RAMB Novembro/Dezembro 2015

ueb

534

ssoc

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2015; 61(6):530-535

In 2003, Izzo and Halbe found reduced ovarian volume

after LD, with reduced serum levels of testosterone and an-

drostenedione, without interference in the level of gonad-

otropins. The post DL pregnancy rate was similar to that

obtained after ovulation induction cycles with recombinant

follicle stimulating hormone.

In addition to providing

similar conception rates compared to the use of gonado-

tropins, laparoscopic drilling does not require monitoring

of the cycle. With a single surgical treatment, several cycli-

cal ovulations can be obtained, whereas one gonadotropin

cycle yields a single ovulation cycle. A study conducted in

New Zealand showed that the cost to achieve a live birth af-

ter ovulation induction with gonadotropins is two-thirds

higher than that obtained using a surgical treatment.

Thus,

the best advantage of LD is its simplicity and effectiveness

as a method. Regarding the risks, these are inherent to all

abdominal surgical procedures, and include the risks of an-

esthesia, injury to the bowel, bladder, blood vessels, infec-

tion and formation of postoperative adhesions.

The long-term (over five years) effect of LD is un-

known, so it seems prudent to recommend the procedure

only to patients who are decidedly seeking pregnancy.

There is no data relating LD with menopause but epide-

miological studies show early menopause in women un-

dergoing any type of surgery with reduction of the ova-

ries. Another factor that contributes to the reduced

number of surgical patients is the use of agents that re-

duce insulin resistance, allowing ovulation in patients

previously resistant to CC.

We should also consider that

candidates for laparoscopic drilling should not present

factors of infertility other than polycystic ovary syndrome,

which would make treatment little or non-effective.

The balance of risks and benefits between LD and the

use of gonadotropins appears somewhat similar. Due to

the invasiveness of the surgical method, some patients

may opt for clinical induction of ovulation despite an in-

creased risk of hyper-stimulation and multiple pregnan-

cies. Laparoscopic ovarian drilling is an attractive option

in selected cases.

Therefore, LD should not be discarded in the prepa-

ration and implementation of health policies for the treat-

ment of human infertility, in order to ensure maximum

effectiveness of the law (constitutional) for family plan-

ning (article 226, paragraph 7 of the Brazilian Constitu-

tion). The decision to have children should be taken in

the scope of people’s private lives, without any form of

coercion by the State, but it is up to the State to offer con-

ditions for families to be able to decide whether to have

children, independently and with clarification, with the

help of scientific techniques of contemporary medicine.

onclusion

Laparoscopic drilling may be indicated for patients with

PCOS and ovulatory resistance to the use of clomiphene

citrate.

As for the surgical technique, studies in the literature

are very heterogeneous, hindering this type of analysis. It

is not possible to identify an optimal surgical technique.

However, the most successfully used technique is per-

forming 5 to 10 perforations to the surface of the ovary,

bilaterally, using monopolar energy.

esumo

Drilling

: indicações e técnica

Introdução:

a anovulação é uma das principais causas de

infertilidade feminina, e a síndrome dos ovários policísticos

(SOP) é a principal causa de anovulação. As mulheres com

SOP, quando submetidas a induçãomedicamentosa da ovu-

lação, costumam ter resposta satisfatória, recrutando folí-

culos. No entanto, algumas podem não recrutar folículos

ou, muitas vezes, têm uma produção excessiva deles, o que

pode resultar em síndrome de hiperestímulo ovariano e/ou

gravidez múltipla. O tratamento cirúrgico por laparoscopia

com

drilling

ovariano pode evitar ou reduzir a necessidade

de indução da ovulação commedicamentos.

Objetivos:

identificar as indicações atuais do

drilling

ova-

riano laparoscópico e qual a melhor técnica operatória.

Método:

revisão da literatura médica, por meio de bus-

ca sistemática nas bases de dados MEDLINE, LILACS e

Cochrane, utilizando as palavras-chave: laparoscopia, sín-

drome dos ovários micropolicísticos e

drilling

Resultados:

foram encontrados 105 artigos na literatu-

ra, sendo 27 de grande relevância descrevendo achados

sobre o

drilling

ovariano.

Conclusão:

drilling

laparoscópico está indicado para pa-

cientes comSOP com resistência ovulatória ao uso do citra-

to de clomifeno, índice de massa corpórea (IMC) inferior a

30 kg/m² e hormônio luteinizante (LH) pré-cirúrgico supe-

rior 10 UI/L. A técnica operatória de preferência deve ser a

realização de 5 a 10 perfurações na superfície de cada ová-

rio bilateralmente por meio do uso de energia monopolar.

Palavras-chave:

clomifeno, laparoscopia, anovulação,

síndrome do ovário policístico, perfuração de percussão.

eferences

Mitra S, Nayak PK, Agrawal S. Laparoscopic ovarian drilling: an alternative

but not the ultimate in the management of polycystic ovary syndrome. J

Nat Sci Biol Med. 2015; 6(1):40-8.