Thesis submitted as partial fulfillment of the Master Degree in OBGYN Dr.Ahmed Sameh Ghoubara Tanta faculty of medicine Egypt 2012

1. SUPERVISIORS
SUPERVISIORS
Ovarian Volume Prof.Dr.
Prof.Dr.
Thesis
Basal Safaa Kamal Submitted for partial
FSH Level Maraie the
fulfillment of fulfillment of the
Professor of Obstetrics and Gynecology
And Professor of Obstetrics and Gynecology
Faculty of Medicine requirements of
Faculty of Medicine
Antral Follicles Tanta University
Tanta University
Prof.Dr.
Prof.Dr.
the M.S. Degree
In
Count
‫بسم ا الرحمن الرحيم‬
Naglaa Mohammad Lotfy Dabees
Obstetrics and Gynecology
Assistant professor of Diagnostic Radiology
Assistant professor of Diagnostic Radiology
before and after By Faculty of Medicine
Faculty of Medicine
Laparoscopic Ahmed Sameh
Tanta University
Tanta University
Dr.
Dr.
Ovarian Drilling Talat Ghoubara
Mohamed Ahmed El-Sharawy
in Women with of Obstetrics and Gynecology
Lecturer of Obstetrics and Gynecology
Lecturer
(M.B.B.CH.)
Faculty of Medicine
Faculty of Medicine
PCOS Tanta University
Tanta University
2012
2012

2. Aim of the Work
This study aims to evaluate
ovarian volume
basal follicular stimulating hormone level
and
antral follicles count
as predictors of
ovarian reserve
before and after
laparoscopic ovarian drilling
in women with
polycystic ovarian syndrome.

4. Ovarian Bank of
follicles is called
the
ovarian reserve

5. Quantity
The number
and and
their
Reproductive
of
quality
restingof
potential
follicles
growing follicles

6. Ovarian reserve tests:
Static tests: Dynamic tests:
Female Age CCCT
OVVOL EFORT
AFC GAST
bFSH
AMH
Inhibin-b
E2

7. x GnRH
E2 -ve FB on
hypothalamus
The idea of bFSH
as an ORT
x FSH
E2/Inhibin-B -ve FB on
pituitary
Decreased –ve FB of
E2 on FSH 
E2/ rise in FSH
Inhibin-B

8. FSH is most common used ORT in
clinical practice, it can diagnose:
Normal ovarian function
Premature ovarian failure
Perimenopause and menopause
DOR

9. Some studies concluded that
bFSH > 20 mIU/ml
Marked decrease in Marked decrease in succeeded
spontaneous pregnancy IVF pregnancy

10. Because of the test variability and false +ve
results
bFSH is just a screening test
for the purpose of counselling

11. x x x
we cannot exclude patients from IVF cycles
on the basis of bFSH alone

12. Antrum
(Cavity)

13. The AFC is indicative of the number of
primordial follicles
as each primordial follicle can develop to
antral follicle

14. The AFC is the best indicator of
poor or good ovarian response
to stimulation for IVF

15. So that
Childbearing Perimenopause Postmenapsue
AFC is related to
the reproductive events and aging

16. 35 years old
AFC >6 per ovary AFC < 5 per ovary
Natural Premature
Menopause Menopause
at age of 48 -51 at age of 38-45

17. Volume of prolate
shape by using
te
ola the prolate ellipsoid
Pr
formula
0.524 * Height * Width * Depth

18. Ovarian volume is related to the remaining
primordial follicles

19. Average OVVOL < 3 cc 
High chance of failure of COH

20. Polycystic heterogenous
group of signs and
Ovarian symptoms that
Syndrome are.…

21. … gathered to form a
spectrum of disorders in
[Endocrine]
[Reproductive]
[Metabolic]

22. The commonest cause of anovulatory infertility

23. There was no agreed
definition of PCOS
Until

24. Rotterdam, 2003

26. PCOS is
defined as …
2 out of 3

27.  Oligo or
anovulation
 Hyper-
Where the US
androgenism (clinical pictures of
or biochemical)
PCOS are …
 US features of
PCOS

28.  12 or more
follicles (2-9
mm) per ovary D1= 3cm
D2= 4cm
 OVVOL > 10
cc per ovary

29. X
XX

30. How could we treat PCOS?
Anti-Estrogens
Clomiphene Citrate Aromatase Inh.

31. How could we treat PCOS?
GnRH Agonist Metformin
(adjuvant)

32. How could we treat PCOS?
Laparoscopic Ovarian Drilling

33. Patients and Methods

34. We selected our
The present
patients
Study was
according to the
conducted on
following inclusion
30 patients
criteria:

35. 1. Primary infertility
2. Less than 35 years old
3. BMI < 30
4. Rotterdam Criteria of PCOS
5. No ovulation induction for 3 months
6. Indicated for LOD
??

