to 100 (Greenblatt and Casper 1987)The mean adhesion score of the patient treated with CO2 laser was significantly higher than that treated with electrocautery (Cohen 1995)


Factors influencing adhesion formation Thermal dosage

(So the reduction in damage was produced by unilateral ovarian drilling (Roy et al 2009)may reduce the postoperative adhesion formation)

Pelvic lavage and induction of artificial ascitesldquothe solution to pollution is dilution


2- Ovarian atrophy and premature ovarian failure Ovarian atrophy has been reported by Dabirashrafi (1989) as a complication of excessive drilling of polycystic ovaries It is therefore advised that no coagulation should be done within 1 cm of the ovarian helium the number of cauterization points should be individualized according to the ovarian size and the wattage chosen should depend on the thickness of the ovarian capsule

Is ovarian reserve diminished after laparoscopic ovarian drilling

The PCOS women both with and without LOD had significantly greater ovarian reserve than the age-matched controls having normal ovulatory menstruation(Weerakiet et al 2007) LOD if applied properly normalizes the exaggerated ovarian morphologic and endocrinologic properties (normalization of ovarian function rather than a reduction of ovarian reserve )(Api2009)


3- Epithelial ovarian tumors There is a theoretrical concern that ovarian drilling

may increase the incidence of epithelial ovarian tumours

There is no long-term follow-up to evaluate this association

Current status in LOD

LOD is not superior to CC as a first-line method of OI in women with PCOS (Amer etal2009)LOD as a 2nd line therapy has been the subject of much debate with competition between LOD gonadotropin and metformin However with the awareness of the predictors of successfailure of each of these treatments we should tailor the treatment according to the patientrsquos characteristics


LOD may be preferred as 2nd line therapy (Amer2008) LOD and gonadotropins have been shown to be equally effective in ovulation and pregnancy rates(Farquhar et al2005) (Moderately quality evidence)No significant difference between LOD and metformin in pregnancy or ovulation rates ([60 vs 64] and (84vs 80)respectively) Pirwany et al200) ( very low-quality evidence)

LOD Vs Gonadotropin therapy

NO difference in the live birth rate and miscarriage rate in women with Clomiphene-resistant PCOS undergoing LOD compared to gonadotrophin treatment The reduction in multiple pregnancy rates in women undergoing LOD makes this option attractive However there are ongoing concerns about long-term effects of LOD on ovarian function Farquhar et al2007 Cochrane Database Syst Rev 2007(3)CD001122

Advantages of LOD over gonadotropins

Mono-ovulationLow risk of OHSSLess costly (cost of a live birth was one third

lower in LOD compared to who received gonadotrophins)

Single action lead to repeated ovulationsNeed no complex monitoringLower miscarriage rate(cohen1995)

The Society of Obstetricians and Gynecologists of Canada 2010

1-Weight loss exercise and lifestyle modifications have been proven effective in restoring ovulatory cycles and achieving pregnancy in overweight women with PCOS and should be the first-line option for these women (II-3A)

2 Clomiphene citrate has been proven effective in ovulation induction for women with PCOS and should be considered the first-line therapy (I-A)


3-Metformin may be added to clomiphene citrate in women with clomiphene resistance who are older and who have visceral obesity (I-A) Metformin combined with clomiphene citrate may increase ovulation rates and pregnancy rates but does not significantly improve the live birth rate over that of clomiphene citrate alone (I-A)

4 Gonadotropins should be considered second-line therapy for fertility in anovulatory women with PCOS The treatment requires ultrasound and laboratory monitoring High costs and the risk of multiple pregnancy and ovarian hyperstimulation syndrome are drawbacks of the treatment (II-2A)


5 Laparoscopic ovarian drilling may be considered in women with Clomiphene-resistant PCOS particularly when there are other indications for laparoscopy (I-A)

Surgical risks need to be considered in these patients (III-A)

6 In vitro fertilization should be reserved for women with PCOS who fail gonadotropin therapy or who have other indications for IVF treatment (II-2A)

