RAMB Novembro/Dezembro 2015

rilling

medical

indications

and

surgical

technique

ssoc

ras

2015; 61(6):530-535

533

pregnancies after LD was significantly lower compared to

that of the group using gonadotropins (OR=0.13; 95CI

0.03 to 0.52; p=0.004). The authors concluded that there

is no evidence of significant difference in the rates of preg-

nancy, live birth or abortion in women resistant to CC

treated with LD compared to other medical therapies for

anovulation. The reduction in multiple pregnancy rates

makes surgical treatment an attractive option.

A literature review conducted by a research center in

Istanbul, Turkey studied trauma after ovarian drilling

with the possibility of decreased ovarian reserves and pre-

mature failure of the organ. Despite the data from the

literature being very limited (only four clinical trials), the

author found that FSH, inhibin, ovarian volume and an-

tral follicle count were worse after LD than before the

procedure. However, the values after drilling were high-

er than those of normal women with the same character-

istics, that is, without PCOS. Thus, the authors conclud-

ed that most changes in markers of ovarian reserves after

drilling are due to the normalization of ovarian function

and not to a decrease in reserves. When applied properly,

LD normalizes exaggerated ovarian morphology, as well

as endocrine properties.

iscussion

Ovulation disorders are the leading cause of female in-

fertility and PCOS is the most common etiology, often

associated with being overweight or obese. It is well es-

tablished that changes in lifestyle with the practical in-

troduction of physical exercise and weight loss improve

hyperandrogenism, decrease insulin resistance, reduce

LH levels and may restore ovulation and, therefore, fer-

tility.

In addition to these measures, the first line drug

treatment for chronic anovulation is clomiphene citrate.

And for those patients whose ovulation attempts fail af-

ter CC, new therapies are indicated, such as gonadotro-

pins or ovarian drilling.

20,21

The use of metformin seems

to improve the response to clomiphene, though it should

be prescribed with caution to non-obese patients.

The

surgical approach has been a strong option constituting

the second-line treatment.

Many forms of ovarian drilling are described, includ-

ing electrocautery or laser use. All of these share a com-

mon goal, which is creating focal areas of damage in the

ovarian cortex. There is no evidence that one method con-

sistently produces results superior to another. Neverthe-

less, the use of laser therapy has become less popular. The

method most commonly used worldwide at the moment

is monopolar needle or hook due to ease of installation

and the wide availability of the necessary equipment.

tients. The adhesions were significantly more frequent in

the left ovary regardless of the number of perforations.

In 2005, Malkawi published a study comparing the

realization of 5 or 10 bilateral ovarian punctures in rela-

tion to regulating menstrual cycle, ovulation rate and

pregnancy. For this purpose, 26 patients were submitted

to LD with 5 perforations in each ovary and 37 patients

to LD with 10 bilateral punctures. There was no statisti-

cally significant difference in relation to clinical and re-

productive results between the groups.

Case series

In 2010, the University of Paris described a new technique

for ovarian drilling using bipolar energy. Ninety patients

underwent laparoscopy under general anesthesia with a

10 mm infraumbilical puncture and two suprapubic punc-

tures measuring 3 mm each. A bipolar electrosurgical Ver-

sapoint probe by Johnson & Johnson was used, in addi-

tion to continuous saline irrigation to activate the

bipolar energy. The entire electrode length (15 mm) was

inserted into the ovary at right angle, with pure cut co-

agulation and 100 W. The current was turned on for 2

seconds and eight to 10 punctures were performed in

each ovary. The main outcome of the surgical LD tech-

niques is always spontaneous ovulation and pregnancy

rates. The follow-up of these series was too short to eval-

uate such results.

Literature reviews and meta-analysis

The Cochrane Library updated a review whose purpose was

to determine the effectiveness and safety of laparoscopic

ovarian drilling compared to other ovulation induction

techniques in PCOS patients resistant to clomiphene ci-

trate. Twenty-five randomized clinical trials were includ-

ed. The primary outcome was the rate of live birth and

multiple pregnancies. Secondary outcomes included mis-

carriage, ovulation rate, pregnancy rate, ovarian hyper-stim-

ulation, quality of life and costs. Nine clinical trials includ-

ing 1,210 women reported live birth rates of 34% after LD,

and 38% in the other treatment groups (CC tamoxifen, go-

nadotropins, aromatase inhibitors; CC; CC metformin).

There was no difference in the rate of live births when com-

paring LD and CC tamoxifen (OR=0.81; p=0.51); LD with

gonadotropins (OR=0.97; p=0.89); LD with aromatase in-

hibitors (OR=0.84; p=0.44) and LD with CC (OR=1.21;

p=0.05). There was evidence of a lower rate of post-LD live

births compared to the group treated with CC metformin

(OR=0.44; p=0.01); however, there was a lot of heterogene-

ity in this subgroup. Thirteen clinical trials made reference

to multiple pregnancies (n=1,305). The rate of multiple