ARTICLE INFO

Article Type

Original Research

Authors

Saremi   A.T. (*)
Tarazi   B. (1)
Ghanbari   F. (2)






(*) ‎“Sarem Fertility & Infertility Research Center (SAFIR)” and “Sarem Cell Research Center (SCRC)” ‎, Sarem Women’s Hospital, Tehran, Iran
(1) ‎Aban Hospital, Tehran, Iran
(2) Sarem Women’s Hospital, Tehran, Iran

Correspondence

Article History

Received:  February  4, 2017
Accepted:  May 14, 2017
ePublished:  June 15, 2018

BRIEF TEXT


Polycystic ovarian syndrome (PCOS) consists of large poly follicular sclerotic ovaries with clinical ‎manifestations of menstrual dysfunction and hirsutism [1-3]. Disruption of ovulation and ‎menstruation as oligomenorrhea and androgenic characteristics are characteristic of this syndrome [1, ‎‎2]. In addition, another major complication of this syndrome is infertility.‎

Different non-surgical treatments include weight loss, the use of anti-androgens agents, ovulation ‎stimulants such as administration of clomiphene citrate-gonadotropins, insulin-stimulating stimuli, ‎etc. [4]. Surgical treatments including Wedge resection, Electrocoagulation, Laser and vaporization, etc. ‎are recommended for the improvement of these patients, that the first step in the administration is ‎clomiphene citrate [5]. Some of these patients may not respond to clomiphene, and despite the ‎increase in the amount and length of treatment, ovulation may not occur again [4, 5]. Alternative ‎treatments such as Wedge Resection can be used in this group of people. This method was first ‎performed by Ironig Stein and Michelle Leontal in 1935 and was the only long-standing treatment in ‎people who did not respond to drug treatments [6, 7]. In 1972, Raoul Palmer in France invented a ‎forceps for ovary biopsy and introduced the ovarian cauterizing as one of the surgical methods in the ‎world [6].‎

The purpose of this study was to evaluate the efficacy of laparoscopic ovarian electrocautering in ‎infertile patients with resistant PCOS.‎

This is an experimental study.‎

In this study, female patients who referred to Sarem Specialized Hospital in Tehran during a five-year ‎period due to infertility and who were diagnosed as resistant to PCOS, were subjected to ovarian ‎electrocautery therapy.‎

‎183 patients underwent surgery. Sampling was done in a continuous census over 5 years. The criteria ‎for entering the study included clinical symptoms (obesity, hirsutism, menstrual disorders and ‎infertility), and ultrasound criteria for polycystic ovaries (PCO) including at least 10 follicles with a ‎diameter of 6-10 mm and a necklace-like state.‎

These patients underwent laparoscopy after complete infertility tests such as hormonal tests (FSH and ‎LH), spermograms, PCT and hysterosalpingography due to lack of response to medical treatment. An ‎electrocauter was performed through Unipolar (Coutom) with a w40 and a depth of 8 mm and a ‎diameter of 7 mm at 8 to 15 points in terms of ovarian surface area. The patients were immediately ‎assigned to their previous ovulation stimulation protocols and the results were evaluated. Finally, the ‎ovarian response was evaluated along with variables such as age and infertility, menstrual status, LH ‎and FSH, hirsutism, and laparoscopy and ovulation time intervals. After laparoscopy and electro ‎cautery, HMG, clomid and metformin (based on previous treatment) were prescribed. Information was collected through a researcher-made checklist. Data analysis was done at descriptive ‎and analytical levels using SPSS software. In addition to determining the central indices and dispersion, ‎Chi-square and independent T tests were used to determine whether or not there was a relationship ‎between variables and severity.‎

