Ovarian Surgery For Ovarian Surgery For Polycystic Ovarian Polycystic Ovarian

SyndromeSyndrome

AHMED WALID ANWAR MURAD,MDAHMED WALID ANWAR MURAD,MDLecturer of Obstetrics and Gynecology

Benha Faculty of MedicineBenha University

Egypt2008

Presented byPresented by

Introduction:Introduction:

Polycystic Ovarian SyndromePolycystic Ovarian Syndrome

First described by First described by stein& Leventhalstein& Leventhal ( (19351935) ) who reported who reported dramatic effectdramatic effect of of ovarian ovarian wedge resectionwedge resection in 7 women with in 7 women with 2ndry 2ndry amenorrhea, 2ndry infertility, obesity, amenorrhea, 2ndry infertility, obesity, Hirsutism and cystic ovaries.Hirsutism and cystic ovaries.

Diagnostic Criteria of PCOSDiagnostic Criteria of PCOS

Rotterdam definitionRotterdam definition(ESHRE/ASRM) (ESHRE/ASRM) (2003):(2003):Published 2004Published 2004

PCO is defined by presence of 2 of the PCO is defined by presence of 2 of the following 3 featuresfollowing 3 features::

1.1. Oligomenorrhea. and / or anovulation.Oligomenorrhea. and / or anovulation.2.2. Hyperandrogenism and / or Hyperandrogenism and / or

hyperandrogenemia.hyperandrogenemia.3.3. U/S criteria of Polycystic ovaries.U/S criteria of Polycystic ovaries.

N.B:N.B: HyperandrogenismHyperandrogenism= Manifestations of = Manifestations of hyperandroginemiahyperandroginemia..

Incidence:Incidence:

Commonest endocrinal gynecologic disorder:Commonest endocrinal gynecologic disorder:

- - About 2% of general population.About 2% of general population.

- - 4-10% based on clinical, biochemical and u/s 4-10% based on clinical, biochemical and u/s criteria.criteria.

- - 20-10% based on U/s only.20-10% based on U/s only.

- - 30% of infertility.30% of infertility.

- 90% of Hirsutism with regular cycle.- 90% of Hirsutism with regular cycle.

- - 87% of case of oligomenorrhea.87% of case of oligomenorrhea.

- - 82% of cases with recurrent miscarriage.82% of cases with recurrent miscarriage.

Long term risks of PCOLong term risks of PCOI) Definite risk.I) Definite risk. II) Possible riskII) Possible risk III) Unlikely III) Unlikely

riskrisk

- - Type II D.M.Type II D.M.

- Dyslipidemia- Dyslipidemia ((↑↑cholesterol and cholesterol and ↑↑LDL LDL with with ↓↓ HDL). HDL).

- - Endometrial Endometrial carcinoma due tocarcinoma due to::

Unopposed E1&E2Unopposed E1&E2+ + Hyperinsulinemia Hyperinsulinemia stimulate IGFI stimulate IGFI receptors on receptors on endometrium.endometrium.

-Abortion-Abortion..

-Hypertension Hypertension -CVD. CVD.

- Gestational DM. - Gestational DM.

- Pregnancy - Pregnancy induced induced hypertensionhypertension

-Ovarian Cancer, -Ovarian Cancer, and/or uterine and/or uterine Fibroid. Fibroid.

- - Breast cancerBreast cancer

History Of Development In the History Of Development In the Treatment of Anovulation Associated Treatment of Anovulation Associated

with PCOSwith PCOS DateDate TreatmentTreatment

19301930 Bilateral Wedge Resection.Bilateral Wedge Resection.

19611961 Clomiphene Citrate.Clomiphene Citrate.

19671967 Laparoscopic Ovarian Biopsy.Laparoscopic Ovarian Biopsy.

19781978 Laparoscopic Ovarian Drilling {Diathermy}Laparoscopic Ovarian Drilling {Diathermy}

19881988 Laparoscopic Ovarian Drilling {Diathermy}Laparoscopic Ovarian Drilling {Diathermy}

Polycystic ovary syndromePolycystic ovary syndrome

Lines of treatment:Lines of treatment:General measuresGeneral measures

Induction of ovulationInduction of ovulation

Preventing long term health Preventing long term health problems:problems:

