Ovarian reserve and LOD in PCOS

بسم الله الرحمن الرحيم

Ovarian Volume

Basal FSH Level

AndAntral

Follicles Count

before and afterLaparoscopi

c Ovarian Drilling

in Women withPCOS

Thesis Submitted for partial

fulfillment of the requirements of

the M.S. Degree In

Obstetrics and Gynecology

By Ahmed Sameh

Ghoubara (M.B.B.CH.)

SUPERVISIORS Prof.Dr.

Safaa Kamal Maraie Professor of Obstetrics and Gynecology

Faculty of Medicine Tanta University

Prof.Dr.

Naglaa Mohammad Lotfy Dabees

Assistant professor of Diagnostic Radiology Faculty of Medicine

Tanta University Dr.

Mohamed Ahmed Talat El-Sharawy

Lecturer of Obstetrics and Gynecology Faculty of Medicine

Tanta University 2012

Aim of the WorkThis study aims to evaluate ovarian volume

basal follicular stimulating hormone level

and antral follicles count

as predictors of ovarian reserve

before and afterlaparoscopic ovarian drilling

in women with polycystic ovarian syndrome.

Ovarian Bank Ovarian Bank of follicles is of follicles is called the called the

ovarian ovarian reservereserve

The number of

resting follicles

Quantity and

quality of

growing follicles

and theirReproductive

potential

Ovarian reserve tests:Static tests:Female AgeOVVOLAFCbFSHAMHInhibin-b E2

Dynamic tests:CCCTEFORTGAST

GnRH

FSH

E2/Inhibin-B

E2/Inhibin-B -ve FB on pituitary

E2 -ve FB on hypothalamusx

xDecreased –ve FB of E2 on FSH rise in FSH

The idea of bFSH as an

ORT

FSH is most common used ORT in clinical practice, it can

diagnose:

Normal ovarian functionPremature ovarian failurePerimenopause and menopauseDOR

Marked decrease in succeeded

IVF pregnancy

Some studies concluded that

bFSH > 20 mIU/ml

Marked decrease in spontaneous pregnancy

Because of the test variability and false +ve

resultsbFSH is just a screening

testfor the purpose of

counselling

we cannot exclude patients from IVF cycles

on the basis of bFSH alone

x xx

Antrum (Cavity)

The AFC is indicative of the number of

primordial follicles as each primordial follicle can

develop to antral follicle

The AFC is the best indicator of poor or good ovarian

response to stimulation for IVF

So thatAFC is related to

the reproductive events and aging

Childbearing PerimenopausePostmenapsue

AFC < 5 per ovary

Premature Menopause

at age of 38-45

35 years old

AFC >6 per ovary

Natural Menopauseat age of 48 -51

Prola

te

Volume of prolate shape by

using the prolate

ellipsoid formula0.524 * Height * Width * Depth

Ovarian volume is related to the remaining primordial follicles

Average OVVOL < 3 cc High chance of failure of COH

Polycystic Polycystic Ovarian Ovarian

SyndromeSyndrome

heterogenous heterogenous group of signs group of signs and symptoms and symptoms

that are.…that are.…

… … gathered to form a gathered to form a spectrumspectrum of disorders in of disorders in

[[EndocrineEndocrine]][[ReproductiveReproductive]]

[[MetabolicMetabolic]]

The commonest cause of anovulatory infertility

There was There was no no agreed agreed definition definition

of PCOSof PCOSUntil

Rotterdam, 2003Rotterdam, 2003

PCOS is PCOS is defined as defined as

……2 2 out of out of 33

Where the Where the US pictures US pictures of PCOS are of PCOS are

……

Oligo or Oligo or anovulationanovulation

Hyper-Hyper-androgenism androgenism (clinical or (clinical or biochemical)biochemical)

US features US features of PCOSof PCOS

1212 or or more more follicles follicles (2-9 mm) (2-9 mm) per ovaryper ovary

OVVOL > OVVOL > 1010 cc per cc per ovaryovary

D1= 3cmD2= 4cm

XX

XXXX

How could we treat PCOS?

Clomiphene Citrate

Aromatase Inh.

