HOME | CONTENTS | CONTACT US
HOME | CONTENTS | CONTACT
US
By Bruce I. Rose PhD, MD
Last Revised 2/13/95
Published in: Current Opinion in Obstetrics and Gynecology Key Words: polycystic ovarian disease, laparoscopic surgery, ovarian drilling
Polycystic ovarian disease remains a controversial entity with overlapping clinical, endocrine and morphological definitions as well as fragmentary and conflicting underlying endocrine mechanisms [1]. Medical treatment of this entity is occasionally directed at correcting a well defined endocrinopathy, but generally it is targeted at preventing complications of long term unopposed estrogen exposure, cosmetically improving hirsutism, or achieving pregnancy without impacting on the underlying disease entity. The primary challenge of medical therapy lies in helping patients attain pregnancy because patients exhibit a protean response to the pharmacological tools available.
Surgical therapy for polycystic ovarian disease has its roots in bilateral wedge resection of the ovaries. Wedge resection of the ovaries by laparotomy had largely been abandoned in the 1980's, because of the widespread availability and high efficacy of medical therapy and the high incidence of significant pelvic adhesions [2]. Surgical laparoscopic approaches to treatment of polycystic ovarian disease have been described in the gynecological literature for more than a decade, and surgical series of sufficient size to begin to understand the consequences of such therapy have recently been published. This review will organize some of this data and attempt to highlight what appears to be best demonstrated as well as questions suggested, but incompletely answered by these studies.
Investigators have described several different techniques for laparoscopic treatment of polycystic ovarian disease. All are attempts to adapt bilateral wedge resection to a laparoscopic setting. They include bivalving the ovary on its longitudinal axis [3], taking multiple (0.75 cc volume) biopsies along the longitudinal axis of the ovaries laparoscopically [4, 5], and dissecting out multiple subcapsular cysts [6, 7]. However, the predominant technique in the literature involves making multiple holes in the surface of both ovaries using either a laser or electrocautery.
Both because of the simplicity of the technique and the overwhelming abundance of data on it, this review will focus on this latter technique. We will refer to it as ovarian drilling, although it has also been referred to as ovarian diathermy, ovarian cautery, ovarian electrocautery, ovarian laser vaporization, selective follicular reduction, laser photocoagulation, laparoscopic argon laser capsule drilling, multiple punch resection, LEOS (laparoscopic electrocauterization of the ovarian surface), and likely other names. Gjnnaess was one of the first to describe this procedure in the literature and also has published the largest series [8, 9**]. His technique and derivatives of it constitute the bulk of the cases in the published literature and therefore the consequences of this particular technique are best understood. In all Gjnnaess-derived techniques, laparoscopy is performed, the bowel is moved out of the operative field, the ovaries are fixed in place so that so that possible damage to other pelvic organs is minimized, and holes or defects are created in each ovarian surface with unipolar cautery.
The number of defects created in each ovary by electrocautery varies from 3 to 15. Gjnnaess now burns a minimum of 8 holes in each ovary [9**]. The upper limit on the number of defects created is related to ovarian size. It is unclear how many defects are actually necessary. Ovulation can be induced with as few as 3 to 4 defects in each ovary [8]. In a small randomized study, Balen and Jacobs suggested that unilateral cauterization (at 4 points) may be as effective as bilateral cauterization in inducing ovulation [10*]. The surgical objective is to damage focally both the ovarian cortex and stroma. Care is taken to avoid damaging the blood supply to the ovary at the hilum. The defects created in the ovary vary from 2 to 6 mm in diameter and 2 to 5 mm in depth. Current is applied from 2 to 6 seconds. Gjnnaess tries to create a 3 mm diameter defect with a depth of 2 to 4 mm by applying 200 to 300 watts of power for 2 to 4 seconds through a (relatively blunt) biopsy or sterilization forceps [8, 9**]. Greenblatt and Casper use a unipolar laparoscopic scissors with 4 mA of current [11]. Slippage of an instrument off the ovary may result in a significant complication. For this reason, Greenblatt (1987) suggests using a sharper instrument, which for a given current will have a higher power density at is tip and will thus more easily enter the ovary. Armar, et al. use a specially designed unipolar instrument which has an 8 mm spike on its end to help enter the ovary and a 6 mm wide post to help damage the ovarian stroma once it is entered [12, 13]. The primary surgical challenge of ovarian drilling is to enter the ovary at right angles to the ovarian surface to avoid slipping off the surface and this instrument may make that easier to do.