RCOG Guidelines Grade A Laparoscopic ovarian drilling with either

diathermy or laser is an effective treatment for anovulation in women with clomiphene-resistant PCOS Value of LOD as primary treatment of anovulatory PCOS is undetermined No difference in OR or PR when compared to gonadotropins

( level 1)

NICE guidelines 2004

Women with CC resistant PCOS may be offered LOD because it is as effective as gonadotrophin treatment and is not associated with a risk of multiple pregnancy [A]

LOD is now well established as the treatment of first choice for CC-resistant women with PCOS (Dutch Health Council guideline 2003 NICE 2004)

Failed LOD

20-30 of anovulatory women with PCOS

failed to respond to LOD (Farquhar2004)Insufficient thermal dosageInherent resistance of the ovary to the effects

of drillingPost-operative adhesionHyper prolactaenaemia observed in some

patients after LOD

Repeated LOD in polycystic ovary syndrome

Repeat LOD is highly effective in women who

previously responded to the first procedure (Amer et al 2003)

Adjuvants after ovarian drilling CC or low dose gonadotropins NAC is a novel adjuvant therapy after unilateral LOD which might help improve overall reproductive outcome (a pilot study ) (Nasr A2010)زMetformin increases the ovulation and pregnancy rates in infertile women following LOD(Kocak and Ustuumln 2006)Weight reductionIVFRepeat LOD we will add more complications

is it time to relinquish the procedure

1 LOD is a safe and cost effective procedure

2 A single treatment results in uni- follicular ovulation

3 No need of continuous monitoring as seen with hormonal treatment

4 No fear of multiple births and ovarian hyper stimulation

5 LOD increase the sensitivity to gonadotrophins and it is as effective as gonadtrophins in PCOS

Conclusion

Surgical treatment of PCOS not recommended to be the first line of treatment but are advisable for clomiphene resistant cases as they are not free of adverse effects

If your only toy is a hammer every problem will look like

a nail

Background

Polycystic ovarian syndrome (PCOS) is the most

common endocrinopathy encountered in young female population and the most common cause of anovulatory infertility (Hamilton-Fairley and Pearce 1993)

Historically wedge resection of the ovaries was the main therapeutic approach for a long time (Stein and Leventhal 1935)

Background



Background




(Garry 1977)








6-Cosmesis






Indications of LOD










(Daniell 1989)




















































(Amer et al2004)





































( level 1)




Failed LOD




patients after LOD











Conclusion



a nail

Background



Background




(Garry 1977)








6-Cosmesis






Indications of LOD










(Daniell 1989)




















































(Amer et al2004)





































( level 1)




Failed LOD




patients after LOD











Conclusion



a nail

Background




(Garry 1977)








6-Cosmesis






Indications of LOD










(Daniell 1989)




















































(Amer et al2004)





































( level 1)




Failed LOD




patients after LOD











Conclusion



a nail


(Garry 1977)








6-Cosmesis






Indications of LOD










(Daniell 1989)




















































(Amer et al2004)





































( level 1)




Failed LOD




patients after LOD











Conclusion



a nail



6-Cosmesis






Indications of LOD










(Daniell 1989)




















































(Amer et al2004)





































( level 1)




Failed LOD




patients after LOD











Conclusion



a nail

Indications of LOD










(Daniell 1989)




















































(Amer et al2004)





































( level 1)




Failed LOD




patients after LOD











Conclusion



a nail







(Daniell 1989)




















































(Amer et al2004)





































( level 1)




Failed LOD




patients after LOD











Conclusion



a nail




















































(Amer et al2004)





































( level 1)




Failed LOD




patients after LOD











Conclusion



a nail





































( level 1)




Failed LOD




patients after LOD











Conclusion



a nail




Failed LOD




patients after LOD











Conclusion



a nail











Conclusion



a nail


a nail

lod ovarian drilling

Documents

pcos clinical

zakherah et

gurgan et

amer et

ovarian surface sumioki

anovulatory patients

line therapy

precise surgery