Ovarian Diathermy In PCOS : An Alternative

Introduction

PCOS is the most common endocrine disorder in women. Despite its negative effect on reproduction, many women with PCOS can conceive spontaneously. The etiology is still unclear although complex genetic conditions are influenced by environmental factors. Frequently associated with insulin resistance, obesity, infertility obstetrical complication and long-term effects (type 2 diabetes and cardiovascular disease).¹

PCOS – phenotypes²

The Rotterdam and AE-PCOS Society criteria recognize unique clinical phenotypes:

• • Frank PCOS (oligomenorrhea, hyperandrogenism, and PCO)
  • Ovulatory PCOS (hyperandrogenism, PCO, and regular menstrual cycles)
  • Non-PCO PCOS (oligomenorrhea, hyperandrogenism, and normal ovaries).
  • Mild or Normoandrogenic PCOS(oligomenorrhea, PCO, and normal androgens.

Diagnostic criteria²

• • National Institute of Health (1990): both hyperandrogenism and chronic anovulation
  • Rotterdam criteria (ESHRE/ASRM 2003)-Two of the following condition: hyperandrogenism, chronic anovulation, polycystic  ovary
  • Androgen Excess Society (2006): hyperandrogenism as a necessary factor(±ovarian dysfunction and /or polycystic ovary)

Treatment:

• • Clinical symptoms
  • Infertility
  • CounsellingandLifestyle modifications
  • First-line treatment: CC(max 6 cycles) ± metformin
  • Second-line intervention: laparoscopic ovarian surgery (LOS) or Gn stimulation(both efficient)
  • Third-line treatment: IVF

Laparoscopic ovarian drilling (LOD)³

Thessaloniki, Greece – 2008 consensus on LOD

• • Alternative to Gn for CC- resistant anovulatory PCOS
  • Achieves unifollicular ovulation
  • Reduced risk of OHSS or multiple pregnancies
  • Intensive follicular monitoring not required
  • Reduced direct and indirect cost

RCOG

Ovarian electrocautery should be considered for selected anovulatory patients, especially those with a normal BMI, as an alternative to ovulation induction.

SOFC Clinical practice guidelines

Laparoscopic ovarian drilling may be considered in women with Clomiphene-resistant PCOS, particularly when there are other indications for laparoscopy (I-A) and Surgical risks always need to be considered in these patients (III-A).

How many punctures?

• • The number of punctures is empirically chosen depending on the ovarian size.
  • In the original procedure, 3-8 diathermy punctures (each of 3 mm diameter and 2-4 mm depth) per ovary were applied, using power setting of 200-300 W for 2-4 s

Most surgeons perform four punctures per ovary, each for 4 s at 40 W (rule of 4), delivering 640 J of energy per ovary (the lowest effective dose recommended)  (Armar et al 1990).

Rule of Four

• • • 40 W
    • 4 seconds
    • 4 puncture points

Ovarian Volume

• • • Ovarian volume is calculated by the measurement of the length, width and thickness and use of the classical formula for a prolate ellipsoid: L × W × T ×0.5. Three-dimensional ultrasound is a recognized diagnostic modality to assess the ovarian volume

Is ovarian reserve diminished after laparoscopic ovarian drilling?

• • • The PCOS women both with and without LOD had significantly greater ovarian reserve than the age-matched controls having normal ovulatory menstruation
    • LOD, if applied properly, normalizes the exaggerated ovarian morphologic and endocrinologic properties. (Normalization of ovarian function rather than a reduction of ovarian reserve)

Complications related to drilling

• • • Bleeding from the drilling site
    • Laceration of utero-ovarian ligament
    • The use of an excessive amount of energy will destroy a large number of follicles resulting in decreased ovarian reserve.
    • Ovarian atrophy and premature ovarian failure.
    • Adhesion formation

Conclusion

Polycystic ovaries are not specific for all types of PCOS. Hence, LOD is used only as a method of surgical induction of ovulation and should not be offered for non-fertility indications. LOD is the primary choice in CC resistance patients. Apart from a few advantages, potential complications include the formation of adhesions & long-term effects of tissue damage on ovarian function can occur. Hence proper post-surgical follow-up including ART should be counseled in those patients.

References

1. 1. Ndefo UA, Eaton A, Green MR. Polycystic ovary syndrome: a review of treatment options with a focus on pharmacological approaches. P T. 2013;38(6):336-355.
   2. Sachdeva, G., Gainder, S., Suri, V., Sachdeva, N., & Chopra, S. (2019). Comparison of the Different PCOS Phenotypes Based on Clinical Metabolic, and Hormonal Profile, and their Response to Clomiphene. Indian journal of endocrinology and metabolism, 23(3), 326–331.
   3. Mitra, Subarna et al. “Laparoscopic ovarian drilling: An alternative but not the ultimate in the management of polycystic ovary syndrome.” Journal of natural science, biology, and medicine vol. 6,1 (2015): 40-8.

Dr. Sayamstuti Pattanaik., MBBS, M.S. (OBG), Consultant Obstetrician and Gynaecologist, Laparoscopic Surgeon and Infertility specialist Shanti Memorial Hospital, Rourkela, Odisha.