ovarian drilling as a meathod of ovulation inductiuon

1. Dr sundar narayanan
M.D, DIP LAP, DIP ART, DIP US
LAPAROSCOPIC OVARIAN DRILLING FOR
PCOS
DO’S & DONT’S

2. INTRODUCTION
• Polycystic ovary is the most common metabolic
abnormality in young female today of
reproductive age
• Most common cause of infertility in women
• Studies of PCOS in India reported a prevalence
of 3.7% to 22.5% and upto 36% prevalence in
adolescents
IAGES COLOMBO 2017

3. Thecommonestcauseofanovulatoryinfertility
PCOS
The commonest cause of anovulatory infertility
IAGES COLOMBO 2017

4. DIAGNOSTIC
CRITERIA
IAGES COLOMBO 2017

5. IAGES COLOMBO 2017

6. NATIONAL INSTITUTES OF HEALTH AND
CHILD HEALTH AND HUMAN
DEVELOPMENT(1990)
Chronic anovulation
Hyperandrogenemia
Clinical signs of hyperandrogenism
Exclusion of other androgenic disorders
IAGES COLOMBO 2017

7. IAGES COLOMBO 2017

8. ROTTERDAM CRITERIA
(2003)
• Polycystic ovaries (>12 peripheral
follicles or increased ovarian volume
>10cm3)
• Clinical and/or biochemical signs of
hyperandrogenism
• And exclusion of other etiologies such as
hypothyroidism, hyperprolactinemia, congenital
adrenal hyperplasia, cushing syndrome, androgen
secreting tumors
IAGES COLOMBO 2017
• 2 out of 3

9. Polycystic VS. Multicystic Ovaries
Polycystic ovaries
•Bilateral
•At least 12 follicles
•Follicular diameter 2 - 9 mm
•Stroma increased
• Multicystic ovaries
• Bilateral
• Multiple cysts
• Cyst diameter usually > 10
mm
• Stroma not increased
IAGES COLOMBO 2017

10. AE-PCOS SOCIETY 2006
• Hyperandrogenism-hirsutism and/ or
hyperandrogenemia
• And
• Ovarian dysfunction-oligo-anovulation
and/ or polycystic ovaries
• Exclusion of other androgen excess or
related disorders
IAGES COLOMBO 2017

11. PCOS – PHENOTYPES (2014)
The Rotterdam and AE-PCOS Society criteria
recognize at least 3 unique clinical phenotypes:
(1) Frank PCOS (oligomenorrhea, hyperandrogenism,
and PCO)
(2) Ovulatory PCOS (hyperandrogenism, PCO, and
regular menstrual cycles)
(3) Non-PCO PCOS (oligomenorrhea,
hyperandrogenism, and normal ovaries).
(4)Mild or Normoandrogenic PCOS(oligomenorrhea,
PCO, and normal androgens.
IAGES COLOMBO 2017

12. CLINICAL
PRESENTATION
IAGES COLOMBO 2017

13. Reference: Sirmans SM, Pate KA. Epidemiology, diagnosis, and management of polycystic ovary syndrome. Clin Epidemiol. 2014;6:1–3.
Obesity

14. TREATMENT
IAGES COLOMBO 2017

15. • Life style modification
• Medical management
Adolescent age
• LOD has a role only as a
method of surgical induction
Reproductive
age
• Medical management
Post
Menopausal
age
IAGES COLOMBO 2017

16. • No clear evidence that LOD
improves menstrual regularity and
androgenic symptoms of PCOS
IAGES COLOMBO 2017

17. LOD-INDICATION
IAGES COLOMBO 2017

18. Consensus on infertility treatment
related to PCOS
FIRST LINE
CLOMIPHENE CITRATE
SECOND LINE
LOD/GONADOTROPINS
THIRD LINE
IVF
The Thessaloniki ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group March
2–3, 2007, Thessaloniki, Greece. Human Reproduction 2008
R
E
S
I
S
T
A
N
C
E
R
E
S
I
S
T
A
N
C
E
F
A
I
L
U
R
E
IAGES COLOMBO 2017

