RAMB Novembro/Dezembro 2015

rilling

medical

indications

and

surgical

technique

ssoc

ras

2015; 61(6):530-535

531

is the basis of the ovulation restoration mechanism. The

most plausible theory involves the sharp drop in intra-

ovarian androgens (and perhaps estrogens) resulting in

an increase in the secretion of follicle-stimulating hor-

mone (FSH) and an intra-follicular environment more

conducive to normal follicular maturation and ovulation.

From a public health perspective, laparoscopic drill-

ing might serve as an effective option for the development

of policies, providing access of patients to a constitution-

al right to family planning, given that it is an alternative

treatment for female infertility that does not require ex-

cessively large investments in human resources, infra-

structure and technology.

bjective

To identify the current indications of laparoscopic ovar-

ian drilling and the best surgical technique that can be

implemented as public health policies in order to enable

the realization of individual life plans, especially with re-

gard to the perpetuation of the species.

ethod

A review of the medical literature available in the Med-

line, Lilacs and Cochrane Library databases was performed

by selecting articles published on any date, on human be-

ings, written in English, Portuguese or Spanish. The key-

words used were laparoscopy, polycystic ovary syndrome,

and drilling.

In all, 105 articles were found, their abstracts being

read. We selected 27 of these articles: two meta-analyzes,

two systematic literature reviews, nine reviews of the lit-

erature, seven randomized prospective studies, six retro-

spective cohort studies and one case series.

Studies involving treatment of polycystic ovaries with

laparoscopic drilling that had as a main outcome the

birth rate of live fetuses and multiple pregnancies were

included. Secondary outcomes included miscarriage, ovu-

lation rate, pregnancy rate, ovarian hyper-stimulation,

quality of life and costs.

esults

Retrospective studies

An Austrian study published in 2011 reviewed the results

of a gynecological laparoscopy service at the University

of Vienna in relation to the drilling technique with a mo-

nopolar hook. Thirty eight patients with PCOS resistant

to clomiphene citrate (CC), that is, that did not ovulate

after treatment with this medication and who had un-

dergone surgical treatment were assessed. A monopolar

hook was used to make three to six ovarian capsule per-

forations in each ovary. This resulted in a 75.8% rate of

spontaneous ovulation, a total rate of pregnancies in one

year of 80.6%, and subsequent 67.7% of live births.

Hayashi et al. studied 40 patients with PCOS and re-

sistance to CC who were treated with drilling. In the sur-

gical procedure, 10 to 40 ovarian perforations were per-

formed using electro-cauterization with Argon beam. The

number of perforations depended on the size of the ova-

ry. An ovulation rate of 83% and pregnancy rate of 55%

were found after the procedure. It was also observed that

preoperative serum levels of luteinizing hormone (LH)

were significantly higher among women who achieved

ovulation after surgery, with a “cut-off ” of 8 IU/L.

In 2011, a Chinese group retrospectively studied 89 in-

fertile patients with PCOS who underwent laparoscopic

drilling and were monitored for 5 years. The surgical pro-

cedure consists of three to 10 monopolar needle punctures

measuring 2 mm in diameter and 8 mm in depth in both

ovaries. The patients were placed into two groups: with

metabolic syndrome and without metabolic syndrome, and

the results were compared. The authors found no statisti-

cal difference in the spontaneous ovulation rate, cumula-

tive rate of pregnancy and risk of gestational diabetes be-

tween the groups. Ovarian drilling was effective in inducing

ovulation in PCOS patients regardless of whether they had

metabolic syndrome or otherwise. After 16 months of fol-

low-up, 61% of the patients had spontaneous ovulation

and the cumulative pregnancy rate for the entire cohort

was 63%. There were 4 cases of multiple births, none of

which resulted from spontaneous conception.

In 2010, Johannes Ott et al. studied 120 patients

with PCOS who become pregnant after some form of

treatment for ovulation. Forty were resistant to CC and

had spontaneous ovulation after laparoscopic drilling,

while other 40 pregnant women obtained ovulation af-

ter stimulation with CC, and the remaining 40 pregnant

women ovulated after the use of metformin as an iso-

lated therapy. LD was performed with a monopolar hook

and 5 to 10 perforations of 2 to 3 mm in the capsule of

each ovary bilaterally. The experimental group with CC

realized an average of 1.6 ± 0.8 cycles of medication with

dosages of 50 to 100 mg. Patients receiving metformin

as a single treatment, used 1500 mg/day for at least two

months in order to become pregnant. There were no cas-

es of ovarian hyper-stimulation and twin pregnancy rates

were higher in the group receiving CC. When evaluat-

ing the totality of gestational complications, such as

miscarriages, premature births, birth defects, develop-

ment of preeclampsia or gestational diabetes, the fol-

lowing occurrence the was found: 70% (28/40) in the CC