3. ‫الحسن‬ ‫قال‬‫ال‬ ‫البصرى-رحمه‬
‫مما‬ ‫أكثر‬ ‫يفسده‬ ‫ما‬ ‫كان‬ ‫علم‬ ‫بغير‬ ‫عمل‬ ‫من‬
‫غير‬ ‫على‬ ‫كالسائر‬ ‫علم‬ ‫بغير‬ ‫والعامل‬ ، ‫يصلحه‬
، ‫بالعبادة‬ ‫يضر‬ ‫ل‬ ‫طلبا‬ ‫العلم‬ ‫فاطلبوا‬ ، ‫طريق‬
‫يضر‬ ‫ل‬ ‫طلبا‬ ‫العبادة‬ ‫واطلبوا‬‫بالعلم‬
2-12-12laparoscopic surgery

4. 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).

5. 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; Pritts,2002).

6. 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 .

7. 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.

8. General advantages of operative
laparoscopy

9. 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.

10. 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 LH.
Prevention of long term morbidity
(metabolic and cardiovascular risks).??
(Amer et al,2007 found no benefit )

11. 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)

12. 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 (Amin,1994).

13. Evolution of Surgical management of
PCOS
Unilateral ovarian drilling (Balen and
Jacobs,1994, Zakherah et al 2004).
Single Puncture Electrocoagulation of Ovarian
Stroma "SPECOS“ Shawki,1996
Transvaginal ultrasound-guided electrocautery
(Syritsa,1998)
Removing one ovary (Kaaijk, 1999).
Transvaginal hydrolaparoscopy (Gordts et
al,2009,fertil steril).
Single port laparoscopic surgery LOD (2010)

14. Methodology of Ovarian Drilling
Preoperative requirements
1. Documented PCOS (clinical, hormonal and
sonographic).
2.Clomiphene resistance
3.Normal prolactin or treated.
4.Inability or unwilling to undergo gonadotropin
therapy
5.Normal endometrial cavity with patent tubes.
6.Normal semen analysis

15. Methodology of Ovarian Drilling
Operative requirements
General endotracheal anaesthesia
High flow CO2 insufflator
Video 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).

16. 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 saline.
No coagulation should be done within 1 cm from
the helium may lead to ovarian atrophy.
At the end of the procedure both ovaries should be
irrigated with Ringer's lactate It was concluded that
“the solution to pollution is dilution“.

17. 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.


19. 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
al,1994).

20. linear incision 5-7 mm in depth .
Laparoscopic ovarian drilling using a
harmonic scalpel (Takeuchi et al,2002).
laparoscopic ovarian multi-needle
intervention (LOMNI) (Kaya et al,2005)
Ultrasound-guided transvaginal ovarian
needle drilling (UTND)(Badawy et al,2009)
Other techniques of LOS

21. 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 stroma
Correcting abnormal ovarian pituitary feedback
(Balen and Jacobs, 1994)
VEGF and IGF-1, which are typically increased in
patients with PCOS(Amin et al,2003)
Reduction of ovarian inhibin with a resultant rise in
FSH ????(Amer et al,2007 found no change)

22. Outcomes of Ovarian Drilling
Clinical Outcome of Ovarian Drilling
Restoration of regular menstruation in
approximately 80%.
The mean ovulation rate was 70% and the
cumulative pregnancy and live birth rate was 76%
and 64% , respectively (Bayram et al,2004)
Miscarriage rate is similar to general population .
Reproductive performance seems to last for may
years in about one third of cases (Amer et al,2002).

23. 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

24. Outcome of Ovarian Drilling
Hormonal Changes After Ovarian Drilling
 Decline in the LH levels
Decrease in androgens (testosterone and
androstenedione) (Armar etal,1990)
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

25. Predictors of the outcome
Clinical predictors
Marked obesity(BMI≥35)
History of infertility >3 years .
Biochemical predictors
 High LH levels≥10IU)
Marked hyperandrogenemia.
Insulin resistance
(Amer et al,2004)

26. Complications of ovarian drilling
A part from the need of surgery under general
anesthesia and the risk of any surgical procedure
1- Pelvic adhesions
Adhesion 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).

27. 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 ascites
“the solution to pollution is dilution"

28. 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 .

29. 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)

30. 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

31. Current status in LOD
LOD is not superior to CC as a first-line method
of OI in women with PCOS (Amer etal,2009)
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
success/failure of each of these treatments , we
should tailor the treatment according to the
patient’s characteristics .

32. Current status in LOD
.
LOD may be preferred as 2nd
line therapy
(Amer,2008)
 LOD and gonadotropins have been shown to be
equally effective in ovulation and pregnancy
rates(Farquhar et al,2005). (Moderately
quality evidence)
No significant difference between LOD and
metformin in pregnancy or ovulation rates ([60% vs
64%] and (84%vs 80),respectively) Pirwany et
al,200). ( very low-quality evidence).

33. 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 al,2007. Cochrane Database Syst Rev. 2007;(3

34. Advantages of LOD over gonadotropins
Mono-ovulation
Low risk of OHSS
Less costly (cost of a live birth was one third
lower in LOD compared to who received
gonadotrophins).
Single action lead to repeated ovulations
Need no complex monitoring
Lower miscarriage rate(cohen,1995)????

35. 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)

36. 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).

37. 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).

38. 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)

39. 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),

40. Failed LOD
 20-30% of anovulatory women with PCOS
failed to respond to LOD (Farquhar,2004).
Insufficient thermal dosage
Inherent resistance of the ovary to the effects
of drilling.
Post-operative adhesion
Hyper prolactaenaemia observed in some
patients after LOD

42. Repeated LOD in polycystic ovary syndrome
Repeat LOD is highly effective in women who
previously responded to the first
procedure (Amer ,et al ,2003)

43. Adjuvants after ovarian drilling
CC or low dose gonadotropins
NAC is a novel adjuvant therapy after unilateral
LOD which might help improve overall reproductive
‫ز‬outcome (a pilot study ) (Nasr A,2010).
Metformin increases the ovulation and pregnancy
rates in infertile women, following LOD(Kocak and
Ustün ,2006).
Weight reduction.
IVF.
Repeat LOD ,we will add more complications

44. 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

45. 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.

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