presented at woosp conference 2012

1. LAPAROSCOPIC
OVARIAN DRILLING:
FOR SURGICAL
INDUCTION OF
OVULATION IN PCOS
Dr Ameya Padmawar
Gynaecological Endoscopic Surgeon
Rotunda Blue fertility centre and keyhole surgery centre , Mumbai
Sanjeevan Medical centre, Borivali, Mumbai
Dr. Rizwana Syed
MD

2. 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
ovaries
ESHRE and ASRM : 2003 criterion: any 2
1 . Oligomenorrhea / anovulation
2 . Hyper androgenism [ clinical and biochemical ]
3 . USG appearance of PCOS

4. INFERTILITY ANOVULATION
Infertility due to chronic anovulation is the most common
reason for women seeking counseling or treatment
Many treatment protocols ,medical and surgical have been
proposed but the optimal treatment for infertile women with
PCOS is not yet defined.

5. 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

6. LAPAROSCOPIC OVARIAN
DRILLING:
• 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 ]

7. Indications:
• Clomiphene citrate Resistance
• Patients undergoing laparoscopy for tubal patency
• Poor response to any ovulation inducing agents whether
clomiphene citrate or gonadotropins

8. 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

9. Basic Endoscopic Setup for
LOD

10. Instrumentation for LOD:

11. Laparoscopic Electrocauterisation of ovarian Surface:

12. 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

13. Laser vs Electrocautery
Electrocautery 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 ]

14. Optimal Energy modality :laser
or electrocoagulation:
Cumulative ovulation and pregnancy rates at 12 months of LOD
after EC or Laser:[Saleh and Khalil: 2004]
Spontaneous Pregnancy rates
ovulation
Electrocoagulation 82.7% 64.8%
Laser vaporization 77.5% 54.5%

15. Mechanism of Action
Destruction 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 levels
Removes intra ovarian block to follicular maturation
that precedes ovulation, resulting in recruitment of
new cohort of follicles and subsequent ovulation.

16. 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 ]

17. RISKS involving LOD:
• Adhesion formation
• Potential surgical risks
• Anesthesia risks
• Premature Ovarian Failure (theoretical complication)

18. Postoperative adhesions following LOD:

19. 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.

20. Post operative premature
ovarian 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.

21. 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]

22. 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]

23. 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]

24. Long Term Outcome after LOD
Amer et al :2002
Duration 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

25. LOD vs Metformin
Comparison 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 ]

26. 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

27. 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.

29. Thank you
abpadmawar@yahoo.com