Ovarian Wedge Resection for Polycystic Ovaries

Some women have a lot of trouble ovulating because they have a condition called polycystic ovaries. There are several variations on this condition, but mainly, when eggs are developing toward ovulation and subsequent release of the egg, they fail to complete their development, thus the “old eggs” remain in the ovary. When the old eggs remain in the ovary, they are no longer able to produce the female hormone estrogen, but sometimes they will produce male hormones, thereby suppressing future ovulations. As a result, the old eggs persist in the form of cysts, which result in a condition known as polycystic ovaries (PCOS).
This condition was first described many years ago by two doctors named Stein and Leventhal, and thus the condition was known as Stein-Leventhal syndrome. This condition can also be accompanied by excessive male hormones resulting in a more masculine appearance in a woman such as male hair patterns. One can also find obesity.
For decades now, beginning with the work of Stein and Leventhal, the standard of care in treatment of the syndrome was an ovarian wedge resection. It was found that removing a wedge of ovarian tissue and then sewing the ovary back together had a beneficial effect on ovulation. Later, with the advent of drugs to stimulate ovulation, this tried and true old procedure fell out of favor. The most commonly used drug to stimulate ovulation is probably Clomid. However, some ovaries are resistant to Clomid. Clomid has been linked by some to a risk for miscarriage or birth defects, and while it often causes ovulation, it does not always cause pregnancy. Clomid is anti-estrogenic, therefore, it tends to “dry up” the cervical mucus.
The reason why ovarian wedge resection fell out of favor was that while the ovaries ovulated well, there were a lot of adhesions and scarring that occurred after the surgery; thus, while the ovary ovulated better, scarring could prevent pregnancy. In modern times, many new surgical procedures have been developed to limit the formation of scarring and adhesions. These include methods that place a barrier around the ovary or fallopian tubes which will prevent scarring and adhesions in the near term, but will dissolve and disappear in the long term. There are also medical measures to prevent adhesions; these include drugs, nutrients and hormones. If the problem of adhesion formation could be suppressed, then perhaps the old operation could be revived. Some authors have recently called for a revival of ovarian wedge resection, but coupled with a program of adhesion prevention. This would take advantage of the beneficial effects of the surgery, while mitigating its harmful effects.
Recently, one of my patients had an ovarian wedge resection. She had previously had at least three different drugs to stimulate ovulation, and despite months of therapy, she still did not ovulate. She had an ovarian wedge resection coupled with numerous medical and surgical means of adhesion prevention, including anti-adhesion barriers, nutrients, and medication. Since this patient was charting by the Creighton model of the ovulation method (www.creightonmodel.com), the return of ovulation has clearly been demonstrated in her ovulation method chart. While she no ovulatory activity for months prior to the surgery, in less than a week after the surgery she began to notice fertile mucus which would be consistent with the restoration of her ovulatory function. Revival of this old operation is part of the new and growing armamentarium of a new specialty called NaProTechnology.
A recent article appeared in the European Journal of Obstetrics and Gynecology and Reproductive Biology, Volume 107, pages 85-87 in the year 2003. In this study, 134 patients received newly modified operations for polycystic ovarian syndrome. Within two years, there were a total of 121 pregnancies (90% success rate). Seventy-eight percent (78%) of the patients achieved pregnancy within the first six months and 13% in the subsequent 18 months. Postoperatively, 24 patients had Cesarean delivery and 20 had diagnostic laparoscopy. Out of these 44 patients, only 5 were found to have minimal adhesions. Yil Dirim and colleagues concluded that the new technique offers high pregnancy rates and minimal adhesion formation. They concluded that ovarian wedge resection by mini laparotomy might be an alternative treatment approach in patients with polycystic ovarian syndrome who did not conceive with standard ovulation induction protocols.
Copyright 2005 Paddy Jim Baggot

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