Himalayan Journal of Medicine and Surgery Surgical Option in The

Himalayan Journal of Medicine and Surgery Open Access

Research Article Surgical Option in the Treatment of the Polycystic Ovary Syndrome

Rasha Raheem Abed, Esra MohammedJawad AbdulRadi and Raghad Naser Hussein Ministry of Health, Thi Qar Health Office, Bint Al-Huda Maternity & Children Hospital, Thi-Qar, Iraq Abstract: This research aims to know the benefits of surgical intervention for women *Corresponding Author patients with the syndrome polycystic ovary. 130 samples were collected from Bint Al- Rasha Raheem Abed Huda Maternity & Children Hospital, Thi-Qar, Iraq, and private clinics where the ovaries were drilled through the use of an endoscope, using a needle, as success rates ranged Article History from 59% to 70%, as it helps in improving Efficient ovulation and the presence of Received: 20.05.2021 endometriosis in more than 86% of cases, which has an impact on increasing the Accepted: 01.05.2021 hypothesis of pregnancy and the chances of it continuing in the first trimester. The Published: 10.06.2021 method of treating ovarian cysts laparoscopically is to remove most of the cysts that are located next to the ovaries or one of them in the same way as in the process of removin g Citations: ovarian cysts by surgery, but the difference is that the abdominal area is not deformed by Rasha Raheem Abed, Esra making a large opening, but it is limited to the doctor making a small wound. MohammedJawad AbdulRadi and Raghad Naser Hussein.(2021); Surgical Option in Keywords: surgical intervention for womenm. the Treatment of the Polycystic Ovary Syndrome. Hmlyn Jr Med Surg, 2(3) 17- 21

INTRODUCTION Polycystic ovary syndrome (PCOS) is a group of signs caused by a hormonal imbalance. It is very common, affecting between 5 and 10% of women, and can be characterized by an unusual increase in the production of androgens (male hormones) in the ovaries. This syndrome impairs the growth of ovarian follicles and disrupts the production of eggs. It can increase the size of the ovaries.

PCOS arises from a hormonal imbalance. Two hormones called FSH and LH (secreted by a gland at the base of the brain) regulate the ovarian cycle: their levels vary throughout the cycle, leading to ovulation.

In PCOS, the level of LH often increases, which causes stimulation of the ovaries that produce excess androgens and impede the growth of follicles. The result: In addition, the level of testosterone rises in the blood, causing an increase in body hair and acne. Finally, the level of insulin in the blood - a hormone used to regulate blood sugar levels - also tends to increase. However, if there is an overproduction of insulin, the body will secrete additional male hormones.

Polycystic ovary syndrome (PCOS) is one of the most common causes of infertility in women of reproductive age (up to 5-15% of cases). The main clinical manifestations of the disease are characterized by disorders of menstrual function of the type of oligomenorrhea, secondary amenorrhea, in some cases - menometrorrhagia as a result of endometrial hyperplasia, manifestations of androgenization of varying severity, overweight. Currently, there is a rethinking of the place of PCOS in the structure of endocrine pathology, considering it as a socially significant disease, given the direct connection between it with metabolic disorders (dyslipidemia, hyperinsulinism, insulin resistance, impaired glucose tolerance), leading to the development of arterial hypertension, abdominal-visceral obesity, early atherosclerosis, coronary artery disease hearts. Indeed, numerous epidemiological studies in various countries of the world have shown a high prevalence of PCOS among women of reproductive age up to 3-10% of the population. The risk of developing myocardial infarction and ischemic heart disease in hyperandrogenism of non-neoplastic genesis is 7 times higher than in the general population of 40% of women.

