Overview
Ovarian drilling, done during laparoscopy, is a procedure in which a laser fibre or electrosurgical needle punctures the ovary 4 to 10 times.
This treatment results in a dramatic lowering of male hormones within days and is often performed in women who have polycystic ovary syndrome (PCOS). Studies have shown that up to 80 percent of patients will benefit from such treatment.
Many women who fail to ovulate with clomiphene or Metformin therapy will respond when these medications are reintroduced to the system after ovarian drilling. Side effects are rare, but may result in adhesion formation or ovarian failure if there are complications during the procedure.
What is Ovarian Drilling ?
Ovarian drilling is a surgical technique dedicated to the treatment of Polycystic Ovary Syndrome. It consists of performing micro-perforations in ovaries in order to induce ovulation. Polycyctic Ovary Syndrome (PCOS) is characterized by ovulation disorders and represents the most common cause of infertility in women of reproductive age.
Ovarian drilling, which was commonly performed by laparoscopy, is now currently performed by fertiloscopy, benefiting in turn from its mini-invasiveness and physiological approach.
The technique of Ovarian Drilling
In 1935 Drs Stein and Leventhal described 7 women with irregular periods (oligomenorrhea), increased body hair (hirsutism) and obesity, who at the time of surgery were found to have enlarged ovaries with a smooth "pearly white" appearance (See figure 1). The smooth appearance of the ovaries was presumed to be due to the lack of sites of ovulation that typically would leave scars. The ovaries were several times the normal size, which along with the elevated male hormone testosterone raised the possibility of ovarian tumors. Biopsies of these ovaries did not show tumors but instead revealed multiple, small "cysts" that were found to be immature follicles, and overgrowth of the part of the ovary that secretes testosterone (stromal theca cells).
Surprisingly after the surgery, where up to 1/2 to 3/4 of each ovary had been removed for biopsy ("wedged"), the patients began having regular menstrual periods and 2 became pregnant. In addition, the testosterone levels declined in these patients. Bilateral ovarian wedge resection (BOWR) of the ovaries was then introduced as a procedure that could assist patients with polycystic ovary syndrome to ovulate. It was the only method available until the introduction of the oral medicine clomiphene citrate in the mid 1960's. The problems with BOWR were that it required a major abdominal incision and that almost all patients developed scar tissue (adhesions) around the tubes and ovaries that further exacerbated their infertility (Buttram, 1975).
Treatment of both ovaries is usually preformed, but reports that treatment of only one ovary can be successful have been published. Many physicians try to make the areas of cautery as far away from the fallopian tube as possible to try to limit the chance of tubal scarring. Others will wrap the ovaries with dissolvable materials that inhibit scar formation. Despite these efforts, adhesions around the tubes and ovaries can occur, but tend to be milder than with the classic BOWR, and do not appear to effect pregnancy rates (Naether, 1993; Greenblatt, 1993). Rarely the ovaries can undergo irreparable damage and cease to function (atrophy) (Dabirashrafi, 1989).
The success rates for laparoscopic ovarian drilling appear to be better for patients at or near their ideal body weight, as opposed to those with obesity. Over a dozen studies have been published with success rates for ovulation between 53% and 92% (Daniell, 1989; Gjonnaess, 1984). Success rates may be slightly higher with electrical energy (which tends to destroy more tissue), but the laser may lead to fewer adhesions. Patients with decreases in hormone production (testosterone and luteinizing hormone) are more likely to ovulate and achieve pregnancy than those without hormonal improvement. Patients not ovulating after the procedure have been found in many cases to become responsive to clomiphene citrate if they were previously resistant. Pregnancy rates have ranged from 37% to 86%.
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