- Email: [email protected]
Adhesion formation after laparoscopic electrocoagulation of the ovarian surface in polycystic ovary patients
Vol. 60, No. 1, July 1993
FERTILITY AND STERILITY
Printed on acid-free paper in U. S. A.
Copyright c 1993 The American Fertility Society
Adhesion formation after laparoscopic electrocoagulation of the ovarian surface in polycystic ovary patients
Olaf G. J. Naether, M.D.* Robert Fischer, M.D. Institute for Hormone and Fertility Research at the University of Hamburg, Hamburg, Germany
Objective: To evaluate the incidence and extent of periovarian adhesion formation subsequent to laparoscopic electrocoagulation of the ovarian surface in infertility patients with polycystic ovarian disease (PCOD). Design: From a total of 199 PCOD patients treated with ovarian electrocautery, 50 cases of laparoscopy and 12 cesarean sections served as second-look investigation. A subgroup of 30 patients had abdominal lavage and artificial ascites after surgery; they underwent "early" second-look (2 to 14 days after laparoscopy). Setting: All patients were referred to our fertility outpatient clinic affiliated with the university hospital. Patients: Infertility patients with polycystic ovarian reaction to hormonal stimulation therapy underwent laparoscopic electrocoagulation of the ovarian surface. Results: Adhesion formation was detected in 19.3%; the incidence reduced to 16.6% with the use of abdominal lavage. The adhesions found were obviously due to bleeding of the ovarian capsule caused by electrocautery. Adhesiolysis was easily possible during "early" second-look. Conclusion: The incidence of de novo adhesion formation caused by laparoscopic electrocoagulation of the ovarian surface seems to be lower than after ovarian wedge resection; it can be reduced by abdominal lavage and artificial ascites. Fertil Steril 1993;60:95-8 Key Words: Laparoscopic electrocoagulation of the ovarian surface, ovarian electrocautery, ovarian photocoagulation, polycystic ovarian disease, ovarian hyperstimulation syndrome, multiple pregnancies
Polycystic ovarian reaction to hormonal stimulation therapy in anovulatory infertility used to be treated with ovarian wedge resection (OWR) for many years (1-4). Currently, different laparoscopic techniques using laser beams (5-8) or electrocoagulation (9-14) are introduced to achieve the same endocrine effects without running the high risk of adhesion formation (3, 4, 15-20). We hereby report our experience with second-look investigation of62 patients who underwent laparoscopic ovarian electrocautery.
Received August 27, 1992; revised and accepted March 19, 1993. *Reprint requests: Olaf G. J. Naether, M.D., Institute for Hormone and Fertility Research at the University of Hamburg, Grandweg 64, 2000 Hamburg 54, Germany. Vol. 60, No. 1, July 1993
MATERIALS AND METHODS
Between October 1986 and July 1992, 199 patients underwent laparoscopic electrocoagulation of the ovarian surface because of polycystic reaction to ovarian stimulation in anovulatory infertility or hyperandrogenemia resistant to oral contraceptives and/or glucocorticoids. The operation was carried out as ultima ratio after all other therapeutic regimens had failed or were contraindicated. The preoperative treatment protocols, including clomiphene citrate (CC), hMG, FSH, GnRH-analogues, and hCG, resulting pregnancy rates (PRs) and details of the operation technique have been described recently (14). Between February 1987 and July 1992, 50 second-look laparoscopies after laparoscopic electro-
N aether and Fischer Adhesion formation after ovarian electrocautery
95
coagulation of the ovarian surface have been carried out to evaluate the incidence and extent of postoperative adhesions and, if possible, perform adhesiolysis; in 12 patients a cesarian section served as second-look investigation. From March 1990 on, all patients (n = 32) undergoing ovarian electrocautery were advised to have an "early" second-look 2 to 14 days (mean, 3. 7 days) after coagulation, i.e., before adhesions had been vascularized to prevent new bleeding caused by adhesiolysis. Our decision to perform early second-look after such a short period of time after surgery was based on the findings of di Zerega (21), who described well the different phases of peritoneal repair. The remaining 30 patients underwent late second -look between 160 and 943 days (mean, 481.3 days) after surgery. Since April 1990 (30 patients), the ovarian surface and abdominal cavity were rinsed with sterile saline solution after ovarian electrocautery to remove blood and coagulated tissue and thereby try to reduce the incidence of de novo adhesion formation (Aqua Porator; Storz, Tuttlingen, Germany). After this lavage, 300 to 500 mL of saline solution were left in the peritoneal cavity as an artificial ascites. RESULTS