The carbon dioxide, argon, KTP, neodymium-Yag (contact and non-contact techniques) lasers have also been utilized for analogous procedures [14, 15, 16, 17]. Laser techniques differ from electrocautery techniques in the number of defects thought necessary to create in each ovary. Twenty to forty defects are created depending on ovarian size. Additional defects are thought to be necessary because of less ovarian damage caused by (for example, carbon dioxide) laser compared to electrocautery [18]. Each type of laser requires slightly different variations in technique, but the objective and appearance of ovarian defects are similar to the Gjnnaess-varient techniques. Although lasers provide greater control over the type of damage induced in the ovary, this does not appear to translate into a clinical advantage. Using an argon laser, Heylen, et al. compared shallow broad ovarian defects to deeper, narrower defects. There was no difference in the ovulation or pregnancy rates [16]. The impact of these different techniques on reducing adhesion formation remains theoretical.
Although many small series demonstrate high ovulation and pregnancy rates, we are aware of only 4 different series containing more than 50 patients (Table 1). Spontaneous ovulation rates in these ranged from 55 to 92% and overall pregnancy rates ranged from 56 to 70%. Comparisons between series are complicated by patient selection. Within one series, the ovulation rate after ovarian drilling in patients who had failed to ovulate on a dose of 150 mg clomiphine citrate was 53%; whereas for non clomiphine resistant patients, it was 85% [14]. Most pregnancies occur in the first six months after surgery. Pregnancies and ovulations after ovarian drilling are more likely to occur in non clomiphene resistant patients than in clomiphine resistant patients. However, new responsiveness to clomiphene or improved response to gonadotropins after ovarian drilling is common.
Confounding infertility problems make interpretation of impact of surgery difficult. In patients with additional non-ovulatory subfertility problems, Gjnnaess found a crude pregnancy rate of 84% (116/138); whereas when polycystic ovaries were not the only problem, the pregnancy rate was 36% (29/81) [9**]. Most investigators have found that ovarian drilling results in decreased LH levels, decreased androgen levels, and increased FSH levels when postoperative levels are compared to preoperative levels in the same patient [10, 11, 12, 17]. Clinical androgenic effects of polycystic ovarian syndrome decrease after ovarian drilling [24**]. Serum insulin levels and levels of insulin growth factor binding protein-1 do not change after surgery [19].
Adhesion formation is a potential complication of any laproscopic procedure in which pelvic surfaces are damaged. The incidence of pelvic adhesions after ovarian drilling has been reported to occur in between 0 and 100% of patients [14, 15, 18, 20, 21, 22, 23]. Naether and Fischer have the largest series of unselected patients having undergone second look laparoscopy 2 to 14 days after ovarian drilling [22]. Based on 50 second look laparoscopies, the incidence of adhesions was 24% (not including their 12 patients without adhesions evaluated at cesarean section). One third of these cases involved bilateral adhesions and in one case the adhesion score was moderate. With use of abdominal lavage to remove coagulated tissue and carbon particles from the ovary and with artificial ascites (300 to 500 ml of fluid left behind in the abdomen for a floatation effect), the incidence of de novo adhesions formation was reduced to 11% [24**] and resulting adhesions were milder in extent [22]. Higher volume artificial ascites has not been evaluated in this setting [25].
Greenblatt and Casper wrapped one ovary with Interceed (Ethicon, Inc., Summerville, NJ, USA) after bilateral ovarian drilling [21]. The side of the wrapped ovary was randomized and a short interval second-look procedure was performed by a surgeon not knowing which side had previously been wrapped. There were minimal to severe adhesions in all patients. Interceed did not reduce the incidence of adhesions.
