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 Table of Contents  
REVIEW ARTICLE
Year : 2022  |  Volume : 31  |  Issue : 2  |  Page : 121-124

Outcome following ovarian drilling in Nigerian women with polycystic ovary syndrome: A systematic review


1 Department of Obstetrics and Gynaecology, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
2 Department of Obstetrics and Gynaecology, Madonna University Teaching Hospital, Rivers State, Abuja, Nigeria
3 Department of Obstetrics and Gynaecology, University of Abuja Teaching Hospital, Abuja, Nigeria

Date of Submission03-Jan-2022
Date of Decision12-Feb-2022
Date of Acceptance14-Feb-2022
Date of Web Publication29-Apr-2022

Correspondence Address:
Prof. Nkeiruka Ameh
Department of Obstetrics and Gynaecology, Ahmadu Bello University Teaching Hospital, Zaria
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/NJM.NJM_1_22

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  Abstract 


Background: Polycystic ovary syndrome (PCOS) is a common condition characterized by endocrinopathies which can lead to infertility. Various modalities of treatment have been employed including ovarian drilling, but the outcome of such ovarian drilling in Nigerian women is not known. Aim: This is a systematic review of the outcome of ovarian drilling on the menstrual pattern and pregnancy rate in Nigerian women. Materials and Methods: Google scholar and PubMed databases were searched for studies that relate to PCOS management using ovarian drilling and other modalities in Nigeria. The citation lists of relevant articles and studies were also searched. Case reports, retrospective studies, and prospective studies were included. Review articles, systematic reviews, and meta-analysis were excluded. Six studies were found to be suitable and consisted of two case reports and prospective studies each, respectively, and one clinical trial and retrospective study each, respectively. Results: There were a total of 107 patients aged 17–49 years. While all the patients presented with a complaint of abnormal menstruation, 50%–70% complained of inability to conceive. All the patients had used clomiphene citrate as first-line drug to manage their complaints. Ovarian drilling was carried out using the conventional unipolar diathermy and 4 or more drills per ovary. Following the procedure, 76% resumed normal menstruation and 30% conceived. Conclusion: Reports of ovarian drilling in Nigeria reveal a positive outcome but the number of published studies are few and quality of evidence low. Further well-designed studies including randomized controlled trials are needed to make definite conclusions.

Keywords: Outcome, ovarian drilling in Nigeria, polycystic ovary syndrome


How to cite this article:
Ameh N, Adesiyun AG, Okohue JE, Adewole ND. Outcome following ovarian drilling in Nigerian women with polycystic ovary syndrome: A systematic review. Niger J Med 2022;31:121-4

How to cite this URL:
Ameh N, Adesiyun AG, Okohue JE, Adewole ND. Outcome following ovarian drilling in Nigerian women with polycystic ovary syndrome: A systematic review. Niger J Med [serial online] 2022 [cited 2022 May 21];31:121-4. Available from: http://www.njmonline.org/text.asp?2022/31/2/121/344372




  Introduction Top


Polycystic ovary syndrome (PCOS) is a condition seen in 5%–10% of women in reproductive age.[1] The Rotterdam criteria are defined by the presence of oligomenorrhea or amenorrhea, PCOS and clinical or endocrine signs of hyperandrogenism. The presence of two or more of the above conditions defines PCOS.[2] PCOS patients present with complaints of menstrual irregularities and infertility. Common findings on examination usually include obesity, male pattern hair distribution, and ultrasound finding of enlarged polycystic ovaries.[3],[4]

Several treatment options exist for PCOS. The first line of treatment is usually medical, followed by surgical options. Medical treatment includes administration of clomiphene citrate, metformin, and gonadotrophins.[2],[4] A few studies have revealed the use of a combination of the medical modalities.[4]

In Nigeria, ovarian drilling is commonly used in the treatment of PCOS but definite conclusions on the outcome of this treatment is uncertain. This is a systematic review of outcomes of ovarian drilling in Nigerian women with PCOS over a 30-year period. The review is intended to provide more definite conclusions and facilitate evidence-based ovarian drilling for PCOS in Nigeria.


  Materials and Methods Top


The Preferred Reporting Items for Systematic Review and Meta-Analysis was used to design and report the results of this systematic review.

Search strategy

Electronic search was carried out using Google scholar and PubMed for studies that relate to PCOS management using ovarian drilling and other modalities of treatment in Nigeria from 1991 to 2020. The citation lists of relevant articles and studies were also searched. The key search words were PCOS, Ovarian drilling, Nigeria and limited to 1991–2020.

Selection criteria

We included case reports, retrospective, and prospective studies. Review articles, systematic reviews, and meta-analysis were excluded. Methodological quality of all the studies was evaluated using the standard scoring system developed by Jadad et al.[5] The screening of the studies, selection, data extraction validation, and assessment of methodological quality were carried out by (NA and AGA). There were no disagreements on the decisions.

Outcome measures

The primary outcome was normalization of the menstrual cycle and secondary outcome measure was achievement of pregnancy.