No adhesions were detected in 12 patients who underwent cesarean sections (0% ). Twelve of 50 laparoscopies showed de novo formation of adnexal adhesions (24%); this rate reduced to 16.6% (5 of30 patients [not significant {NS}, P = 0.575]) with the abdominal lavage; therefore, the overall adhesion rate in this study was 19.3% (12 of 62 cases of second-look investigation). One patient had an ectopic implantation in a pre-existing hydrosalpinx, andredevelopment of adnexal adhesions was observed after adhesiolysis had been carried out during ovarian electrocautery. In four cases both sides showed adhesions; in 8 patients only one adnex was involved. In five cases, adhesions were tubo-ovarian (2 minimal, 2 mild, and 1 moderate according to The American Fertility Society [AFS] classification of adnexal adhesions [22]), the ovaries were attached to the pelvic wall in five patients (all minimal, 1 bilateral, 4 unilateral), and in two patients the bowel was attached to one ovary (minimal). Only 5 of the 30 patients treated with the Aqua Porator developed adhesions (16.6%) that were all ranked minimal and were located on one side (4 ovary to pelvic wall, 1 tubo-ovarian). Adhesiolysis during early second-look laparoscopy was easily possible without any bleeding in all cases. These 96
minimal adhesions did only occur in those patients in whom an intraoperative bleeding from the coagulation site complicated the laparoscopic ovarian electrocautery procedure. After abdominal lavage and artificial ascites, early second-look did not detect debris or blood on the ovarian surface nor any signs of inflammation.
DISCUSSION
The polycystic ovarian reaction to different stimulation protocols using CC, hMG, hCG, FSH, and GnRH-a is a demanding problem in infertility treatment. Ovarian wedge resection has been the therapy of choice for many years (1-4, 19) and was discarded (3, 4, 15-18, 20) because of high incidences of adnexal adhesions (between 42%, Weinstein and Polishuk [17], and 100% Adashi et al. [3], as well as Kistner [15], Buttram and Vaquero [16], and Toaff et al. [18]). Even though the onset of pregnancy is no proof for patency of both tubes or absence of adnexal adhesions in three papers cited (3, 16, 17), the reported incidence of postoperative adhesions is referred to the (high) number of initially operated patients instead of the (lower) number of patients undergoing second-look. Therefore, in Table 1 the comparison of postoperative adhesion formation after different methods of surgery for polycystic ovarian disease is not done by percentages but by absolute numbers of patients. Since the work of Gjonnaess (9), various laparoscopic techniques using different laser beams and electrocoagulation have been developed (Table 2). Although the endocrine effects of these laparoscopic treatments seemed to be equal to OWR (8, 10-12), the complications, i.e., adhesion formation seemed to be less. In former publications (see Table 1) the incidence of adhesion formation was reported to vary between 0% (Daniell and Miller [5], 8 patients, laser) and 86% (Giirgan et al. [23], 7 patients, laparoscopic electrocoagulation). Lyles et al. (Lyles R, Goldzieher JW, Betts JW, Franklin RR, Buttram VC, Feste JR, et al., abstract) even reported periovarian adhesions in 100% detected by second-look laparoscopy 3 to 4 weeks after laparoscopic electrocoagulation or neodymium-yttrium aluminum garnet (ND: Y ag) laser photocoagulation, respectively; the two groups however consisted only of four and two patients, respectively. A comparison of laser and cautery techniques concerning postoperative formation of de novo adhesions was done by Giirgan et al. (23); no significant difference was
Naether and Fischer Adhesion formation after ovarian electrocautery
Fertility and Sterility
Table 1
Adhesion Rates After Different Methods of Surgical Treatment of PCOD Patients
Authors
Year
Method
Adashi eta!. (3) Kistner (15) Buttram and Vaquero (16) Weinstein and Polishuk (17) Toaff et a!. (18) Protuondo et a!. (20) Daniell and Miller (5) Giirgan et a!. (23) Weise eta!. (13) Naether et a!. (14) Giirgan et a!. (23) Dabirashrafi et a!. (24) Naether and Fischer Protuondo et a!. (20)
1981 1969 1975 1975 1976 1984 1989 1991 1991 1993 1991 1991 1993 1984
OWR* OWR* OWR* OWR* OWR* OWR* C0 2 + KTP lasert ND:YAG lasert Electrocoagulation t Electrocoagulation t Electrocoagulation t Electrocoagulation t Electrocoagulation t Ovarian biopsyt
*Laparotomy.
