Page 42 - WJOLS - Laparoscopic Journal

Laparoscopic Ovarian Drilling versus Medical Treatment in Management of Clomiphene Citrate Polycystic Ovarian Syndrome

Operative and Postoperative Complications were found to be lower than the before LOD values by
means of ovarian reserve markers, the after values stayed

The procedure is devoid of major complications, and yield higher than normal when compared with normal women
satisfactory ovulation and conception rates. However, without PCOS. 17,18 Even though the fear for ovarian reserve
adhesion formation is a potential complication following such and premature ovarian failure is not unfounded with LOD,
procedures. 4,5 Other potential complications include hormone replacement therapy could be used if need be.
3
premature ovarian failure in the future. The procedure Some studies have tried to identify makers for positive
usually done as a day case and patient need not be admitted. response to LOD to include high levels of Luteinizing
Postoperative pain is relieved with mild analgesics such as hormones and androstendione, short period of infertility
paracetamol for 2 to 3 days. Other potential risks is that of (< 3 years) and absence of pre-existing tubal disease and
anesthesia which is beyond the scope of this review. advocate their use to identify patients who will respond
well to LOD. 19,20
Safety and Cost-effectiveness
The procedure does not add to more cost or risk from Quality-of-life Analysis
anesthesia for a patient having diagnostic laparoscopy for LOD promotes a better quality-of-life when used in women
evaluation of infertility. Successful pregnancy from especially amongst those who have not conceived following
treatment with LOD will of course treat the patients infertility treatment. A study on women’s health-related quality-of-
fulfilling the desire of the patient. LOD is more effective life (HRQoL) on 168 CC-resistant women with PCOS that

than or equivalent to metformin, GnRHa, or FSH in resolving were randomly assigned to receive either laparoscopic

anovulation and pregnancy. 3,9-11 Systematic review has electrocauteryof the ovaries followed by CC or recombinant

shown that there is no difference in ongoing pregnancy, FSH (rFSH) if anovulation persisted. Overall, HRQoL was

births and miscarriages between LOD and FSH but LOD notaffected in both groups. In women still under treatment,

12
has reduced risk of multiple pregnancy. FSH and to lower rFSH was slightly more burdensome for women’s HRQoL

extent CC have the added risk of causing ovarian than electrocautery. 21
4
hyperstimulation syndrome (OHSS), which is a potentially Future prospects of LOD:
fatal condition. Futhermore, GnRHa is expensive and could With increasing evidence that LOD is more effective
cause distressing pseudomenopausal symptoms and which with less cost, and as techniques to reduce periovarian
may require add back hormone therapy for the treatment to adhesions improves, more practitioners will begin to consider
4
continue. The cumulative cost of treatment with FSH over it ahead of chemotherapeutic agents in treatment of CC-
LOD was found to be higher in a randomized trials and one resistant PCOS.
systematic review. 13-15 This may be similar with other
chemotherapeutic agents that have higher risks of multiple CONCLUSION
gestation. In a study, the median time to pregnancy after
LOD was 135 days and LOD alone resolves infertility within LOD has obvious comparative advantages to competitive
4 to 6 months in 50 to 60% of couples. The researchers chemotherapeutic agents. Reduction in overall cost of
were advocating a strategy of diagnostic laparoscopy and treatment and risk of multiple gestation implies that it may
LOD as the first line of treatment of infertility in women be the treatment of choice in women with CC-resistant
with PCOS as this will shorten the time to pregnancy for PCOS.
many women, reduce the need for medical ovulation
induction and enable diagnosis of those women with REFERENCES
anatomic infertility, who can achieve pregnancy only by in 1. The Rotterdam ESHRE/ASRM-sponsored PCOS Consensus
vitro fertilization treatment. 16 Work-shop Group. Revised 2003 consensus on diagnostic
There is however, a risk of periovarian adhesions and criteria and long-term health risks related to polycystic ovary
syndrome. Fertil Steril 2004;81(1):19-25.
premature ovarian failure in the future. Studies to determine 2. Balen AH, Laven JSE, Tan SL, Dewailly D. Ultrasound
ovarian reserve and possibility of future premature ovarian assessment of the polycystic ovary. IntConsensus Definitions.
failure are few and equivocal. There were statistically Human Reprod Update 2003;9:505-14.
significant differences between Day 3 FSH, inhibin B levels, 3. Malkawi HY. Laparoscopic ovarian drilling in the treatment of
polycystic ovary syndrome: How many punctures per ovary
ovarian volume and antral follicle count before and after are needed to improve the reproductive outcome? J Obstet
LOD in some of the reports. Although, the after LOD values Gynaecol Res 2005;31(2):115-19.

World Journal of Laparoscopic Surgery, May-August 2010;3(2):99-102 101