19. Thessaloniki, Greece – 2008 consensus on LOD
•Alternative to Gn for CC-
resistant anovulatory PCOS
•Achieves unifollicular ovulation
•Reduced risk of OHSS or
multiple pregnancy
•Intensive follicular monitoring
not required
•Reduced direct and indirect
cost
IAGES COLOMBO 2017

20. LOD as a first line alternate to CC
S.A. Amer, RCT, HR 2009
CC should therefore remain the standard first-line OI in anovulatory womenwith
PCOS. However, LOD could be recommended as a first line if laparoscopy is
indicated for other reasons in these women, and as an adjunct to CC treatment
should monotherapy fail to produce a pregnancy after a limited duration of
exposure. The value of detecting and treating sub-clinical endometriosis requires
furtherevaluation.IAGES COLOMBO 2017

21. RCOG
Green-top Guideline No. 33
November 2014
Ovarian electrocautery should be
considered for selected anovulatory
patients, especially those with a
normal BMI, as an alternative to
ovulation induction.
IAGES COLOMBO 2017

22. Laparoscopic ovarian drilling may be considered
in women with Clomiphene-resistant
PCOS, particularly when there are other
indications for laparoscopy (I-A)
Surgical risks always need to be considered in
these patients (III-A).
IAGES COLOMBO 2017

23. MECHANISM OF ACTION
IAGES COLOMBO 2017

24. • Destruction of androgen producing stroma
• Drainage of follicles with high androgen and
inhibin content
• Alterations in intraovarian growth factor
(IGF-1)-sensitizes ovary to circulating FSH
Intraovarian
mechanisms
• Markedly reduced LH amplitudes with no
change in pulse frequency
• Hypothalamic-pituitary ovarian axis
synchrony
Central
mechanisms
IAGES COLOMBO 2017

25. Removes intraovarian block to follicular
maturation that precedes ovulation,resulting in
recruitment of new cohort of follicles and
subsequent ovulation
• Decrease in LH & AMH concentration
• Release of inhibition of FSH action
• Occurs rapidly & sustained for several
years
Hormonal
changes
IAGES COLOMBO 2017

26. EVOLUTION OF
SURGICAL
MANAGEMENT OF
PCOS
IAGES COLOMBO 2017

27. • Initially , laparoscopic wedge resection by Stein
&Leventhal (1938)
IAGES COLOMBO 2017

28. • 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)
•Transvaginal ultrasound follicular
aspiration (Maio et al , 1991).
IAGES COLOMBO 2017

29. •Unilateral ovarian drilling (Balen and
Jacobs,1994, Zakherah et al 2004).
•LOMNI (2005)
•Transvaginal hydrolaparoscopy (Gordts et
al,2009,fertil steril).
•LOD using hormonic scalpel (2012)
IAGES COLOMBO 2017

30. IAGES COLOMBO 2017

31. PREDICTORS OF RESPONSE
•Poor responders to LOD :
-BMI >35 kg/m2
-serum testosterone concentration >4.5nmol/l
-Free androgen index (FAI) >15
-AMH > or = 7.7 ng/ml
•Predictor of higher probability of pregnancy : LH
levels >10 IU/l in LOD responders
•LH/FSH ratio most indicative
IAGES COLOMBO 2017

32. SURGICAL TECHNIQUE
IAGES COLOMBO 2017

33. •Being a fertility enhancing procedure LOD
should be done only as a part of Diagnostic
Hysterolaparoscopy
•Laparoscopy should be preceeded by
Vaginoscopy/Vaginohysteroscopy
IAGES COLOMBO 2017

34. HYSTEROSCOPY
IAGES COLOMBO 2017

35. HYSTEROSCOPIC CANNULATION
IAGES COLOMBO 2017

36. Septal resection
IAGES COLOMBO 2017

37. Hysteroscopic myomectomy
IAGES COLOMBO 2017

38.  Laparoscopy performed with one primary
and two contralateral ports
 Utero-ovarian ligament grasped using
atraumatic grasper moving the ovary
towards anterior abdominal wall &
anterior aspect of uterus
 A double insulated retractable needle
electrode connected to a electrosurgical
generator is used
IAGES COLOMBO 2017