No. of patients with adnexal adhesions/ no. of patients undergoing second-look
90 16 173
7/7 16/16 59/59 8/19 7/7 11/12 0/8 8/10 7/10 7/26 6/7 2/12 12/62 0/24
72
7 12 85 10 39 133 7 31 199 24 t Laparoscopy.
found. The same finding in a rabbit model is reported by Pittaway et al. (25). In another study also dealing with a rabbit model Rittenhouse et al., (Rittenhouse D, Reyes J, Beingesser K, Vasquez C, Bezmalinovic Z, Sueldo C, abstract) however, detected a significantly (P < 0.05) higher incidence of adhesion formation after laser drilling compared with electrocoagulation. The reTable 2
No. of patients undergoing surgery
duction of this complication in our subgroup of patients with abdominal lavage (16.6% versus 21.9%, NS, P = 0.575) is probably due to the use of the Aqua Porator, equipment to rinse the ovarian surface and abdominal cavity with sterile saline solution subsequent to the coagulation procedure; in addition, artificial ascites of 300 to 500 mL was left in the abdomen of these patients. All adhesions
Ovulation and PRs After Different Surgical Treatments of PCOD Patients Desiring Pregnancy
Authors
Year
Method
Stein and Leventhal (1) Rhodes (2) Adashi et a!. (3) Lunde (4) Kistner (15) Buttram and Vaquero (16) Weinstein and Polishuk
1935 1968 1981 1982 1969 1975
OWR* OWR* OWR* OWR* OWR* OWR*
1975
OWR*
1976 1989 1989 1990 1991 1991 1984
OWR* C0 2 + KTP lasert ND:YAG lasert C0 2 lasert ND:YAG lasert ND:YAG lasert Electrocoagulation t
1987 1990 1990 1991 1993 1991
Electrocoagulation t Electrocoagulation t Electrocoagulation t Electrocoagulation t Electrocoagulation t Electrocoagulation t
No. of patients ovulating/ no. of patients evaluated
Ovulation rate
No. of patients pregnant/no. of patients desiring pregnancy
PR
2/7 22/30 43/90 58/92 2/16 64/150
28 73 48 63 12 43
38/57
67
3/12 48/85 0/8 7/19 4/11 4/10 24/35
25 56 0 44 36 40 80
4/6 11/21 3/9 23/39 73/104 4/7
66 52 33 59 70 57
%
(17)
26/30 82/90 58/62 9/16
86 91 94 56
%
Vejlstedt and Albrechtsen
(19) Daniell and Miller (5) Huber eta!. (6) Keckstein et a!. (7) Rossmanith eta!. (8) Giirgan eta!. (23) Gjiinnaess (9) Greenblatt and Casper
(10) Armar et a!. (11) Sakata eta!. (12) Weise eta!. (13) Naether eta!. (14) Giirgan eta!. (23) *Laparotomy. Vol. 60, No. 1, July 1993
84/85 5/8 15/19 8/11 7/10 57/62
99 62 79 73 70 92
5/6 17/21 8/9
83 81 89
90/104 5/7
86 71
t Laparoscopy. N aether and Fischer
Adhesion formation after ovarian electrocautery
97
found in this group ranked minimal and were located only on one side. With higher numbers of patients, this tendency might reach statistical significance so that future patients would only have to undergo second-look laparoscopy when ovarian electrocautery caused a bleeding of the ovarian surface. If surgical treatment of polycystic ovaries is considered, laparoscopic electrocoagulation of the ovarian surface (the authors suggested [14] establishing the abbreviation "LEOS" for the described procedure) seems to be easier, less expensive, and more effective than laser methods or even OWR, especially because the rate of postoperative formation of adnexal adhesions appears to be less frequent. Acknowledgment. We thank Vera Baukloh, M.S., (Insitute for Hormone and Fertility Research, Hamburg, Germany) for statistic evaluation and critical review of the manuscript. REFERENCES 1. Stein IF, Leventhal ML. Amenorrhea associated with bilateral polycystic ovaries. Am J Obstet Gynaecol1935;29:18191. 2. Rhodes P. The effects of wedge resection of the ovaries in 63 cases of Stein-Leventhal syndrome. J Obstet Gynaecol Br Commonw 1968;75:1108-12. 3. Adashi EY, Rock JA, Guzick D, Wentz AC, Jones GS, Jones HW Jr. Fertility following bilateral ovarian wedge resection: a critical analysis of 90 consecutive cases of the polycystic ovary syndrome. Fertil Steril 1981;36:320-5. 4. Lunde 0. Polycystic ovarian syndrome: a retrospective study of the therapeutic effect of ovarian wedge resection after unsuccessful treatment with clomiphene citrate. Ann Chir Gynaecol 1982;71:330-3. 5. Daniell JF, Miller W. Polycystic ovaries treated by laparoscopic laser vaporization. Fertil Steril 1989;51:232-6. 6. Huber J, Hosmann J, Spona J. Endoskopisch vorgenommene Laserinzisionen des polycystischen Ovars. Geburtshilfe Frauenheilkd 1989;49:37-40. 7. Keckstein G, Wolf AS, Borchers K, Lauritzen Ch. Pelviskopischer Einsatz des C0 2 - Lasers· zur Behandlung des Polyzysischen Ovarsyndroms. Zentralbl Gynakol1990;112:361-8. 8. Rossmanith WG, Keckstein J, Spatzier K, Lauritzen Ch. The impact of ovarian laser surgery on the gonadotropin secretion in women with polycystic ovarian disease. Clin Endocrinol (Oxf) 1991;34:223-30. 9. Gjonnaess H. Polycystic ovarian syndrome treated by ovarian electrocautery through the laparoscope. Fertil Steril 1984;41:20-5.
