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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
General advantages of operative laparoscopy
General advantages of operative laparoscopy
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)
Evolution of Surgical management of PCOS
Transvaginal ultrasound follicular
aspiration (Maio et al 1991)Cryocautery ( Ali 1992 )Bipolar diathermy of PCO (Kovacs
1993)Endo coagulation (Amin1994)
Evolution of Surgical management of PCOS
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
Methodology of Ovarian Drilling
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)
Methodology of Ovarian Drilling
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
Methodology of Ovarian Drilling
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)
Outcomes of Ovarian Drilling
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)
Complications of ovarian drilling
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
Complications of ovarian drilling
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)
Complications of ovarian drilling
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
Current status in LOD
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)
The Society of Obstetricians and Gynecologists of Canada 2010
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)
The Society of Obstetricians and Gynecologists of Canada 2010
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
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
General advantages of operative laparoscopy
General advantages of operative laparoscopy
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)
Evolution of Surgical management of PCOS
Transvaginal ultrasound follicular
aspiration (Maio et al 1991)Cryocautery ( Ali 1992 )Bipolar diathermy of PCO (Kovacs
1993)Endo coagulation (Amin1994)
Evolution of Surgical management of PCOS
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
Methodology of Ovarian Drilling
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)
Methodology of Ovarian Drilling
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
Methodology of Ovarian Drilling
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)
Outcomes of Ovarian Drilling
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)
Complications of ovarian drilling
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
Complications of ovarian drilling
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)
Complications of ovarian drilling
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
Current status in LOD
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)
The Society of Obstetricians and Gynecologists of Canada 2010
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)
The Society of Obstetricians and Gynecologists of Canada 2010
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
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
General advantages of operative laparoscopy
General advantages of operative laparoscopy
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)
Evolution of Surgical management of PCOS
Transvaginal ultrasound follicular
aspiration (Maio et al 1991)Cryocautery ( Ali 1992 )Bipolar diathermy of PCO (Kovacs
1993)Endo coagulation (Amin1994)
Evolution of Surgical management of PCOS
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
Methodology of Ovarian Drilling
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)
Methodology of Ovarian Drilling
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
Methodology of Ovarian Drilling
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)
Outcomes of Ovarian Drilling
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)
Complications of ovarian drilling
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
Complications of ovarian drilling
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)
Complications of ovarian drilling
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
Current status in LOD
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)
The Society of Obstetricians and Gynecologists of Canada 2010
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)
The Society of Obstetricians and Gynecologists of Canada 2010
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
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
General advantages of operative laparoscopy
General advantages of operative laparoscopy
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)
Evolution of Surgical management of PCOS
Transvaginal ultrasound follicular
aspiration (Maio et al 1991)Cryocautery ( Ali 1992 )Bipolar diathermy of PCO (Kovacs
1993)Endo coagulation (Amin1994)
Evolution of Surgical management of PCOS
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
Methodology of Ovarian Drilling
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)
Methodology of Ovarian Drilling
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
Methodology of Ovarian Drilling
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)
Outcomes of Ovarian Drilling
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)
Complications of ovarian drilling
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
Complications of ovarian drilling
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)
Complications of ovarian drilling
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
Current status in LOD
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)
The Society of Obstetricians and Gynecologists of Canada 2010
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)
The Society of Obstetricians and Gynecologists of Canada 2010
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
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
General advantages of operative laparoscopy
General advantages of operative laparoscopy
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)
Evolution of Surgical management of PCOS
Transvaginal ultrasound follicular
aspiration (Maio et al 1991)Cryocautery ( Ali 1992 )Bipolar diathermy of PCO (Kovacs
1993)Endo coagulation (Amin1994)
Evolution of Surgical management of PCOS
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
Methodology of Ovarian Drilling
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)
Methodology of Ovarian Drilling
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
Methodology of Ovarian Drilling
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)
Outcomes of Ovarian Drilling
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)
Complications of ovarian drilling
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
Complications of ovarian drilling
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)
Complications of ovarian drilling
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
Current status in LOD
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)
The Society of Obstetricians and Gynecologists of Canada 2010
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)
The Society of Obstetricians and Gynecologists of Canada 2010
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
General advantages of operative laparoscopy
General advantages of operative laparoscopy
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)
Evolution of Surgical management of PCOS
Transvaginal ultrasound follicular
aspiration (Maio et al 1991)Cryocautery ( Ali 1992 )Bipolar diathermy of PCO (Kovacs
1993)Endo coagulation (Amin1994)
Evolution of Surgical management of PCOS
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
Methodology of Ovarian Drilling
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)
Methodology of Ovarian Drilling
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
Methodology of Ovarian Drilling
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)
Outcomes of Ovarian Drilling
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)
Complications of ovarian drilling
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
Complications of ovarian drilling
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)
Complications of ovarian drilling
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
Current status in LOD
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)
The Society of Obstetricians and Gynecologists of Canada 2010
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)
The Society of Obstetricians and Gynecologists of Canada 2010
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
General advantages of operative laparoscopy
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)
Evolution of Surgical management of PCOS
Transvaginal ultrasound follicular
aspiration (Maio et al 1991)Cryocautery ( Ali 1992 )Bipolar diathermy of PCO (Kovacs
1993)Endo coagulation (Amin1994)
Evolution of Surgical management of PCOS
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
Methodology of Ovarian Drilling
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)
Methodology of Ovarian Drilling
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
Methodology of Ovarian Drilling
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)
Outcomes of Ovarian Drilling
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)
Complications of ovarian drilling
