Page 8 - World Journal of Laparoscopic Surgery

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
3
cm ) 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
7,8
of clomiphene citrate (CC). 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
13
150mg) “Clomiphene Citrate Resistant (CCR)”. Clomiphene citrate within 6–8 weeks following LOD.
is successful in 80% of cases. The remaining 20% of patients who • Clomiphene citrate-resistant PCOS; PCOS patients who failed to
did not ovulate this drug are declared CCR. 14 ovulate with 150 mg/day dose of clomiphene citrate
The use of gonadotropins and metformin and ovarian drilling
are the treatment modalities for those with CCR. 13 Outcome Variables
15
Gjonnaess first described LOD in 1984. 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 epigastric vessels using the
Gynaecology Department, Bowen University Teaching Hospital, baseball diamond concept. The surgeon then inserts a 0-degree
Ogbomoso, between January 01, 2014, and June 30, 2016. The 10 mm telescope through the primary port and carries diagnostic
center started gynecological endoscopy procedures in 2007 though laparoscopy with chromopertubation for tubal patency.
mainly diagnostic. Operative procedures began in 2013. The surgeon then lifts the ovaries out of the ovarian fossa with
an irrigation cannula inserted through the ipsilateral secondary
Inclusion and Exclusion Criteria ports. The cannula is wedged against the cervicouterine junction,
We recruited patients with PCOS diagnosis based on the Rotterdam giving a robust platform for drilling. We use a uterine manipulator
12
criteria who have had up to a daily dose of 150 mg clomiphene to manipulate the uterus. The monopolar needle is then introduced
citrate without evidence of ovulation. We excluded those with from the contralateral secondary port and approaches the ovaries
absolute contraindication for laparoscopy. We also excluded at right angles. We usually carry out 4–10 drills on each ovary based
patients with tubal pathology, severe endometriosis, severe male on the size of the ovary. We then carried out suction irrigation of the
factor, and those who refuse LOD as a treatment modality. ovaries and peritoneal lavage using normal saline after the drill. The
surgeon carries out irrigation to cool the ovaries and clear the pelvis
Methods of any blood clots and debris. After the procedure, the assistant
We obtained sociodemographic data and other important removes the hand instruments and lets out pneumoperitoneum
information from the patient at the presentation. Information on through the secondary ports. We remove these ports under the
the patient’s level of education and the husband’s occupation vision, followed by the laparoscope, and the 10-mm trocar. The
was also collected to group them into different social classes (i.e., surgeon then closes the port wounds with subcuticular suturing
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socioeconomic classes 1 to 5). We further regroup the patients as using Vicryl 2/0.
upper, middle, and lower classes. We group classes 1 and 2 as upper
social class, class 3 as a middle social class, while classes 4 and 5 were Treatment Protocol
grouped as a lower social class to aid data analysis. Research assistants fill the forms as part of the postoperative
Investigation results, including transvaginal ultrasound (TVS) instructions for a repeat hormonal profile, especially for those
results, hormonal profile results (before and after LOD), body mass who resume menses before their follow-up visits. A repeat Day

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