Rasha Raheem Abed et al., Hmlyan Jr Med Surg; Vol-2, Iss- 3 (May-June, 2021): 17-21

There is increasing interest in the development of ovulation, and taking these medications helps restore combined PCOS treatment regimens in which them. metformin a significant role is assigned. Thus, it has been shown that the combined use of metformin (1500- ATIENT AND ETHOD 1700 mg/day) and clomiphene citrate (100 mg/day) is P M highly effective by the method of induction of ovulation 125 samples were collected from Bint Al-Huda in PCOS This combination is prescribed in case of Maternity & Children Hospital, Thi-Qar, Iraq of patient resistance to clomiphene, as well as the first patients and private clinics with polycystic ovaries, stage of therapy in the presence of obesity, severe where standard endoscopic treatment was performed. dyslipidemia, impaired glucose tolerance in PCOS. Isolated needle electrode treatment on both ovaries. Another rational combination is the combination of metformin 1500-1700 mg/day and antiandrogen The needle was inserted as perpendicular to the flutamide (125-500 mg /days), which leads to a surface of the ovary as possible. synergistic effect about the normalization of the  The current used is 100 watts menstrual cycle, decrease in hirsutism, decrease in  The activation used to the current and 40 watts blood testosterone levels, decrease the amount of  Using a crystal solution to wash bleach visceral fat, an increase in HDL levels Additional  The incisions are made on the ovarian cortex and appointment to these drugs of low-dose oral are usually 4–10 mm deep and 3 mm wide. contraceptives led to an additional increase in the level  Ovarian drilling is performed laparoscopically and of CVH, which further reduced the index free via the navel (laparoscopy) androgens Thus, the use of metformin in the treatment of PCOS is a pathogenetic agent therapy aimed at The main cause of PCOS is hyperandrogenism, correcting hyperinsulinism and insulin resistance, which which is responsible for hirsutism, and indirectly, for leads to a significant effect about almost all clinical irregular ovulation and irregular menstruation. components of the disease (restoration of the menstrual Hyperandrogenism is caused by several hormonal cycle, induction of ovulation, reduction of hirsutism) changes' characteristic of PCOS, such as increased and laboratory parameters. levels of the hormone LH (luteinizing hormone), and increased ovarian production of the hormone's estrogen Conventional treatment for PCOS includes: and androgen. In particular, it is the abnormal secretion Take contraceptives, which are usually of LH that overly stimulates the ovaries and produces recommended for women who are not planning to large amounts of these hormones. become pregnant. This approach is not a cure for PCOS, it masks symptoms and helps preserve fertility if In PCOS, concentrations of FSH, a follicle- a woman desires to have children in the future. stimulating hormone secreted by the pituitary gland, are very low, and the secretory contrast between LH and Taking diabetes medications: Metformin, used to FSH associated with menstruation and ovulation is treat type 2 diabetes, maybe excellent for treating suppressed. symptoms of PCOS. However, the use of this drug to treat PCOS has not been approved by the Ministry of In 30% of patients with PCOS, an increase in Health. prolactin up to twice the level of prolactin is observed in healthy women. Preparations for infertility treatment (clomiphene (Clomid) injection, Gonadotropin) for women who RESULTS: - want to become pregnant. Infertility problems in women with PCOS are associated with a lack of

Table 1- effect of surgical intervention on patients P before After LH IU/l 13.1±0.9 8.1±0.5 Androstenedione level (nmol/L) 7.7±0.3 5.4±0.4 DHEAS level (nmol/L) 7.5 ±0.4 4.1±0.3 DHEA level (nmol/L) 22.9±1.6 10.4±1.1 Testosterone level (pmol/L) 3.1±0.3 2.2±0.2 FSH level (IU/L) 6.1±0.3 5.7±0.3

Rasha Raheem Abed et al., Hmlyan Jr Med Surg; Vol-2, Iss- 3 (May-June, 2021): 17-21

Figure.1 – p-value of parameter

Figure.2- explain Menstrual pattern

Figure.3- Ovulatory status

Rasha Raheem Abed et al., Hmlyan Jr Med Surg; Vol-2, Iss- 3 (May-June, 2021): 17-21

