What is OVARIAN DRILLING?
Ovarian drilling is a surgical procedure/technique dedicated to the treatment of infertile women with Polycystic Ovary Syndrome (PCOS). Sometimes ovarian drilling can be used in non-married girls who suffer from severe PCOS symptoms like oligomenorrhea and/or hirsutism. Ovarian drilling consists of performing micro-perforations in ovaries in order to induce ovulation. As Polycyctic Ovary Syndrome (PCOS) is characterized by ovulation disorders and represents the most common cause of infertility, mainly ovarian drilling is recommended to infertile women with PCOS.
Ovarian drilling is a procedure in which a laser fibre or electrosurgical needle punctures the ovary 4 to 10 times. In most cases the ovarian drilling is done during laparoscopy – it results in a dramatic lowering of male hormones within days and is often performed in women who have polycystic ovary syndrome (PCOS).
Studies have shown that up to 80% of patients will benefit from such treatment. Many women who fail to ovulate with ovulation induction drugs (Clomiphene or Metformin) will respond when these medications are used after ovarian drilling. Side effects are rare, but may result in adhesion formation or ovarian failure if there are complications during the procedure.
OVARIAN DRILLING history
In 1935 Dr Stein and Dr Leventhal described 7 women with irregular periods (oligomenorrhea), increased body hair (hirsutism) and obesity, who at the time of surgery were found to have enlarged ovaries with a smooth “pearly white” appearance. The smooth appearance of the ovaries was presumed to be due to the lack of sites of ovulation that typically would leave scars. The ovaries were several times the normal size, which along with the elevated male hormone testosterone raised the possibility of ovarian tumors. Biopsies of these ovaries did not show tumors but instead revealed multiple, small “cysts” that were found to be immature follicles, and overgrowth of the part of the ovary that secretes testosterone (stromal theca cells). Surprisingly after the surgery, where up to 1/2 to 3/4 of each ovary had been removed for biopsy (“wedged”), the patients began having regular menstrual periods and 2 became pregnant. In addition, the testosterone levels declined in these patients. Bilateral ovarian wedge resection (BOWR) of the ovaries was then introduced as a procedure that could assist patients with polycystic ovary syndrome to ovulate. It was the only method available until the introduction of the oral medicine clomiphene citrate in the mid 1960’s. The problems with BOWR were that it required a major abdominal incision and that almost all patients developed scar tissue (adhesions) around the tubes and ovaries that further exacerbated their infertility (Buttram, 1975).
Dr Stein and Dr Leventhal had postulated that the outside of the ovary was too thick to allow eggs to release from the ovary, a concept we now know to be untrue. We now understand that high levels of testosterone and its derivatives within the ovary inhibit ovulation. The theory as to how wedge resection of the ovary works is that it destroys enough of the testosterone producing part of the ovary to allow ovulation to occur. In the early 1980’s several scientific reports of partial ovarian destruction by laparoscopic surgery began to appear as 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), the use of a needle point electrode with electrical energy (Gjonnaess, 1984) or a laser beam (Daniell, 1989) to burn holes in the ovaries (drilling), or actually removing one ovary (Kaaijk, 1999). Others have described using a vaginal ultrasound to guide a needle through the vagina into the small follicles on the surface of the ovary and draining the fluid (Myo, 1991). The most popular of these techniques is ovarian drilling.
Who can be a candidate for OVARIAN DRILLING
- PCOS infertile clients;
- PCOS clients with irregular or absent menstrual periods along with elevated serum testosterone and androstenedione leading to abnormal bleeding, obesity, excess hair grown, hair loss and acne;
- PCOS patients undergoing a diagnostic laparoscopy for tubal patency;
- Clomiphene resistant patients;
- Infertile women with poor response to any ovulation inducing drugs.
OVARIAN DRILLING technique
The goal of ovarian drilling is to destroy the testosterone producing tissue of the ovary. Laparoscopic ovarian drilling can trigger ovulation in patients with PCOS, however it is a surgical treatment, and is presently considered more of a “last try” to be used in women who are still not ovulating after losing weight and taking fertility medications.
Ovarian drilling could be done using:
- Cautery, and
- Multiple punch biopsies.
The technique of ovarian drilling is to destroy (cauterize) the testosterone producing tissue of the ovary. There are generally small follicles which are visible on the surface of the ovary; this is where the electrical or laser energy will be directed, as this is presumed to be the spots where hormone production is at its maximum. Usually the small follicles visible on the surface of the ovary are chosen as 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 3 millimeters deep. Treatment of both ovaries is usually performed.
Many physicians try to make the areas of cautery as far away from the fallopian tube as possible to try to limit the chance of tubal scarring. Others will wrap the ovaries with dissolvable materials that inhibit scar formation.
OVARIAN DRILLING advantages
- Improved endocrine hormonal status – reduced androgens;
- Spontaneous ovulation;
- Increased response to ovulation induction (Clomiphene Citrate, Seraphene, Clomid);
- Reduction in gonadotropin doses for ovulation induction and hence reduction in cost of further stimulated cycles;
- Improvement in pregnancy rates;
- Reduction in multiple pregnancy rates;
- Reduction in first trimester abortions;
- Reduction in ovarian hyperstimulation.
OVARIAN DRILLING disadvantages
- Possibility of adhesion formation;
- Surgical and anesthesia risk as with any surgical procedure.
OVARIAN DRILLING success rates
It has been noticed that success rates of the ovarian drilling is better in patients who were at or near their ideal body rate as opposed to the patients who remained obese at the time of the surgery. Success rates for future ovulation range from 53% to 92%, with a slightly higher success rate when using electrical energy, which tends to destroy more tissue. Aproximately 80% of patients who underwent ovarian drilling resumed ovulation, while nearly 50% were able to become pregnant. Patients who are not ovulating after an ovarian drilling procedure have been shown, in many cases, to be more responsive to clomiphene citrate, even if they were previously impervious to the drug.
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