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
Complications of ovarian drilling
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)
Complications of ovarian drilling
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
Current status in LOD
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)
The Society of Obstetricians and Gynecologists of Canada 2010
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)
The Society of Obstetricians and Gynecologists of Canada 2010
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
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)
Evolution of Surgical management of PCOS
Transvaginal ultrasound follicular
aspiration (Maio et al 1991)Cryocautery ( Ali 1992 )Bipolar diathermy of PCO (Kovacs
1993)Endo coagulation (Amin1994)
Evolution of Surgical management of PCOS
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
Methodology of Ovarian Drilling
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)
Methodology of Ovarian Drilling
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
Methodology of Ovarian Drilling
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)
Outcomes of Ovarian Drilling
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)
Complications of ovarian drilling
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
Complications of ovarian drilling
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)
Complications of ovarian drilling
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
Current status in LOD
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)
The Society of Obstetricians and Gynecologists of Canada 2010
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)
The Society of Obstetricians and Gynecologists of Canada 2010
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
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)
Evolution of Surgical management of PCOS
Transvaginal ultrasound follicular
aspiration (Maio et al 1991)Cryocautery ( Ali 1992 )Bipolar diathermy of PCO (Kovacs
1993)Endo coagulation (Amin1994)
Evolution of Surgical management of PCOS
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
Methodology of Ovarian Drilling
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)
Methodology of Ovarian Drilling
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
Methodology of Ovarian Drilling
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)
Outcomes of Ovarian Drilling
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)
Complications of ovarian drilling
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
Complications of ovarian drilling
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)
Complications of ovarian drilling
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
Current status in LOD
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)
The Society of Obstetricians and Gynecologists of Canada 2010
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)
The Society of Obstetricians and Gynecologists of Canada 2010
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
Evolution of Surgical management of PCOS
Transvaginal ultrasound follicular
aspiration (Maio et al 1991)Cryocautery ( Ali 1992 )Bipolar diathermy of PCO (Kovacs
1993)Endo coagulation (Amin1994)
Evolution of Surgical management of PCOS
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
Methodology of Ovarian Drilling
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)
Methodology of Ovarian Drilling
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
Methodology of Ovarian Drilling
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)
Outcomes of Ovarian Drilling
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)
Complications of ovarian drilling
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
Complications of ovarian drilling
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)
Complications of ovarian drilling
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
Current status in LOD
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)
The Society of Obstetricians and Gynecologists of Canada 2010
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)
The Society of Obstetricians and Gynecologists of Canada 2010
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
Evolution of Surgical management of PCOS
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
Methodology of Ovarian Drilling
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)
Methodology of Ovarian Drilling
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
Methodology of Ovarian Drilling
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)
Outcomes of Ovarian Drilling
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)
Complications of ovarian drilling
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
Complications of ovarian drilling
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)
Complications of ovarian drilling
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
Current status in LOD
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)
The Society of Obstetricians and Gynecologists of Canada 2010
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)
The Society of Obstetricians and Gynecologists of Canada 2010
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
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
Methodology of Ovarian Drilling
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)
Methodology of Ovarian Drilling
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
Methodology of Ovarian Drilling
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)
Outcomes of Ovarian Drilling
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)
Complications of ovarian drilling
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
Complications of ovarian drilling
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)
Complications of ovarian drilling
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
Current status in LOD
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)
The Society of Obstetricians and Gynecologists of Canada 2010
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)
The Society of Obstetricians and Gynecologists of Canada 2010
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
Methodology of Ovarian Drilling
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)
Methodology of Ovarian Drilling
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
Methodology of Ovarian Drilling
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)
Outcomes of Ovarian Drilling
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)
Complications of ovarian drilling
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
Complications of ovarian drilling
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)
Complications of ovarian drilling
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
Current status in LOD
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)
The Society of Obstetricians and Gynecologists of Canada 2010
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)
The Society of Obstetricians and Gynecologists of Canada 2010
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
Methodology of Ovarian Drilling
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
Methodology of Ovarian Drilling
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)
Outcomes of Ovarian Drilling
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)
Complications of ovarian drilling
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
Complications of ovarian drilling
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)
Complications of ovarian drilling
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
Current status in LOD
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)
The Society of Obstetricians and Gynecologists of Canada 2010
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)
The Society of Obstetricians and Gynecologists of Canada 2010
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
Methodology of Ovarian Drilling
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)
Outcomes of Ovarian Drilling
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)
Complications of ovarian drilling
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
Complications of ovarian drilling
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)
Complications of ovarian drilling
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
Current status in LOD
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)
The Society of Obstetricians and Gynecologists of Canada 2010
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)
The Society of Obstetricians and Gynecologists of Canada 2010
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
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)
Outcomes of Ovarian Drilling
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)
Complications of ovarian drilling
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
Complications of ovarian drilling
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)
Complications of ovarian drilling
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