– Hirsutism.Hirsutism.– End. Hyperplasia.End. Hyperplasia.– DUBDUB

STEPWISE APPROACH FOR STEPWISE APPROACH FOR OVULATION INDUCTION IN OVULATION INDUCTION IN

PCOSPCOS:: ACOG,2002ACOG,2002

1. Weigh loss: If BMI >30 K/m21. Weigh loss: If BMI >30 K/m2

2. Clomiphene citrate (CC).2. Clomiphene citrate (CC).

3. CC + corticosteroids if DHES > 2ug/ml3. CC + corticosteroids if DHES > 2ug/ml

4. CC + Metformin4. CC + Metformin

5. Low dose FSH injection5. Low dose FSH injection

6. Low dose FSH injection + Metformin6. Low dose FSH injection + Metformin

7. Ovarian drilling ???? 7. Ovarian drilling ????

8. IVF 8. IVF

Ovarian Surgery For Ovulation Ovarian Surgery For Ovulation Induction In PCOSInduction In PCOS

I} Laparoscopic Techniques of Ovarian Surgery I} Laparoscopic Techniques of Ovarian Surgery {LOS}{LOS} – Laparoscopic Ovarian Drilling (LOD) Laparoscopic Ovarian Drilling (LOD) → →

diathermy / LASER.diathermy / LASER.

II} II} Transvaginal Techniques of Ovarian Surgery Transvaginal Techniques of Ovarian Surgery {TVOS}{TVOS}– 1) Transvaginal mini-laparoscopy {Fertiloscopy}1) Transvaginal mini-laparoscopy {Fertiloscopy}– 2) Transvaginal ultrasound (TVS)-guided ovarian 2) Transvaginal ultrasound (TVS)-guided ovarian

drilling. drilling.

IndicationsIndications

I} Ovulation induction: INI} Ovulation induction: IN a) a) C.C resistant PCOC.C resistant PCO: : Defined as:Defined as:

– Failure to ovulate on a dose of CC, {100 mg, for 5 Failure to ovulate on a dose of CC, {100 mg, for 5 days recently in 3 cycles, in contrast to 6 cycles days recently in 3 cycles, in contrast to 6 cycles in the past }in the past } or, or,

– Failure to ovulate on incremental doses of CC, Failure to ovulate on incremental doses of CC, {50-150 mg}.{50-150 mg}.

b) b) C.C failureC.C failure:: DefinedDefined whenwhen pregnancy does not pregnancy does not occur despite of regular ovulation on C.C for 6-9 occur despite of regular ovulation on C.C for 6-9 cycles.cycles.

c) c) C.C pregnancy failure:C.C pregnancy failure: Defined asDefined as failure to failure to maintain pregnancy conceived with C.Cmaintain pregnancy conceived with C.C..

IndicationsIndications

II} Other potential indications:II} Other potential indications:1.1. LH hypersecretion.LH hypersecretion.

2.2. Patient cannot follow treatment regularly.Patient cannot follow treatment regularly.

3.3. Prevention of long term morbidity in PCOS Prevention of long term morbidity in PCOS patient.patient.

4.4. Menstrual irregularity in PCOS patient. Menstrual irregularity in PCOS patient.

5.5. Acne and hirsutism resistant to treatment Acne and hirsutism resistant to treatment in PCOS patient. in PCOS patient.

Mechanism of action Of LOSMechanism of action Of LOS

1} 1} Drainage of atretic follicles with high {A+ Drainage of atretic follicles with high {A+ Inhibin} content.Inhibin} content.

2} 2} Destruction of ovarian stroma that produce A.Destruction of ovarian stroma that produce A.

3} 3} LOS → Postoperative ↑ of FSH →↑Intra-LOS → Postoperative ↑ of FSH →↑Intra-follicular aromatase activityfollicular aromatase activity

1,2,31,2,3 → →

↓↓Intra-follicular androgenic environmentIntra-follicular androgenic environment → → remove remove intraovarian block to follicular maturation that intraovarian block to follicular maturation that precede ovulation.precede ovulation.

Mechanism of action Of LOSMechanism of action Of LOS

4}4}Surgical trauma to the ovary :Surgical trauma to the ovary :

- - Production of non steroidal factors → Production of non steroidal factors → Restore hypothalamo-pitutary-ovarian Restore hypothalamo-pitutary-ovarian function.function.