Gjnnaess followed a large cohort of women and his data suggest that of the women who ovulate in response to ovarian drilling, only 3 to 4% stop ovulating in each subsequent year [9**]. For example, of 51 responders followed for 5 years, only 2 stopped ovulating in the fifth year. Naether, et al., followed 206 patients for up to 72 months and reported that many patients had persistent normalization of cycle length; 70% of cycles evaluated after 72 months were ovulatory [24**]. Several moderate size series also note that some patients achieve more than one pregnancy after a single ovarian drilling [4, 9, 13].
Many studies have used patients who failed to ovulate on 150 mg of clomiphine citrate or who hyper-responded to gonadotropin therapy [3, 4, 5, 10, 11, 13, 15, 20, 21, 22, 26]. However, since 1979, Gjnnaess has also used ovarian drilling as a treatment for primary infertility [9**]. He now also recommends ovarian drilling for all women with polycystic ovaries who are undergoing laparoscopy for non-fertility reasons. Patient selection is on the basis of menstrual irregularity, chronic anovulation, endocrine profile, and the appearance of ovaries. Such women may then most benefit by being placed on oral contraceptives after the surgical procedure until they wish to achieve pregnancy. The basis for his recommendation is the low incidence of side effects and the long term positive impact of the procedure on ovarian function.
A second issue in patient selection lies in determining who will best respond to the procedure. Ovulation after ovarian drilling is more likely to occur in those women of normal body weight [9**]. For normal weight women, those most likely to fail to ovulate after ovarian drilling have lower LH levels and androgen levels than those who ovulate (small sample size) [9**]. Gadir (1990) also noted that LH levels where higher in responders than in non-responders [27]. Smokers are less likely to achieve pregnancy after ovarian drilling than non-smokers (27% versus 94%) [26]. The pregnancy rate after ovarian drilling drops significantly after age 35 [24**].
There is limited data on the incidence of miscarriage after pregnancy achieved secondary to ovarian drilling. Preliminary data suggests that the incidence of miscarriage may be lower than pregnancies achieved by other means in similar patients [27, 28]. This would be consistent with studies attributing the increased miscarriage rate in polycystic ovarian patients with their increased LH levels [29, 30]. Ovarian drilling may reduce societal healthcare costs. Gadir, et al.'s randomized study demonstrated that ovarian drilling was as effective as gonadotropin therapy in achieving pregnancy in clomiphene resistant patients [27]. When ovarian drilling was used in conjunction with gonadotropin therapy, it reduced cycle cancellations, medication requirements, and the number of dominant follicles [28]. Additional savings may be achieved by lowering the incidence of multiple gestations (3.5% of 145 pregnancies) [24**]. Investigators have raised the possibility that because of the damage caused to the ovary by ovarian drilling, the procedure might result in premature menopause. There is no data to support this hypothesis. Another theoretical concern is the potential for causing future neoplasia in the ovary. All techniques cause the deposition of carbon particles in the cortex of the ovary and require the ovarian epithelium to undergo healing. The data from wedge resections does not support this concern, but we only poorly understand the pathogenesis of ovarian cancer.
Ovarian drilling is a powerful tool in the treatment of polycystic ovarian disease. The medical literature is in the early stages of defining who are the best candidates for this procedure and what the long term impacts of this surgery will be. Preliminary data is encouraging.