39. •Unipolar current is advised in a cutting mode to
minimize thermal damage; the power is activated
just before touching the ovary and preferably avoid
lateral and inferior surface of ovary and helium.
•4 to 10 punctures to a depth of 2 to 4mm on
each ovary according to ovarian volume
•40W for 4s and four punctures – A good thumb
rule
IAGES COLOMBO 2017

40. LAP OVARIAN DRILLING
IAGES COLOMBO 2017

41. •Flushing of the ovaries with normal saline ( 500ml)
prevents overheating and post operative adhesion
formation
Pelvic structures are inspected for any abnormality
including tubal patency testing.
IAGES COLOMBO 2017

42. IRRIGATION
IAGES COLOMBO 2017

43. TUBAL PATENCY
IAGES COLOMBO 2017

44. Monopolar versus bipolar laparoscopic ovarian
drilling in clomiphene-resistant polycystic ovaries
(PCO): a preliminary study
· April 2016
Utilizing bipolar LOD is superior to monopolar LOD due
to a significantly higher postoperative incidence of
resumption of spontaneous ovulation and spontaneous
pregnancy and theoretical less adhesion formation
following bipolar LOD

45.  Saleh AM et al, Obst Gynecol Scand2004
Electrocoagula
tion group
LASER group OR (95% CI)
Spontaneous
ovulation
82.7 77.5 1.4
0.9-2.1
Pregnancy rate 64.8 54.5 1.5
1.1-2.1
LASER Vs Electrocautery
IAGES COLOMBO 2017

46. •Electrocautery is superior to LASER in
achieving ovulation and pregnancy
( li et al,1998)
•Electrocautery is less costly ,easier to use
and its effect may last longer
(Naether etal,1994).
• LASER especially CO2 may be associated
with a higher risk of adhesion formation
(keckstein et al :1989)
Thus, Electrocautery is superior
IAGES COLOMBO 2017

47. A Modified Technique of Laparoscopic
Ovarian Drilling for Polycystic Ovary
Syndrome Using Harmonic Scalpel
2012 Nasr AA, et al.
•LOD using harmonic scalpel
produce similar results like
electrocautery.
• As well is associated with a
minimal effect on ovarian
reserve and post operative
adhesion.
IAGES COLOMBO 2017

48. HORMONIC SCALPEL
IAGES COLOMBO 2017

49. COMPLICATIONS
IAGES COLOMBO 2017

50. Related to anaesthesia & laparoscopy procedure
Related to drilling
-Bleeding from drilling site
-Laceration of utero-ovarian ligament
-Use of excessive amount of energy will
destroy large number of follicles resulting
in decreased ovarian reserve.
Ovarian atrophy and premature ovarian
failure.
-Adhesion formation
IAGES COLOMBO 2017

51. Is ovarian reserve diminished after LOD ?
•The PCOS women both with and without LOD had
significantly greater ovarian reserve (? Quality)than
the age matched controls having normal ovulatory
menstruation
•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)
IAGES COLOMBO 2017

52. Duration <1 yr 1 – 3 yrs > 4- 9 yrs
LH : FSH ratio
Mean Ovarian
volume
---- 8.5 ml 8.4 ml
Menstrual
regularity
67% 37% 55%
Conception rate
49% 38% 38%
Improvement in
Hirsuitism and
acne
---- ---- 23% - 40%
Long term outcome of LOD
Amer et al : 2002
IAGES COLOMBO 2017

53. Alternative
techniques
IAGES COLOMBO 2017

54. Laparoscopic ovarian multineedle
intervention (LOMNI)
Hakan Kaya et al 2005
 A specially designed laparoscopic instrument (Kaya
laparoscopic drilling device) was inserted through
the 5-mm ancillary port.
 This instrument is 37 cm long with a distal
grasper-like tip containing two prongs.
 Each prong is 25 x 4 mm in area and consists of 10
needle-like teeth, which are 2 mm in length and
0.4 mm in diameter.
IAGES COLOMBO 2017

