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Transvaginal Hydrolaparoscopic Ovarian Drilling for Infertile Women with Polycystic Ovary Syndrome

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Transvaginal Hydrolaparoscopic Ovarian Drilling for Infertile Women with Polycystic Ovary Syndrome Current Women’s Health Reviews, 2006, 2, 91-95 91 Transvaginal Hydrolaparoscopic Ovarian Drilling for Infertile Women with Polycystic Ovary Syndrome Hiroaki Shibahara*, Yuki Hirano and Mitsuaki Suzuki Department of Obstetrics and Gynecology, Jichi Medical School, Tochigi, Japan Abstract: Polycystic ovary syndrome (PCOS) is a syndrome of ovarian dysfunction showing cardinal features of hyperandrogenism and polycystic ovarian morphology. It is one of the most common reproductive endocrine disorders in young adult women, showing clinical signs of menstrual disorder, anovulation, hirsutism, acne, and obesity. Frequently, this group of patients present with infertility due to chronic oligoovulation or anovulation. In cases that do not respond to medical induction of ovulation, ovarian surgery such as ovarian wedge resection via laparotomy or ovarian drilling by trans-abdominal laparoscopy has been utilized. Laparoscopic ovarian drilling (LOD) by the trans-abdominal approach has been widely used to induce ovulation in PCOS women after failure of treatment with clomiphene citrate. So far, many authors have reported high rates of ovulation (~ 80%) and pregnancy (~ 60%) following LOD. Recently, a transvaginal method for laparoscopy, named transvaginal hydrolaparoscopy (THL), was developed near the end of the 20th century. Since then, THL has been performed for diagnostic purposes in infertile women. More recently, THL has been performed for operative laparoscopy, especially for ovarian drilling in women with PCOS. This novel technique, transvaginal hydrolaparoscopic ovarian drilling (THLOD) using a laser or bipolar electrosurgery, appears to be an effective minimally invasive procedure to induce ovulation in women with PCOS. Larger studies to assess the safety and long-term efficacy of THLOD are needed. This review article describes the minimally invasive operation for infertile women with PCOS by THLOD. Keywords: Polycystic ovary syndrome, anovulation, transvaginal hydrolaparoscopic ovarian drilling, ovarian wedge resection, laparoscopic ovarian drilling. INTRODUCTION In recent years, however, because of the rapidly expanding use of techniques involving laparoscopy, surgical Polycystic ovary syndrome (PCOS) is a syndrome of treatment has received renewed interest. Laparoscopic ovarian dysfunction showing cardinal features of ovarian drilling (LOD) by the trans-abdominal approach has hyperandrogenism and polycystic ovarian morphology [1]. It been widely used to induce ovulation in women with PCOS is one of the most common reproductive endocrine disorders after failure of treatment with clomiphene citrate [4]. So far, in young adult women, showing clinical signs of menstrual it has been shown that LOD is effective for inducing disorder, anovulation, hirsutism, acne, and obesity. ovulation, and the pregnancy rate following LOD seems to Frequently, this group of patients present with infertility due be acceptable. to chronic oligoovulation or anovulation. Approximately 15 % of patients with PCOS remain anovulatory despite Near the end of the 20th century, a transvaginal method treatment with clomiphen citrate, and half of patients with for laparoscopy, named transvaginal hydrolaparoscopy PCOS who become ovulatory on this treatment fail to (THL), was developed and it was initially performed as a conceive [2]. The alternative of gonadotropin stimulation or diagnostic laparoscopy in infertile women [5]. Afterwards, surgical treatment is often the next step for the treatment of THL was offered for the operative laparoscopy, especially in clomiphene citrate-resistant infertile women with PCOS. women with PCOS for ovarian drilling [6]. This novel technique, transvaginal hydrolaparoscopic ovarian drilling Since Stein and Leventhal reported that all women (THLOD) using a laser or bipolar electrosurgery, appears to menstruated regularly post ovarian wedge resection and be an effective minimally invasive procedure to induce some of them conceived [3], ovarian surgery has been used ovulation in women with PCOS [7-9]. It was suggested that to induce ovulation following unsuccessful medical THLOD has the same effectiveness as trans-abdominal induction of ovulation. Ovarian surgery has also been LOD. indicated in women who hyper-respond to gonadotropin therapy in order to avoid such complications as ovarian OVARIAN WEDGE RESECTION hyperstimulation syndrome (OHSS) or multiple gestations. In 1935, Stein and Leventhal found that some women with secondary amenorrhea displayed bilateral polycystic *Address corresponding to this author at the Department of Obstetrics and ovaries when laparotomy was performed to collect