Received Date: February 17, 2014; Accepted Date: May 18, 2014; Published Date: May 28, 2014
Citation: Pieta W, Wilczynska A, Radowicki S (2014) Hydrolaparoscopy - as an Alternative Method after a Failure of the Pharmacological Therapy for PCOS Induced Infertility. Gynecol Obstet (Sunnyvale) 4:222. doi: 10.4172/2161-0932.1000222
Copyright: © 2014 Pieta W, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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Objectives: To evaluate the effectivness of hydrolaparoscopy among infertile women with a Polycystic Ovarian Syndrome (PCOS) resistant to clomephine.
Design: Retrospective study including eighteen women with a resistant to clomiphene PCOS induced infertility who underwent hydrolaparoscopy including ovarian drilling with bipolar probe, hysteroscopy and chromopertubation.
Material and methods: Mean age was 31.4 (6.5) years (95% CI: 28-34.6) and mean body mass index 26.6 (6.9) kg/m2 (95% CI: 22.3-30.6). Laparoscopic conversion was required in 3 cases (16.6%) due to a failure of entering Douglas cavity.
Results: Seventeen women (94%) had a positive chromopertubation and 2 women had uterine anomaly (n=1 T-shaped uterine cavity, n=1 endometrial polyp). Transvaginal hydrolaparoscopic ovarian drilling (THLOD) resulted in the successful pregnancy in 10 cases (55.5%). In 5 cases (27%) pregnancy has occurred spontaneously, in the further four cases (22.2%) ovarian stimulation was required and in one case the patient underwent in-vitro Fertilization.
Conclusion: The ovarian drilling by hydrolaparoscopy is a minimally invasive method to treat clomiphene resistant PCOS infertility. In addition it allows to assess the anatomy of the reproductive organs.
Infertility; Policistic ovaries; Pregnancy; Ovulation induction
PCOS is characterized by presence of the hyperandrogenism, oligo- or anovulation . It is one of the most common reproductive endocrine disorders in the adolescent women. Females with PCOS present with a dysregulation in the menstrual cycle, hirsutism, anovulation, acne, and obesity. An approximately 5-10% of women in Poland suffer from PCOS and 10-15% of them are infertile . In this group to induce ovulation the patients have to undergo up to 6 cycles of ovarian stimulation with the clomiphene citrate or gonadotropin. However some women do not respond to the hormonal treatment. Stein and Leventhal reported that surgery should be considered in the case of the clomiphene citrate-resistant PCOS induced infertility . Laparoscopic ovarian drilling (LOD) is one of surgical methods which was reported to be effective in inducing ovulation. Hovewer it can lead to serious complications including gastrointestinal and major vascular injuries . In 1998 transvaginal hydrolaparoscopy (THL) was introduced as the first line treatment in the exploration of the adnexal structures in infertile women . THL can be performed in the conjunction with chromopertubation, salpingoscopy, microsalpingoscopy, and hysteroscopy. Watrelot et al. introduced the term “fertiloscopy” for the combination of these procedures . This procedure appears to be an effective and minimally invasive method for induction of the ovulation in women with PCOS. It can be used to evaluate the posterior uterus, pelvic sidewalls, and adnexae . THL has the advantage over Hysterosalpingography (HSG) because it allows for direct visualization of the tubal mucosa in addition to determining tubal patency. This method does not require an abdominal incision and can be undertaken as a day case procedure under local anesthesia .
Transvaginal Hydrolaparoscopic Ovarian Drilling (THLOD) is another method and its success depends on gaining an access to Douglas cavity through the posterior fornix. In addition this method allows for a good visualisation of the reproductive organs.
The aim of this study was to evaluate effectiveness of THLOD as the second line treatment in PCOS induced infertility.
Eighteen women with a clomiphen resistant infertility secondary to PCOS were included in the study. All of the patients were treated for at least 6 months with clomiphene. There was no evidence of the increase in the ovarian cyst in any of subjects prior to the surgery.
Mean age was 31.4 (6.5) years (95% CI: 28-34.6) and mean BMI 26.6 (6.9) kg/m2 (95% CI: 22.3-30.6).