98
10. Greenblatt E, Casper RF. Endocrine changes after laparoscopic ovarian cautery in polycystic ovarian syndrome. Am J Obstet Gynecol 1987;56:279-85. 11. Armar NA, McGarrigle HHG, Honour J, Holownia B, Jacobs HS, Lachelin GCL. Laparoscopic ovarian diathermy in the management of anovulatory infertility in women with polycystic ovaries: endocrine changes and clinical outcome. Fertil Steril 1990;53:45-9. 12. Sakata M, Tasaka K, Kurachi H, Terakawa N, Miyake A, Tanizawa 0. Changes ofbioactive luteinizing hormone after laparoscopic ovarian cautery in patients with polycystic ovarian syndrome. Fertil Steril 1990;53:610-3. 13. Weise HC, Naether 0, Fischer R, Berger-Bispink S, Defls T. Behandlungsergebnisse mit der Oberfliichenkauterisierung polyzystischer Ovarien bei Sterilitiitspatientinnen. Geburtshilfe Frauenheilkd 1991;51:920-4. 14. Naether OGJ, Fischer R, Weise HC, Delfs T, Rudolf K. Laparoscopic electrocoagulation of the ovarian surface in infertility patients with polycystic ovarian disease. Fertil Steril. 1993;60:88-94. 15. Kistner RW. Peri-tubal and peri-ovarian adhesions subsequent to wedge resection of the ovaries. Fertil Steril 1969;20:35-42. 16. Buttram VC Jr, Vaquero C. Post-ovarian wedge resection adhesive disease. Fertil Steril1975;26:874-6. 17. Weinstein D, Polishuk WZ. The role of wedge resection of the ovary as a cause for mechanical sterility. Surg Gynecol Obstet 1975;141:417-8. 18. Toaff R, Toaff ME, Peyser MR. Infertility following wedge resection of the ovaries. Am J Obstet Gynecol 1976;124:92-6. 19. Vejlstedt R, Albrechtsen R. Biochemical and clinical effect of ovarian wedge resection in the polycystic ovary syndrome. Obstet Gynecol1976;47:575-80. 20. Protuondo J, Melchor J, Neyro J, Alegre A. Periovarian adhesions following ovarian wedge resection or laparoscopic biopsy. Endoscopy 1984;16:143-5. 21. di Zerega GS. The peritoneum and its response to surgical injury. Prog C!in Bioi Res 1990;358:1-11. 22. The American Fertility Society classifications of adnexal adhesions, distal tubal occlusion, tubal occlusion secondary to tubal ligation, tubal pregnancies, Mullerian anomalies and intrauterine adhesions. Fertil Steril 1988;49:944-55. 23. Giirgan T, Kisnisci H, Yarali H, Develioglu 0, Zeyneloglu H, Aksu T. Evaluation of adhesion formation after laparoscopic treatment of polycystic ovarian disease. Fertil Steril 1991;56:1176-8. 24. Dabirashrafi H, Mohamad K, Behjatnia Y, Moghadami-Tabrizi N. Adhesion formation after ovarian electrocauterization on patients with polycystic ovarian syndrome. Fertil Steril1991;55:1200-1. 25. Pittaway DE, Maxson WS, Daniell JF. A comparison of the C0 2 laser and electrocautery on postoperative intraperitoneal adhesion formation in rabbits. Fertil Steril 1983;40: 366-8.
