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polycistic ovary
Discussion in 'All Categories' started by sana wahab - Feb 1st, 2012 1:08 am.
sana wahab
sana wahab
i have pcos..n i want to get pregnant.. is it poosible? my doctor is suggesting me for it the right option for me?
re: polycistic ovary by Dr M K Gupta - Feb 3rd, 2012 8:45 pm
Dr M K Gupta
Dr M K Gupta
Dear Mrs. Wahab
Ovarian drilling by laparoscopic surgery is a good option for your problem. Ovarian drilling, done during laparoscopy, is a procedure in which a laser fibre or electrosurgical needle punctures the ovary 4 to 10 times.
This treatment results in a dramatic cut in male hormones within days and it is often performed in women who have pcos (PCOS). Research indicates that as much as 80 % of patients will benefit from such treatment. A lot of women who fail to ovulate with clomiphene or Metformin therapy will respond when these medications are reintroduced somewhere after ovarian drilling. Negative effects are rare, but may lead to adhesion formation or ovarian failure if there are complications during the procedure. Ovarian drilling is a surgical technique dedicated to the treatment of Pcos. It includes performing micro-perforations in ovaries to be able to induce ovulation. Polycyctic Ovary Syndrome (PCOS) is seen as a ovulation disorders and represents the most common cause of infertility in women of reproductive age. Ovarian drilling, which was commonly performed by laparoscopy, is now currently performed by fertiloscopy, benefiting in turn from the mini-invasiveness and physiological approach.

In 1935 Drs Stein and Leventhal described 7 women with irregular periods (oligomenorrhea), increased hair (hirsutism) and obesity, who at the time of surgery were found to have enlarged ovaries with a smooth "pearly white" appearance (See figure 1). The graceful appearance from the ovaries was presumed to be due to the insufficient sites of ovulation that typically would leave scars. The ovaries were several times the standard size, which combined with the elevated male hormone testosterone raised the potential of ovarian tumors. Biopsies of those ovaries did not show tumors but instead revealed multiple, small "cysts" that were found to be immature follicles, and overgrowth of the area of the ovary that secretes testosterone (stromal theca cells). Surprisingly after the surgery, where as much as 1/2 to 3/4 of each ovary had been removed for biopsy ("wedged"), the patients began having regular menstrual periods and a pair of became pregnant. In addition, the testosterone levels declined during these patients. Bilateral ovarian wedge resection (BOWR) from the ovaries was then introduced like a method that could assist patients with pcos to ovulate. It was in order to available before the introduction from the oral medicine clomiphene citrate in the mid 1960's. The problems with BOWR were it required a significant abdominal incision and that just about all patients developed scar tissue (adhesions) round the tubes and ovaries that further exacerbated their infertility (Buttram, 1975).

Drs Stein and Leventhal had postulated the outside of the ovary was too thick to permit eggs to release in the ovary, a concept we now know to be untrue. We now realize that high amounts of testosterone and its derivatives within the ovary inhibit ovulation. The theory as to how wedge resection of the ovary works, is it destroys an adequate amount of the testosterone producing area of the ovary to permit ovulation to happen. In early 1980's several scientific reports of partial ovarian destruction by laparoscopic surgery started to appear because the modern version of BOWR. The laparoscopic approach uses several small (1/2 to 1 centimeter) incisions instead of a large abdominal incision, and avoids inpatient hospitalization. Several techniques have been described including: multiple small ("punch") biopsies of the ovarian surface (Sumioki, 1988), using a needle point electrode with electrical power (Gjonnaess, 1984) or perhaps a laser beam (Daniell, 1989) to lose holes in the ovaries (drilling), or actually removing one ovary (Kaaijk, 1999). Others have described using a vaginal ultrasound to guide a needle with the vagina into the small follicles at first glance from the ovary and draining the fluid (Myo, 1991). Typically the most popular of these techniques is ovarian drilling.

The technique of ovarian drilling would be to destroy (cauterize) the testosterone producing tissue from the ovary. Usually the small follicles visible at first glance from the ovary are chosen because the spots to direct the electrical or laser energy, because presumably this is where hormone production is maximal. From 4-20 "holes" can be made in each ovary, usually 3 millimeters wide and three millimeters deep. Management of both ovaries is generally preformed, but reports that treatment of just one ovary could be successful happen to be published. Many physicians try to result in the regions of cautery as far away in the fallopian tube as you possibly can to try to limit the risk of tubal scarring. Others will wrap the ovaries with dissolvable materials that inhibit scar formation. Despite these efforts, adhesions round the tubes and ovaries can occur, but sometimes be milder than with the classic BOWR, and do not appear to effect pregnancy rates (Naether, 1993; Greenblatt, 1993). Rarely the ovaries can undergo irreparable damage and cease to operate (atrophy) (Dabirashrafi, 1989).

The success for laparoscopic ovarian drilling seem to be better for patients at or near their ideal body weight, instead of those with obesity. On the dozen research has been published with success for ovulation between 53% and 92% (Daniell, 1989; Gjonnaess, 1984). Success rates may be slightly higher with electrical energy (which tends to destroy more tissue), however the laser may lead to fewer adhesions. Patients with decreases in hormone production (testosterone and luteinizing hormone) may ovulate and get pregnancy compared to those without hormonal improvement. Patients not ovulating after the procedure have been discovered in many cases to become responsive to clomiphene citrate when they were previously resistant. Pregnancy rates have ranged from 37% to 86%. Overall these success rates are similar to the use of clomiphene citrate (80% chance of ovulation and 40% possibility of pregnancy). Frequently, the surgical approach is chosen whenever a patient has already didn't ovulate on clomiphene citrate at maximal doses and has not responded to insulin sensitizing agents. The use of this process for other facets of testosterone excess for example acne or hirstuism has yielded inadequate results and isn't recommended.

Laparoscopic ovarian drilling isn't recommended as the first type of strategy to women with pcos who don't ovulate. Medical therapy is frequently successful utilizing either clomiphene citrate, insulin sensitizing agents or injectable fertility medications (gonadotropins); however, the use of gonadotropins is associated with at least a 20% risk of multiple births (mostly twins) and also the chance of high order multiple gestations (triplets and above). Many patients are unwilling to accept our prime rate of multiple births associated with gonadotropins therapy. Additionally, gonadotropins are expensive and often not covered by health care insurance. Laparoscopic ovarian drilling is recognized as an appropriate choice for patients who have failed medications and therefore are unwilling or unable to use gonadotropins, or those patients already undergoing laparoscopy for an additional indication. The benefits of the process are that ovulation usually produces only one egg per cycle, decreasing the chance of multiple gestations, and in one study 80% of patients remained as ovulating Ten years following the procedure. Another study suggested this procedure result in lower miscarriage rates (14%) when compared with gonadotropin ovulation induction (50%) (Abdel Gadir, 1992). The potential risks from the procedure include all of the risks related to laparoscopic surgery, as well as the possibility of tubal adhesions and also the very rare chance of ovarian atrophy. As with any treatment, an entire discussion from the benefits, risks and alternatives having a physician that has comprehensively evaluated the patient's specific medical condition is mandatory.

With regards
M.K. Gupta
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