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Laparoscopic ovarian drilling : Not too much Not too little
1. Prof. Mahmoud Zakherah
Prof of Obstetrics and Gynecology,
Women’s Health Hospital Assiut University
Egypt
mszakhera@gmail.com
22-12-17
2.
3. A “stepwise approach” to the management
of infertility in PCOS
Ovarian Drilling in PCOS: Is it Really
Useful?
4. Ovarian Drilling in PCOS: Is it
Really Useful?
RCOG,[2007] ACOG,[2009] Society of
Obstetricians and Gynecologists, Canada[2010]
and the PCOS consensus working group[2008),
All recommend LOD use in highly selected
cases, particularly in those with hypersecretion
(LH), normal body mass index, needing
laparoscopic assessment of the pelvis or who live
too far away from the hospital for the intensive
monitoring required during gonadotropin
therapy.
5. Ovarian Drilling in PCOS: Is it
Really Useful?
This implies that LOD
is a valid, but not the
sole option for CC-
resistant PCOS
Mitra et al ,2015
6. All meta-analysis confirmed
that LOD is a second-line
treatment in PCOS patients,
especially those with CC
resistance.
Mayenga et al Gynecol Obstet Fertil (2011) .
Farquhar et al Cochrane Database Syst
Rev (2012).
14. PCO not equal PCOS
Rotterdam criteria 2004 ,entails the
presence of ≥12 follicles within the
ovary with a diameter of 2-9 mm and/or
ovarian volume ≥10 cm.
Polycystic ovaries may present in
healthy women, s0 the inclusion of this
sign to the diagnostic criteria of
polycystic ovary syndrome is still
questioned.
15. PCO not equal PCOS
Sonographically diagnosed polycystic
ovaries by Rotterdam Criteria increase in
the percentage of polycystic
ovary syndrome .
Recently , 26 versus 12 follicles-is required
to distinguish among women with PCOS and
healthy women from the general population
(Lujan et al. Hum Reprod. 2013)
16. PCOS imitators
The most important step to
diagnose PCOS to exclude
other conditions of
CA/Hyperandrogenism
21. How many punctures?
The number of punctures is empirically
chosen depending on the ovarian size.
In the original procedure, 3-8
diathermy punctures (each of 3 mm
diameter and 2-4 mm depth) per ovary
were applied, using power setting of
200-300 W for 2-4 s ( Gjönnaess ,1984).
22. How many punctures?
Most surgeons perform four punctures per
ovary, each for 4 s at 40 W (rule of 4),
delivering 640 J of energy per ovary (the
lowest effective dose recommended)
(Armar et al 1990).
Rule of Four
➢40 W
➢4 seconds
➢4 puncture points
23. How many punctures?
The aim of fixed number of puncture
points regardless of ovary size (Felemban et
al,2000) or unilateral ovary cauterization to
decrease the potential risks of ovarian
failure and adnexal adhesions (Balen and
Jacob,1994).
May be too little
24. How many punctures?
In earlier studies there was an
assumption that the greater the
amount of energy, the more
effective the procedure.
(Gjonnaess,1989)
May be too much
25. How many punctures?
The clinical response is dose-dependent,
with higher ovulation and pregnancy
rates observed by increasing dose of
thermal energy up to 600 J/ovary,
irrespective of ovarian volume (Amer
2003).
Most gynecologists still perform bilateral
over unilateral drilling.
(Roy et al,2009 , Farquhar et al,2012).
26. Unilateral versus Bilateral
Unilateral as effective as bilateral (Balen
and Jacob,1994).
Contralateral ovary may ovulate first
(Al-Mizyen and Grudzinskas 2007)
28. Adjusted LOD
New terminology
Means tailoring the number of
punctures according to Ovarian Volume
(Zakherah et al ,2011)
29. Ovarian Volume
Ovarian volume is calculated by the
measurement of the length, width and
the thickness and use of the classical
formula for a prolate ellipsoid: L × W × T ×
0.5 (Adams et al ,1985 Chen et al ,2008).
The volume of each ovary was calculated as follows: length ×
width × height × 0.523 (Higgins et al ,1990).
Three-dimensional ultrasound is a recognized
diagnostic modality to assess ovarian volume
30. The antral follicle count(AFC)
➢AFC was defined as the total number of
follicles < 9 mm in diameter in both
ovaries
➢FNPO is best predictor for diagnosis
PCOS
Christ et al , Fertil Steril,. 2014
Lie Fong et al, Hum Reprod. 2017
31. Methodology of Adjusted LOD
We suggested dose was 625 J/10.8 cm3= 60
J/cm3 of ovarian tissue.
