Ovarian drilling

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Ovarian drilling
Specialty gynaecology

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 favored over wedge resection because cutting into the ovary might result in adhesions, potentially complicating 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]

Contents

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. [7] Patients are considered resistant if the treatment fails for six months at the appropriate dosage. [1] Women who are resistant to the medication clomiphene citrate are commonly treated with medications that induce ovulation such as gonadotrophins. [8] Medications that induce ovulation such as CC can also be associated with multiple pregnancies and problems with the women's cycle and this therapy is very expensive due to the route of administration (daily by injection) and the requirement for regular ultrasounds, laparoscopic ovarian drilling is sometimes considered by medical professionals for treating anovulation. [8] Known side effects and risks include the need for anesthesia, the risk of infection, and a risk of adhesions forming. [8] There may sometimes be a smaller risk of the person losing ovarian function. [8]

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 fertilisation (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] [8] 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]

Related Research Articles

<span class="mw-page-title-main">Polycystic ovary syndrome</span> Set of symptoms caused by abnormal hormones in females

Polycystic ovary syndrome, or polycystic ovarian syndrome (PCOS), is the most common endocrine disorder in women of reproductive age. The syndrome is named after cysts which form on the ovaries of some women with this condition, though this is not a universal symptom, and not the underlying cause of the disorder.

<span class="mw-page-title-main">Ovulation</span> Release of egg cells from the ovaries

Ovulation is the release of egg cells from the ovaries as part of the ovarian cycle for most vertebrates. In women, this event occurs at the end of the follicular phase, when the ovarian follicles rupture and release the secondary oocyte ovarian cells.

Amenorrhea or amenorrhoea is the absence of a menstrual period in a female who has reached reproductive age. Physiological states of amenorrhoea are seen, most commonly, during pregnancy and lactation (breastfeeding). Outside the reproductive years, there is absence of menses during childhood and after menopause.

<span class="mw-page-title-main">Ovarian cyst</span> Fluid-filled sac in the ovary

An ovarian cyst is a fluid-filled sac within the ovary. They usually cause no symptoms, but occasionally they may produce bloating, lower abdominal pain, or lower back pain. The majority of cysts are harmless. If the cyst either breaks open or causes twisting of the ovary, it may cause severe pain. This may result in vomiting or feeling faint, and even cause headaches.

Anovulation is when the ovaries do not release an oocyte during a menstrual cycle. Therefore, ovulation does not take place. However, a woman who does not ovulate at each menstrual cycle is not necessarily going through menopause. Chronic anovulation is a common cause of infertility.

<span class="mw-page-title-main">Hyperandrogenism</span> Excess androgens (male-related hormones) in the body

Hyperandrogenism is a medical condition characterized by high levels of androgens. It is more common in women than men. Symptoms of hyperandrogenism may include acne, seborrhea, hair loss on the scalp, increased body or facial hair, and infrequent or absent menstruation. Complications may include high blood cholesterol and diabetes. It occurs in approximately 5% of women of reproductive age.

Fertility medications, also known as fertility drugs, are medications which enhance reproductive fertility. For women, fertility medication is used to stimulate follicle development of the ovary. There are very few fertility medication options available for men.

<span class="mw-page-title-main">Anti-Müllerian hormone</span> Mammalian protein found in humans

Anti-Müllerian hormone (AMH), also known as Müllerian-inhibiting hormone (MIH), is a glycoprotein hormone structurally related to inhibin and activin from the transforming growth factor beta superfamily, whose key roles are in growth differentiation and folliculogenesis. In humans, it is encoded by the AMH gene, on chromosome 19p13.3, while its receptor is encoded by the AMHR2 gene on chromosome 12.

<span class="mw-page-title-main">Follicular atresia</span>

Follicular atresia refers to the process in which a follicle fails to develop, thus preventing it from ovulating and releasing an egg. It is a normal, naturally occurring progression that occurs as mammalian ovaries age. Approximately 1% of mammalian follicles in ovaries undergo ovulation and the remaining 99% of follicles go through follicular atresia as they cycle through the growth phases. In summary, follicular atresia is a process that leads to the follicular loss and loss of oocytes, and any disturbance or loss of functionality of this process can lead to many other conditions.

Ovulation induction is the stimulation of ovulation by medication. It is usually used in the sense of stimulation of the development of ovarian follicles to reverse anovulation or oligoovulation.

Poor ovarian reserve is a condition of low fertility characterized by 1): low numbers of remaining oocytes in the ovaries or 2) possibly impaired preantral oocyte development or recruitment. Recent research suggests that premature ovarian aging and premature ovarian failure may represent a continuum of premature ovarian senescence. It is usually accompanied by high FSH levels.

The fertiloscope is a type of laparoscope, modified to make it suitable for trans-vaginal application, which is used in the diagnosis and treatment of female infertility.

<span class="mw-page-title-main">Endometrioma</span> Medical condition

Endometrioma is the presence of tissue similar to, but distinct from, the endometrium in and sometimes on the ovary. It is the most common form of endometriosis. Endometrioma is found in 17–44% patients with endometriosis.

Reproductive surgery is surgery in the field of reproductive medicine. It can be used for contraception, e.g. in vasectomy, wherein the vasa deferentia of a male are severed, but is also used plentifully in assisted reproductive technology. Reproductive surgery is generally divided into three categories: surgery for infertility, in vitro fertilization, and fertility preservation.