N aether and Fischer Adhesion formation after ovarian electrocautery
Fertility and Sterility
FERTILITY AND STERILITY
Printed on acid-free paper in U. S. A.
Copyright c 1993 The American Fertility Society
Adhesion formation after laparoscopic electrocoagulation of the ovarian surface in polycystic ovary patients
Olaf G. J. Naether, M.D.* Robert Fischer, M.D. Institute for Hormone and Fertility Research at the University of Hamburg, Hamburg, Germany
Objective: To evaluate the incidence and extent of periovarian adhesion formation subsequent to laparoscopic electrocoagulation of the ovarian surface in infertility patients with polycystic ovarian disease (PCOD). Design: From a total of 199 PCOD patients treated with ovarian electrocautery, 50 cases of laparoscopy and 12 cesarean sections served as second-look investigation. A subgroup of 30 patients had abdominal lavage and artificial ascites after surgery; they underwent "early" second-look (2 to 14 days after laparoscopy). Setting: All patients were referred to our fertility outpatient clinic affiliated with the university hospital. Patients: Infertility patients with polycystic ovarian reaction to hormonal stimulation therapy underwent laparoscopic electrocoagulation of the ovarian surface. Results: Adhesion formation was detected in 19.3%; the incidence reduced to 16.6% with the use of abdominal lavage. The adhesions found were obviously due to bleeding of the ovarian capsule caused by electrocautery. Adhesiolysis was easily possible during "early" second-look. Conclusion: The incidence of de novo adhesion formation caused by laparoscopic electrocoagulation of the ovarian surface seems to be lower than after ovarian wedge resection; it can be reduced by abdominal lavage and artificial ascites. Fertil Steril 1993;60:95-8 Key Words: Laparoscopic electrocoagulation of the ovarian surface, ovarian electrocautery, ovarian photocoagulation, polycystic ovarian disease, ovarian hyperstimulation syndrome, multiple pregnancies
Polycystic ovarian reaction to hormonal stimulation therapy in anovulatory infertility used to be treated with ovarian wedge resection (OWR) for many years (1-4). Currently, different laparoscopic techniques using laser beams (5-8) or electrocoagulation (9-14) are introduced to achieve the same endocrine effects without running the high risk of adhesion formation (3, 4, 15-20). We hereby report our experience with second-look investigation of62 patients who underwent laparoscopic ovarian electrocautery.
Received August 27, 1992; revised and accepted March 19, 1993. *Reprint requests: Olaf G. J. Naether, M.D., Institute for Hormone and Fertility Research at the University of Hamburg, Grandweg 64, 2000 Hamburg 54, Germany. Vol. 60, No. 1, July 1993
MATERIALS AND METHODS
Between October 1986 and July 1992, 199 patients underwent laparoscopic electrocoagulation of the ovarian surface because of polycystic reaction to ovarian stimulation in anovulatory infertility or hyperandrogenemia resistant to oral contraceptives and/or glucocorticoids. The operation was carried out as ultima ratio after all other therapeutic regimens had failed or were contraindicated. The preoperative treatment protocols, including clomiphene citrate (CC), hMG, FSH, GnRH-analogues, and hCG, resulting pregnancy rates (PRs) and details of the operation technique have been described recently (14). Between February 1987 and July 1992, 50 second-look laparoscopies after laparoscopic electro-
N aether and Fischer Adhesion formation after ovarian electrocautery
95
coagulation of the ovarian surface have been carried out to evaluate the incidence and extent of postoperative adhesions and, if possible, perform adhesiolysis; in 12 patients a cesarian section served as second-look investigation. From March 1990 on, all patients (n = 32) undergoing ovarian electrocautery were advised to have an "early" second-look 2 to 14 days (mean, 3. 7 days) after coagulation, i.e., before adhesions had been vascularized to prevent new bleeding caused by adhesiolysis. Our decision to perform early second-look after such a short period of time after surgery was based on the findings of di Zerega (21), who described well the different phases of peritoneal repair. The remaining 30 patients underwent late second -look between 160 and 943 days (mean, 481.3 days) after surgery. Since April 1990 (30 patients), the ovarian surface and abdominal cavity were rinsed with sterile saline solution after ovarian electrocautery to remove blood and coagulated tissue and thereby try to reduce the incidence of de novo adhesion formation (Aqua Porator; Storz, Tuttlingen, Germany). After this lavage, 300 to 500 mL of saline solution were left in the peritoneal cavity as an artificial ascites. RESULTS