Figure.4- quantity women Pregnancy and not Pregnancy

DISCUSSION: - CONCLUSION: - Through the use of the statistical analysis program, Ovarian drilling has lower rates of ovarian it was observed that there was an inverse relationship hyperstimulation syndrome and multiple fetus before and after drilling through the p-value, which was pregnancy. The advantages of the procedure also larger than 0.01. include its treatment, unlike many trials of ovulation induction. Other benefits of this technique include its Reducing androgen levels in the blood After cost-effectiveness and can be performed as an destroying the androgen-producing stroma of Ovaries outpatient procedure. may reduce the amount of substrate available Peripheral aromatization of estrogens. After the patient is EFERENCES submerged in anesthesia, the doctor makes several R small incisions (holes) in the abdomen, into which 1. Abdelhafeez, M. A., Ali, M. S., & Sayed, S. N. trocars are inserted - special ports through which the (2013). Unilateral versus bilateral laparoscopic endoscope, camera, and light are inserted into the ovarian drilling in clomiphene citrate resistant abdominal cavity. Because the abdominal wall rises, polycystic ovary syndrome. Life Sci J, 10(1), 3057- carbon dioxide is injected into the cavity, and the 3060. surgeon gets an overview of the area of the upcoming 2. Abu Hashim, H., El Lakany, N., & Sherief, L. operation. (2011). Combined metformin and clomiphene citrate versus laparoscopic ovarian diathermy for Ovarian drilling involves making small (up to 2 ovulation induction in clomiphene‐resistant women mm) holes in the thick ovarian capsule. For this, a laser with polycystic ovary syndrome: A randomized Due to the drilling, the volume of the androgen- controlled trial. Journal of Obstetrics and producing luteal tissue decreases. This stimulates the Gynaecology Research, 37(3), 169-177. start of ovulation. 3. Ashrafinia, M., Hosseini, R., Moini, A., Eslami, B., & Asgari, Z. (2009). Comparison of metformin After drilling, the surgeon reviews the abdominal treatment and laparoscopic ovarian diathermy in cavity, then removes the tools and sutures the puncture patients with polycystic ovary sites with one or two stitches. syndrome. International Journal of Gynecology & Obstetrics, 107(3), 236-239. Polycystic ovaries are therefore diagnosed to 4. Badawy, A., Khiary, M., Ragab, A., Hassan, M., & include at least one of the following either 12 or more Sherief, L. (2009). Ultrasound-guided transvaginal follicles with a diameter of 2-9 mm, or an increased ovarian needle drilling (UTND) for treatment of ovarian size (>10 cm3). If there is a bulb with a polycystic ovary syndrome: a randomized diameter greater than 10 mm controlled trial. Fertility and sterility, 91(4), 1164- 1167. 5. Elgafor, A. (2013). Efficacy of combined metformin‐letrozole in comparison with bilateral ovarian drilling in clomiphene‐resistant infertile women with the polycystic ovarian syndrome. Archives of Gynecology and Obstetrics, 288 (1), 119‐23.

Rasha Raheem Abed et al., Hmlyan Jr Med Surg; Vol-2, Iss- 3 (May-June, 2021): 17-21

