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Ovarian reserve and LOD in PCOS


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Thesis submitted as partial fulfillment of the Master Degree in OBGYN
Dr.Ahmed Sameh Ghoubara
Tanta faculty of medicine

Published in: Health & Medicine
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Ovarian reserve and LOD in PCOS

  1. 1. SUPERVISIORS SUPERVISIORSOvarian Volume Prof.Dr. Prof.Dr. ThesisBasal Safaa Kamal Submitted for partial FSH Level Maraie the fulfillment of fulfillment of the Professor of Obstetrics and Gynecology And Professor of Obstetrics and Gynecology Faculty of Medicine requirements of Faculty of MedicineAntral Follicles Tanta University Tanta University Prof.Dr. Prof.Dr. the M.S. Degree In Count ‫بسم ا الرحمن الرحيم‬ Naglaa Mohammad Lotfy Dabees Obstetrics and Gynecology Assistant professor of Diagnostic Radiology Assistant professor of Diagnostic Radiology before and after By Faculty of Medicine Faculty of Medicine Laparoscopic Ahmed Sameh Tanta University Tanta University Dr. Dr.Ovarian Drilling Talat Ghoubara Mohamed Ahmed El-Sharawy in Women with of Obstetrics and Gynecology Lecturer of Obstetrics and Gynecology Lecturer (M.B.B.CH.) Faculty of Medicine Faculty of Medicine PCOS Tanta University Tanta University 2012 2012
  2. 2. Aim of the Work This study aims to evaluate ovarian volumebasal follicular stimulating hormone level and antral follicles count as predictors of ovarian reserve before and after laparoscopic ovarian drilling in women with polycystic ovarian syndrome.
  3. 3. Ovarian Bank offollicles is called theovarian reserve
  4. 4. Quantity The number and and theirReproductive of qualityrestingof potential folliclesgrowing follicles
  5. 5. Ovarian reserve tests:Static tests: Dynamic tests:Female Age CCCTOVVOL EFORTAFC GASTbFSHAMHInhibin-bE2
  6. 6. x GnRH E2 -ve FB on hypothalamus The idea of bFSH as an ORT x FSH E2/Inhibin-B -ve FB on pituitary Decreased –ve FB of E2 on FSH E2/ rise in FSHInhibin-B
  7. 7. FSH is most common used ORT in clinical practice, it can diagnose:Normal ovarian functionPremature ovarian failurePerimenopause and menopauseDOR
  8. 8. Some studies concluded that bFSH > 20 mIU/ml Marked decrease in Marked decrease in succeededspontaneous pregnancy IVF pregnancy
  9. 9. Because of the test variability and false +ve results bFSH is just a screening test for the purpose of counselling
  10. 10. x x xwe cannot exclude patients from IVF cycles on the basis of bFSH alone
  11. 11. Antrum(Cavity)
  12. 12. The AFC is indicative of the number of primordial folliclesas each primordial follicle can develop to antral follicle
  13. 13. The AFC is the best indicator ofpoor or good ovarian response to stimulation for IVF
  14. 14. So thatChildbearing Perimenopause Postmenapsue AFC is related to the reproductive events and aging
  15. 15. 35 years oldAFC >6 per ovary AFC < 5 per ovary Natural Premature Menopause Menopause at age of 48 -51 at age of 38-45
  16. 16. Volume of prolate shape by using te ola the prolate ellipsoidPr formula0.524 * Height * Width * Depth
  17. 17. Ovarian volume is related to the remaining primordial follicles
  18. 18. Average OVVOL < 3 cc High chance of failure of COH
  19. 19. Polycystic heterogenous group of signs and Ovarian symptoms thatSyndrome are.…
  20. 20. … gathered to form aspectrum of disorders in [Endocrine] [Reproductive] [Metabolic]
  21. 21. The commonest cause of anovulatory infertility
  22. 22. There was no agreed definition of PCOS Until
  23. 23. Rotterdam, 2003
  24. 24. PCOS isdefined as …2 out of 3
  25. 25.  Oligo or anovulation Hyper- Where the US androgenism (clinical pictures of or biochemical) PCOS are … US features of PCOS
  26. 26.  12 or more follicles (2-9 mm) per ovary D1= 3cm D2= 4cm OVVOL > 10 cc per ovary
  27. 27. XXX
  28. 28. How could we treat PCOS? Anti-EstrogensClomiphene Citrate Aromatase Inh.
  29. 29. How could we treat PCOS? GnRH Agonist Metformin (adjuvant)
  30. 30. How could we treat PCOS?Laparoscopic Ovarian Drilling
  31. 31. Patients and Methods
  32. 32. We selected our The present patients Study was according to the conducted onfollowing inclusion 30 patients criteria:
  33. 33. 1. Primary infertility2. Less than 35 years old3. BMI < 304. Rotterdam Criteria of PCOS5. No ovulation induction for 3 months6. Indicated for LOD ??
  34. 34. We DRILL when there is:1. Anovulatory infertility with CC resistance2. Persistent hyper-secretion of LH3. Repeated overresponse to Gonadotropins or CC4. Patients who found it difficult to keep attendance for close monitoring of folliculo- metry
  35. 35. We excluded patients with:1.More than 35 years old2.BMI of Equal to or more than 30 kg/m23.History of pelvic surgery4.History of ovarian disease (Tumors, Cysts,TOA)5.History of ovulation induction within 3 monthsprior to the procedure6.+ve pregnancy test during the study
  36. 36. To fulfill the inclusion and exclusion criteria: History taking special comments on marital, husband and sexual history Examination special comments on local gynecological examination Investigations Routine investigations e.g. CBC, LFTs, ….
  37. 37. Basal period Mid-Cycle FSH LH 1. Basal FSH level 2. AFC 3. Ovarian volume ////////////////////////////0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28Menses Blood
  38. 38. bFSH was measured by theAutomated methodUsing the automated analyzer: TOSOH ® AIA-600III Japan
  39. 39. The preoperative AFC and OVVOLwere measured by using the trans-vaginal probe of: LOGIQ PRO 100 GE Healthcare® India
  40. 40. The transvaginal probe:Convex arrayFrequency: 5 mHzRadius :40 mmField of view: 68o
  41. 41. Before we countMeasuring thethe antral follicles,average diameter:Only follicles thatidentification of2 perpendicularrange from 2-9them is requireddiameters dividedmm were countedfirstby 2
  42. 42. Because the ovary is prolate rather than ovoidWe used the prolateellpsoid formula of volume
  43. 43. The prolate ellipsoid formula0.524 * Height * Width * Depth
  44. 44.  bFSH bFSH AFC AFC OVVOL OVVOL Preoperative Preoperative LOD
  45. 45. Micro digital camera California
  46. 46. Xenon light source Germany
  47. 47. Electrosurgical diathermyFORCE 2 Valleylab Germany
  48. 48. InstrumentsCalifornia
  49. 49. LOD Bilateral 4 punctures per each ovary 4 seconds per each puncture 40 Watt diathermy
  50. 50.  bFSH bFSH  bFSH  bFSH  bFSH  bFSH AFC AFC  AFC  AFC  AFC  AFC OVVOL OVVOL  OVVOL  OVVOL  OVVOL  OVVOLPreoperativePreoperative First PO cycleSecondPO cycleThirdPO cycle Second PO cycle First PO cycle Third PO cycle cycle cycle LOD
  51. 51. Results
  52. 52. The age ranged19 – 31 years oldMean: 24.6SD: +/- 3.35
  53. 53. The BMI ranged24-29 years oldMean: 26.7SD: +/- 1.7
  54. 54. P value ofANOVA was 0.89FSHNo Significant difference between thepreoperative andpostoperative basal FSH mean values
  55. 55. Student’s t- test P value of 0.001 0.476ANOVA Significant difference No significant was difference0.001AFC Significant difference Preoperative Preoperative cycle cycle First PO cycle Second PO Third PO cycle First PO cycle Second PO Third PO cycle cycle cycle between thepreoperative LOD andpostoperative mean AFC 0.001 Significant difference
  56. 56. P value of Student’s t- test 0.001 0.787ANOVA Significant No significant was difference difference0.001OVSignificant difference Preoperative Preoperative cycle cycle First PO cycle Second PO Third PO cycle First PO cycle Second PO Third PO cycle cycle cycleVOL between thepreoperative and LODpostoperativemean ovarian volume 0.001 Significant difference
  57. 57. The reduction in AFC and OVVOL remained inthe normal ranges
  58. 58. Conclusion
  59. 59. According to this study: there is no decrease in ovarian reserve after using LOD HOWEVER studies with long term follow up may be required for clinical assessment of DOR after LOD by using other ovarian reserve markers anddifferent techniques of LOD with or without ovulatory stimulants in relation to IVF and pregnancy outcomes
  60. 60. It was an Honor to work under my supervisors Special thanks to The professor Dr. Safaa Marie for 2 reasons : Supreme supervision and guidance She was the one that hadmanaged my labor when I was a newborn on 1984
  61. 61. ‫اللهم أحقن دماء المسلمين في سوريا‬‫‪THANK YOU‬‬