Biology:Ovarian drilling

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Ovarian drilling
Specialtygynaecology

Ovarian drilling, also known as multiperforation or laparoscopic ovarian diathermy, is a surgical technique of puncturing the membranes surrounding the ovary with a laser beam or a surgical needle using minimally invasive laparoscopic procedures.[1] It differs from ovarian wedge resection, which involves the cutting of tissue. Minimally invasive ovarian drilling procedures have replaced wedge resections.[2] Ovarian drilling is preferred to wedge resection because cutting into the ovary can cause adhesions which may complicate postoperative outcomes.[3] Ovarian drilling and ovarian wedge resection are treatment options to reduce the amount of androgen producing tissue in women with polycystic ovarian syndrome (PCOS).[4] PCOS is the primary cause of anovulation, which results in female infertility.[5] The induction of mono-ovulatory cycles can restore fertility.[6]

Laparoscopic ovarian drilling (LOD) may improve the effectiveness of other ovulation induction treatments and results in lower multiple pregnancy rates than other treatment options like gonadotropins.[7] The oral drug clomiphene citrate (CC) is the first-line treatment for PCOS-related infertility, yet one-fifth of women are resistant to the drug and fail to ovulate.[8] Patients are considered resistant if the treatment fails for six months at the appropriate dosage.[1] Ovarian drilling is a surgical alternative to CC treatment or recommended for women with WHO Group II ovulation disorders.[6] Other non-surgical medical options in the treatment of PCOS include the oestrogen receptor modulator tamoxifen, aromatase inhibitors, insulin sensitising drugs, and hormonal ovarian stimulation.[9] The effectiveness of the surgical procedure is similar to CC or gonadotropin treatment for induced ovulation for PCOS patients, but results in fewer multiple pregnancies per ongoing pregnancy regardless if the technique is unilaterally or bilaterally performed.[10]

If patients do not become pregnant six months after ovulation has been reestablished from ovarian drilling treatment, drug treatments may be reintroduced or in vitro fertilization (IVF) may be considered.[1]

Hormonal effects

Part of the criteria of PCOS diagnosis includes elevated levels of androgens in the bloodstream or other signs of androgen excess (hyperandrogenism).[1] The procedure causes a drop in serum androgen levels and possibly in estrogen levels.[5] After ovarian follicles and stroma are destroyed, there is a reduction in these hormone levels.[11] The procedure results in a decrease in plasma luteinizing hormone (LH) and in pulsations as well as a periodic drop in inhibin B levels.[1] The most plausible theory states that the reduction of these hormone concentrations leads to an increase in the secretion of follicle-stimulating hormone (FSH) and sex hormone-binding globulin, leading to effective follicular maturation and ovulation.[5][1] Low serum oestradiol concentrations are associated with decreased aromatase activity.[1] Inflammatory growth factors such as insulin-like growth factor-1 are produced due to injury and aid the effects of FSH through greater blood flow and gonadotropin delivery.[11] Circulating and intrafollicular levels of anti-Müllerian hormone (AMH), which can help quantify recruitable ovarian follicle activity, are reduced after laparoscopic ovarian drilling in women with PCOS.[12]

Procedures

When the clinician determines that ovarian drilling is appropriate and the woman decides to undergo this treatment, consent is obtained. The risks are communicated to the woman.[13]

The most commonly performed method is with a monopolar needle or hook because of the equipment's availability and simple installation.[6] Other common instrumentation consists of the use of a bipolar electrical surgical electrodes or a CO2, argon, or ND-YAG laser.[14] This instrumentation has the ability to produce the intended results with a very focal approach. Typically, a 100 W electrical cautery dissector is first used to cross the ovarian cortex, then electrocoagulation is performed at 40 W, however rates range from 30 to 400 W.[1] The surgical punctures are performed on the ovarian cortex and are usually 4–10 mm deep and 3 mm wide.[10][11] The number of punctures is related to subsequent ability to conceive—it has been found that five to ten punctures are more likely to produce the intended conception.[13] Ovarian drilling is performed laparoscopically and either transumbilical (culdoscopy) or transvaginal (fertiloscopy).[1]

Risks

Though preferable to creating incisions on the ovary, ovarian drilling does have some risks. These are: pelvic adhesion formation, hemorrhage, gas embolism, pneumothorax, premature ovarian failure, long-term ovarian function, developing hyperstimulation syndrome, adhesion formation, infertility and multiple births.[2][13][6][15] Transvaginal hydrolaparoscopy (THL) ovarian drilling may minimize the risk of iatrogenic adhesion formation and decreased ovarian reserve (DOR), which can impinge upon fertility.[16] LOD does not contribute to the risk of decreased ovarian reserve.[12] There is risk of electrical accidents with monopoly current.[1] A rare complication of LOD is major vascular injury, mostly on the small vessels in the anterior abdominal wall when the Veress needle and trocar are inserted at the beginning of the procedure.[15]

