Drilling: medical indications and surgical technique / Drilling: indicações e técnica

SUMMARY Introduction: anovulation is a major cause of female infertility, and polycystic ovary syndrome (PCOS) is the leading cause of anovulation. While undergoing drug-induced ovulation, women with PCOS usually have a satisfactory response recruiting follicles, but some are unable to recruit follicles or often produce an excessive number of follicles, which can result in ovarian hyper-stimulation syndrome and/or multiple pregnancy. Surgical laparoscopy with ovarian "drilling" may prevent or reduce the need for drug-induced ovulation. Objective: to identify the current indications of laparoscopic ovarian drilling and the best surgical technique. Method: a review of the medical literature based on systematic search in the Medline, Lilacs and Cochrane databases, using as keywords laparoscopy, polycystic ovary syndrome, and drilling. Results: we found 105 articles in the literature, 27 of these highly relevant, describing findings on ovarian drilling. Conclusion: laparoscopic drilling is indicated for patients with polycystic ovary syndrome with ovulatory resistance to the use of clomiphene citrate, body mass index less than 30 kg/m2 and preoperative luteinizing hormone above 10 IU/L. The preferred surgical technique should be the realization of 5 to 10 perforations on the surface of each ovary bilaterally using monopolar energy.

RESUMO 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 indução medicamentosa da ovulação, costumam ter resposta satisfatória, recrutando folículos. 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 comdrilling ovariano pode evitar ou reduzir a necessidade de indução da ovulação com medicamentos. Objetivos: identificar as indicações atuais do drilling ovariano laparoscópico e qual a melhor técnica operatória. Método: revisão da literatura médica, por meio de busca sistemática nas bases de dados MEDLINE, LILACS e Cochrane, utilizando as palavras-chave: laparoscopia, síndrome dos ovários micropolicísticos edrilling. Resultados: foram encontrados 105 artigos na literatura, sendo 27 de grande relevância descrevendo achados sobre o drilling ovariano. Conclusão: o drilling laparoscópico está indicado para pacientes com SOP com resistência ovulatória ao uso do citrato de clomifeno, índice de massa corpórea (IMC) inferior a 30 kg/m2 e hormônio luteinizante (LH) pré-cirúrgico superior 10 UI/L. A técnica operatória de preferência deve ser a realização de 5 a 10 perfurações na superfície de cada ovário bilateralmente por meio do uso de energia monopolar.

Electrocoagulación ovárica en pacientes anovulatorias / Ovarian electrocoagulation in anovulatory patients

Dieciocho pacientes anovulatorias refractarias al uso de Citrato de Clomifeno (CC) fueron sometidas a electrocoagulación ovárica durante una laparoscopia realizada como parte del estudio de su infertilidad. Catorce pacientes (78%) ovularon espontáneamente o con CC y 10 (56%) se embarazaron, 7 de ellas con CC. Tres pacientes (21%) tuvieron un aborto espontáneo de I trimestre y una paciente (5,6%) presentó falla ovárica después de la cirugía. Se concluye que en pacientes anovulatorias refractarias al CC, puede efectuarse electrocoagulación ovárica durante la laparoscopia diagnóstica que forma parte del estudio de la mujer infértil.

Eighteen anovulatory patients resistant to treatment with clomiphene were treated by ovarian electrocautery through the laparoscope. Fourteen patients (78%) ovulated spontaneously or after clomiphene treatment and 10 (56%) became pregnant, 7 of them after clomiphene. There patients (21%) had a first trimester abortion and one patient (5.6%) had ovarian failure after surgery. We conclude that ovarian electrocautery can be performed during laparoscopy in infertile anovulatory patients resistant to clomiphene.

Tratamiento de la infertilidad por síndrome de ovario poliquístico mediante electropunciones ováricas múltiples vía laparoscópica / Treatment of the infertility caused by polycystic ovary syndrome using laparoscopic ovarian electrocautery

Se presentan los resultados, en función de recuperación de la ovulación y embarazo, de la electrocauterización o electropunción múltiple laparoscópica de los ovarios (EPOM) en pacientes infértiles anovulatorias con síndrome de ovarios poliquísticos (SOP), refractarias al citrato de clomifeno (CC). Se estudiaron fichas de 27 pacientes con un período de observación de 18 meses para evaluar resultados. Veinticinco pacientes completaron el período de observación; 2 abandonaron el control. Se logró embarazo en 15 pacientes (60 por ciento). El 60 por ciento de éstos se produjo antes de 6 meses y 85 por ciento en el lapso de 10 meses post EPOM. Veinte pacientes recuperaron la ovulación (74 por ciento). se confirma, como en otras publicaciones, que la electropunción ovárica por laparoscopia es efectiva y se presenta como una alternativa de tratamiento en las pacientes con infertilidad anovulatoria por SOP refractaria al CC y sin otros factores de infertilidad

Laparoscopic laser vaporization, endocoagulation and electrocauterization of polycystic ovaries [PCO] in management of clomiphenecitrate resistant anovulatory women

This study included 120 anovulatory women seeking fertility, they failed to ovulate after six cycles of clomiphene citrate [CC] 200 mg/day for five days. PCO was diagnosed according to clinical, ultrasonic, hormonal and laparoscopic criteria. Patients were classified according to laparoscopic ovarian technique into three groups: Group I included 40 cases of electrocauterization, Group II included 40 cases for endocoagulation and Group III included 40 cases for Co laser vaporization. Menstruation, ovulation and conception rates were recorded. The findings of the second look laparoscopy [SLL] were reported. Menstruation was established in 82.5%, 70% and 75% in groups I, II and III, respectively. It was concluded that laparoscopic management of anovulation in women with PCOS after exhaustive trial of CC therapy seemed to be useful and effective in those who ovulated. SLL was m and atory for reassessment and adhesiolysis. Laparoscopic ovarian electrocauterization was superior to endocoagulation and C02 laser vaporization for ovulation and conception rates. Laparoscopic ovarian electrocauterization was recommended for clomiphene resistant anovulatory infertility in women with PCOS as a result of being simple, available, inexpensive and effective