The required number of punctures then was
calculated by dividing total individual
ovarian dose with dose delivered in each
puncture point. ( e.g. 12 cm3 x60=720 j
÷150=4.8 punctures)
33. How many punctures?
Adjusting thermal dose based on
ovarian volume (60 J/cm3 ) has
better reproductive outcomes with
similar postoperative adhesion rates
than fixed dose of 600 J/ovary
(Zakherah et al ,20011)
34.
35. 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 ) (Api,2009)
37. Assessment of ovarian reserve after
unilateral diathermy with thermal
doses adjusted to ovarian volume .
Dose-adjusted unilateral diathermy
(60 J/cm(3)) does not have significant and
long-term effects on ovarian reserve.
Sunj et al , Gynecol Endocrinol. 2014
38. Anti-Müllerian hormone, testosterone and free
androgen index following the dose-adjusted unilateral
diathermy in women with polycystic ovary syndrome
The value of T is the strongest and consistent
indicator of ovulatory response after
diathermy
Sunj et al .Eur J Obstet Gynecol Reprod Biol. 2014
39. Does unilateral laparoscopic
diathermy adjusted to ovarian volume increase the
chances of ovulation in women with polycystic
ovary syndrome?
The pregnancy rate was significantly
higher in patients with a larger right
ovary compared with those with a
smaller right ovary, regardless of the
treatment group
Sunj et al Hum Reprod. 2013
40. .
Conclusions :Accurate and documented
diagnosis of PCOS, appropriate surgical
training, adjusted thermal injury and
adjusted number of punctures are
essential for the avoidance of excessive
damageto the ovaries.
41. The impact of laparoscopic ovarian drilling on
AMH & ovarian reserve: a meta-analysis
LOD significantly lowers circulating AMH, but this
may not necessarily reflect a real damage to
ovarian reserve.
Given its proven efficacy and its long-term
benefits, LOD should remain as an option in the
management of anovulatory PCOS patients.
(Saad A Amer1, Tarek T El Shamy2, Cathryn James, Ali H
Yosef , Ahmed A. Mohamed, 2017)
42. How to avoid DOR
Adjust your dose ALOD
Cutting mode instead of coagulating
mode
Short time 5 seconds
Low wattage 30 watt
Lavage Before and After
Unilateral RT ovary –Adjusted
Never drill unless
43. To Avoid DOR
Avoid cauterization at
Mesovarium
Hilum
Corpus luteum
Ovarian ligament
Infudibulopelvic ligament
44. Never Drill
Ovarian volume less than 10 cm3.
FSH more than 9 IU/L
Previous ovarian drilling .except
AMH less than 5 ng/ml or more
than 8.3 ng/ml
Only used as a 2rd line therapy
45. Repeated LOD in polycystic ovary
syndrome
✓ DO NOT Repeat
✓ You will repeat failure
✓ After 1 y follow up IVF
✓ Antagonist Vs Long protocols
✓ Repeat LOD is ONLY in women
who previously responded to the
first procedure (Amer ,et al
,2003).
46. Take home messages
Lod still has a place and still
useful .
Proper diagnosis
Exclude PCOS imitators
LOS is 2nd line therapy for
clomiphene resistant cases
Adjust thermal dose
47. Take home messages
LOD is currently recommended as a safe, efficacious
and cost-effective alternative to gonadotropins for
OI in infertile, anovulatory, CC-resistant PCOS
women without the risks of OHSS or multiple
gestation.
Although iatrogenic adhesion formation and DOR
are potential complications, they are of little clinical
significance and can be minimized by adjusting the
number of punctures and energy applied.
48. Take home messages
LOD improves ovarian responsiveness to
CC and gonadotropins, these may be
considered after LOD failure instead of
repeat LOD, before proceeding to the last
resort that is, IVF.
LOD is only an alternative, not the
ultimate in management of PCOS
49. Take home messages
LOD NOT the first NOR
last line of treatment of
PCOS.
There are safe and efficacious oral alternatives
and relatively safe as low-dose step-up
regimen of gonadotropin therapy before
proceeding to the last resort that is, IVF.
50. If your only toy is a hammer
every problem will look like
a nail