Transvaginal ultrasound-guided electrocautery of the ovaries in infertile patients with polycystic ovarian disease

Transvaginal ovarian trauma, poor responders and improvement of success rates in IVF: anecdotal data and a hypothesis

In this report, we propose an intervention capable of improving IVF outcomes in subfertile women with poor ovarian response. This intervention derives from anecdotal data and observations in our daily practice, but most importantly from trials on experimental models and subfertile women with Polycystic Ovarian Syndrome (PCOS). Our hypothesis suggests that transvaginal induction of trauma to the ovary in the cycle preceding IVF should benefit poor ovarian responders and their lowered pregnancy rates by increasing - at least - the number of retrieved oocytes during oocyte retrieval. Up-to-the minute data show that, via this means, there is a unique response of the ovarian surface epithelium and stroma to the induced trauma. The potential pathways of this beneficial response involve an improvement of the raised gonadotrophins to act either through the mechanical reduction of the size of the ovary or through alterations of the hormonal profile by lowering LH, inhibin and local androgen concentrations through hypothalamic-pituitary axis feedbacks, the induction of increased blood flow to the ovaries, a differentiated local immune reaction and a non-elucidated as yet role of reactive oxygen species. In this report, we also describe the technique and the associated possible negative points while we try to point out the needed research steps to ensure its efficiency before it enters daily clinical practice.

Adequacy of ovarian diathermy under ultrasound control: an experimental model

Background

To develop a minimally invasive ovarian cauterization technique under transvaginal ultrasound control and evaluate the safety and feasability of monopolar cauterization to cause ovarian injury using female cattle of reproductive age as an experimental model.

Method

Experimental study in a university research center was performed. Eleven female bovines of reproductive age were submitted to monopolar transvaginal ovarian cauterization. The right ovary (RO) was punctured at four sites and 40 W was applied for 5 s at each point, resulting in a total of 800 J (Joules) of thermal energy. In the left ovary (LO), the procedure was similar, with the same time and 80 W, resulting in a thermal energy of 1600 J. Macroscopic and microscopic lesions were assessed.

Results

Of 22 ovaries punctured, 20 were cauterized and exhibited macroscopic and typical microscopic lesions. No lesions could be found in the needle path. The measures of the areas of microscopic electrocautery lesions calculated estimating a cylindrical volume showed a median of 1.12% in the right ovary and 1.65% in the left ovary. When the estimate was calculated by spherical shape, the medians were 1.77% in the right ovary and 3.06% in the left ovary. There was a statistically significant difference in these two estimates (sphere, p = 0.008; cylinder, p = 0.021).

Conclusion

The experimental animal model described for transvaginal ultrasound-guided ovarian needle cauterization seems to be feasible. The ovaries were successfully cauterized without injuries in needle path and more energy resulted in significantly more thermal lesion. The safety and effectiveness of this technique, theoretically less invasive than current ovarian drilling methods, could be tested in anovulatory women with PCOS.

Transvaginal ultrasound ovarian diathermy: sheep as an experimental model

BACKGROUND

Some techniques of transvaginal ovarian drilling have been previously described. Nevertheless a monopolar transvaginal ovarian cauterization, that use the expertise and safety of transvaginal puncture for oocyte captation seems to be an easier and feasible approach. The aim of this study was to develop a minimally invasive ovarian cauterization technique under transvaginal ultrasound control, and to evaluate the safety of the transvaginal ovarian monopolar cauterization, female sheep at reproductive age were used as an experimental model.

FINDINGS

An experimental study was performed in a university research center. Seventeen female sheep (15 Corriedale e 2 Suffolk) in reproductive age were submitted to transvaginal ovarian cauterization with a monopolar Valleylab Force 2 electrocautery. Macroscopic and microscopic lesions were assessed. Ovarian size were 1.31 cm2 ± 0,43 (Corriedale) and 3.41 cm2 ± 0,64 (Suffolk). From 30 ovaries from Corriedale sheep punctured, only 3 were cauterized, presenting macroscopic and typical microscopic lesion. In the Suffolk sheep group, only one ovary was cauterized. No lesion could be found in the needle path.

CONCLUSIONS

This is the first experimental animal model described for ovarian cauterization needle guided by transvaginal ultrasound. The sheep does not seem to be the ideal animal model to study this technique. Another animal model, whose ovaries are better identified by transvaginal ultrasound should be sought for this technique, theoretically less invasive, before it could be offered safely to women with polycystic ovary syndrome.