The mean age of the patients was 25.81 ± 0.37 years, of which 50% were over 26 years of age. The ‎mean duration of infertility was 5.02 ± 0.22 years, so that infertility was 50% in women less than 4.5 ‎years old. Regarding the menstrual status, 77.1% of these patients had oligomenorrhea, 3.8% had ‎primary amenorrhea and 8.2% had regular menstruation. The incidence of hirsutism was 55.9% ‎‎(Table 1).‎ The mean LH in these patients was 13.01 ± 0.72 IU / L. LH levels were more than 11.5 IU /1 in more ‎than half of the patients. The mean FSH of patients was 5.09 ± 0.31 mIU / ml, so that the range of ‎changes was0.2-41. The FSH level was higher than 4.6 in half of patients. The mean LH / FSH was 3.99 ‎‎± 0.76.‎ Ovulation was observed in 149 (81.4%) patients after the administration of HMG, clomid and ‎metformin to patients (according to previous treatment) after laparoscopy and electrocautery, and in ‎‎24 (13.1%) patients, the result was negative ovulation and 10 (5.5%) samples were also part of the ‎missing data. Only 26% of patients achieved pregnancy successfully.‎ The response rate of ovaries was completely independent of FSH and LH, as well as their ratio (p = ‎‎0.498). Mean LH did not show any significant difference in both ovulatory and non-ovulatory groups. ‎The relationship between ovarian response and postoperative treatment protocol was significant (p = ‎‎0.0001), indicating a curative response to each ovulation induction with clomid, so that metformin, ‎clomid and HMG stimulation, and even metformin and clomid combinations had a lower response ‎expected to be.‎

‎... [1, 2, 8, 9]. PCO treatment is divided into two types of medical and surgical treatments: medical ‎treatments includes weight loss counseling, clomid administration, gonadotropins, insulin resistance ‎lowering drugs [10-12], contraceptive pills [13], glucocorticoids such as dexamethasone, anti-‎androgens such as spironolactone, cyproterone acetate, phenotamide, 1-alpha reductase inhibitor, ‎ketoconazole, long-acting analogues (GnRHa LA), cimetidine and bromocriptine [14-16]. In 1964, in a study by Stein, 108 patients had a 95% return on normal menstruation, and a pregnancy ‎rate of 86%. Since then, surgical treatment has been widely accepted. In other studies, electrocautery ‎surgeries, capsule resection, multiple punch biopsy, laser and evaporation have been performed, ‎among which the most commonly used method is single-polar electrocautery [10, 15, 17, 18]. The ‎mechanism of the effect of such surgeries has not yet been well known, but it seems that factors such ‎as decreasing the thickness of the cortex, reducing the negative feedback, or increasing positive ‎feedback resulting from the removal of an androgenic fluid from the ovary environment and normal ‎secretion of FSH, a sudden increase in LH and LH after completion Surgery are effective in creating ‎therapeutic effects [3, 7, 19]. Studies have shown that almost in all patients after surgery, there is a ‎decrease in circulating androgen levels, which can stimulate gonadotropin for follicular growth and ‎ovulation through stromal degradation and reduced androgen levels [20]. Also, an increase in serum ‎insulin levels after electrocautery has been reported [17].‎ Today, ovarian drilling is performed via electrocautery or via laser (CO2 or argon) to treat PCOS. The success rate of laparoscopy and ovarian cautery in fertility of infertile patients is reported to be ‎between 50% and 60% on average within one to two years after surgery, and ovulation return is up to ‎‎80% [4]. Based on previous studies, the rate of ovulation was reported at 41% -92% and the pregnancy ‎rate was 20% -75% [13, 21]. In the present study, the rate of ovulation was about 81.2%, which is ‎remarkably close to the published statistics of non-Iranian researchers. Two major factors affect the use of this method, which include: complications during surgery and post-‎surgical complications including viscous trauma, bleeding, ovarian atrophy, premature menopause ‎and pelvic adhesions.‎ In the present study, the only adhesive complication was observed in patients with cesarean section ‎‎(by the medical team at Sarem Hospital), which included 12.5% of the patients. In the case of non-‎pregnant patients, the Second Look operation was performed after one year of failure. Regarding therapeutic response, this study shows that there is no correlation between ovarian ‎response and FSH, LH and their ratio. On the other hand, there is no relationship between the age and ‎duration of infertility with ovarian response, but the assumption that it is likely that age below the age ‎of 37 and the incidence of less than 4 years of infertility would increase the probability of ovarian ‎response following ovarian electrocautery is highly implicated in the need for more research. In ‎addition, it seems that there is a significant relationship between the type of post-operative ovulation ‎stimulation protocol and ovarian response (using clomid).‎ ‎

When hormone therapy fails or in cases where the risk of excessive ovarian excitation is high, and ‎because of the possibility of postoperative adhesion, ovarian electrocautery is recommended through ‎laparoscopy.‎



In PCOS resistant infertile patients with medical treatments, standard ovarian electrocautery is an ‎appropriate therapeutic approach.‎









