Tomislav Čanić

Does unilateral laparoscopic diathermy adjusted to ovarian volume increase the chances of ovulation in women with polycystic ovary syndrome

STUDY QUESTION Does unilateral volume-adjusted laparoscopic diathermy increase the chances of ovulation in women with polycystic ovary syndrome (PCOS)? SUMMARY ANSWER Although unilateral laparoscopic ovarian drilling (ULOD) using adjusted thermal doses was more efficient than bilateral laparoscopic ovarian drilling (BLOD) using fixed doses, the chances of ovulation were improved in patients irrespective of the technique used. WHAT IS KNOWN ALREADY The adjustment of the thermal dose to ovarian volume in BLOD increases ovulation and pregnancy rates compared with fixed-dose treatment, but BLOD causes the formation of adhesions, particularly on the left ovary, and increases the risk of damage to ovarian tissue. In contrast, ULOD with a fixed thermal dose minimizes the risk of ovarian tissue damage, and can increase the activity in both right and left ovaries, although this varies in humans and in other species. STUDY DESIGN, SIZE, DURATION This prospective, longitudinal, study, between September 2009 and January 2013, included 96 infertile women with PCOS who were unresponsive to clomiphene citrate treatment and had underwent either ULOD or BLOD. After surgery, the groups were followed up for 6 months to assess ovulatory response. PARTICIPANTS/MATERIALS, SETTING, METHODS Patients were assigned to two groups; one group underwent laparoscopic ovarian drilling of the right ovary alone, while both ovaries were treated in the second group. The ULOD group (n = 49) received thermal doses adjusted to the volume of the right ovary (60 J/cm³). The BLOD group (n = 47) received fixed doses of 600 J per ovary, regardless of its volume. The two treatment groups were matched by the number of participants, age and baseline parameters. MAIN RESULTS AND THE ROLE OF CHANCE The ovulation rate during the first menstrual cycle after LOD was significantly higher in the ULOD group than in the BLOD group [73 versus 49%; absolute risk reduction (ARR), -0.25; 95% confidence interval (CI), -0.44 to -0.03; P = 0.014]. Treatment with ULOD on the right ovary significantly increased the chances of ovulation in patients with a larger right ovary compared with those who had a smaller right ovary (100 versus 36%; ARR, -0.64; 95% CI, -0.84 to -0.37; P = 0.004). Interestingly, the chances of ovulation were also significantly higher in patients in the BLOD group who had a larger right ovary compared with those who had a smaller right ovary (88 versus 33%; ARR, -0.55; 95% CI, -0.73 to -0.28; P = 0.002). The pregnancy rate was also significantly higher in patients with a larger right ovary compared with those with a smaller right ovary, regardless of the treatment group. LIMITATIONS, REASONS FOR CAUTION The 6-month follow-up was too short to demonstrate any long-term differences in the ovulation rates. Future research should therefore extend the follow-up beyond 6 months. Another limitation is that ULOD was used to treat only the right ovary. Future studies should investigate whether ULOD treatment of the larger ovary, whether left or right, would significantly increase the ovulation rate. WIDER IMPLICATIONS OF THE FINDINGS This study represents an advance in the determination of the optimal laparoscopic treatment for women with PCOS, as it was shown that improved results can be achieved using less thermal energy in volume-adjusted ULOD.

Assessment of ovarian reserve after unilateral diathermy with thermal doses adjusted to ovarian volume