Anti-Estrogens


GnRH Agonist

Metformin

(adjuvant)

Laparoscopic Ovarian Drilling


Patients and Methods

The present Study was

conducted on 30 patients

We selected our patients according to the following

inclusion criteria:

1.1. Primary Primary infertilityinfertility2.2. Less than Less than 35 years 35 years oldold3.3. BMI BMI < 30< 304.4. RotterdamRotterdam Criteria of Criteria of

PCOSPCOS5.5. No ovulation induction for No ovulation induction for

3 months3 months6.6. IndicatedIndicated for LOD for LOD????

WeWe DRILL DRILL when there is:when there is:

1.1.Anovulatory infertility with Anovulatory infertility with CC CC resistanceresistance

2.2.Persistent Persistent hyper-secretion of hyper-secretion of LHLH

3.3.Repeated overresponse Repeated overresponse to to Gonadotropins or CCGonadotropins or CC

4.4.Patients who found it Patients who found it difficult difficult to keep attendanceto keep attendance for close for close monitoring of folliculo-metry monitoring of folliculo-metry

We excluded patients with:1.More than 35 years old2.BMI of Equal to or more than 30 kg/m2 3.History of pelvic surgery4.History of ovarian disease (Tumors, Cysts, TOA)5.History of ovulation induction within 3 months prior to the procedure6.+ve pregnancy test during the study

To fulfill the inclusion and exclusion criteria: History takingspecial comments on marital, husband and sexual history

Examinationspecial comments on local gynecological examination

InvestigationsRoutine investigations e.g. CBC, LFTs, ….

Menses Blood

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28

LHFSH

////////////////////////////

Mid-CycleBasal period

1. Basal FSH level2. AFC3. Ovarian volume

bFSH was measured by the Automated methodUsing the automated analyzer:

TOSOH ®

AIA-600IIIJapan

The preoperative AFC and OVVOL were measured by using the trans-vaginal probe of:

LOGIQ PRO 100GE Healthcare®

India

The transvaginal probe:Convex arrayFrequency: 5 mHz Radius :40 mmField of view: 68o

Before we count the antral follicles, identification of them is required first

Measuring the average diameter:2 perpendicular diameters divided by 2

Only follicles that range from 2-9 mm were counted

Because the ovary is

prolate rather than ovoid

We used the prolate ellpsoid

formula of volume

0.524 * Height * Width * Depth

The prolate ellipsoid formula

bFSH AFC OVVO

L

LOD

Preoperative

Micro digital camera

California

Xenon light source

Germany

Electrosurgical diathermy

FORCE 2 Valleylab

Germany

Instruments

California

LOD

Bilateral 4 punctures per

each ovary 4 seconds per

each puncture 40 Watt

diathermy

bFSH AFC OVVO

L

Third PO

cycle

Second PO

cycleFirst PO

cycle

LOD

Preoperative

cycle

bFSH AFC OVVO

L

bFSH AFC OVVO

L

Results

The age ranged

19 – 31 years oldMean: 24.6SD: +/- 3.35

24-29 years oldMean: 26.7SD: +/- 1.7

The BMI ranged

FSH

P value of ANOVA was

0.89No

Significant difference between

the preoperativ

e and

postoperative basal

FSH mean values

AFC

P value of

ANOVA was

0.001Significant difference between

the preoperativ

e and

postoperative mean

AFC

Student’s t- test

Third PO

cycle

Second PO cycle

First PO

cycle

LOD

Preoperative

cycle

0.001Significant difference


0.476No significant

difference

OVVOL

P value of

ANOVA was

0.001Significant difference between

the preoperativ

e and

postoperative mean ovarian volume

Student’s t- test

Third PO

cycle

Second PO cycle

First PO

cycle

LOD

Preoperative

cycle



0.787No significant

difference

The reduction in AFC and OVVOL

remained in the normal ranges

Conclusion

According to this study: there is no decrease in

ovarian reserve after using LOD

HOWEVERstudies with long term follow up

may be required for clinical

assessment of DOR after LOD by using other ovarian reserve markers anddifferent techniques of LOD with or without

ovulatory stimulants in relationto IVF and pregnancy outcomes

It was an Honor to work under my supervisors

Special thanks to The professor Dr. Safaa

Marie for 2 reasons

: Supreme supervision and

guidanceShe was the one that

had managed my labor when I was a newborn

on 1984

THANK YOUTHANK YOU

المسلمين في سوريا المسلمين في سوريادماءدماءاللهم أحقن اللهم أحقن

Ovarian reserve and LOD in PCOS

Health & Medicine

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