-- Production of ovarian growth Production of ovarian growth factors{IGF-1}→ Sensitize ovary to factors{IGF-1}→ Sensitize ovary to circulating FSH.circulating FSH.

Effect of LOSEffect of LOS

1}Hormonal changes: 1}Hormonal changes:

- - Rapid &persistent ↓in circulating Rapid &persistent ↓in circulating AA{T/ {T/ Androstenedione}Androstenedione}

- Gonadotrophins: LH&FSH ↑ 24-48h - Gonadotrophins: LH&FSH ↑ 24-48h after LOS then LH gradually ↓.after LOS then LH gradually ↓.

- - Circulating inhibin B→ No change.Circulating inhibin B→ No change.

Effect of LOSEffect of LOS

2}Metabolic changes:2}Metabolic changes:

No improvement of insulin sensitivity & No improvement of insulin sensitivity & lipoprotein abnormalitylipoprotein abnormality → persistence of → persistence of risk factors of DM&CVD.risk factors of DM&CVD.

3}Temporary 3}Temporary ↑ in total ovarian +stromal ↑ in total ovarian +stromal volume then ↓.volume then ↓.

4}↓ Pulsatility4}↓ Pulsatility index index of ovarian artery. of ovarian artery.

RisksRisks::

1-Adhesion formation, 1-Adhesion formation,

2-Potential surgical risks (bleeding and infection)2-Potential surgical risks (bleeding and infection)

3-Anesthesia risks, 3-Anesthesia risks,

4-Premature ovarian failure (theoretical 4-Premature ovarian failure (theoretical complication) complication)

Technique Of LOSTechnique Of LOS

-Laparoscopy:-Laparoscopy: 3 Puncture technique. 3 Puncture technique.

- - Utero-ovarian Utero-ovarian ligamentligament is grasped is grasped by atrumatic by atrumatic forceps moving the forceps moving the ovaryovary {towards {towards anterior abdominal anterior abdominal wall& in front of the wall& in front of the uterus}.uterus}.

-Unipolar -Unipolar diathermydiathermy {hold {hold perpendicular perpendicular against against antimesentric antimesentric border away border away from the from the hilum}.hilum}.

Technique Of LOSTechnique Of LOS

--60 Watt,60 Watt, 3-4 second3-4 second, 3-4mm , 3-4mm depth,3-depth,3-4mm in diameter4mm in diameter, 4-8 points., 4-8 points.-Ovary is irrigated with saline before -Ovary is irrigated with saline before releasing it. releasing it. --Crystalloid solutionCrystalloid solution is instilled at end of is instilled at end of the procedure.the procedure.Other technique:Other technique: Making linear incision Making linear incision into ovarian surface to a depth of 5-into ovarian surface to a depth of 5-7mm7mm→↑ complication.→↑ complication.

Use of LASER for LOS:Use of LASER for LOS:

-LASER-LASER can be used instead of electrocautery. can be used instead of electrocautery.

--LASER ModalitiesLASER Modalities:: 4 {Nd:YAG, CO2, Argon 4 {Nd:YAG, CO2, Argon and KPT}.and KPT}.

--MethodsMethods::– 1} Non contact mode1} Non contact mode:: LASER fibers is applied at a LASER fibers is applied at a

distance of 5-10mm of antimesentric surface of distance of 5-10mm of antimesentric surface of the ovary with a power setting of 30-the ovary with a power setting of 30-100W→Incision, puncture or coagulation100W→Incision, puncture or coagulation..

– 2} Contact mode2} Contact mode::

LASER versus LASER versus electrocautery for LOS:electrocautery for LOS:

Electrocautery IS superiorElectrocautery IS superior whywhy??1} Less coast &easy application.1} Less coast &easy application.2} Achieve higher ovulation and pregnancy 2} Achieve higher ovulation and pregnancy

rate.rate.3} Less surface injury than CO2 LASER → 3} Less surface injury than CO2 LASER →

Surface adhesion.Surface adhesion.4} Effect of diathermy may last longer than 4} Effect of diathermy may last longer than

the effect of LASER . the effect of LASER .

