LAPAROSCOPICOVARIAN DRILLING:FOR SURGICALINDUCTION OFOVULATION IN PCOSDr Ameya PadmawarGynaecological Endoscopic SurgeonRotunda Blue fertility centre and keyhole surgery centre , MumbaiSanjeevan Medical centre, Borivali, MumbaiDr. Rizwana SyedMD
POLYCYSTIC OVARIAN SYNDROME(PCOS) is one of the most common endocrinopathies, affecting 5-10% of women of reproductive age group.It is characterised by infertility, oligomenorrhoea or amenorrhea, hirsuitism , acne and bilaterally enlarged cystic ovariesESHRE and ASRM : 2003 criterion: any 2 1 . Oligomenorrhea / anovulation 2 . Hyper androgenism [ clinical and biochemical ] 3 . USG appearance of PCOS
INFERTILITY ANOVULATIONInfertility due to chronic anovulation is the most common reason for women seeking counseling or treatmentMany treatment protocols ,medical and surgical have been proposed but the optimal treatment for infertile women with PCOS is not yet defined.
TREATMENT OPTIONS AVAILABLE:As per international workshop held in Greece 2007 •Life style modification :body weight with the aids of Diet, Exercise , Pharmacological agents and Bariatic surgery with Loss of at least 5% of initial weight •Clomiphene Citrate :First Choice, taken orally, although 20% of women fail to ovulate •Gonadotrophins and GnRH analouges: ~30% chances of multiple pregnancy & severe OHSS of ~ 4.6% •Laparoscopic Ovarian Surgery :Alternative treatment for women resistant to C.C with minimal risk of multiple pregnancy and OHSS
LAPAROSCOPIC OVARIANDRILLING:• Surgical approaches to ovulation induction have been developed from the traditional wedge resection [ Stein and Leventhal : 1938 ] to modern day minimal access surgery. [ Gjoaness et al : 1984]• Ovarian Biopsy and electrocautery [ Cohen :1972]• Multiple ovarian punctures performed either by diathermy [monopolar or bipolar ]or by laser is known as LAPAROSCOPIC OVARIAN DRILLING.• Transvaginal hydrolaparoscopy [ bipolar / saline ]• Ultrasound guided transvaginal ovarian needle drilling [UTND]• LOMNI: laparoscopic ovarian multi- needle Intervention [ no energy modality used ]
Indications:• Clomiphene citrate Resistance• Patients undergoing laparoscopy for tubal patency• Poor response to any ovulation inducing agents whether clomiphene citrate or gonadotropins
Technique of Ovarian Drilling• Ovarian Electrocautery is the creation of multiple openings through the capsule• Using Monopolar , Bipolar electrode or Laser energy.• Standard laparoscopic approach is utilized, with two ancillary ports
Laparoscopic Electrocauterisation of ovarian Surface:
Surgical steps:• Laparoscopy performed with one primary [10mm] and two contralateral ancillary ports[5 mm].• Utero-ovarian ligament is grasped using a grasper moving the ovary (towards anterior abdominal wall & in front of uterus)• Using a double insulated retractable needle electrode connected to a electrosurgical generator & 40 wattage isolated cauterization is undertaken. The number of puncture points depends on the size of the ovary but 4-5 points are sufficient.• Each crater should be 1-3 mm in diameter and 4 mm in depth
Laser vs ElectrocauteryElectrocautery is superior WHY?• Less Cost and Easy application, surgery possible with basic endoscopy equipment• Achieve higher ovulation and pregnancy rates• Less surface injury than CO2 laser therefore less adhesions.[ Keckstein et al : 1989 ]• Effects of Electrocautery may last longer than effect of laser. [ Saleh and Khalil : 2004 ]
Optimal Energy modality :laseror electrocoagulation:Cumulative ovulation and pregnancy rates at 12 months of LODafter EC or Laser:[Saleh and Khalil: 2004] Spontaneous Pregnancy rates ovulation Electrocoagulation 82.7% 64.8% Laser vaporization 77.5% 54.5%
Mechanism of ActionDestruction of the ovarian stroma causes• Marked decrease in circulating levels of androgens namely DHEAS and testosterone [ keckstein et al: 1989]• Decrease in circulating levels of estradiol.• Reduction in the concentration of immunoreactive LH as well as LH bioactivity. [ Ligouri et al:1996]• Decrease LH/FSH ratio• Temporary decrease in inhibin levelsRemoves intra ovarian block to follicular maturation that precedes ovulation, resulting in recruitment of new cohort of follicles and subsequent ovulation.
