Ovulation Induction and Controlled Ovarian Stimulation, 2st ed.

11. Laparoscopic Ovarian Drilling

Roy Homburg1

(1)

Homerton Fertility Centre, Homerton University Hospital, London, UK

Abstract

The original treatment for PCOS, proposed by Stein and Levanthal in 1935, was bilateral wedge resection of the ovaries. This met with remarkable success regarding resumption of ovulation but was abandoned due to the high probability of inducing pelvic adhesions and the advent of medical means of inducing ovulation. Today the same effect of decreasing the amount of active ovarian tissue can be achieved by laparoscopic ovarian drilling (LOD) by diathermy or laser and this method now presents a further treatment option for women with anovulatory infertility associated with PCOS. No less than four and no more than ten punctures to a depth of 2–4 mm on each ovary should be made according to the size of the ovary. The main advantages of ovarian drilling are a very high prevalence of monofollicular ovulation and therefore a significant reduction in multiple pregnancy rates compared with gonadotrophin therapy, a reported reduction in miscarriage rates and the fact that it is an often successful “one-off” procedure which may avoid the use of expensive medical therapy and the exclusion of ovarian hyperstimulation syndrome. If ovulation is not forthcoming within 2–3 months following LOD, then ovulation induction can often be more successfully employed than preceding the operation with clomifene or FSH if clomifene fails to induce ovulation. Follow-up after LOD showed that 49 % conceived spontaneously within a year and a further 38 % within 1–9 years following the operation. Women with anovulatory PCOS who are of normal weight and have high LH concentrations seem to have the most favourable prognosis. LOD should not be employed merely for the treatment of other symptoms of PCOS.

Keywords

Laparoscopic ovarian drillingPCOSOvariesPelvic adhesionsOvulationOvarian tissueDiathermyLaserAnovulatory infertilityPCOSElectrocauteryGonadotrophinFSHClomifene citratePregnancyMonofollicular ovulationOvarian hyperstimulation syndromeGonadotrophinsAnovulatory PCOSLHAMHGnRH

The original treatment for PCOS, proposed by Stein and Levanthal in 1935, was bilateral wedge resection of the ovaries. This met with remarkable success regarding resumption of ovulation but was abandoned due to the high probability of inducing pelvic adhesions and the advent of medical means of inducing ovulation. Thanks to modern technology, by which the same effect of decreasing the amount of active ovarian tissue is achieved, laparoscopic ovarian drilling (LOD) by diathermy or laser now presents a further treatment option for women with anovulatory infertility associated with PCOS.

11.1 Surgical Methods

Laparoscopic ovarian drilling has most popularly employed a bipolar coagulating current but unipolar diathermy is less traumatic to the ovary. Laser puncture of the ovary produces similar results. Using electrocautery, 40 W for 4 s for each puncture is a good rule of thumb. No less than four and no more than ten punctures to a depth of 2–4 mm on each ovary should be made. Less than four punctures on each ovary results in poorer pregnancy rates but more than ten may cause ovarian damage that will do more harm than good. Ten punctures of the ovary should only be used on very large ovaries. Flushing of the ovaries with normal saline prevents over-heating and many use an anti-adhesion preparation.

11.2 Results

An analysis of the first 35 reports, mostly uncontrolled series, showed that 82 % of 947 patients ovulated following the operation and 63 % conceived either spontaneously or after treatment with medications to which they had previously been resistant [1]. A Cochrane data base analysis of four randomized controlled trials comparing laparoscopic ovarian drilling with gonadotrophin therapy, showed similar cumulative ongoing pregnancy rates 6–12 months after LOD and after three to six cycles of gonadotrophin therapy [2]. However, when comparing ongoing cumulative pregnancy rates 6 months following ovarian cautery with six cycles of gonadotrophin therapy, then the latter was preferable with a significant odds ratio of 1.48. The largest of the studies included in this meta-analysis was a multicenter study in The Netherlands, showed parity in the results of LOD and low-dose FSH therapy [3]. This was, however tempered by the fact that if ovarian cautery had not yielded ovulation after 8 weeks, clomifene citrate and even FSH was administered and these ‘evened-up’ the pregnancy rates.

Assuming, for the moment, equivalence of results, then the advantages and disadvantages of each procedure should be weighed up. The main advantages of ovarian drilling are a very high prevalence of monofollicular ovulation and therefore a significant reduction in multiple pregnancy rates compared with gonadotrophin therapy, a reported reduction in miscarriage rates [4], and the fact that it is an often successful “one-off” procedure which may avoid the use of expensive medical therapy and the exclusion of ovarian hyperstimulation syndrome. If ovulation is not forthcoming within 2–3 months following LOD, then ovulation induction can often be more successfully employed than preceding the operation with clomifene or FSH if clomifene fails to induce ovulation. However, in a large number of cases spontaneous ovulation has been induced even for several years following LOD in a similar fashion to ovarian wedge resection, the “predecessor” of LOD [5]. A study of long-term follow-up after LOD showed that 54/110 women (49 %) conceived spontaneously within a year and a further 42 women (38 %) within 1–9 years following the operation [6]. For those who respond to LOD but relapse into anovulation, a repeat procedure has been shown to be effective [7] although this has not been widely adopted.

Taking into account clomiphene resistant patients and the possible additional cost of an increased multiple pregnancy rate with gonadotrophins, LOD would probably prove more cost effective in most countries. In countries with a far-flung population, this ‘one-off’ treatment may be better accepted to avoid repeat visits necessary for other forms of therapy. The drawbacks of LOD also have to be weighed up however. The immediate and long-term effects of a surgical procedure are few but exist nevertheless and we have encountered some reticence to undergo this procedure from patients who, on the whole, seem to prefer a medical induction of ovulation rather than an operative procedure.

11.3 Patient Selection and Mechanism of Action

Women with anovulatory PCOS who are of normal weight and have high LH concentrations seem to have the most favourable prognosis [48]. LOD should not be employed merely for the treatment of other symptoms of PCOS.

11.4 How Does It Work?

Although the mechanism involved in the restoration of ovulation by LOD is not clear, the principle endocrine changes of a dramatic decrease in LH and AMH concentrations about 2 days after the operation, seem to be an integral ingredient. Either as a consequence of the decrease in LH concentrations or coinciding with this event, androgen concentrations also drop dramatically. This is followed by an increase of FSH levels. It is reasonable to assume that local destruction of androgen producing cells is the trigger for these changes but the decrease in AMH may well be involved in releasing an inhibition of FSH action and the decreasing LH concentrations indicate an equally dramatic change in hypothalamic GnRH activity. It is certainly not merely local ovarian changes that trigger ovulation but a consequent signal that courses to the hypothalamus that clicks the hypothalamic-pituitary-ovarian axis into correct synchrony.

11.5 The Order of Treatment Options

The place of LOD in the ‘hierarchy’ and order of possible therapeutic regimes has not yet been fully determined and often depends on the expertise and experience of the treating clinic. A proposed treatment scheme is illustrated in Fig. 8.​2. Here I have suggested that clomiphene resistant patients who have failed to conceive on four to six ovulatory cycles of low-dose FSH could be offered the alternative of LOD or IVF. Only a handful of women with PCOS as the only obvious factor causing infertility should arrive to this stage. This suggests that this handful have an additional undiscovered factor involved. LOD may be considered as a viable alternative to low-dose FSH administration following clomiphene resistance, especially for patients who are of normal weight with high LH concentrations.

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