Innovations in surgery to perform an ovarian drilling

ElsevierVolume 52, Issue 1, January 2023, 102499Journal of Gynecology Obstetrics and Human ReproductionAbstractBackground

Ovarian drilling is a surgical technique for patients with dysovulatory polycystic ovarian syndrome. It is proposed as a second-line treatment in case of failure of medical treatment with Clomiphene citrate, Metformin or Letrozole. The 2020 Cochrane study comparing gonadotrophin stimulation and drilling has found the same pregnancy rate in both cases. The literature review concludes that 50% of spontaneous ovulation occurs in the first three months after drilling and 80% of pregnancy occurs in the following year. Ovarian drilling has also an impact on androgen excess and metabolic syndrome.

Aims

To update on the different surgical techniques to perform an ovarian drilling: surgical approach, energy used, operative risks.

Techniques

The objective of an ovarian drilling is to destroy 5% of the ovarian stroma. It is recommended to perform 8 to 10 perforations in each ovary with bipolar energy. Laser C02 and monopolar energy can be used but increase the risk of adhesion. The surgical approach is actually laparoscopic. Abdominal laparoscopy or transvaginal laparoscopy by vNOTES can be performed. The advantage of the second one is to provide an easier access to the pelvic cavity in case of obesity and patient have no abdominal scare. Both laparoscopic approaches allow an evaluation of tubal patency and adhesiolysis or fimbrioplasty. That it's not the case of an alternative technique: the fertiloscopy, due to coaxial instrumentation in spite of less rate of post-operative adhesions. Operative risks are abdominal adhesions, damage to neighboring organs and due to the general anesthesia.

Conclusion

Different surgical techniques exist to perform an ovarian drilling. The surgeon can choose the one that he masters best and that will involve the least risk for the patient. It is recommended to use bipolar energy.

Introduction

The first full description of polycystic ovary syndrome (PCOS) has been reported by Stein and Leventhal in 1935 [1]. PCOS currently affects 5 to 10% of women of childbearing age [2]. To confirm the diagnosis of PCOS, patients must satisfy two of the three Rotterdam criteria: oligo-anovulation causing infertility, clinical or biological hyper androgenism, and the ultrasound appearance of polycystic ovaries, meaning enlarged ovaries (>10 mL) with more than 12 antral follicles per ovary and a peripheral distribution [3]. The criterion of the number of follicles has evolved with the progress of ultrasound and is increased to 20 per ovary. Other than infertility and androgen excess, they present a metabolic syndrome with an increased risk of obesity, of type 2 diabetes and cardiovascular events [4,5]. The management of anovulation in case of desire of pregnancy is first of all the hygienic-dietary rules and then the medical treatments such as Letrozole, Metformin or Clomiphene citrate [6]. In case of failure, it is possible to proceed with either ovarian drilling or stimulation by gonadotropin [[6], [7], [8]]. The 2020 Cochrane study comparing the two solutions has found the same pregnancy rate in both cases OR 0.86, 95% [IC 0.72 to 1.03] [9]. The live birth rate in the drilling group has estimated to be between 38 and 53 % versus 44 % in the gonadotropin stimulation group. There would be a decrease in the live birth rate in the drilling group OR à 0.71 [IC 95% 0.54-0.92], but when the analysis has made only on randomized comparative studies, this difference is no longer significant OR 0.90 [IC 95% 0.59 to 1.36]. At some point, it appears that drilling is less of a risk for multiple pregnancies OR 0.34 [IC 95% 0.18 to 0.66] or hyperstimulation OR 0.25 [IC 95% 0.07 to 0.91]. It is also more cost-effective in the long term. Indeed, the effect of drilling is estimated at 9 years on AMH and spontaneous ovulations [10,11]. It has also been shown that drilling reduces androgen excess and metabolic syndrome [[12], [13], [14]]. The literature review concludes that 50% of spontaneous ovulation occurs in the first three months after drilling and 80% of pregnancy occurs in the following year [7,9]. The predictive factors for the effectiveness of drilling are a BMI of less than 26, a follicular count of less than 50 and infertility of less than 3 years [15]. The effect of ovarian drilling is not well known. We observe a normalization of the LH/FSH ratio, a decrease in testosterone and estrogen with the reactivation of follicular development and ovulation in 80% of cases [16]. The question of the surgical technique used for drilling arises. The objective of this review is to provide an overview of the current surgical possibilities to perform a drilling.

Section snippetsTechniques

The goal of an ovarian drilling is to destroy around 5 % of each ovary [7,16,17]. The first effective drilling on fertility has been described in 1935 [18]. In the first surgeries, to reduce the ovarian volume, a cuneiform or partial resection of the ovary was performed, or an unilateral ovariectomy [[18], [19], [20]]. Finally, it was the multi perforations of the ovary that has been adopted in order to limit the risk of ovarian insufficiency and per and post-operative bleeding [21,22]. No

Conclusion

Drilling is a second-line treatment for PCOS with anovulation. It has the same pregnancy rate as gonadotropin stimulation. The aim is to destroy 5% of the ovary with bipolar energy. Several techniques have been described, in particular with the laparoscopic approach and the fertiloscopy. More recently the technique of ovarian drilling by vNOTES with fertility checkup at the same time has been described and appears to be relevant for these patients who are often obese with a non-obvious

Declaration of Competing Interest

The authors declare to have not conflict of interest

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