Current status in LOD
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)
The Society of Obstetricians and Gynecologists of Canada 2010
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)
The Society of Obstetricians and Gynecologists of Canada 2010
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
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)
Outcomes of Ovarian Drilling
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)
Complications of ovarian drilling
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
Complications of ovarian drilling
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)
Complications of ovarian drilling
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
Current status in LOD
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)
The Society of Obstetricians and Gynecologists of Canada 2010
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)
The Society of Obstetricians and Gynecologists of Canada 2010
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
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)
Outcomes of Ovarian Drilling
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)
Complications of ovarian drilling
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
Complications of ovarian drilling
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)
Complications of ovarian drilling
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
Current status in LOD
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)
The Society of Obstetricians and Gynecologists of Canada 2010
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)
The Society of Obstetricians and Gynecologists of Canada 2010
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
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)
Outcomes of Ovarian Drilling
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)
Complications of ovarian drilling
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
Complications of ovarian drilling
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)
Complications of ovarian drilling
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
Current status in LOD
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)
The Society of Obstetricians and Gynecologists of Canada 2010
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)
The Society of Obstetricians and Gynecologists of Canada 2010
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
Outcomes of Ovarian Drilling
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)
Complications of ovarian drilling
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
Complications of ovarian drilling
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)
Complications of ovarian drilling
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
Current status in LOD
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)
The Society of Obstetricians and Gynecologists of Canada 2010
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)
The Society of Obstetricians and Gynecologists of Canada 2010
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
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)
Complications of ovarian drilling
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
Complications of ovarian drilling
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)
Complications of ovarian drilling
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
Current status in LOD
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)
The Society of Obstetricians and Gynecologists of Canada 2010
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)
The Society of Obstetricians and Gynecologists of Canada 2010
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
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)
Complications of ovarian drilling
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
Complications of ovarian drilling
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)
Complications of ovarian drilling
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
Current status in LOD
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)
The Society of Obstetricians and Gynecologists of Canada 2010
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)
The Society of Obstetricians and Gynecologists of Canada 2010
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
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)
Complications of ovarian drilling
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
Complications of ovarian drilling
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)
Complications of ovarian drilling
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
Current status in LOD
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)
The Society of Obstetricians and Gynecologists of Canada 2010
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)
The Society of Obstetricians and Gynecologists of Canada 2010
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
Complications of ovarian drilling
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
Complications of ovarian drilling
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)
Complications of ovarian drilling
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
Current status in LOD
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)
The Society of Obstetricians and Gynecologists of Canada 2010
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)
The Society of Obstetricians and Gynecologists of Canada 2010
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
Complications of ovarian drilling
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)
Complications of ovarian drilling
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
Current status in LOD
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)
The Society of Obstetricians and Gynecologists of Canada 2010
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)
The Society of Obstetricians and Gynecologists of Canada 2010
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
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)
Complications of ovarian drilling
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
Current status in LOD
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)
The Society of Obstetricians and Gynecologists of Canada 2010
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)
The Society of Obstetricians and Gynecologists of Canada 2010
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
Complications of ovarian drilling
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
Current status in LOD
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)
The Society of Obstetricians and Gynecologists of Canada 2010
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)
The Society of Obstetricians and Gynecologists of Canada 2010
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
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
Current status in LOD
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)
The Society of Obstetricians and Gynecologists of Canada 2010
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)
The Society of Obstetricians and Gynecologists of Canada 2010
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
Current status in LOD
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)
The Society of Obstetricians and Gynecologists of Canada 2010
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)
The Society of Obstetricians and Gynecologists of Canada 2010
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
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)
The Society of Obstetricians and Gynecologists of Canada 2010
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)
The Society of Obstetricians and Gynecologists of Canada 2010
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
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)
The Society of Obstetricians and Gynecologists of Canada 2010
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)
The Society of Obstetricians and Gynecologists of Canada 2010
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
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)
The Society of Obstetricians and Gynecologists of Canada 2010
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)
The Society of Obstetricians and Gynecologists of Canada 2010
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
The Society of Obstetricians and Gynecologists of Canada 2010
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)
The Society of Obstetricians and Gynecologists of Canada 2010
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
The Society of Obstetricians and Gynecologists of Canada 2010
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
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
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
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
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
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
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
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