6. Farquhar, C. M., Williamson, K., Gudex, G., 13. Roy, K. K., Baruah, J., Sharma, A., Sharma, J. B., Johnson, N. P., Garland, J., & Sadler, L. (2002). A Kumar, S., Kachava, G., & Karmakar, D. (2010). A randomized controlled trial of laparoscopic ovarian prospective randomized trial comparing the clinical diathermy versus gonadotropin therapy for women and endocrinological outcome with rosiglitazone with clomiphene citrate-resistant polycystic ovary versus laparoscopic ovarian drilling in patients with syndrome. Fertility and sterility, 78(2), 404-411. polycystic ovarian disease resistant to ovulation 7. Giampaolino, P., Morra, I., Tommaselli, G. A., Di induction with clomiphene citrate. Archives of Carlo, C., Nappi, C., & Bifulco, G. (2016). Post- gynecology and obstetrics, 281(5), 939-944. operative ovarian adhesion formation after ovarian 14. Selim, M. F. (2011). The optimal number of drilling: a randomized study comparing ovarian punctures to be applied during laparoscopic conventional laparoscopy and transvaginal ovarian diathermy in women with Polycystic hydrolaparoscopy. Archives of gynecology and Ovarian syndrome. Journal of Gynecologic obstetrics, 294(4), 791-796. Surgery, 27(4), 217-224. 8. Hamed, H. O., Hasan, A. F., Ahmed, O. G., & 15. Sharma, M., Kriplani, A., & Agarwal, N. (2006). Ahmed, M. A. (2010). Metformin versus Laparoscopic bipolar versus unipolar ovarian laparoscopic ovarian drilling in clomiphene-and drilling in infertile women with resistant polycystic insulin-resistant women with polycystic ovary ovarian syndrome: a pilot study. Journal of syndrome. International Journal of Gynecology & gynecologic surgery, 22(3), 105-111. Obstetrics, 108(2), 143-147. 16. Sorouri, Z. Z., Sharami, S. H., Tahersima, Z., & 9. Hashim, H. A., Mashaly, A. M., & Badawy, A. Salamat, F. (2015). Comparison between unilateral (2010). Letrozole versus laparoscopic ovarian and bilateral ovarian drilling in clomiphene citrate diathermy for ovulation induction in clomiphene- resistance polycystic ovary syndrome patients: a resistant women with polycystic ovary syndrome: a randomized clinical trial of efficacy. International randomized controlled trial. Archives of gynecology journal of fertility & sterility, 9(1), 9. and obstetrics, 282(5), 567-571. 17. Takeuchi, S., Futamura, N., Takubo, S., Noda, N., 10. Kaya, H., Sezik, M., & Ozkaya, O. (2005). Minoura, H., & Toyoda, N. (2002). Polycystic Evaluation of a new surgical approach for the ovary syndrome treated with laparoscopic ovarian treatment of clomiphene citrate-resistant infertility drilling with a harmonic scalpel. A prospective, in polycystic ovary syndrome: laparoscopic ovarian randomized study. The Journal of reproductive multi-needle intervention. Journal of minimally medicine, 47(10), 816-820. invasive gynecology, 12(4), 355-358. 18. Taskin, O., Yalcinoglu, A. I., Kafkasli, A., Burak, 11. Palomba, S., Falbo, A., Battista, L., Russo, T., F., & Ozekici, U. (1996). Comparison of the effects Venturella, R., Tolino, A., ... & Zullo, F. (2010). of ovarian cauterization and gonadotropin-releasing Laparoscopic ovarian diathermy vs clomiphene hormone agonist and oral contraceptive therapy citrate plus metformin as second-line strategy for combination on endocrine changes in women with infertile anovulatory patients with polycystic ovary polycystic ovary disease. Fertility and syndrome: a randomized controlled trial. American sterility, 65(6), 1115-1118. journal of obstetrics and gynecology, 202(6), 577- 19. Youssef, H., & Atallah, M. M. (2007). Unilateral e1. ovarian drilling in polycystic ovarian syndrome: a 12. Roy, K. K., Baruah, J., Moda, N., & Kumar, S. prospective randomized study. Reproductive (2009). Evaluation of unilateral versus bilateral biomedicine online, 15(4), 457-462. ovarian drilling in clomiphene citrate resistant 20. Zakherah, M. S., Kamal, M. M., & Hamed, H. O. cases of polycystic ovarian syndrome. Archives of (2011). Laparoscopic ovarian drilling in polycystic gynecology and obstetrics, 280(4), 573-578. ovary syndrome: efficacy of adjusted thermal dose based on ovarian volume. Fertility and sterility, 95(3), 1115-1118.