Is there any difference among the most frequently used laparoscopic ovarian drilling techniques?

Abstract

To the Editor: I read with interest the article by Hendriks et al. (1Hendriks M.L. van der Valk P. Lambalk C.B. Broeckaert M.A. Homburg R. Hompes P.G. Extensive tissue damage of bovine ovaries after bipolar ovarian drilling compared to monopolar electrocoagulation or carbon dioxide laser.Fertil Steril. December 17, 2008; Google Scholar), and I would like to raise certain considerations. Because ovaries with polycystic ovary syndrome (PCOS) in humans have different endocrinologic and morphologic properties, the normal bovine ovary model for the evaluation of the amount of damage at different energy modalities seems inadequate. The ovaries with PCOS in human are mostly bigger (volume difference), contain several subcortical antral follicles (morphologic difference), are usually anovulatory (functional difference), and secrete more androgen than their non-PCOS counterparts (endocrinologic difference). The suggested ovarian reserve marker reduction after laparoscopic ovarian drilling (LOD) could be interpreted as either a harmful effect or a requirement of the procedure (2Api M. Is ovarian reserve diminished after laparoscopic ovarian drilling?.Gynecol Endocrinol. 2009; (In press)PubMed Google Scholar). During laparoscopy, the surgeon starts drilling on the protuberant areas of the ovarian surface. The decision on the number of punctures is commonly made by the operator subjectively according to the size and appearance of the ovaries during the operation. The follicular fluid spurt is commonly observed when the monopolar energy-activated needle tips are inserted on the ovarian surface. This observation suggests that the tissue destruction is generally created on the cystic component of the ovary. Hendriks et al. (1Hendriks M.L. van der Valk P. Lambalk C.B. Broeckaert M.A. Homburg R. Hompes P.G. Extensive tissue damage of bovine ovaries after bipolar ovarian drilling compared to monopolar electrocoagulation or carbon dioxide laser.Fertil Steril. December 17, 2008; Google Scholar) applied and demonstrated the procedure on the solid tissue component of normal bovine ovaries. The shape of the area of destruction on the ovarian surface should be different between monopolar and bipolar techniques, which should be circular and ovoid in shape, respectively. Calculation of the volume of a circular-based cylindrical volume and ovoid-based cylindrical volume should be different. If the same formula is used in the estimation of the damaged tissue volume during the LOD procedure, one may use the short axis or long axis of the ovoid base which may cause underestimation or overestimation. The authors suggested that the whitening around the charred area was excluded in the estimation of the extent of damage caused by the technique. It is well known that monopolar energy modality creates wider tissue damage around the visible coagulation field (beyond the whitening). When the visible and invisible tissue damage are both taken into consideration, the extent of tissue destruction would be wider using the monopolar energy than the bipolar. Furthermore, the laser energy beam has very limited penetration properties. This issue has the potential to change the conclusion of the study. The bipolar cautery possibly creates wider surface area destruction than the monopolar because two closely approximated electrodes are used. The tissue destruction on the ovarian surface created by the laser could be even wider. The less the laser beam is focused on a point, the more surface ovarian tissue destruction is expected. Those surface damages possibly cause different amounts of postoperative adhesion formations, and it is reported that women who conceived after the surgery were treated with diathermy rather than laser (3Li T.C. Saravelos H. Chow M.S. Chisabingo R. Cooke I.D. Factors affecting the outcome of laparoscopic ovarian drilling for polycystic ovarian syndrome in women with anovulatory infertility.Br J Obstet Gynaecol. 1998; 105: 338-344Crossref PubMed Scopus (114) Google Scholar). In conclusion, the bovine ovary model for elucidating and investigating the damage inflicted by the use of different techniques has several shortcomings for representing the current application of LOD in infertile women with PCOS. Reply of the Authors: Is there any difference among the most frequently used laparoscopic ovarian drilling techniques?Fertility and SterilityVol. 91Issue 6PreviewWe thank Dr. Api for the comments on our article. We disagree, however, over some statements made. Using a bovine ovary model instead of human ovaries is not ideal, but bovine ovaries do have a very high resemblance to human polycystic ovary syndrome ovaries, given that the size and cellular morphology approximately match. We stated in the article that direct interpolation of the bovine results to the human clinical situation cannot be done, but the results provide a good indication of the amount of expected tissue damage and the differences between the techniques. Full-Text PDF