Abstract Women with polycystic ovary syndrome seem to have a larger ovarian reserve. However, regardless of a greater reserve, diminished ovarian reserve has been reported after laparoscopic diathermy. The aim of this article was to determine whether the doses adjusted unilateral laparoscopic ovarian drilling with diathermy (ULOD) diminishes ovarian reserve to compare with bilateral laparoscopic ovarian drilling with diathermy (BLOD). Ninety-six women were assigned in two groups. One group underwent ULOD receiving thermal doses (0–840 J per ovary) adjusted to volume one ovary. The other group underwent BLOD receiving fixed doses (600 J per ovary). Ovarian reserve markers [anti-Müllerian hormone (AMH); antral follicle count (AFC) and ovarian volume] were measured before and after surgery (1 and 6 months). Both groups showed a decrease in AMH after surgery, but it was significantly more distinct in the BLOD versus ULOD group (2.0 ng/mL versus 1.3 ng/mL; p = 0.018) in the first follow-up month and remained significantly different through the sixth follow-up month (1.9 ng/mL versus 1.15 ng/mL; p = 0.023). In contrast, in the sixth month, the ULOD versus BLOD showed a significantly greater increase AFC (p < 0.001) and volume (p = 0.013). Our findings evidenced that the dose-adjusted unilateral diathermy (60 J/cm3) does not have significant and long-term effects on ovarian reserve. Chinese abstract 患有多囊卵巢综合征的妇女似乎具有更多的卵巢储备，然而也有腹腔镜透热打孔术后卵巢储备功能降低的报道。本篇文章的目的为探究与双侧腹腔镜下卵巢打孔术(BLOD)相比，调整透热剂量单侧腹腔镜下卵巢打孔术(ULOD)对卵巢储备降低是否有影响。96名妇女被分为两组，一组接受了根据其一侧卵巢体积所调整透热剂量的ULOD（0-840J每卵巢），另一组接受了固定透热剂量的BLOD（600J每卵巢）。在术前和术后（1个月及6个月）均测定了卵巢储备指标[抗苗勒氏管激素（AMH）；窦卵泡计数（AFC）和卵巢体积] 。两组在术后都出现了AMH的降低，但在术后一个月BLOD组相较于ULOD组表现得更为明显（2.0ng/mL 比1.3ng/mL; p=0.018），术后六个月这种明显的区别仍然存在（1.9 ng/mL 比1.15 ng/mL; p=0.023）。与此相比，在第六个月ULOD组AFC与卵巢体积升高的幅度与BLOD组相比显著增多。研究结果表明根据卵巢体积调整剂量的单侧卵巢透热疗法(60 J/cm3)对卵巢储备功能无显著和长期的影响。

Anti-Müllerian hormone, testosterone and free androgen index following the dose-adjusted unilateral diathermy in women with polycystic ovary syndrome

OBJECTIVE The aim of this study was to investigate changes of anti-Müllerian hormone, testosterone and free androgen index after two diathermy methods. We have also aimed at evaluating prognostic value of these parameters for an ovulatory response. STUDY DESIGN This prospective, comparative study included ninety-six women with polycystic ovary syndrome unresponsive to clomiphene citrate. Patients were assigned to two groups; the first group underwent unilateral laparoscopic ovarian drilling with thermal doses adjusted to ovarian volume: median of 720J (IQR), while the second group underwent bilateral drilling with fixed doses of 1200J. Anti-Müllerian hormone (AMH), testosterone (T), free androgen index (FAI)and luteinizing hormone (LH) were measured at baseline, at 1st and 6th month of follow up. RESULTS AMH, T and LH levels significantly decreased (P<0.001, P≤0.024, P<0.001) after diathermy in both responders and nonresponders from either treatment group. On contrary, FAI levels (P<0.001) significantly changed only in responders, irrespective of the treatment. In 1st and 6th month of follow up median levels of AMH, T and FAI among responders from different treatment groups were equivalent, whereas the responders in bilateral group had higher LH levels in the 1st month of follow up (P=0.003). Nonresponders differed between treatment groups only in AMH level which was decreased in unilateral group throughout the follow up (P≤0.021). The baseline value of T (semi-standardized coefficient, β=-0.28) and value of T in the 1st month (β=-0.72) after the diathermy were significant and consistent indicator of the response to therapy within 6months and the ovulation response in the 1st month. CONCLUSIONS The value of T is the strongest and consistent indicator of ovulatory response after diathermy. CLINICAL TRIAL REGISTRATION www.ClinicalTrials.gov , NCT01833949.

Diagnosing genitourinary tuberculosis by exclusion.

glands immunohistochemistry may be useful with CD10, estrogen receptor, and progesterone receptor immunostains. In our case there was no bleeding or discharge from the umbilical nodule, neither was there cyclical pain or swelling. The patient did not have any features of pelvic endometriosis. The diagnosis was made on FNAC from the umbilical nodule and confirmed on histopathology. Intraoperatively the nodule was confined to skin only, suggesting a type of cutaneous endometriosis. A photomicrograph (Fig. 1) shows endometrial glands in the dermis (40 ). For cutaneous endometriosis, implantation of intra-abdominal endometrial cells most likely occurs through lymphatic or vascular Diagnosing genitourinary tuberculosis by exclusion