Prof. Mahmoud ZakherahProf of Obstetrics and Gynecology,

Women’s Health Hospital Assiut University Egypt

mszakhera@gmail.com

22-12-17

A “stepwise approach” to the managementof infertility in PCOS

Ovarian Drilling in PCOS: Is it Really Useful?

Ovarian Drilling in PCOS: Is it Really Useful?RCOG,[2007] ACOG,[2009] Society of

Obstetricians and Gynecologists, Canada[2010]and the PCOS consensus working group[2008),

All recommend LOD use in highly selected

cases, particularly in those with hypersecretion(LH), normal body mass index, needinglaparoscopic assessment of the pelvis or who livetoo far away from the hospital for the intensivemonitoring required during gonadotropintherapy.

Ovarian Drilling in PCOS: Is it Really Useful?

This implies that LODis a valid, but not thesole option for CC-resistant PCOS

Mitra et al ,2015

All meta-analysis confirmedthat LOD is a second-linetreatment in PCOS patients,especially those with CCresistance.Mayenga et al Gynecol Obstet Fertil (2011) .

Farquhar et al Cochrane Database SystRev (2012).

How many punctures?

How many punctures

Four Facts

You are lucky PCOS patient has the advantage of being have a good ovarian reserve than their peers who are NON PCOS

Infertility

with increased risk of

Metabolic syndrome➢ Type II diabetes

➢ Cardiovascular disease.

➢Endometrial cancer

PCO not equal PCOS Polycystic-appearing ovaries on ultrasound examination are a nonspecific finding in PCOS.

Criteria of diagnosis of PCOS

PCO not equal PCOS

Rotterdam criteria 2004 ,entails the

presence of ≥12 follicles within the

ovary with a diameter of 2-9 mm and/or

ovarian volume ≥10 cm.

Polycystic ovaries may present inhealthy women, s0 the inclusion of thissign to the diagnostic criteria ofpolycystic ovary syndrome is stillquestioned.

PCO not equal PCOS

Sonographically diagnosed polycysticovaries by Rotterdam Criteria increase inthe percentage of polycysticovary syndrome .

Recently , 26 versus 12 follicles-is requiredto distinguish among women with PCOS andhealthy women from the general population(Lujan et al. Hum Reprod. 2013)

PCOS imitatorsThe most important step to diagnose PCOS to exclude other conditions of CA/Hyperandrogenism

PCOS imitators

NC CAH 17 hydroxyprogesterone

Hypothyrodism TSH

Hyperprolacinemia prolactin

Adrenal tumors DHES

Ovarian tumors total testosterone

Cushing’s syndrome cortisol

How many punctures?

How many punctures

How many punctures? Too little is insufficient

Too much is harmful

The solution is : Adjust

How many punctures?The number of punctures is empirically

chosen depending on the ovarian size.

In the original procedure, 3-8diathermy punctures (each of 3 mmdiameter and 2-4 mm depth) per ovarywere applied, using power setting of200-300 W for 2-4 s ( Gjönnaess ,1984).

How many punctures?Most surgeons perform four punctures per

ovary, each for 4 s at 40 W (rule of 4), delivering 640 J of energy per ovary (the lowest effective dose recommended) (Armar et al 1990).

Rule of Four ➢40 W➢4 seconds➢4 puncture points

How many punctures?

The aim of fixed number of puncturepoints regardless of ovary size (Felemban etal,2000) or unilateral ovary cauterization todecrease the potential risks of ovarianfailure and adnexal adhesions (Balen andJacob,1994).

May be too little

How many punctures?

In earlier studies there was an assumption that the greater the amount of energy, the more effective the procedure.(Gjonnaess,1989)

May be too much

How many punctures?

The clinical response is dose-dependent,

with higher ovulation and pregnancy rates observed by increasing dose of thermal energy up to 600 J/ovary, irrespective of ovarian volume (Amer2003).

Most gynecologists still perform bilateral over unilateral drilling.

(Roy et al,2009 , Farquhar et al,2012).

Unilateral versus Bilateral

Unilateral as effective as bilateral (Balen and Jacob,1994).

Contralateral ovary may ovulate first

(Al-Mizyen and Grudzinskas 2007)

How many punctures?

Adjusted laparoscopic ovarian drilling of PCOS

Adjusted LOD New terminology

Means tailoring the number of punctures according to Ovarian Volume (Zakherah et al ,2011)

Ovarian Volume

Ovarian volume is calculated by the

measurement of the length, width and the thickness and use of the classical formula for a prolate ellipsoid: L × W × T ×

0.5 (Adams et al ,1985 Chen et al ,2008).

The volume of each ovary was calculated as follows: length ×width × height × 0.523 (Higgins et al ,1990).