Statistical analysis

The demographic characteristics, presenting complaint, treatment modality, and outcomes of treatment have been analyzed. Due to marked heterogeneity of the studies, pooled data analysis could not be done.


  Results Top


The electronic search identified 28 studies while 2 studies were identified from the reference section of the 28 studies. Twenty-two studies were excluded for lack of relevance. Eight studies were screened, and the full text were searched out. Of the eight studies, two were not found, while six full studies were found and adjudged to be relevant for the systemic review [Figure 1].
Figure 1: Preferred reporting items for systematic review and meta-analysis flow chart for systematic review on outcome following ovarian drilling in Nigerian women with polycystic ovary syndrome

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The studies consisted of two case reports, two prospective studies, one clinical trial, and one retrospective study. There was a total of 107 patients in the studies, aged 17–49 years [Table 1].
Table 1: Demographics of 107 patients with polycystic ovary syndrome

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All the patients presented with a complaint of abnormal menstruation and 50%–70% complained of inability to conceive. All patients had used clomiphene citrate as first-line drug to manage their complaints. Ovarian drilling was carried out using the conventional unipolar diathermy and 4 or more drills were made per ovary.

Outcome

Resumption of normal menstruation was achieved in 76.7% of the patients 30% conceived following the procedure. No patient required a repeat or second ovarian drilling. There were no miscarriages [Table 2].
Table 2: Summary of 6 studies included in systematic review (n=107 patients)

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Quality of evidence

The level of quality of evidence in the 6 studies included in the systematic review was poor in 2 studies and medium in 4.


  Discussion Top


PCOS is the most common cause of anovulatory infertility with a prevalence rate of 5%–15% from a European study but reported to be 2.2% in a Nigerian study.[1],[6] The Rotterdam classification for this condition includes menstrual irregularity, physical signs, and symptoms as well as biochemical changes. Two or more of the criteria qualify a patient as having PCOS.[7] All the patients in the various studies included in the present review met two or more of these criteria.[8] The age range of the patients was within the reproductive age group. This is expected as the symptoms are seen in the reproductive age.[9]

Menstrual irregularity was a presenting complaint in 5 out of the 6 studies and infertility was a complaint in all the studies as in another report.[2] Except for one study which assigned patients to various groups including clomiphene citrate, gonadotrophins, weight loss and laparoscopic ovarian treatment, all other studies reported previous treatments on the patients before a resort to laparoscopic ovarian drilling.[10],[11] This may imply that ovarian drilling was reserved for difficult cases of PCOS who fail to respond to other treatments. This may well create a bias in interpretation of the effectiveness of various treatment modalities.[12] Other treatment modalities are medical and as such may be easier to deploy as a first-line treatment rather than surgical approach.[11],[12]

The number of drills per ovary was initially put at 4/ovary at 4 watts for 4 s using a monopolar needle.[13] In recent times, the number of drills per ovary is dependent on the size of the ovary and may be up to 9 as in one report.[10] Some studies reported a reduction in fertility after ovarian drilling[13],[14] probably from ovarian burn injuries but none of the studies in the present review addressed the issue of fertility reduction. Other routes of ovarian drilling are through the vagina and by a mini laparotomy, but these routes are not as popular as laparoscopy.[15]

Outcome

Time for resumption of menstruation varied from 1 to 14 days in 76.7%–100% of the women and was associated with the disruption of the testosterone-producing ovarian cortex.[13] This compares with 66% in another report.[16]

Time for resumption of ovulation after ovarian drilling is varied and is evidenced by conception as seen in 30%–100% of the patients in the present review. This is notably higher than 48% reported from another study.[15] This is the desired outcome, but the 100% pregnancy outcome may be because of inclusion of case reports in this review with a resultant skewing of the results. This observed difference may be due to differences in study designs. Some patients needed further treatments with clomiphene citrate, but none had a second ovarian drill before conceiving in this review. One study reported a repeat of ovarian drilling in more than 50% of their patients.[3] Need for repeat medical or surgical treatment may be affected by the presence of other pathologies such as hyperprolactinemia in the patient.[16] High antral follicular count which indicates a larger-sized ovary is associated with a need for a second modality of treatment before pregnancy can be achieved.[16] Thus, apart from managing the ovarian pathology, other conditions need to be treated in other to restore ovulation and achieve pregnancy. There was no report of multiple gestation following ovarian drilling in the present report, this significant as the medical treatment for PCOS is more associated with multiple gestation.[16] Pregnancy following ovarian drilling is likely to be complicated by a miscarriage.[16]

Deliveries ranged from 14% to 49% among the reported patients, but two studies did not indicate the delivery rates. This rate is lower than the 42% take-home babies in another report.[16] The observed difference may be due to the inclusion of case reports in the present systematic review. Duration of follow-up also affects the report of term deliveries. In this review, patients were followed up until delivery except in one study.

Strength of the studies

The studies included in this review were retrospective or case reports in nature, limiting the quality of evidence. Given the low evidence level of the studies, no definite conclusions can be made.