bilateral Gynecology, Jichi Medical School, 3311-1 Yakushiji, Minamikawachi- ovarian samples by wedge biopsies [3]. A series of seven machi, Kawachi-gun, Tochigi 329-0498, Japan; Tel: +81-285-58-7376; Fax: women underwent bilateral ovarian wedge resection thereby +81-285-44-8505; E-mail: [email protected] removing approximately 50 to 75 % of each ovary. All 1573-4048/06 $50.00+.00 © 2006 Bentham Science Publishers Ltd. 92 Current Women’s Health Reviews, 2006, Vol. 2, No. 1 Shibahara et al. women were still menstruating regularly at the time of of punctures to ameliorate the hyperandrogenic status in follow-up. After the surgery, pregnancies were achieved in PCOS women, previous studies have described a various infertile women [3]. These authors were the first to number of punctures carried out in each ovary, ranging from demonstrate the association of the unique polycystic ovarian 4 to 40 [14-16,19-22]. Recently, Amer et al. [23] showed by morphology with the key symptoms such as anovulation and a retrospective study that three punctures per ovary seemed abnormal uterine bleeding. to represent the plateau dose compared with two punctures Although the effectiveness of bilateral ovarian wedge per ovary. Malkawi et al. [24] also reported 5 punctures per resection for patients with PCOS has been well established, ovary were sufficient to improve the clinical and possible complications have been recognized. Removal of reproductive outcome compared with > 10 punctures per ovary. too much ovarian tissue may be the cause of ovarian dysfunction. Any operation on the ovary tends to produce As shown before, the vast majority of patients were adhesions that may involve the tubes. Toaff et al. [10] found to have adhesive disease following bilateral wedge reported that all of seven patients afflicted with continuing resection, while postoperative adhesions are less common infertility after bilateral ovarian wedge resection were found after laparoscopy than after laparotomy [25]. This was also to display peri-tubal adhesions. Three of them displayed confirmed in a rabbit model [26]. ovarian atrophy. Buttram and Vaquero [11] also reported Recently, the use of an insulated needle cautery [27] or that all patients were found to have adhesive disease within that of a harmonic scalpel [28] was shown to be associated one year of bilateral wedge resection in a series of 59 PCOS with a minimal complications including adhesion formation. patients. Therefore, ovarian wedge resection was largely In the former report, 11 (73.3 %) of 15 women performed abandoned because of the risks. It was replaced by medical LOD with insulated needle cautery were found to be free of ovulation induction with clomiphene and gonadotropins. adhesions by a second-look laparoscopy. However, Donesky and Adashi reported an overall The effectiveness and safety of LOD for ovulation aggregate pregnancy rate of 58.8 %, calculated after classical induction in infertile women with clomiphene citrate- bilateral ovarian wedge resection in 1,766 patients, in a resistant PCOS were systematically reviewed by Cochrane review collected from papers including uncontrolled series Database [29]. The author concluded that there is insufficient [12]. An interesting report by Stein noted regular menses evidence of a difference in cumulative ongoing pregnancy lasting more than 31 years in a patient after bilateral ovarian rates between LOD after 6-12 months of follow-up and 3-6 wedge resection [13]. However, the mechanism of action of cycles of ovulation induction with gonadotropins as a ovarian wedge resection is not fully understood. Therefore, it primary treatment. However, the rate of multiple pregnancies is unclear why some women with PCOS do not respond to was considerably reduced in those women who conceived the operation. Some possible mechanisms for the effects of following LOD. These findings suggest that LOD could be bilateral ovarian wedge resection or ovarian drilling have selected for women with clomiphene citrate-resistant PCOS been proposed, but they remain to be proven. For examples, who do not desire multiple pregnancies. a reduction in the levels of LH might lead to a decrease in stromal androgen production along with increasing FSH Donesky and Adashi [12] summarized the findings about levels, allowing follicular development to proceed to conception after LOD. A total of 729 patients were available ovulation [14]. Another mechanism is that inhibin levels are for the study from 27 references. Among them, 614 (82.4%) reduced after ovarian surgery, resulting in a secondary rise of ovulated either spontaneously or with the addition of FSH accompanied by reduced intrafollicular androgen levels medications (predominantly clomiphen citrate) to which they with subsequent appropriate follicular growth [15]. had not responded preoperatively. Four hundred and six of Furthermore, a 40% increase
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