Advantages

Ovarian drilling has lower rates of ovarian hyperstimulation syndrome and of multi-fetal gestation.[17][7] The advantages of the procedure also include its singular treatment, as opposed to several trials of ovulation inductions.[2] Other benefits of this technique include cost-effectiveness and that it can be performed as an outpatient procedure.[6]

History

Ovarian drilling was first used in the treatment of PCOS in 1984 and has evolved as a safe and effective surgery.[11] After performing laparoscopic electrosurgical ovarian drilling in CC-resistant patients in 1984, Gjönnaess found that this technique increased ovulation rates to 45 percent and pregnancy rates to 42 percent.[18] In 1988, laparoscopic multiple punch resection of ovaries on the hypothalamo-pituitary axis, slightly modified from Gjönnaess's operation, caused a reduction in LH pulsation and pituitary responsiveness in the treatment of PCOS.[19] In 1989, ovarian drilling was conducted with argon, carbon dioxide (CO2) or potassium-titanyl-phosphate (KTP) laser vaporization causing spontaneous ovulation in 71 percent of those treated.[14] The procedure has been modified and popularized in the treatment of patients with CC-resistance.[11]

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 Fernandez, H.; Morin-Surruca, M.; Torre, A.; Faivre, E.; Deffieux, X.; Gervaise, A. (2011). "Review: Ovarian drilling for surgical treatment of polycystic ovarian syndrome: a comprehensive review.". Reproductive Biomedicine Online 22 (6): 556–568. doi:10.1016/j.rbmo.2011.03.013. PMID 21511534. 
  2. ↑ 2.0 2.1 2.2 Berger, Joshua J.; Bates, G. Wright (2014-01-01). "Optimal management of subfertility in polycystic ovary syndrome". International Journal of Women's Health 6: 613–621. doi:10.2147/IJWH.S48527. PMID 24966697. 
  3. ↑ Portuondo, J. A.; Melchor, J. C.; Neyro, J. L.; Alegre, A. (1984-07-01). "Periovarian adhesions following ovarian wedge resection or laparoscopic biopsy". Endoscopy 16 (4): 143–145. doi:10.1055/s-2007-1018560. ISSN 0013-726X. PMID 6236073. 
  4. ↑ Ndefo, Uche Anadu; Eaton, Angie; Green, Monica Robinson (2013-06-01). "Polycystic ovary syndrome: a review of treatment options with a focus on pharmacological approaches". Pharmacy and Therapeutics 38 (6): 336–355. ISSN 1052-1372. PMID 23946629. 
  5. ↑ 5.0 5.1 5.2 Hueb, Cristina Kallás; Dias Júnior, João Antônio; Abrão, Maurício Simões; Filho, Elias Kallás (2015-11-01). "Drilling: medical indications and surgical technique". Revista da Associação Médica Brasileira 61 (6): 530–535. doi:10.1590/1806-9282.61.06.530. ISSN 1806-9282. PMID 26841163. 
  6. ↑ 6.0 6.1 6.2 6.3 6.4 Lebbi, Issam; Ben Temime, Riadh; Fadhlaoui, Anis; Feki, Anis (2015-01-01). "Ovarian Drilling in PCOS: Is it Really Useful?". Frontiers in Surgery 2: 30. doi:10.3389/fsurg.2015.00030. PMID 26236709. 
  7. ↑ 7.0 7.1 Farquhar, Cindy; Brown, Julie; Marjoribanks, Jane (2012-06-13). "Laparoscopic drilling by diathermy or laser for ovulation induction in anovulatory polycystic ovary syndrome". The Cochrane Database of Systematic Reviews (6): CD001122. doi:10.1002/14651858.CD001122.pub4. ISSN 1469-493X. PMID 22696324. 
  8. ↑ Moazami Goudarzi, Zahra; Fallahzadeh, Hossein; Aflatoonian, Abbas; Mirzaei, Masoud (2014-08-01). "Laparoscopic ovarian electrocautery versus gonadotropin therapy in infertile women with clomiphene citrate-resistant polycystic ovary syndrome: A systematic review and meta-analysis". Iranian Journal of Reproductive Medicine 12 (8): 531–538. ISSN 1680-6433. PMID 25408702. 