36. We DRILL when there
is:
1. Anovulatory infertility with CC resistance
2. Persistent hyper-secretion of LH
3. Repeated overresponse to Gonadotropins or
CC
4. Patients who found it difficult to keep
attendance for close monitoring of folliculo-
metry

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

38. To fulfill the inclusion and exclusion criteria:
History taking
special comments on marital, husband and sexual
history
Examination
special comments on local gynecological
examination
Investigations
Routine investigations e.g. CBC, LFTs, ….

39. Basal period Mid-Cycle
FSH LH
1. Basal FSH level
2. AFC
3. Ovarian volume
////////////////////////////
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
Menses Blood

40. bFSH was measured by the
Automated method
Using the automated analyzer:
TOSOH ®
AIA-600III
Japan

41. The preoperative AFC and OVVOL
were measured by using the trans-
vaginal probe of:
LOGIQ PRO 100
GE Healthcare®
India

42. The transvaginal probe:
Convex array
Frequency: 5 mHz
Radius :40 mm
Field of view: 68o

43. Before we count
Measuring the
the antral follicles,
average diameter:
Only follicles that
identification of
2 perpendicular
range from 2-9
them is required
diameters divided
mm were counted
first
by 2

44. Because the ovary
is prolate rather
than ovoid
We used the prolate
ellpsoid formula of
volume

45. The prolate ellipsoid formula
0.524 * Height * Width * Depth

46.  bFSH
 bFSH
 AFC
 AFC
 OVVOL
 OVVOL
Preoperative
Preoperative
LOD

47. Micro digital camera
California

48. Xenon light source
Germany

49. Electrosurgical
diathermy
FORCE 2 Valleylab
Germany

50. Instruments
California

51. LOD
 Bilateral
 4 punctures per each
ovary
 4 seconds per each
puncture
 40 Watt diathermy

52.  bFSH
 bFSH  bFSH
 bFSH  bFSH
 bFSH
 AFC
 AFC  AFC
 AFC  AFC
 AFC
 OVVOL
 OVVOL  OVVOL
 OVVOL  OVVOL
 OVVOL
Preoperative
Preoperative
First PO cycleSecondPO cycleThirdPO cycle
Second PO cycle
First PO cycle Third PO cycle
cycle
cycle
LOD

53. Results

54. The age ranged
19 – 31 years old
Mean: 24.6
SD: +/- 3.35

55. The BMI ranged
24-29 years old
Mean: 26.7
SD: +/- 1.7

57. P value of
ANOVA
was
0.89
FSH
No Significant
difference
between the
preoperative
and
postoperative
basal FSH
mean values

58. Student’s t- test
P value of 0.001 0.476
ANOVA Significant
difference
No significant
was difference
0.001
AFC
Significant
difference
Preoperative
Preoperative
cycle
cycle
First PO cycle Second PO Third PO cycle
First PO cycle Second PO Third PO cycle
cycle
cycle
between the
preoperative LOD
and
postoperative
mean AFC 0.001
Significant
difference

59. P value of
Student’s t- test
0.001 0.787
ANOVA Significant No significant
was difference difference
0.001
OVSignificant
difference
Preoperative
Preoperative
cycle
cycle
First PO cycle Second PO Third PO cycle
First PO cycle Second PO Third PO cycle
cycle
cycle
VOL
between the
preoperative
and
LOD
postoperative
mean ovarian
volume 0.001
Significant
difference

60. The reduction in
AFC and OVVOL
remained in
the normal ranges

61. Conclusion

62. According to this study:
there is no decrease in ovarian reserve
after using LOD
HOWEVER
studies with long term follow up
may be required for
clinical
assessment of DOR after LOD
by using other ovarian reserve markers and
different techniques of LOD with or without ovulatory stimulants
in relation
to IVF and pregnancy outcomes

63. It was an Honor to work under my supervisors
Special thanks to
The professor Dr. Safaa Marie
for 2 reasons :
Supreme supervision and guidance
She was the one that had
managed my labor when I was a
newborn on 1984

64. ‫اللهم أحقن دماء المسلمين في سوريا‬
‫‪THANK YOU‬‬