ORIGINAL ARTICLE The Outcome of Laparoscopic Ovarian Drilling in Patients with Clomiphene-resistant Polycystic Ovarian Syndrome in Ogbmoso, Nigeria: A Prospective Evaluation Akintunde O Fehintola1, Olufemi T Awotunde2, Olumuyiwa A Ogunlaja3, Samuel E Akinola4, Sunday A Oladeji5, Olurotimi I Aaron6, Funmito O Fehintola7 ABSTRACT Background: Polycystic ovary syndrome (PCOS) is commonly encountered in women with anovulatory infertility. The surgical ovarian drilling procedure aims to restore spontaneous ovulatory cycles. This function is similar to the goal of clomiphene citrate and/or metformin. Objective: We conducted this study to determine the outcome of laparoscopic ovarian drilling (LOD) among patients who presented with clomiphene-resistant PCOS. Materials and methods: The study was prospective in design. We studied 43 patients with clomiphene-resistant PCOS who had laparoscopic ovarian drilling (LOD) using monopolar diathermy at the Bowen University Teaching Hospital, Ogbomoso. The study took place between January 2014 and June 2016. Clinical data recorded at different intervals of follow-up included the menstrual pattern and reproductive history. Results: We successfully performed laparoscopic ovarian drilling without any complication. Four (9.3%) of the patients were lost to follow-up. Thirty (76.9%) of the remaining 39 patients resumed regular menstrual cycles with spontaneous ovulation, while 23 (59.1%) patients achieved spontaneous pregnancy within 6 and 18 months following LOD. No record of multiple pregnancies. Factors associated with failed LOD treatment included obesity and a long duration of infertility. Conclusion: LOD is a feasible and effective first-line treatment option in patients with clomiphene-resistant PCOS in sub-Saharan Africa. Emphasis should be on weight reduction with early application of LOD to treat patients with clomiphene-resistant PCOS. This will reduce the time to achieve pregnancy and the need for gonadotropins to induce ovulation. Keywords: Clomiphene-resistant polycystic ovary syndrome, Laparoscopic ovarian drilling, Treatment outcome. World Journal of Laparoscopic Surgery (2020): 10.5005/jp-journals-10033-1418 INTRODUCTION 1Department of Obstetrics and Gynaecology, Faculty of Clinical The most common endocrinopathy in women within the Sciences, Obafemi Awolowo University, Ile-Ife, Osun, Nigeria reproductive-age group is polycystic ovary syndrome (PCOS). It 2–5 1–4 Department of Obstetrics and Gynaecology, Bowen University affects about 6–8% of this age-group. PCOS forms a spectrum of Teaching Hospital, Ogbomoso, Oyo, Nigeria disorders from a heterogeneous collection of signs and symptoms. 6Department of Anaesthesia, Faculty of Clinical Sciences, Obafemi Its presentation may be mild in some, while reports show severe Awolowo University, Ile-Ife, Osun, Nigeria disturbance of reproductive, endocrine, and metabolic functions in 7Community Health Department, Faculty of Clinical Sciences, Obafemi others.5 The prevalence of PCOS varies among races and ethnicities Awolowo University, Ile-Ife, Osun, Nigeria with a range between 5 and 10%3 Corresponding Author: Akintunde O Fehintola, Department of Previous data reported the highest prevalence rate of 52% Obstetrics and Gynaecology, Faculty of Clinical Sciences, Obafemi among the South Asian immigrants in Britain, of whom 49.1% had 2 Awolowo University, Ile-Ife, Osun, Nigeria, Phone: +2348037998247, menstrual irregularity. About 10% of the diagnosis of PCOS is made e-mail: [email protected] during gynecologic visits.2 Approximately 30–75% are obese, while How to cite this article: Fehintola AO, Awotunde OT, Ogunlaja OA, 50% of patients have hirsutism3 1 4 et al. The Outcome of Laparoscopic Ovarian Drilling in Patients with In Nigeria, Ugwu et al. and Omokanye et al. reported Clomiphene-resistant Polycystic Ovarian Syndrome in Ogbmoso, prevalence rates of 18.1% and 31%, respectively. In their series, Nigeria: A Prospective Evaluation. World J Lap Surg 2020;13(3):101–107. the majority of the patients presented with infertility and oligo- Source of support: Nil menorrhea.2 PCOS is responsible for about 75% of anovulatory Conflict of interest: None infertility.6 PCOS predisposes women to diabetes mellitus, endometrial carcinoma, and cardiovascular disease.7–9 The exact pathophysiology in PCOS is unknown. However, a PCOS based on the history and examination findings. According to genetic component is likely, since the condition tends to run in families. an international consensus, the syndrome can be diagnosed using Also, the pattern of inheritance is X-linked dominance.10 Furthermore, the “Rotterdam criteria (presence of at least two of the following studies have shown the occurrence of PCOS in approximately 50% conditions): Oligomenorrhea or amenorrhea, hyperandrogenism, of first-degree relatives.11 We can make a presumptive diagnosis of and polycystic ovaries on ultrasound. Researchers defined the © The Author(s). 