Recommendation

Reports of ovarian drilling in Nigeria indicate a positive outcome. However, given the low level of evidence in the studies, no definite conclusions can be made. Well-designed, multicenter studies are needed to determine the scientific importance of ovarian drilling in the management of PCOS in Nigeria.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ott J, Kurz C, Nouri K, Wirth S, Vytiska-Binstorfer E, Huber JC, et al. Pregnancy outcome in women with polycystic ovary syndrome comparing the effects of laparoscopic ovarian drilling and clomiphene citrate stimulation in women pre-treated with metformin: A retrospective study. Reprod Biol Endocrinol 2010;8:45.  Back to cited text no. 1
    
2.
Ugwu GO, Iyoke CA, Onah HE, Mba SG. Prevalence, presentation and management of polycystic ovary syndrome in Enugu, south east Nigeria. Niger J Med 2013;22:313-6.  Back to cited text no. 2
  [Full text]  
3.
Debras E, Fernandez H, Neveu ME, Deffieux X, Capmas P. Ovarian drilling in polycystic ovary syndrome: Long term pregnancy rate. Eur J Obstet Gynecol Reprod Biol X 2019;4:100093.  Back to cited text no. 3
    
4.
Omokanye LO, Ibiwoye Jaiyeola OA, Olatinwo AW, Abdul IF, Durowade KA, Biliaminu SA. Polycystic ovarian syndrome: Analysis of management outcomes among infertile women at a public health institution in Nigeria. Niger J Gen Pract 2015;13:44-8.  Back to cited text no. 4
  [Full text]  
5.
Jadad AR, Moore RA, Carroll D, Jenkinson C, Reynolds DJ, Gavaghan DJ, et al. Assessing the quality of reports of randomized clinical trials: Is blinding necessary? Control Clin Trials 1996;17:1-12.  Back to cited text no. 5
    
6.
Igwegbe AO, Eleje GU, Enechukwu CI. Polycystic ovary syndrome. A review of management outcomes in a low resource setting. J Womens Health 2013;2:3.  Back to cited text no. 6
    
7.
Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome (PCOS). Hum Reprod 2004;19:41-7.  Back to cited text no. 7
    
8.
Omokanye LO, Olatinwo AW, Durowade KA, Panti AA, Salaudeen AG, Adewara EO. A review of pregnancy outcomes following laparoscopic ovarian drilling for infertile women with clomiphene resistant polycystic ovarian syndrome at a public health facility in Ilorin, Nigeria. Trop J Obstet Gynaecol 2014;31:74-81.  Back to cited text no. 8
    
9.
Fehintola AO, Awotunde OT, Ogunlaja OA, Akinola SE, Oladeji SA, Aaron OL, et al. The outcome of laparoscopic ovarian drilling in patients with clomiphene -resistant polycystic ovarian syndrome in Ogbomosho Nigeria: A prospective evaluation. World J Lap Surg 2020;13:101-7.  Back to cited text no. 9
    
10.
Ikechebelu JI, Mbamara SU, Okeke CA. Pregnancy following laparoscopic ovarian drilling for clomiphene resistant polycystic ovarian syndrome. Niger J Clin Pract 2010;13:235-7.  Back to cited text no. 10
[PUBMED]  [Full text]  
11.
Omokanye LO, Olatinwo AW, Salaudeen AG. Pregnancy following laparoscopic ovarian drilling for clomiphene resistant polycystic ovarian syndrome in Nigeria. Res J Health Sci 2013;1:38-44.  Back to cited text no. 11
    
12.
Bordewijk EM, Bonnie NK, Rakic L, Mol JB, Brown J, Crawford TJ, et al. Laparoscopic ovarian drilling for ovulation induction in women with anovulatory polycystic ovary syndrome. Cochrane Syst Rev 2020;2:CD001122.  Back to cited text no. 12
    
13.
Kandil M, Selim M. Hormonal and sonographic assessment of ovarian reserve before and after laparoscopic ovarian drilling in polycystic ovary syndrome. BJOG 2005;112:1427-30.  Back to cited text no. 13
    
14.
Shibahara H, Hirano Y, Kikuchi K, Suzuki T, Takamizawa S, Suzuki M. Postoperative endocrine alterations and clinical outcome of infertile women with polycystic ovary syndrome after transvaginal hydrolaparoscopic ovarian drilling. Fertil Steril 2006;85:244-6.  Back to cited text no. 14
    
15.
Chundawat RS, Gupta A. Effectiveness of laparoscopic ovarian drilling (LOD) on restoration of menstrual cycles, ovulation and pregnancy in clomiphene citrate resistant women with PCOS. Int J Reprod Contracept Obstet Gynecol 2017;6:5425-8.  Back to cited text no. 15
    
16.
Moazami Goudarzi Z, Fallahzadeh H, Aflatoonian A, Mirzaei M. Laparoscopic ovarian electrocautery versus gonadotropin therapy in infertile women with clomiphene citrate-resistant polycystic ovary syndrome: A systematic review and meta-analysis. Iran J Reprod Med 2014;12:531-8.  Back to cited text no. 16
    


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