Three-dimensional ultrasound is a recognizeddiagnostic modality to assess ovarian volume

The antral follicle count(AFC)➢AFC was defined as the total number of

follicles < 9 mm in diameter in both ovaries

➢FNPO is best predictor for diagnosis PCOS

Christ et al , Fertil Steril,. 2014

Lie Fong et al, Hum Reprod. 2017

Methodology of Adjusted LOD

We suggested dose was 625 J/10.8 cm3= 60J/cm3 of ovarian tissue.

The required number of punctures then wascalculated by dividing total individualovarian dose with dose delivered in eachpuncture point. ( e.g. 12 cm3 x60=720 j÷150=4.8 punctures)

Thermal Dose in Adjusted LOD

How many punctures?

Adjusting thermal dose based onovarian volume (60 J/cm3 ) hasbetter reproductive outcomes withsimilar postoperative adhesion ratesthan fixed dose of 600 J/ovary(Zakherah et al ,20011)

Is ovarian reserve diminished after laparoscopic ovarian drilling?

✓The PCOS women both with and without

LOD had significantly greater ovarian reserve

than the age-matched controls having

normal ovulatory menstruation (Weerakiet et

al ,2007).

✓ 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)

Adjusted bilateral ovarian drilling based on ovarian volume has no detrimental effect on the ovarian reserve (Zakherah,2014).

Assessment of ovarian reserve after unilateral diathermy with thermal doses adjusted to ovarian volume .

Dose-adjusted unilateral diathermy (60 J/cm(3)) does not have significant and long-term effects on ovarian reserve.

Sunj et al , Gynecol Endocrinol. 2014

Anti-Müllerian hormone, testosterone and free androgen index following the dose-adjusted unilateral diathermy in women with polycystic ovary syndrome

The value of T is the strongest and consistent indicator of ovulatory response after diathermy

Sunj et al .Eur J Obstet Gynecol Reprod Biol. 2014

Does unilateral laparoscopic diathermy adjusted to ovarian volume increase the chances of ovulation in women with polycystic ovary syndrome?

The pregnancy rate was significantly higher in patients with a larger right ovary compared with those with a smaller right ovary, regardless of the treatment group

Sunj et al Hum Reprod. 2013

.

Conclusions :Accurate and documenteddiagnosis of PCOS, appropriate surgicaltraining, adjusted thermal injury andadjusted number of punctures areessential for the avoidance of excessivedamageto the ovaries.

The impact of laparoscopic ovarian drilling on AMH & ovarian reserve: a meta-analysis

LOD significantly lowers circulating AMH, but thismay not necessarily reflect a real damage toovarian reserve.

Given its proven efficacy and its long-termbenefits, LOD should remain as an option in themanagement of anovulatory PCOS patients.

(Saad A Amer1, Tarek T El Shamy2, Cathryn James, Ali HYosef , Ahmed A. Mohamed, 2017)

How to avoid DOR Adjust your dose ALOD

Cutting mode instead of coagulating mode

Short time 5 seconds

Low wattage 30 watt

Lavage Before and After

Unilateral RT ovary –Adjusted

Never drill unless

To Avoid DOR

Avoid cauterization at Mesovarium

Hilum

Corpus luteum

Ovarian ligament

Infudibulopelvic ligament

Never DrillOvarian volume less than 10 cm3.

FSH more than 9 IU/L

Previous ovarian drilling .except

AMH less than 5 ng/ml or morethan 8.3 ng/ml

Only used as a 2rd line therapy

Never Drill

Repeated LOD in polycystic ovary syndrome

✓ DO NOT Repeat✓ You will repeat failure✓ After 1 y follow up IVF✓ Antagonist Vs Long protocols✓ Repeat LOD is ONLY in women

who previously responded to thefirst procedure (Amer ,et al,2003).

Take home messagesLod still has a place and still

useful .

Proper diagnosis

Exclude PCOS imitators

LOS is 2nd line therapy for clomiphene resistant cases

Adjust thermal dose

Never Drill

Take home messages LOD is currently recommended as a safe, efficacious

and cost-effective alternative to gonadotropins forOI in infertile, anovulatory, CC-resistant PCOSwomen without the risks of OHSS or multiplegestation.

Although iatrogenic adhesion formation and DORare potential complications, they are of little clinicalsignificance and can be minimized by adjusting thenumber of punctures and energy applied.

Take home messagesLOD improves ovarian responsiveness to

CC and gonadotropins, these may beconsidered after LOD failure instead ofrepeat LOD, before proceeding to the lastresort that is, IVF.

LOD is only an alternative, not theultimate in management of PCOS

Take home messages

LOD NOT the first NORlast line of treatment ofPCOS.

There are safe and efficacious oral alternativesand relatively safe as low-dose step-upregimen of gonadotropin therapy beforeproceeding to the last resort that is, IVF.

If your only toy is a hammer

every problem will look like

a nail