1. Vaclav I, Bruno L: Pathophysiology of Polycystic Ovarian Disease: New Insights. Human Reproduction 1991, 6:1025--1029. 2. Buttram V, Vaquero C: Post-Ovarian Wedge Resection Adhesive Disease. Fertil Steril 1975, 26:874--876. 3. Ostrzenski A: Endoscopic Carbon Dioxide Laser Ovarian Wedge Resection in Resistant Polycystic Ovarian Disease. Int J Fertil 1992, 37:295--299. 4. Campo S, Garcea N, Caruso A, Siccardi P: Effect of Celioscopic Ovarian Resection in Patients with Polycystic Ovaries. Gynecol Obstet Invest 1983, 15:213--222. 5. Campo S, Felli A, Lamanna M A, Barini A, Garcea N: Endocrine Changes and Clinical Outcome After Laparoscopic Ovarian Resection in Women with Polycystic Ovaries. Human Reproduction 1993, 8:359--363. 6. Sumioki H, Utsunomyiya T, Matsuoka K, Korenaga M, Kadota T: The Effect of Laparoscopic Multiple Punch Resection of the Ovary on Hypothalmic-Pituitary Axis in Polycystic Ovary Syndrome. Fertil Steril 1988, 50:567--572. 7. Utsunomiya T, Sumioki H, Taniguchi I: Hormonal and Clinical Effects of Multifollicular Puncture and Resection on the Ovaries of Polycystic Ovary Syndrome. Horm Res 1990, 33:35-39. 8. Gjonnaess H: Polycystic Ovarian Syndrome Treated by Ovarian Electrocautery Through the Laparoscope. Fertil Steril 1984, 41:20--25. **9. Gjonnaess H: Ovarian Electrocautery in the Treatment of Women with Polycystic Ovary Syndrome (PCOS). Acta Obstet Gynecol Scand 1994, 73:407--412. This series of 252 patients treated by ovarian drilling is the largest to date. Duration of effect and factors relating to successful treatment or failure of treatment are some of the issues evaluated. The impact of body weight is looked at in detail. *10. Balen A, Jacobs H: A Prospective Study Comparing Unilateral and Bilateral Laparoscopic Ovarian Diathermy in Women with the Polycystic Ovary Syndrome. Fertil Steril 1994, 62:921--924. Ten patients are randomized into bilateral or unilateral ovarian drilling. Unilateral treatment resulted in ovulation from both ovaries. 11. Greenblatt E, Casper R: Endocrine Changes After Laparoscopic Ovarian Cautery in Polycystic Ovarian Syndrome. Am J Obstet Gynecol 1987, 156:279--285. 12. Armar N, McGarrigle H, Honour J, Holownia P, Jacobs H, Lachelin G: Laparoscopic Ovarian Diathermy in the Management of Anovulatory Infertility in Women with Polycystic Ovaries: Endocrine Changes and Clinical Outcome. Fertil Steril 1990, 53:45--49. 13. Armar N, Lachelin G: Laparoscopic Ovarian Diathermy: An Effective Treatment for Anit-Oestrogen Resistant Anovulatory Infertility in Women with the Polycystic Ovary Snydrome. British J of Obstet Gynecol 1993, 100:161--164. 14. Daniell J, Miller W: Polycystic Ovaries Treated by Laparoscopoic Laser Vaporization. Fertil Steril 1989, 51:232--236. 15. Gurgan T, Urman B, Aksu T, Yarali H, Develioglu O, Kisnisci H: The Effect of Short-Interval Laparoscopic Lysis of Adhesions on Pregnancy Rates Following Nd-YAG Laser Photocoagulation of Polycystic Ovaries. Obstet Gynecol 1992, 80:45--47. 16. Heylen S, Puttemans P, Brosens I: Polycystic Ovarian Disease Treated by Laparoscopic Argon Laser Capsule Drilling: Comparison of Vaporization Versus Perforation Technique. Human Reproduction 1994, 9:1038--1042. 17. Rossmanith W, Keckstein J, Spatzier K, Lauritzen C: The Impact of Ovarian Laser Surgery on the Gonadotrophin Secretion in Women with Polycystic Ovarian Disease. Clinical Endocrinology 1991, 34:223--230. 18. Gurgan T, Yarali H, Urman B: Laparoscopic Treatment of Polycystic Ovarian Disease. Human Reproduction 1994, 9:573--577. 19. Tiitinen A, Tenhunen A, Seppala M: Ovarian Electrocauterization Causes LH-Regulated but not Insulin-Regulated Endocrine Changes. Clinical Endocrinology 1993, 39:181--184. 20. Gurgan T, Kisnisci H, Yarali H, Develioglu O, Zeyneloglu H, Aksu T: Evaluation of Adhesion Formation After Laparoscopoic Treatment of Polycystic Ovarian Disease. Fertil Steril 1991, 56:1176--1178. 