No adhesions were detected in 12 patients who underwent cesarean sections (0% ). Twelve of 50 laparoscopies showed de novo formation of adnexal adhesions (24%); this rate reduced to 16.6% (5 of30 patients [not significant {NS}, P = 0.575]) with the abdominal lavage; therefore, the overall adhesion rate in this study was 19.3% (12 of 62 cases of second-look investigation). One patient had an ectopic implantation in a pre-existing hydrosalpinx, andredevelopment of adnexal adhesions was observed after adhesiolysis had been carried out during ovarian electrocautery. In four cases both sides showed adhesions; in 8 patients only one adnex was involved. In five cases, adhesions were tubo-ovarian (2 minimal, 2 mild, and 1 moderate according to The American Fertility Society [AFS] classification of adnexal adhesions [22]), the ovaries were attached to the pelvic wall in five patients (all minimal, 1 bilateral, 4 unilateral), and in two patients the bowel was attached to one ovary (minimal). Only 5 of the 30 patients treated with the Aqua Porator developed adhesions (16.6%) that were all ranked minimal and were located on one side (4 ovary to pelvic wall, 1 tubo-ovarian). Adhesiolysis during early second-look laparoscopy was easily possible without any bleeding in all cases. These 96
minimal adhesions did only occur in those patients in whom an intraoperative bleeding from the coagulation site complicated the laparoscopic ovarian electrocautery procedure. After abdominal lavage and artificial ascites, early second-look did not detect debris or blood on the ovarian surface nor any signs of inflammation.
DISCUSSION
The polycystic ovarian reaction to different stimulation protocols using CC, hMG, hCG, FSH, and GnRH-a is a demanding problem in infertility treatment. Ovarian wedge resection has been the therapy of choice for many years (1-4, 19) and was discarded (3, 4, 15-18, 20) because of high incidences of adnexal adhesions (between 42%, Weinstein and Polishuk [17], and 100% Adashi et al. [3], as well as Kistner [15], Buttram and Vaquero [16], and Toaff et al. [18]). Even though the onset of pregnancy is no proof for patency of both tubes or absence of adnexal adhesions in three papers cited (3, 16, 17), the reported incidence of postoperative adhesions is referred to the (high) number of initially operated patients instead of the (lower) number of patients undergoing second-look. Therefore, in Table 1 the comparison of postoperative adhesion formation after different methods of surgery for polycystic ovarian disease is not done by percentages but by absolute numbers of patients. Since the work of Gjonnaess (9), various laparoscopic techniques using different laser beams and electrocoagulation have been developed (Table 2). Although the endocrine effects of these laparoscopic treatments seemed to be equal to OWR (8, 10-12), the complications, i.e., adhesion formation seemed to be less. In former publications (see Table 1) the incidence of adhesion formation was reported to vary between 0% (Daniell and Miller [5], 8 patients, laser) and 86% (Giirgan et al. [23], 7 patients, laparoscopic electrocoagulation). Lyles et al. (Lyles R, Goldzieher JW, Betts JW, Franklin RR, Buttram VC, Feste JR, et al., abstract) even reported periovarian adhesions in 100% detected by second-look laparoscopy 3 to 4 weeks after laparoscopic electrocoagulation or neodymium-yttrium aluminum garnet (ND: Y ag) laser photocoagulation, respectively; the two groups however consisted only of four and two patients, respectively. A comparison of laser and cautery techniques concerning postoperative formation of de novo adhesions was done by Giirgan et al. (23); no significant difference was
Naether and Fischer Adhesion formation after ovarian electrocautery
Fertility and Sterility
Table 1
Adhesion Rates After Different Methods of Surgical Treatment of PCOD Patients
Authors
Year
Method
Adashi eta!. (3) Kistner (15) Buttram and Vaquero (16) Weinstein and Polishuk (17) Toaff et a!. (18) Protuondo et a!. (20) Daniell and Miller (5) Giirgan et a!. (23) Weise eta!. (13) Naether et a!. (14) Giirgan et a!. (23) Dabirashrafi et a!. (24) Naether and Fischer Protuondo et a!. (20)
1981 1969 1975 1975 1976 1984 1989 1991 1991 1993 1991 1991 1993 1984
OWR* OWR* OWR* OWR* OWR* OWR* C0 2 + KTP lasert ND:YAG lasert Electrocoagulation t Electrocoagulation t Electrocoagulation t Electrocoagulation t Electrocoagulation t Ovarian biopsyt
*Laparotomy.
