Page 11 - World Journal of Laparoscopic Surgery

Laparoscopic Ovarian Drilling, Clomiphene-resistant PCOS, Treatment Outcome
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We used a monopolar diathermy needle (Tritome) in this study BMI and BMI of <30 kg/m than those with a BMI of >30 kg/m .
for LOD. Researchers proposed different modifications of the classic This finding is similar to that observed in a cross-sectional done
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needle electrode techniques. These modifications include using the by Omokanye et al.; hence, alternative treatment methods may
bipolar needle, laparoscopic ovarian multi-needle intervention, LOD need to be used for this group of patients, such as weight reduction,
using a monopolar hook electrode, LOD using the harmonic scalpel, metformin treatment, gonadotropin therapy, or IVF to achieve
and office micro laparoscopic ovarian drilling. 29–32 Researchers conception.
also developed various transvaginal methods such as transvaginal The infertility duration of 5 years and below had the most
hydrolaparoscopy (fertiloscopy) and transvaginal sonography– substantial impact as a predictor of success. This result is in
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guided ovarian interstitial laser treatment. 33–35 However, more agreement with the previous study. A possible explanation for
extensive prospective studies are needed to validate use, safety, the role of infertility duration may be the emergence of other
efficacy, and long-term effects of alternate techniques. subfertility factors as the duration of infertility increases. 26
The exact mechanism of LOD is unknown. The destruction of One of LOD’s main shortcomings is iatrogenic adhesions due to
androgen-producing stroma was the proposed beneficial effect. bleeding from the ovarian surface or premature contact between
There is a reduction in the circulating and intra-ovarian levels. the ovary and the bowel after cauterization. Adhesion rates ranged
Previous data showed that LOD also has a modulating effect on from 0 to 100%, 12,33,34,36,37 involving higher risks with laser. 36,37 This
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the pituitary–ovarian axis. The resumption of regular cycles and higher figure is probably due to less thermal penetration (2–4 mm)
ovulation is due to the rapid endocrine changes that may last for by the cone-shaped laser drilling lesions compared to cylinder-
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months to years. The assessment of tubal patency and diagnosis shaped lesions (8 mm) of monopolar electrocoagulation. Most
of other pelvic pathologies, done simultaneously, is an additional studies reported mild-to-moderate adhesions, which do not seem
advantage of LOD. Previous evidence showed that the sensitivity to affect pregnancy rates after LOD. Adhesion prevention strategies
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of the ovaries to ovulation induction agents increases after the such as liberal peritoneal lavage, adhesion barriers like intercede,
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procedure. Other benefits of LOD include more orderly growth and adhesiolysis performance at early second-look laparoscopy
of follicles, reduced chances in cycle cancellation, and decreased are not effective in preventing de novo adhesions or in improving
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risk of OHSS. pregnancy rates. We raised the ovaries before applying energy in
An environment with low androgen, AMH, LH levels, and this study and saline washed after the procedure to decrease the
relatively fewer follicles are more favorable for proper follicular temperature, reducing the risk of injury.
growth. Another potential risk is premature ovarian failure, significantly
The majority (76.9%) of the patients resumed menses with if the ovarian blood supply is damaged inadvertently or if the
spontaneous ovulation. This finding is similar to 84.2% and 77.7% surgeon makes a large number of punctures, leading to excessive
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reported in Japan and Poland, respectively, but lower than destruction of ovarian follicular pool or production of anti-ovarian
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finding from Ilorin South-Western Nigeria. The higher ovulation antibodies. When applied correctly, as done in this study, the
rate in the study done in Ilorin may be because the patients were coagulation puncture does not appear to compromise the ovarian
started on clomiphene citrate on the resumption of menses reserve. A prospective comparative study found that the extent
following LOD. of ovarian tissue damage was limited, ranging from 0.4% after
The clinical pregnancy rate of 59% falls within the range of four to 1% after eight coagulation punctures, each of 40 W for 5
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43–84% reported by some studies 14,15,24,25 although slightly higher seconds. We can interpret changes in ovarian reserve markers
than Ilorin’s rate. The difference may be due to the effects of other as normalization of ovarian function rather than reducing ovarian
infertility factors not excluded in the Ilorin study. reserve. Surgeons should not do coagulation within 8–10 mm of
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Previous reports have shown that PCOS patients have higher the ovarian hilum. The use of unilateral drilling, 28,41 use of the
miscarriage rates as compared to the general population. Elevated harmonic scalpel, 32,42 and use of bipolar energy 15,43 are associated
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LH is the main culprit. Other significant contributors to the increased with a less risk of adhesions and Decreased Ovarian Reserve (DOR)
miscarriage rates in PCOS patients include hyperinsulinemia and but with equivalent reproductive outcomes with bilateral drilling
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obesity. LOD reduces LH levels as well as the risk of miscarriage. using monopolar diathermy.
Previous data reported a miscarriage rate of 14% after LOD than the Readers should interpret the findings from this study in light of
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30 to 40% expected rate in PCOS patients. The miscarriage rate in some limitations. First, the small sample size makes it difficult for
this study was 10.3%. This result is comparable to 14% reported by the results to be generalized. Also, the limited laboratory resources
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Ikechebelu et al. The live birth rate in this study was 48.7%. This at the study center made it difficult to assay some hormones that
discovery is similar to the finding of Mandeep et al. could have added to this study’s quality.
There was no record of multiple pregnancies or OHSS in the Nevertheless, our findings have significant implications for
study participants, which further established the safety of LOD Nigeria’s reproductive interventions since anovulatory infertility is
over gonadotropins. a significant public health issue in our area and globally.
Predictors of failed LOD in this study were aged above 35
years, duration of infertility above 5 years, and moderate to morbid
obesity. These are similar to the findings of other studies. 13,14 conclusIon
To our knowledge, this study is one of the very few studies Laparoscopic ovarian drilling is a feasible, safe, and effective
that assessed prognostic factors for an ovarian response following first-line treatment option in patients with clomiphene-resistant
laparoscopic electrocautery using a logistic regression model with PCOS in sub-Saharan Africa. Emphasis should be on weight
prospective data collection in West Africa. Other studies done reduction with early recourse to LOD in managing patients with
so far are either cross-sectional or retrospective, while few other clomiphene-resistant PCOS. Early recourse will reduce the time
prospective studies did not look out for failed LOD predictors. LOD to achieve pregnancy and the need for ovulation induction using
had a higher successful pregnancy outcome in patients with normal gonadotropins.

World Journal of Laparoscopic Surgery, Volume 13 Issue 3 (September–December 2020) 105