TABLES and CHARTS

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CITIATION LINKS

[1]Hull M. Epidemiology of infertility and polycystic ovarian disease: Endocrinological and demographic studies. Gynecol Endocrinol. 1987;1(3):235-45.
[2]Isikoglu M, Berkkanoglu M, Cemal H, Ozgur K. Polycystic ovary syndrome: What is the role of obesity?. In: Allahabadia GN, Agrawal R, editors. Polycystic Ovary Syndrome. United Kingdom: Anshan; 2007. p.157-63.
[3]Stein IF, Leventhal ML. Amenorrhea associated with bilateral polycystic ovaries. Am J Obstet Gynecol. 1935;29(2):181-91.
[4]Zareian Z, Zareian P. Laparoscopic treatment of polycystic ovaries with unipolar forceps cautery. Razi J Med Sci. 2003;10(34):223-8.
[5]Esmailzadeh S, Nazari T. Effect of laparoscopic electrocautery of ovaries on ovarian response and fertility in poor response PCOS patients. Sci J Kurd Univ Med Sci. 2007;12(1):60-5.
[6]Cohen J. Laparoscopic procedures for treatment of infertility related to polycystic ovarian syndrome. Hum Reprod Update. 1996;2(4):337-44.
[7]Alborzi S, Robati M, Parsanejad M. The effectiv eness of laparoscopic electrocautery in clomip hene citrate resistant patients with p olycystic ovary syndrome in relation to ovarian size. Med J Islam Repub Iran. 2001;15(3):143-7.
[8]Sheehan MT. Polycystic Ovarian syndrome: Diagnosis and management. Clin Med Res. 2004;2(1):13-27.
[9]Carmina E, Koyama T, Chang L, Stanczyk FZ, Lobo RA. Does ethnicity influence the prevalence of adrenal hyperandrogenism and insulin resistance in polycystic ovary syndrome?. Am J Obstet Gynecol. 1992;167(6):1807-12.
[10]Barbieri Rl, Makris A, Randall Rw, Daniels G, Kistner Rw, Ryan KJ. Insulin stimulates androgen accumulation in incubations of ovarian stroma obtained from women with hyperandrogenism. J Clin Endocrinol Metab. 1986;62(5):904-10.
[11]Dunaif A, Graf M. Insulin administration alters gonadal steroid metabolism independent of changes in gonadotropin secretion in insulin-resistant women with the polycystic ovary syndrome. J Clin Invest. 1989;83(1):23-9.
[12]Dunaif A. Insulin resistance and the polycystic ovary syndrome: Mechanism and implications for pathogenesis. Endocr Rev. 1997;18(6):774-800.
[13]Daniell JF, Miller W. Polycystic ovaries treated by laparoscopic laser vaporization. Fertil Steril. 1989;51(2):232-6.
[14]Buvat J, Buvat-herbaut M, Marcolin G, Racadot A, Fourlinnie JC, Beuscart R, et al. A double blind controlled study of the hormonal and clinical effects of bromocriptine in the polycystic ovary syndrome. J Clin Endocrinol Metab. 1986;63(1):119-24.
[15]Aakvaag A, GjøNnæss H. Hormonal response to electrocautery of the ovary in patients with polycystic ovarian disease. Br J Obstet Gynaecol. 1985;92(12):1258-64.
[16]Farhi J, Soule S, Jacobs HS. Effect of laparoscopic ovarian electrocautery on ovarian response and outcome of treatment with gonadotropins in clomiphene citrate-resistant patients with polycystic ovary syndrome. Fertil Steril. 1995;64(5):930-5.
[17]Granberg S, Wikland M. A comparison between ultrasound and gynecologic examination for detection of enlarged ovaries in a group of women at risk for ovarian carcinoma. J Ultrasound Med. 1988;7(2):59-64.
[18]Campo S. Ovulatory cycles, pregnancy outcome and complications after surgical treatment of polycystic ovary syndrome. Obstet Gynecol Surv. 1998;53(5):297-308.
[19]Greenblatt E. 9 Surgical options in polycystic ovary syndrome patients who do not respond to medical ovulation induction. Baillière Clin Obstet Gynaecol. 1993;7(2):421-33.
[20]Felemban A, Tan SL, Tulandi T. Laparoscopic treatment of polycystic ovaries with insulated needle cautery: A reappraisal. Fertil Steril. 2000;73(2):266-9.
[21]Ferraretti AP, Gianaroli L, Magli MC, Iammarrone E, Feliciani E, Fortini D. Transvaginal ovarian drilling: A new surgical treatment for improving the clinical outcome of assisted reproductive technologies in patients with polycystic ovary syndrome. Fertil Steril. 2001;76(4):812-6.