No. of patients with adnexal adhesions/ no. of patients undergoing second-look
90 16 173
7/7 16/16 59/59 8/19 7/7 11/12 0/8 8/10 7/10 7/26 6/7 2/12 12/62 0/24
72
7 12 85 10 39 133 7 31 199 24 t Laparoscopy.
found. The same finding in a rabbit model is reported by Pittaway et al. (25). In another study also dealing with a rabbit model Rittenhouse et al., (Rittenhouse D, Reyes J, Beingesser K, Vasquez C, Bezmalinovic Z, Sueldo C, abstract) however, detected a significantly (P < 0.05) higher incidence of adhesion formation after laser drilling compared with electrocoagulation. The reTable 2
No. of patients undergoing surgery
duction of this complication in our subgroup of patients with abdominal lavage (16.6% versus 21.9%, NS, P = 0.575) is probably due to the use of the Aqua Porator, equipment to rinse the ovarian surface and abdominal cavity with sterile saline solution subsequent to the coagulation procedure; in addition, artificial ascites of 300 to 500 mL was left in the abdomen of these patients. All adhesions
Ovulation and PRs After Different Surgical Treatments of PCOD Patients Desiring Pregnancy
Authors
Year
Method
Stein and Leventhal (1) Rhodes (2) Adashi et a!. (3) Lunde (4) Kistner (15) Buttram and Vaquero (16) Weinstein and Polishuk
1935 1968 1981 1982 1969 1975
OWR* OWR* OWR* OWR* OWR* OWR*
1975
OWR*
1976 1989 1989 1990 1991 1991 1984
OWR* C0 2 + KTP lasert ND:YAG lasert C0 2 lasert ND:YAG lasert ND:YAG lasert Electrocoagulation t
1987 1990 1990 1991 1993 1991
Electrocoagulation t Electrocoagulation t Electrocoagulation t Electrocoagulation t Electrocoagulation t Electrocoagulation t
No. of patients ovulating/ no. of patients evaluated
Ovulation rate
No. of patients pregnant/no. of patients desiring pregnancy
PR
2/7 22/30 43/90 58/92 2/16 64/150
28 73 48 63 12 43
38/57
67
3/12 48/85 0/8 7/19 4/11 4/10 24/35
25 56 0 44 36 40 80
4/6 11/21 3/9 23/39 73/104 4/7
66 52 33 59 70 57
%
(17)
26/30 82/90 58/62 9/16
86 91 94 56
%
Vejlstedt and Albrechtsen
(19) Daniell and Miller (5) Huber eta!. (6) Keckstein et a!. (7) Rossmanith eta!. (8) Giirgan eta!. (23) Gjiinnaess (9) Greenblatt and Casper
(10) Armar et a!. (11) Sakata eta!. (12) Weise eta!. (13) Naether eta!. (14) Giirgan eta!. (23) *Laparotomy. Vol. 60, No. 1, July 1993
84/85 5/8 15/19 8/11 7/10 57/62
99 62 79 73 70 92
5/6 17/21 8/9
83 81 89
90/104 5/7
86 71
t Laparoscopy. N aether and Fischer
Adhesion formation after ovarian electrocautery
97
found in this group ranked minimal and were located only on one side. With higher numbers of patients, this tendency might reach statistical significance so that future patients would only have to undergo second-look laparoscopy when ovarian electrocautery caused a bleeding of the ovarian surface. If surgical treatment of polycystic ovaries is considered, laparoscopic electrocoagulation of the ovarian surface (the authors suggested [14] establishing the abbreviation "LEOS" for the described procedure) seems to be easier, less expensive, and more effective than laser methods or even OWR, especially because the rate of postoperative formation of adnexal adhesions appears to be less frequent. Acknowledgment. We thank Vera Baukloh, M.S., (Insitute for Hormone and Fertility Research, Hamburg, Germany) for statistic evaluation and critical review of the manuscript. REFERENCES 1. Stein IF, Leventhal ML. Amenorrhea associated with bilateral polycystic ovaries. Am J Obstet Gynaecol1935;29:18191. 2. Rhodes P. The effects of wedge resection of the ovaries in 63 cases of Stein-Leventhal syndrome. J Obstet Gynaecol Br Commonw 1968;75:1108-12. 3. Adashi EY, Rock JA, Guzick D, Wentz AC, Jones GS, Jones HW Jr. Fertility following bilateral ovarian wedge resection: a critical analysis of 90 consecutive cases of the polycystic ovary syndrome. Fertil Steril 1981;36:320-5. 4. Lunde 0. Polycystic ovarian syndrome: a retrospective study of the therapeutic effect of ovarian wedge resection after unsuccessful treatment with clomiphene citrate. Ann Chir Gynaecol 1982;71:330-3. 5. Daniell JF, Miller W. Polycystic ovaries treated by laparoscopic laser vaporization. Fertil Steril 1989;51:232-6. 6. Huber J, Hosmann J, Spona J. Endoskopisch vorgenommene Laserinzisionen des polycystischen Ovars. Geburtshilfe Frauenheilkd 1989;49:37-40. 7. Keckstein G, Wolf AS, Borchers K, Lauritzen Ch. Pelviskopischer Einsatz des C0 2 - Lasers· zur Behandlung des Polyzysischen Ovarsyndroms. Zentralbl Gynakol1990;112:361-8. 8. Rossmanith WG, Keckstein J, Spatzier K, Lauritzen Ch. The impact of ovarian laser surgery on the gonadotropin secretion in women with polycystic ovarian disease. Clin Endocrinol (Oxf) 1991;34:223-30. 9. Gjonnaess H. Polycystic ovarian syndrome treated by ovarian electrocautery through the laparoscope. Fertil Steril 1984;41:20-5.
