For we doctors- The ultimate “evidence based opinion is Cochrane Review & Recommendation of experts bodies like NICE guidelines & ESHRE.
For women with WHO GROUP II OVULATION DISORDER i.e PCOS who are known to be “Resistant to Clomifene” Citrate – Consider one of the following Second – Line Treatment, depending on clinical circumstances and the women’s preference:
1. Laparoscopy ovarian drilling (LOD) or
2. Combined treatment with clomifene citrate and metformin if not already offered as first – line treatment or
RATIONALE OF SURGICAL TREATMENT by “ovarian drilling is that many small ovarian cysts lying immediately below the capsule of the ovary are cauterized: this is as successful as nonsurgical treatment.
1. This method is an alternative treatment to gonadotropin administration in anovulatory patients with PCOS who are resistant to clomiphene citrate.
LOD is particularry indicated in patients in whom regular monitoring with ultrasound is not feasible.
2. with current technical advances, the interventions is completed in a single session of surgery.
3. LOD can achieve single ovulation without the risk for ovarian hyperstimulation or multiple pregnancies. This is its biggest advantage.
4. Following LOD regular monitoring of follicular development is not required so it is good for women from rural setting.
5. the risk of LOD are small and include complications of laparoscopy per se, the development of adhesion and the destruction of normal ovarian tissue is possible with untrained hands.
6. The damage to the ovaries should be limited as much as possible . there is a rule of four i.e. 4 punctures ,4 seconds,4 mm depth,40watt current with monopolar cautery on anti mesenteric border of ovary Irrigation with ringer lactate solution or any other specific solvents might be useful for the reduction of risk for development of adhesions.
7. LOD should be performed by adequately trained gynaecologist or endoscopy surgeon.
8. finally , LOD should NOT be applied for other indication except infertility with anovulation.
Few Surgeon who are not trained in gynaecology, in India while doing laparoscopy for any other indication do LOD for No Reason what so ever which harms the patients more than doing any good .
In our practice – it is effective in 50% cases in bringing about ovulation..
A . Clomipure Citrate (CC) can be considered after 12 weeks,
B. If no ovulation is detected addition of FSH should be considered after 6 months.
In our experience is in lean PCOS
Prediction of Success of LOD
**LOD has been found to be more effective in learn PCOS patients
• LH levels > 10 iu
• Normal BMI
• Shorter duration of Infertility
We strongly feel, if done well technically, it is effective & does not cause ovarian failure.
In our experience it can be an asset of resistant PCOS cases From rural areas.