2020 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons. org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Laparoscopic Ovarian Drilling, Clomiphene-resistant PCOS, Treatment Outcome morphology of polycystic ovaries as an ovary with 12 or more follicles index (BMI), and the number of perforations per ovary during the measuring 2–9 mm in diameter and increased ovarian volume (>10 procedure, were recorded in a proforma. Patients were followed cm3) on transvaginal ultrasound (TVS)”.12 up on a clinic basis and on the phone to get information on the The goals of the “symptom-oriented” PCOS management are resumption of menses, ovulation, and pregnancy. We confirmed to restore normal menstruation, ovulatory cycles, and fertility ovulation with the ovulation test kit (Predict ®), day 12 to 14 follicular and prevent endometrial hyperplasia/cancer. It also involves the TVS study, and pregnancy after the procedure. We carried out data treatment of acne and infertility. Clinicians achieved ovulation analysis with Statistical Package for Social Sciences (SPSS) version 7 induction in women with PCOS using various means in the past. The 20. A p value of <0.05 was considered statistically significant. first-choice treatment presently in PCOS women is administration of clomiphene citrate (CC).7,8 We termed those who fail to ovulate Definition of Term with a maximum dose of clomiphene citrate (i.e., a daily dose of • Failed LOD; failure to resume regular menses with ovulation 150mg) “Clomiphene Citrate Resistant (CCR)”.13 Clomiphene citrate within 6–8 weeks following LOD. is successful in 80% of cases. The remaining 20% of patients who 14 • Clomiphene citrate-resistant PCOS; PCOS patients who failed to did not ovulate this drug are declared CCR. ovulate with 150 mg/day dose of clomiphene citrate The use of gonadotropins and metformin and ovarian drilling 13 are the treatment modalities for those with CCR. Outcome Variables Gjonnaess first described LOD in 1984.15 The introduction of this procedure reawakened interest in the surgical management of Primary outcome variables include the resumption of menses patients with CCR. This procedure involves the use of cautery or laser with spontaneous ovulation and clinical pregnancy rates. We vaporization to create multiple perforations in the ovary. Previous define clinical pregnancy as the presence of fetal cardiac activity data reported an increase in spontaneous ovulation and conception on ultrasound. We define the clinical pregnancy rate as the rates following LOD, along with improved responsiveness to percentage of patients with clinical pregnancy to the total number subsequent medical therapy.15–17 Clinicians can do LOD as an of participants at the end of the study. Other outcome measures outpatient procedure with less trauma and fewer postoperative included were live birth rate, miscarriage rate, multiple pregnancies, adhesions. Conversely, although useful, gonadotropins expose the and OHSS rates. patients to a series of complications, such as multiple pregnancy and hyperstimulation. Furthermore, gonadotropins are expensive, PROCEDURE and they require repeated doses and intensive monitoring.13 We obtained informed consent for LOD. After general anesthesia This study aimed at evaluating patients’ characteristics as and skin preparation, we use the Veress needle to create well as the results of LOD in patients with CCR polycystic ovarian pneumoperitoneum. With the assistant lifting the anterior syndrome in our center. abdominal wall, the surgeon inserted the needle through a stab incision in the umbilicus’s inferior crease in the mid-line. We perform MATERiaLS AND METHODS Veress needle insertion with the patient in the supine position. After this, the surgeon then places a 10-mm infra-umbilical (primary) Study Setting port on the infraumbilical crease through a transverse incision. The study is prospective in design. We studied patients who had We also place two 5-mm lateral (secondary) ports in the right LOD at the gynecological endoscopy unit of the Obstetrics and and left iliac fossae lateral to inferior