There were no contraindications for THLOD. Prior to procedure patients had smear test to confirm that there was no infection. The procedure was performed in the first phase of ovarian cycle in the lithotomy position. General anesthesia was chosen as a more comfortable for the patient. In the first step, hysteroscopy was performed to evaluate the cavity of uterus and the entrances of oviducts to confirm a normal anatomy. In the second step, a uterine cervix was lifted with a tenaculum placed on the posterior uterine lip and Veress needle was introduced 1.5 cm below the cervix in the direction of posterior fornix and slightly pushed into the pelvic cavity. Under ultrasound guidance 150 ml of NaCl solution was given through the cannula inserted into the pouch of Douglas. In the next step a 3-mm blunt trocar was inserted through the incision in the posterior fornix to allow for the endoscope introduction.
Endoscopic approach allowed for a checking that NaCl solution was instilled into the cavity and also allowed for direct assessment of the uterus, ovaries and tubes (Figures 1 and 2).
In the next part of the procedure ovaries were drilled (10-12 drills per ovary) with a bipolar laser Storz to ablate portions of the ovarian cortex (Figure 3). The focused laser beam was used at a distance of 1.5 mm to 3.0 mm to create holes on the surface of each ovary. The location of the Fallopian tube was confirmed with the indigocarmine (Figure 4). Sutures were used if there was an evidence of bleeding in the posterior fornix.
Laparoscopic conversion was required in 3 cases (16.6%) due to a failure in entering Douglas cavity. There was no Institutional Review Board (IRB) approval. Hydrolaparoscopy is a routine procedure in our hospital since 2 years.
Seventeen women (94%) had positive chromopertubation and 2 women had uterine anomaly (T-shaped uterine cavity, endometrial polyp). THLOD resulted in the successful pregnancy in 10 cases (55.5%). In five cases (27%) pregnancy has occurred spontaneously, in the further four cases (22.2%) ovarian stimulation was required and in one case the patient underwent in-vitro fertilization.
There were many attempts to find a minimally invasive method to treat women with PCOS induced infertility. THLOD uses a laser or bipolar electrosurgery and appears to be an effective minimally invasive procedure to induce ovulation in women with PCOS [4,5]. In the presented study 27% of women became pregnant spontaneously and 22.2% required ovarian stimulation. Similarly Fernandez et al. described, that after THLOD during a mean follow-up of 18.1 months (6.4), 73 women (91%) recovered regular and ovulatory cycles. The cumulative pregnancy rate was 60% (44/73) for spontaneous and stimulated cycles, with 39.7% (29/73) imputed to drilling alone [9,10].
In another study it was found that 7 infertile women with PCOS, including 5 women with clomiphene citrate-resistant PCOS and 2 women with the risk of developing ovarian hyperstimulation syndrome, who underwent THLOD except for one patient who dropped out of the study regained regular ovulatory cycles without developing OHSS. In 4 (67%) of 6 patients, pregnancies were established; one by timed intercourse during the spontaneous cycle, two by intra-uterine insemination following clomiphene-Follicle-Stimulating Hormone (FSH)-Human Chorionic Gonadotropin (HCG) treatment, and one by in vitro fertilization and embryo transfer (IVF-ET). There were no intra- or postoperative complications of THLOD .
Also in our study there were no complications related to the THOLD. The risk and outcome of bowel injury during THL were previously reported by Gordts et al. Researchers carried out a multinational retrospective survey based on confidential, self reported cases from 39 gynecologists in 18 different countries . In their 3667 procedures, a total of 24 bowel injuries were experienced, giving an incidence of 0.65%. In a French study of 400 patients, the occurrence of rectal injury was 0.5% . Similar study among 160 infertile patients reported occurrence of rectal injury as 0.6% which was managed with a conservative treatment consisting of prophylactic antibiotics for 2 days following laparoscopic confirmation of peritoneal integrity .
Ovarian drilling by hydrolaparoscopy is a minimalyl invasive method for treatment of women with clomiphene resistant PCOS infertility. Combination of hysteroscopy with hydrolaparoscopy and chromopertubation in a single procedure allows to assess anatomy of reproductive organs. Ovarian surgery for the treatment of anovulatory infertile women with PCOS who do not respond to medical induction of ovulation should be offered. THOLD is a relatively simple procedure and can also be combined with ovarian drilling, coagulation of endometriosis, lysis of adhesions, treatment of ovarian cysts, and salpingostomy to increase fertility and the rate of pregnancy.