Polycystic ovary syndrome (PCOS) is a very common endocrine disorder that affects female fertility and may cause additional symptoms, such as menstrual disturbances, acne and excess body hair. Approximately 10% of reproductive age women are known to be affected by PCOS, a percentage that is much higher in the subpopulation of women with infertility. The clinical manifestations associated with PCOS, are caused by an underlying hormonal imbalance, namely the altered levels of testosterone, estrogen and other reproductive hormones detected in PCOS patients.
For most cases, medication, such as clomiphene citrate and similar compounds, are the first-line treatment for PCOS patients with regard to infertility, as they facilitate induction of ovulation, allowing for a chance at conception and pregnancy. However, in certain, severe cases, medical treatment is not enough, hence laparoscopic ovarian drilling was introduced. Ovarian drilling works by breaking through parts of the ovary, damaging a small part of the ovarian tissue and follicles, which are responsible for the overproduction of androgens. This lowers the amount of testosterone produced and causes a secondary rise in follicle-stimulating hormone (FSH), which in turn facilitate a return to regular menstrual cycles and ovulation. Additionally, the thermal injury of the ovary, incurred during the procedure, triggers the release of inflammatory growth factors and consequently increases the effect of FSH on folliculogenesis, while an increase in ovarian blood flow due to the surgical intervention, improves the delivery of gonadotropins to the follicles during ovarian stimulation.
Ovarian drilling is performed in a minimally invasive way, via laparoscopy. Four small incisions are made in the abdomen and thin surgical instruments and an endoscopic camera are inserted into the peritoneal cavity. This equipment allows the surgeon direct visualization and access to the ovary. Subsequently, a specialized instrument is used and through electrocautery makes small punctures on the ovaries, without bleeding.
Laparoscopic ovarian bleeding confers several benefits to women with PCOS, namely:
- Restoration of a regular menstrual cycle in the vast majority of cases and a return to normal ovulation.
- Improvement of conception rate, with about 50% of women achieving pregnancy within the first year after surgery.
- Lower dosages of gonadotropins and fewer days of stimulation required before oocyte retrieval.
- Lower risk of ovarian hyperstimulation syndrome (OHSS) during IVF preparation.
- Higher percentage of mature oocytes (meaning higher quality oocytes) after ovarian drilling.
Regarding ovarian drilling risks, as with every medical intervention, there may be adverse effects and complications related with surgery, such as bleeding, injury and infection, however these are rare when the surgery is performed by an experienced Reproductive Surgeon and Team. It should be noted that ovarian drilling is not a permanent solution for PCOS. Unfortunately, as time passes after the surgery, menstrual cycle irregularities and anovulation are likely to return, as the ovary returns to its pre-drilling stage. Furthermore, ovarian drilling is unlikely to help with other symptoms and conditions associated with PCOS, such as obesity, insulin resistance and excessive hair growth, although some patients do report a degree of improvement. Rather, its primary objective is to restore menstrual cycle regularity and help with your fertility treatment (eg IVF) in order to achieve pregnancy as long as the beneficial effects of the intervention last. Finally, it should be noted that there is a small percentage of women, for whom ovarian drilling may not restore regular menstrual cycles. However, these women still benefit from the improved response to other fertility medication, such as gonadotropins.
Overall, laparoscopic ovarian drilling is an effective and relatively safe therapeutic option for more severe cases of PCOS and may be considered as a part of your fertility treatment, with the aim to improve response to ovarian stimulation and the reproductive outcomes of IVF.