21. Greenblatt E, Casper R: Adhesion Formation After Laparoscopic Ovarian Cautery for Polycystic Ovarian Syndrome: Lack of Correlation with Pregnancy Rate. Fertil Steril 1993, 60:766--770. 22. Naether O, Fischer R: Adhesion Formation After Laparoscopic Electrocoagulation of the Ovarian Surface in Polycystic Ovary Patients. Fertil Steril 1993, 60:95--98. 23. Dabirashrafi H, Mohamad K, Behjatnia Y, Moghadami-Tabrizi N: Adhesion Formation After Ovarian Electrocauterization on Patients with Polycystic Ovarian Syndrome. Fertil Steril 1991, 55:1200--1201. **24. Naether O, Baukloh V, Fisher R, Kowalczyk T: Long-Term Follow-Up in 206 Infertility Patients with Polycystic Ovarian Syndrome After Laparoscopic Electrocautery of the Ovarian Surface. Human Reproduction 1994, 9:2341--2349. This series of 206 difficult to manage PCO patients provides information on the duration of the effect of this procedure. The clinical impact of ovarian drilling on aspects of the menstrual cycle, hirsutism, and pregnancy are well described. Confounding infertility factors and the use of ovulation inducing drugs are discussed. 25. Reich H: New Techniques in Advanced Laparoscopic Surgery. In Balliere's Clinical Obstetrics and Gynecology. Sutton C, editor.Philadelphia: WB Saunders; 1989:655--681. 26. Naether O, Fischer R, Weise H, Geiger-Kotzler L, Delfs T, Rudolf K: Laparoscopic Electrocoagulation of the Ovarian Surface in Infertile Patients with Polycystic Ovarian Disease. Fertil Steril 1993, 60:88--94. 27. Gadir A, Mowafi R, Alnaser H, Alrashid A, Alonezi O, Shaw R: Ovarian Electrocautery Versus Human Menopausal Gonadotrophins and Pure Follicle Stimulating Hormone Therapy in the Treatment of Patients with Polycystic Ovarian Disease. Clinical Endocrinology 1990, 33:585--592. 28. Gadir A, Alnaser H, Mowafi R, Shaw R: The Response of Patients with Polycystic Ovarian Disease to Human Menopausal Gonadotropin Therapy After Ovarian Electrocautery or a Luteinizing Hormone-Releasing Hormone Agonist. Fertil Steril 1992, 57:309--313. 29. Balen A, Tan S, MacDougall J, Jacobs H: Miscarriage Rates Following In-Vitro Fertilization are Increased in Women with Polycystic Ovaries and Reduced by Pituitary Desensitization with Buserelin. Human Reproduction 1993, 8:959--964. 30. Watson H, Kiddy D, Hamilton-Fairley D, Scanlon M, Barnard C, Collins W, Bonney R, Franks S: Hypersecretion of Luteinizing Hormone and Ovarian Steroids in Women with Recurrent Early Miscarriage. Human Reproduction 1993, 8:829--833.
Table 1. OVULATION AND PREGNANCY RATES IN LARGE SERIES AFTER OVARIAN DRILLING _____________________________________________________________________________________ Author Number of patients treated Patient population Spontaneous ovulations (%) Pregnancies in first year (%) Crude pregnancy rate Arman and Lachelin [13] 50 Unsuccessful CC treatment 45/50 (86%) 26/50 (52%)a 33/50 (66%) Daniell and Miller [14] 85 Unsuccessful CC treatment or CC resistance; some prior HMG 60/85 (71%) 48/85 (56%)b 48/85 (56%) Gjnnaess [9**] 252 Primary infertiliy and PCO 201/219 (92%) NA 152/219 (69%)c Naether, et al. [24**] 206 Difficult PCO population; many HMG failures 375/487 (81.9%) d 105/206 (50.9%) 145/206 (70.4%)e _____________________________________________________________________________________ NA = not available CC = clomiphine citrate HMG = human menopausal gonadotropins a in first 8 months; 44% pregnancy rate without CC or HMG b in first 6 months; 41% pregnancy rate without CC or HMG c 84% pregnancy rate in women with PCO as only subfertility factor d eumenorrheic cycles after 24 months; 55% of patients [26] e 40% of pregnancies achieved on CC and/or HMG
>
HOME | CONTENTS | CONTACT US
Copyright 2005 Infertility Solutions, P.C., Lehigh Valley, Pennsylvania