Laparoskopik Ovaryen Drilling

Laparoskopik ovaryen drilling (LOD) ilk kez 1984 yı-lında tanımlanmıştır. Ovaryen foliküllerin ve stroma-nın destrüksiyonu ile lokal ve sistemik androjen ve inhibin seviyeleri azalır ve ardından FSH artar. Böy-lece foliküler gelişim ve ovülasyonda artış sağlanır.

LOD işleminin yaygın uygulamasında her overe 3 mm çapında ve 3-4 mm derinliğinde 4 adet delik açı-lır. Ancak LOD’nin unilateral uygulamasının da ovü-lasyon oranları açısından bilateral uygulama kadar etkili olduğu bildirilmiştir (43).

Anovulatuar PKOS’lu subfertil kadınların birinci basamak tedavisinde lazer veya diyatermi ile LOD yoktur. Bu yöntem esas olarak CC rezistan PKOS’lu hastalar için ikinci basamak tedavi olarak önerilmek-tedir (8). Birnci basamak tedavi olarak CC ile karşı-laştıran çalışmalarda klinik gebelik, canlı doğum ve düşük oranları açısından CC ile benzer sonuçlar elde edilmiştir (44, 45). LOD sonrası gebe kalan kadınlarda çoğul gebelik oranı daha azdır. Bazı hastalarda etkisi geçici olabilir ve CC veya gonadotropinlerle adjuvan tedavi gereksinimi olabilir. Laparoskopik ovaryen di-yaterminin ovaryen fonksiyonlar üzerine uzun süreli etkisi bilinmemektedir ve PKOS’lu hastalarda görü-len metabolik bozuklukları düzelttiğine dair kanıt bulunmamaktadır. PKOS’lu kadınların yaklaşık %30’u LOD işlemine cevap vermez (işlemden 8 hafta sonra menstruasyon olmaması ve anovülasyonun devam etmesi), bu nedenle LOD başarısını öngörecek fak-törlerin bilinmesi önemlidir (46). Obezite, 3 yıldan daha uzun süreli infertilite, düşük LH (<10 IU/l), yük-sek testosteron (>4.5 nmol/l) ve yükyük-sek AMH (>7.7 ng/ml) LOD işlemine düşük cevap şansı ile ilişkilidir (46).

BÖLÜM 26 • Polikistik Over Sendromu ve İnfertilite Yönetimi  163

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edilen IVF sikluslarında OHSS riskini azaltmak ama-cıyla tedaviye metformin eklenmesi düşünülmelidir.

Uygulama Önerileri

 Ovülasyon indüksiyon tedavilerine cevap alı-namadığında ya da ek infertilite faktörleri var-lığında.

 Artmış OHSS riski nedeniyle siklus dikkatli şe-kilde monitörize edilmelidir.

 Antagonist protokol daha güvenlidir.

 GnRH agonist ile final oosit matürasyonu OHSS riskini önemli derecede azaltır.

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