Introduction
Roughly five to ten percent of infertile women have polycystic ovarian syndrome (PCOS), a common disease characterized by irregular ovarian cycles. It is responsible for about 80 percent of anovulation (eggs do not get released during the menstrual cycle) related infertility cases. The main goal of the treatment is to cause mono-ovulatory (single pregnancy) cycles, which will eventually help with fertilization. Most patients with PCOS who manage their infertility with practicality usually have positive results. Clomiphene citrate (CC) and losing weight are common first therapies before turning to gonadotropins (these are hormones that function in the gonads and testes in men and ovaries in women). On the other hand, ovarian hyperstimulation and multiple pregnancies are significant concerns when gonadotropin administration is required. Because of this, laparoscopic ovarian drilling surgery is often used to reestablish normal ovulatory cycles as a preventive precaution before starting gonadotropin medication.
What Is Ovarian Drilling?
Laparoscopic ovarian drilling, a surgical technique intended to induce ovulation, is an option available to women with PCOS. This is done by utilizing a laser or heat to specifically kill certain areas of the ovaries. This procedure is not usually the primary therapeutic choice, but it may be explored if other treatments, such as weight loss and fertility medicines, have not produced ovulation in a woman. A tiny incision is made close to the belly button while under general anesthesia, and the abdomen is inflated with carbon dioxide gas to make room for the insertion of a laparoscope, which is a device that allows for visual access to internal organs. If more incisions are needed in the pelvic area for the ovarian drilling process, they can be performed through the same opening or different small incisions.
After the laparoscopic ovarian drilling procedure, most patients go home on that day and can resume their regular lives the next day. However, the amount of time it takes to resume normal activities varies based on how quickly the person recovers; it can take as little as a few days or up to two or four weeks.
How Is Ovarian Drilling Performed?
There is still a lack of standardization in surgical methods for laparoscopic ovarian drilling. The results of reproduction seem to be similar for diathermy and laser techniques. Electrocautery is a widely used technique that typically uses an insulated unipolar needle electrode, while recent research indicates that bipolar energy can be just as effective. Most surgeons choose to perform four punctures per ovary, each lasting four seconds at 40 W (Watts). The number of punctures per ovary varies, usually ranging from three to eight. Higher doses of thermal energy are associated with better rates of ovulation and pregnancy. The clinical response to thermal energy is dose-dependent. Even though there are people who support drilling unilaterally, bilateral treatments are nevertheless common. Other transvaginal approaches and various adaptations to the traditional needle electrode technique have been suggested; however, larger studies are needed to confirm their safety, effectiveness, and long-term consequences.
What Are the Benefits of Ovarian Drilling?
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Reestablishing a woman's menstrual cycle and encouraging ovulation are the main goals of ovarian drilling. Within the first year after the surgery, about 50 percent of women became pregnant. After surgery, some patients may still have irregular cycles, while others may develop further problems with fertility, such as blocked fallopian tubes or low sperm counts that can make conception difficult.
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Ovarian drilling is a one-time procedure as opposed to fertility drugs that must be taken every month. Although the chances of producing twins or triplets are lower with ovarian drilling than with fertility medications, the advantages are temporary. Ovulation and menstrual cycles may return to unpredictable patterns with time.
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It is crucial to remember that not all women with PCOS may see a temporary or permanent resolution to irregular periods and ovulation problems with ovarian drilling. On the other hand, it may increase a woman's receptivity to fertility drugs, thereby raising her chances of becoming pregnant.
What Are the Risks Associated with Ovarian Drilling?
The following are some risks related to laparoscopic ovarian drilling:
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Infection at the site of incision.
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Bleeding at the site of incision.
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Internal bleeding or hemorrhage.
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Accidental damage to major blood arteries or internal organs, possibly from the laparoscope or surgical equipment.
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Postoperative pain is frequently linked to the abdomen's expansion during the procedure.
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Side effects that are caused due to anesthesia administration.
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A woman may experience early menopause if the ovary sustains excessive damage during the ovarian drilling surgery.
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Adhesions, or scarring, between the fallopian tubes and ovaries may develop after the surgery, making it more difficult to conceive.
How to Manage Laparoscopic Ovarian Drilling Failure in PCOS?
Failure of laparoscopic ovarian drilling (LOD) is characterized by the inability to conceive after 12 months of regular ovulation, recurrence of anovulation after an initial response, or lack of ovulation within six to eight weeks after the treatment. Since LOD increases the responsiveness of polycystic ovaries to subsequent ovulation induction (OI) agents, reintroducing medication treatments like Clomiphene citrate (CC) followed by gonadotropins and possibly in vitro fertilization (IVF), can be considered if spontaneous pregnancy does not occur within six months after LOD once ovulation resumes, or after three months without detected ovulation.
In a retrospective study including 20 women who had undergone LOD one to six years prior, the efficacy of a second LOD, or re-drilling, in women with PCOS was investigated. Ovulation and pregnancy rates were 60 percent and 53 percent, respectively, with LOD-sensitive cases showing superior results than LOD-resistant ones (83 percent and 67 percent versus 25 percent and 29 percent, respectively). A randomized controlled trial (RCT) to address this issue is challenging to perform due to concerns surrounding adhesion development and reduced ovarian reserve (DOR). Thus, it should not be encouraged to apply LOD more than once until more information is known.
Conclusion
For women with polycystic ovarian syndrome (PCOS) who have difficulty ovulating and becoming pregnant, laparoscopic ovarian drilling (LOD) is a safe and effective substitute for fertility medicines. It also avoids complications including multiple pregnancies and ovarian hyperstimulation syndrome (OHSS). LOD lowers levels of luteinizing and androgen for a long time while assisting in the restoration of regular ovulation and menstruation. Its effectiveness in treating other PCOS symptoms such as acne, lipid problems, insulin sensitivity, or excessive hair growth is unknown. Hence, it is not recommended for treating non-fertility reasons. Even though problems like adhesion formation or decreased ovarian reserve are possible, they usually do not occur with cautious care.
LOD is not considered the primary choice for treatment. There are other effective oral medicines and low-dose gonadotropin therapies that help improve ovarian responsiveness to fertility drugs. In some cases of anovulatory CC-resistant PCOS, such as young women with high levels of LH (luteinizing hormone), hyperresponsiveness to gonadotropins, inability to comply with frequent monitoring, or those needing laparoscopic pelvic assessment, laparoscopic ovarian drilling (LOD) is especially appropriate. This highlights the fact that it should be considered an alternative rather than a stand-alone cure for PCOS.