55. IAGES COLOMBO 2017

56.  The maximum opening distance achieved between
the two rows of teeth is 30 mm.
 Ovarian tissue was placed between the jaws of the
instrument and squeezed by applying some force.
 The instrument was slipped over to the
neighbouring untreated ovarian tissue, its jaws
closed again, and consequently the entire ovarian
surface was subjected to this procedure
IAGES COLOMBO 2017

57. Advantage of LOMNI over others
 Need for electrosurgery or laser is eliminated,
decreasing the cost and possibly preventing
adhesion formation.
 Although squeezing of ovarian tissue during our
technique might destroy some ovarian tissue, the
extent of destruction might be expected to be
lower than the other techniques
IAGES COLOMBO 2017

58. Hakan Kaya et al. Journal of
Minimally Invasive
Gynecology (2005)
IAGES COLOMBO 2017

59. Transvaginal hydrolaparoscopy
 An advantage of the vaginal approach is the
direct access to the tubo-ovarian organs and
the ovarian fossa without use of any
additional manipulation.
 Access to the pouch of Douglas is obtained
through a needle puncture technique of the
posterior fornix with a spring- loaded
needle, making access through the vaginal
wall fast and easy.
IAGES COLOMBO 2017

60.  A 2.9-mm endoscope with an optical angle of
30 fits in an outer operative sheath of 5-mm
diameter with one working channel.
 Through this channel 5 Fr instruments, like a
bipolar needle or a bipolar coagulation probe,
can be introduced for drilling
 The use of bipolar electric current is mandatory,
because throughout the entire procedure saline
is used as distension medium.
IAGES COLOMBO 2017

61. Specialised instruments
for transvaginal hydro
laparoscopy
IAGES COLOMBO 2017

62. Ovarian drilling by fertiloscopy.
2011, Hackethal et al.
IAGES COLOMBO 2017

63. Advantage of transvaginal hydrolaparoscopy
 Safety of the trans vaginal access.
 Scarless procedure.
 Advantage in obese patients.
 Reduced risk of postoperative adhesion.
 Very low morbidity of the procedure.
 Transvaginal hydrolaparoscopic ovarian drilling with
the bipolar VersaPoint system is a useful therapeutic
option in these women (Alessandro casa et al May
2003 Journal of AAGL)
IAGES COLOMBO 2017

64. Ultrasound-Guided Transvaginal Needle
Ovarian Drilling(UTND)
(Mio Y et al. FS 1991)
 The UTND was performed, under general
anesthesia with Propofol , using a 16-gauge,
35-cm long sharp needle connected to a
continuous manual vacuum pressure.
 Each ovary was repeatedly punctured from
different angles with between three and six
punctures, and all the small follicles visible by
ultrasound were aspirated
IAGES COLOMBO 2017

65. IAGES COLOMBO 2017

66.  The idea of needle drilling came to mind
through the observation of improved ovarian
performance in patients with PCOS after
previous follicular aspiration for IVF trials.
 None of the participants in this trial conceived
in the aspiration cycle. However, the response
to ovulation induction was improved in
subsequent cycles.
IAGES COLOMBO 2017

67. •No clear evidence of different
effectiveness between different
types of LOD except that LOD with
4-5 punctures/ovary may be more
effective than 2 or fewer punctures
IAGES COLOMBO 2017

68. IAGES COLOMBO 2017

69.  Polycystic ovaries are not specific for PCOS
 Proper selection of cases will help in greater
cumulative success rate and help in
predicting response.
 LOD has no role in adolescents and post
menopausal women
• It is used only as a method of surgical induction
of ovulation and Should not be offered for non
fertility indications
IAGES COLOMBO 2017

70. • Work up of the patient is incomplete without
Diagnostic Hysterolaparoscopy
• Potential complications include formation of
adhesions & long-term effects of tissue
damage on ovarian function.
• Proper surgical technique will help in avoiding
damage to normal ovarian tissue and in turn
avoid premature ovarian failure.
• Flushing about 500ml Normal Saline over
ovaries helps to prevent adhesion formation
IAGES COLOMBO 2017

71. IAGES COLOMBO 2017
• LOD is usually effective in 50% of women
and additional ovulation induction may
be required to enhance fertility.
• Hence proper post surgical follow-up
including ART should be counselled

72. IAGES COLOMBO 2017