Surgical trauma to the ovary causes• Production of non steroidal factors which restores hypothalamo-pitutary- ovarian function [ Rossamanith WG, KecksteinJ, et al :1991]• Production of ovarian growth factors (IGF-1) which sensitize ovary to circulating FSH [ Vizer M, etal:2007 ]• Endocrine changes occur rapidly and are sustained for several years and result in recruitment of a new cohort of follicles and restoration of ovulation [ Amer S A etal : 2002 ]
Post operative adhesions:• Varied incidence of post op adhesions 0- 70%• Flimsy adhesions on the ovarian surface of not much significance [ Felemban etal : 2000]• Copious abdominal lavage and use of insulated needle electrocautery may help in reducing adhesions.
Post operative prematureovarian failure:• Excessive use of energy or an electrode introduced deep into the stroma may cause desiccation of hilar vessels and consequent damage• No concrete evidence of a decreased ovarian reserve or POF associated with women undergoing LOD for PCOS [Api et al : 2009 ]• PCOS women had significantly greater ovarian reserve than age matched controls with normal ovulation [ Weerakeit et al : 2007]• Chances remote after appropriately performed LOD.
Results• Ovulation rate 50-90%• Ovulation occurred within 2-4 wks and menstruation within 4- 6 weeks• Cumulative pregnancy rates of 76% and live birth rates 64%• Also improvement in reproductive performance is sustained for many years :49% of women conceived within 1 year of treatment• No significant differences in abortion rates with LOD and Gn [Farquhar et al 2002]
Prediction of response to LOD:• Poor responders to LOD associated with: • BMI more than 35kg/m2 • Serum testosterone more than 4.5 nmol/L • Free androgen index more than 15 [ testo x 100/ SHBG]• Poor response in women with early menarche , low LH/FSH ratio , low serum glucose levels –preop• LH/FSH ratio most indicative• Long term effects were very reassuring in terms of regular menstruation , ovulation and pregnancy rates [ Lunde et al: 2001]
LOD vs Exogenous Gn :• Extensive monitoring is not required [ Farquahar etal :2002]• No risk of multiple follicles ,OHSS :therefore decreased rates of termination of cycles• Lower incidence of Multiple pregnancy [ Farquhar et al :2012]• Live birth rates in LOD and Gn groups were similar[ Farquhar et al : 2012 ]• lower treatment and delivery costs [ Vanvely et al : 2004]• Beneficial improvement in menstrual regularity , reproductive performance , endocrine effects after LOD continue for years . [ Farquhar et al :2004]• In a Prospective trial –lesser OHSS [Remington et al : 1997]
Long Term Outcome after LOD Amer et al :2002Duration SHORT MEDIUM LARGE < 1 yr 1-3 yrs 4-9 yrs LH:FSH ratio Mean Ovarian -- 8.5 ml 8.4 ml Volume (11 ml) Menstrual 67% 37% 55% Regularity Conception Rate 49% 38% 38% Improvement in -- -- 23%-40% Hirsuitism and acne
LOD vs MetforminComparison with Metformin• LOS and Metformin improve menstrual disturbances and ovulatory dysfunction to a similar extent• The pregnancy rates are similar to those after LOD [ Palombo et al : 2005 ]• But the safety of Metformin in pregnancy is not proven• Metformin improved insulin resistance , reduced androgen levels and significantly increased the ovulation and pregnancy rates following LOD [Kocak I et al:2006, Hamed et al :2010 ]
Guidelines:Consensus expert opinion--2008• [ Thessaloniki , Greece: 2007 ; ESHRE / ASRM ;Hum Reprod- 2008]• LOS can achieve unifollicular ovulation with no risk of OHSS or high order multiples• Intensive monitoring of follicular development is not required• LOS is an alternative to gonadotropin therapy for CC- resistant anovulatory PCOS• Reduced direct and Indirect cost for women with CC-resistant PCOS
Consensus:• LOS is a single treatment using existing equipment.• LOS should not be offered for non fertility indications• The risks of surgery are minimal and include the risk of laparoscopy, adhesion formation , and destruction of normal ovarian tissue . Minimal damage should be caused to the ovaries .Irrigation with an adhesion barrier may be useful but there is no evidence of efficacy from prospective studies• Surgery should be performed by appropriately trained personnel.• The treatment is best suited to those for whom frequent ultrasound monitoring is impractical.