98
10. Greenblatt E, Casper RF. Endocrine changes after laparoscopic ovarian cautery in polycystic ovarian syndrome. Am J Obstet Gynecol 1987;56:279-85. 11. Armar NA, McGarrigle HHG, Honour J, Holownia B, Jacobs HS, Lachelin GCL. Laparoscopic ovarian diathermy in the management of anovulatory infertility in women with polycystic ovaries: endocrine changes and clinical outcome. Fertil Steril 1990;53:45-9. 12. Sakata M, Tasaka K, Kurachi H, Terakawa N, Miyake A, Tanizawa 0. Changes ofbioactive luteinizing hormone after laparoscopic ovarian cautery in patients with polycystic ovarian syndrome. Fertil Steril 1990;53:610-3. 13. Weise HC, Naether 0, Fischer R, Berger-Bispink S, Defls T. Behandlungsergebnisse mit der Oberfliichenkauterisierung polyzystischer Ovarien bei Sterilitiitspatientinnen. Geburtshilfe Frauenheilkd 1991;51:920-4. 14. Naether OGJ, Fischer R, Weise HC, Delfs T, Rudolf K. Laparoscopic electrocoagulation of the ovarian surface in infertility patients with polycystic ovarian disease. Fertil Steril. 1993;60:88-94. 15. Kistner RW. Peri-tubal and peri-ovarian adhesions subsequent to wedge resection of the ovaries. Fertil Steril 1969;20:35-42. 16. Buttram VC Jr, Vaquero C. Post-ovarian wedge resection adhesive disease. Fertil Steril1975;26:874-6. 17. Weinstein D, Polishuk WZ. The role of wedge resection of the ovary as a cause for mechanical sterility. Surg Gynecol Obstet 1975;141:417-8. 18. Toaff R, Toaff ME, Peyser MR. Infertility following wedge resection of the ovaries. Am J Obstet Gynecol 1976;124:92-6. 19. Vejlstedt R, Albrechtsen R. Biochemical and clinical effect of ovarian wedge resection in the polycystic ovary syndrome. Obstet Gynecol1976;47:575-80. 20. Protuondo J, Melchor J, Neyro J, Alegre A. Periovarian adhesions following ovarian wedge resection or laparoscopic biopsy. Endoscopy 1984;16:143-5. 21. di Zerega GS. The peritoneum and its response to surgical injury. Prog C!in Bioi Res 1990;358:1-11. 22. The American Fertility Society classifications of adnexal adhesions, distal tubal occlusion, tubal occlusion secondary to tubal ligation, tubal pregnancies, Mullerian anomalies and intrauterine adhesions. Fertil Steril 1988;49:944-55. 23. Giirgan T, Kisnisci H, Yarali H, Develioglu 0, Zeyneloglu H, Aksu T. Evaluation of adhesion formation after laparoscopic treatment of polycystic ovarian disease. Fertil Steril 1991;56:1176-8. 24. Dabirashrafi H, Mohamad K, Behjatnia Y, Moghadami-Tabrizi N. Adhesion formation after ovarian electrocauterization on patients with polycystic ovarian syndrome. Fertil Steril1991;55:1200-1. 25. Pittaway DE, Maxson WS, Daniell JF. A comparison of the C0 2 laser and electrocautery on postoperative intraperitoneal adhesion formation in rabbits. Fertil Steril 1983;40: 366-8.
N aether and Fischer Adhesion formation after ovarian electrocautery
Fertility and Sterility