<span class="mw-page-title-main">Fertility testing</span> Process for assessing human fertility

Fertility testing is the process by which fertility is assessed, both generally and also to find the "fertile window" in the menstrual cycle. General health affects fertility, and STI testing is an important related field.

Infertility in polycystic ovary disease (PCOS) is a hormonal imbalance in women that is thought to be one of the leading causes of female infertility. Polycystic ovary syndrome causes more than 75% of cases of anovulatory infertility.

Endometriosis and its complications are a major cause of female infertility. Endometriosis is a dysfunction characterized by the migration of endometrial tissue to areas outside of the endometrium of the uterus. The most common places to find stray tissue are on ovaries and fallopian tubes, followed by other organs in the lower abdominal cavity such as the bladder and intestines. Typically, the endometrial tissue adheres to the exteriors of the organs, and then creates attachments of scar tissue called adhesions that can join adjacent organs together. The endometrial tissue and the adhesions can block a fallopian tube and prevent the meeting of ovum and sperm cells, or otherwise interfere with fertilization, implantation and, rarely, the carrying of the fetus to term.

Obesity is defined as an abnormal accumulation of body fat, usually 20% or more over an individual's ideal body weight. This is often described as a body mass index (BMI) over 30. However, BMI does not account for whether the excess weight is fat or muscle, and is not a measure of body composition. For most people, however, BMI is an indication used worldwide to estimate nutritional status. Obesity is usually the result of consuming more calories than the body needs and not expending that energy by doing exercise. There are genetic causes and hormonal disorders that cause people to gain significant amounts of weight but this is rare. People in the obese category are much more likely to suffer from fertility problems than people of normal healthy weight.

Gonadotropin surge-attenuating factor (GnSAF) is a nonsteroidal ovarian hormone produced by the granulosa cells of small antral ovarian follicles in females. GnSAF is involved in regulating the secretion of luteinizing hormone (LH) from the anterior pituitary and the ovarian cycle. During the early to mid-follicular phase of the ovarian cycle, GnSAF acts on the anterior pituitary to attenuate LH release, limiting the secretion of LH to only basal levels. At the transition between follicular and luteal phase, GnSAF bioactivity declines sufficiently to permit LH secretion above basal levels, resulting in the mid-cycle LH surge that initiates ovulation. In normally ovulating women, the LH surge only occurs when the oocyte is mature and ready for extrusion. GnSAF bioactivity is responsible for the synchronised, biphasic nature of LH secretion.

Female fertility agents are medications that improve female’s ability to conceive pregnancy. These agents are prescribed for infertile female who fails to conceive pregnancy after 1-year of regular and unprotected sexual intercourse. The following will cover the advancements of female fertility agents, major causes of female infertility. Next, it emphasizes on common female fertility agents in terms of their mechanism of action, side effects, fetal consideration and clinical application and ended up by the introduction of supplements and herbal medicines for female infertility.

References

  1. 1 2 3 4 5 6 7 8 9 10 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. 1 2 3 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 . PMC   4063802 . 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. S2CID   11796110.
  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. PMC   3737989 . PMID   23946629.
  5. 1 2 3 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. 1 2 3 4 5 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 . PMC   4505069 . PMID   26236709.
  7. ↑ 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. PMC   4233311 . PMID   25408702.
  8. 1 2 3 4 5 Bordewijk, Esmée M.; Ng, Ka Ying Bonnie; Rakic, Lidija; Mol, Ben Willem J.; Brown, Julie; Crawford, Tineke J.; van Wely, Madelon (2020-02-11). "Laparoscopic ovarian drilling for ovulation induction in women with anovulatory polycystic ovary syndrome". The Cochrane Database of Systematic Reviews. 2 (2): CD001122. doi:10.1002/14651858.CD001122.pub5. ISSN   1469-493X. PMC   7013239 . PMID   32048270.
  9. ↑ Wang, Rui; Kim, Bobae V.; Wely, Madelon van; Johnson, Neil P.; Costello, Michael F.; Zhang, Hanwang; Ng, Ernest Hung Yu; Legro, Richard S.; Bhattacharya, Siladitya (2017-01-31). "Treatment strategies for women with WHO group II anovulation: systematic review and network meta-analysis". BMJ. 356: j138. doi:10.1136/bmj.j138. ISSN   0959-8138. PMC   5421445 . PMID   28143834.
  10. 1 2 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. PMC   4086009 . PMID   25009712.
  11. 1 2 3 4 5 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. PMC   4367066 . PMID   25810633.
  12. 1 2 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. PMC   5558293 . PMID   28913122.
  13. 1 2 3 Hoffman, Barbara (2012). Williams gynecology. New York: McGraw-Hill Medical. ISBN   9780071716727.
  14. 1 2 Daniell, James F.; Miller, Wayne (1989). "Polycystic ovaries treated by laparoscopic laser vaporization". Fertility and Sterility. 51 (2): 232–236. doi:10.1016/s0015-0282(16)60482-x. PMID   2912769.
  15. 1 2 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". Archives of Gynecology and Obstetrics. 294 (4): 791–796. doi:10.1007/s00404-016-4146-2. ISSN   0932-0067. PMID   27383413. S2CID   39907667.
  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. PMC   4845528 . 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; MD, John E. Nestler; MD, Dimitrios Panidis; MD, Renato Pasquali (eds.). 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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