Ovarian drilling in polycystic ovarian syndrome (PCOS)

Ovarian drilling has replaced wedge resection of the ovary (which was the classical management strategy proposed by Stein in his seminal paper on management of polycystic ovarian syndrome (PCOS) (1))

• laparoscopic ovarian drilling is the modern version of wedge resection
  • this is used in a select group of patients who are unwilling or unable to move on to gonadotropin treatment or in vitro fertilization (IVF) when they are resistant to clomiphene for induction of ovulation (2)
    
    
  • ovarian drilling is effective for a few months after the drilling and the multiple pregnancy rate is the lowest among methods used for ovulation induction (2)
    
    
  • approximately 50% of women will have a live birth and 16% miscarry after the procedure (2)
    
    
  • postoperative adhesion formation has been documented and concerns regarding the effect on long-term ovarian function remain to be addressed (2)
    
    
• a review of ovarian drilling concluded (3) ".. ovarian drilling is a second-line treatment when treatment with clomiphene citrate fails to lead to conception. The benefits of ovarian drilling are that it does not induce either hyperstimulation syndrome or multiple pregnancies. It is concluded that ovarian drilling is an option in the management of female infertility associated with PCOS, especially as a second-line treatment after the failure of clomiphene citrate treatment..."

Notes:

• ovarian drilling can be done using a unipolar needle electrode or laser
  • depending on the size of the ovary, usually 10-20 'holes' are created in the capsule and stroma of each ovary
  • excessive drilling may cause ovarian atrophy and premature menopause
  • creating >20 'holes' per ovary and drilling of the ovarian hilum should be avoided (4)
    • may result in compromising of blood supply to the ovary and may also cause bleeding (4)
    • coagulation on the ovarian surface should be kept as minimal as possible due to the concern of adhesion formation
    • purpose of the procedure is to reduce the androgen-producing cells in the ovarian stroma

Reference:

• 1) Stein IF, Cohen R. Elson Results of bilateral ovarianwedge resection in 47 cases of sterility; 20 year end results; 75 cases of bilateral polycystic ovaries Am J Obstet Gynecol 1949; 58: 267-274
• 2) Bhagavath B, Carson S. Ovulation induction in women with polycystic ovary syndrome: an update.American Journal of Obstetrics and Gynecology 2012; 206 (3): 195-198.
• 3) Fernandez H et al.Ovarian drilling for surgical treatment of polycystic ovarian syndrome: a comprehensive review.Reprod Biomed Online. 2011 Jun;22(6):556-68.
• 4) Tulandi T. Modern surgical approaches to female reproductive tract.Hum Reprod Update. 1996 Sep-Oct;2(5):419-27 .