Bilateral Wedge ResectionBilateral Wedge Resection:: old methodold method , ,no longer be usedno longer be used due to due to

associated adhesions.associated adhesions. Classic BWRClassic BWR Inverted BWRInverted BWR

BaseBase At the ovarian surfaceAt the ovarian surface. . At the ovarian At the ovarian stromastroma. .

ApexApex At the ovarian stroma.At the ovarian stroma. At the ovarian At the ovarian surface. surface.

AdvantagesAdvantages Remove more Remove more stromastroma→→ ↓↓A+A+↓↓E+ E+ Preserve cortex Preserve cortex that contain that contain graffian folliclesgraffian follicles

Predictors of the outcome Predictors of the outcome of LOSof LOS

The following are associated with The following are associated with significant significant ↓↓in ovulation and pregnancy in ovulation and pregnancy ratesrates::– Infertility > 3 years. Infertility > 3 years. – Marked hyperandrogenism: {Serum T Marked hyperandrogenism: {Serum T

>4.5nmo/l or FAI ≥15}. >4.5nmo/l or FAI ≥15}. – Marked obesity: {BMI≥35Kg/m²}.Marked obesity: {BMI≥35Kg/m²}.– Recently:Recently: Insulin resistance determined by Insulin resistance determined by

{{HOMAHOMARIRI} → } → homeostasis model assessment homeostasis model assessment resistance indexresistance index >2.1. >2.1.

Predictors of the outcome Predictors of the outcome of LOSof LOS

The following are associated with significant The following are associated with significant ↑↑in ovulation and pregnancy rates:in ovulation and pregnancy rates:

--Preoperative LH ≥10IU/L.Preoperative LH ≥10IU/L.

The following has The following has no roleno role in the prediction in the prediction of the outcome of LOS:of the outcome of LOS:– Age.Age.– LH/FSH ratio.LH/FSH ratio.– Presence or absence of acne /menstrual Presence or absence of acne /menstrual

irregularity.irregularity.– Ovarian volume. Ovarian volume.

ResultsResults

Short term resultsShort term results::– In respondersIn responders ovulationovulation occur within 2-4 wk,& occur within 2-4 wk,&

menstruation menstruation within 4-6 wks.within 4-6 wks.– Ovulation rateOvulation rate: 50-90%.{Patient with : 50-90%.{Patient with high LH levelhigh LH level

respond better to respond better to LOS}.LOS}. – Cumulative Cumulative Pregnancy &Live birth rates:Pregnancy &Live birth rates:76%-76%-

64% respectively.64% respectively.

Long term resultsLong term results: : Improvement in Improvement in reproductive performance is sustained for many reproductive performance is sustained for many years.{years.{49% Of women conceived within the 149% Of women conceived within the 1stst year year after LOSafter LOS}}

Ovarian diathermyOvarian diathermy Versus Versus GnHr(FSH) therapyGnHr(FSH) therapy

- - No differencesNo differences between between Ovarian Ovarian diathermydiathermy and and GnHr(FSH) therapyGnHr(FSH) therapy in: in: ovulation ratesovulation rates, , pregnancy ratespregnancy rates, live birth , live birth rates, or rates, or miscarriage rates.miscarriage rates.- - Ovarian diathermyOvarian diathermy is is: : – Associated with a Associated with a lower risk of multiple lower risk of multiple

pregnanciespregnancies.. – Resulted in Resulted in decreased resistance to decreased resistance to

clomiphene citrateclomiphene citrate and and greater efficacy of greater efficacy of recombinant FSH recombinant FSH following following surgery.surgery.

Failure of LOSFailure of LOS

*Women are considered to have failed *Women are considered to have failed LOS when:LOS when:

1)No ovulation within 6-8 weeks.1)No ovulation within 6-8 weeks. 2)Recurrence of anovulatory state after 2)Recurrence of anovulatory state after

initial response.initial response. 3) No conception for 12 months despite of 3) No conception for 12 months despite of

regular ovulationregular ovulation..

Failure of LOSFailure of LOS

*Management of failed LOS:*Management of failed LOS:– i) GnH ovarian stimulation.i) GnH ovarian stimulation.– ii) Metformin therapy.ii) Metformin therapy.– iii) IVF, oriii) IVF, or– iv) Repeated LOS {Effective in previously iv) Repeated LOS {Effective in previously

responders to LOS} responders to LOS}

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