  9. ↑ Wang, Rui; Kim, Bobae V.; Wely, Madelon van; Johnson, Neil P.; Costello, Michael F.; Zhang, Hanwang; Ng, Ernest Hung Yu; Legro, Richard S. et al. (2017-01-31). "Treatment strategies for women with WHO group II anovulation: systematic review and network meta-analysis" (in en). BMJ 356: j138. doi:10.1136/bmj.j138. ISSN 0959-8138. PMID 28143834. 
  10. ↑ 10.0 10.1 Bosteels, J.; Weyers, S.; Mathieu, C.; Mol, B. W.; D'Hooghe, T. (2010-01-01). "The effectiveness of reproductive surgery in the treatment of female infertility: facts, views and vision". Facts, Views & Vision in ObGyn 2 (4): 232–252. ISSN 2032-0418. PMID 25009712. 
  11. ↑ 11.0 11.1 11.2 11.3 11.4 Mitra, Subarna; Nayak, Prasanta Kumar; Agrawal, Sarita (2015-01-01). "Laparoscopic ovarian drilling: An alternative but not the ultimate in the management of polycystic ovary syndrome". Journal of Natural Science, Biology, and Medicine 6 (1): 40–48. doi:10.4103/0976-9668.149076. ISSN 0976-9668. PMID 25810633. 
  12. ↑ 12.0 12.1 Paramu, Sobhana (2016). "Impact of laparoscopic ovarian drilling on serum anti-mullerian hormone levels in patients with anovulatory Polycystic Ovarian syndrome". Journal of Turkish Society of Obstetric and Gynecology 13 (4): 203–207. doi:10.4274/tjod.97523. PMID 28913122. 
  13. ↑ 13.0 13.1 13.2 Hoffman, Barbara (2012). Williams gynecology. New York: McGraw-Hill Medical. ISBN 9780071716727. 
  14. ↑ 14.0 14.1 Daniell, James F.; Miller, Wayne (1989). "Polycystic ovaries treated by laparoscopic laser vaporization" (in en). Fertility and Sterility 51 (2): 232–236. doi:10.1016/s0015-0282(16)60482-x. PMID 2912769. 
  15. ↑ 15.0 15.1 Ateş, Seda; Şevket, Osman; Özsoy, Bestami; Zebitay, Ali Galip; Kan, Atilla (2014). "Ovaryan Drilling Sırasında Eksternal İliak Arter Yaralanması: Olgu Sunumu". Haseki Tıp Bülteni 52 (2): 120–122. doi:10.4274/haseki.1388. 
  16. ↑ Giampaolino, Pierluigi; Morra, Ilaria; Tommaselli, Giovanni Antonio; Carlo, Costantino Di; Nappi, Carmine; Bifulco, Giuseppe (2016-10-01). "Post-operative ovarian adhesion formation after ovarian drilling: a randomized study comparing conventional laparoscopy and transvaginal hydrolaparoscopy" (in en). Archives of Gynecology and Obstetrics 294 (4): 791–796. doi:10.1007/s00404-016-4146-2. ISSN 0932-0067. PMID 27383413. 
  17. ↑ Eftekhar, Maryam; Deghani Firoozabadi, Razieh; Khani, Parisa; Ziaei Bideh, Ehsan; Forghani, Hosein (2016-04-01). "Effect of Laparoscopic Ovarian Drilling on Outcomes of In Vitro Fertilization in Clomiphene-Resistant Women with Polycystic Ovary Syndrome". International Journal of Fertility & Sterility 10 (1): 42–47. doi:10.22074/ijfs.2016.4767. ISSN 2008-076X. PMID 27123199. 
  18. ↑ Palomba, Stefano; Zullo, Fulvio; Diamanti-Kandarakis, Evanthia; Jr, Francesco Orio (2007-01-01). "Surgery and Laser Diathermy". in MD, Evanthia Diamanti-Kandarakis (in en). Insulin Resistance and Polycystic Ovarian Syndrome. Contemporary Endocrinology. Humana Press. pp. 191–207. doi:10.1007/978-1-59745-310-3_14. ISBN 9781588297631. 
  19. ↑ Sumioki, Hisao; Utsunomyiya, Takafumi; Matsuoka, Kouichirou; Korenaga, Michio; Kadota, Toru (1988). "The effect of laparoscopic multiple punch resection of the ovary on hypothalamo-pituitary axis in polycystic ovary syndrome". Fertility and Sterility 50 (4): 567–572. doi:10.1016/s0015-0282(16)60184-x. PMID 2971578. 



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