Ovarian drilling, also known as multiperforation or laparoscopic ovarian diathermy, is a surgical technique of puncturing the membranes surrounding the ovary with a laser beam or a surgical needle using minimally invasive laparoscopic procedures. It differs from ovarian wedge resection, which involves the cutting of tissue. Minimally invasive ovarian drilling procedures have replaced wedge resections. Ovarian drilling is preferred to wedge resection because cutting into the ovary can cause adhesions which may complicate postoperative outcomes. Ovarian drilling and ovarian wedge resection are treatment options to reduce the amount of

androgen An androgen (from Greek ''andr-'', the stem of the word meaning "man") is any natural or synthetic steroid hormone that regulates the development and maintenance of male characteristics in vertebrates by binding to androgen receptors. This in ...

producing tissue in women with

polycystic ovarian syndrome Polycystic ovary syndrome, or PCOS, is the most common endocrine disorder in women of reproductive age. The syndrome is named after the characteristic cysts which may form on the ovaries, though it is important to note that this is a sign and no ...

(PCOS). PCOS is the primary cause of anovulation, which results in female infertility. The induction of mono-ovulatory cycles can restore fertility. Laparoscopic ovarian drilling (LOD) may improve the effectiveness of other ovulation induction treatments and results in lower multiple pregnancy rates than other treatment options like

gonadotropins Gonadotropins are glycoprotein hormones secreted by gonadotropic cells of the anterior pituitary of vertebrates. This family includes the mammalian hormones follicle-stimulating hormone (FSH) and luteinizing hormone (LH), the placental/chor ...

. The oral drug clomiphene citrate (CC) is the first-line treatment for PCOS-related infertility, yet one-fifth of women are resistant to the drug and fail to ovulate. Patients are considered resistant if the treatment fails for six months at the appropriate dosage. Ovarian drilling is a surgical alternative to CC treatment or recommended for women with WHO Group II ovulation disorders. Other non-surgical medical options in the treatment of PCOS include the oestrogen receptor modulator

tamoxifen Tamoxifen, sold under the brand name Nolvadex among others, is a selective estrogen receptor modulator used to prevent breast cancer in women and treat breast cancer in women and men. It is also being studied for other types of cancer. It has b ...

aromatase inhibitors Aromatase inhibitors (AIs) are a class of drugs used in the treatment of breast cancer in postmenopausal women and in men, and gynecomastia in men. They may also be used off-label to reduce estrogen conversion when supplementing testosterone ...

, insulin sensitising drugs, and hormonal ovarian stimulation. The effectiveness of the surgical procedure is similar to CC or gonadotropin treatment for induced ovulation for PCOS patients, but results in fewer multiple pregnancies per ongoing pregnancy regardless if the technique is unilaterally or bilaterally performed. If patients do not become pregnant six months after ovulation has been reestablished from ovarian drilling treatment, drug treatments may be reintroduced or in vitro fertilization (IVF) may be considered.

Hormonal effects

Part of the criteria of PCOS diagnosis includes elevated levels of androgens in the bloodstream or other signs of androgen excess (

hyperandrogenism Hyperandrogenism is a medical condition characterized by high levels of androgens. It is more common in women than men. Symptoms of hyperandrogenism may include acne, seborrhea (inflamed skin), hair loss on the scalp, increased body or facia ...

). The procedure causes a drop in serum

levels and possibly in

estrogen Estrogen or oestrogen is a category of sex hormone responsible for the development and regulation of the female reproductive system and secondary sex characteristics. There are three major endogenous estrogens that have estrogenic hormonal ac ...

levels. After ovarian follicles and stroma are destroyed, there is a reduction in these hormone levels. The procedure results in a decrease in plasma

luteinizing hormone Luteinizing hormone (LH, also known as luteinising hormone, lutropin and sometimes lutrophin) is a hormone produced by gonadotropic cells in the anterior pituitary gland. The production of LH is regulated by gonadotropin-releasing hormone (GnRH) ...

(LH) and in pulsations as well as a periodic drop in inhibin B levels. The most plausible theory states that the reduction of these hormone concentrations leads to an increase in the secretion of

follicle-stimulating hormone Follicle-stimulating hormone (FSH) is a gonadotropin, a glycoprotein polypeptide hormone. FSH is synthesized and secreted by the gonadotropic cells of the anterior pituitary gland and regulates the development, growth, pubertal maturation, ...

(FSH) and sex hormone-binding

globulin The globulins are a family of globular proteins that have higher molecular weights than albumins and are insoluble in pure water but dissolve in dilute salt solutions. Some globulins are produced in the liver, while others are made by the immune ...

, leading to effective follicular maturation and ovulation. Low serum oestradiol concentrations are associated with decreased

aromatase Aromatase (), also called estrogen synthetase or estrogen synthase, is an enzyme responsible for a key step in the biosynthesis of estrogens. It is CYP19A1, a member of the cytochrome P450 superfamily, which are monooxygenases that catalyze many ...

activity. Inflammatory growth factors such as

insulin-like growth factor-1 Insulin-like growth factor 1 (IGF-1), also called somatomedin C, is a hormone similar in tertiary structure, molecular structure to insulin which plays an important role in childhood growth, and has Anabolism, anabolic effects in adults. IGF-1 ...

are produced due to injury and aid the effects of FSH through greater blood flow and gonadotropin delivery. Circulating and intrafollicular levels of

anti-Müllerian hormone Anti-Müllerian hormone (AMH), also known as Müllerian-inhibiting hormone (MIH), is a glycoprotein hormone structurally related to inhibin and activin from the transforming growth factor beta superfamily, whose key roles are in growth differen ...

(AMH), which can help quantify recruitable ovarian follicle activity, are reduced after laparoscopic ovarian drilling in women with PCOS.

Procedures

When the clinician determines that ovarian drilling is appropriate and the woman decides to undergo this treatment, consent is obtained. The risks are communicated to the woman. The most commonly performed method is with a monopolar needle or hook because of the equipment's availability and simple installation. Other common instrumentation consists of the use of a bipolar electrical surgical electrodes or a CO₂, argon, or ND-YAG

laser A laser is a device that emits light through a process of optical amplification based on the stimulated emission of electromagnetic radiation. The word "laser" is an acronym for "light amplification by stimulated emission of radiation". The ...

. This instrumentation has the ability to produce the intended results with a very focal approach. Typically, a 100 W electrical cautery dissector is first used to cross the ovarian cortex, then electrocoagulation is performed at 40 W, however rates range from 30 to 400 W. The surgical punctures are performed on the ovarian cortex and are usually 4–10 mm deep and 3 mm wide. The number of punctures is related to subsequent ability to conceive—it has been found that five to ten punctures are more likely to produce the intended conception. Ovarian drilling is performed laparoscopically and either transumbilical (

culdoscopy Culdoscopy is an endoscopic procedure performed to examine the rectouterine pouch and pelvic viscera by the introduction of a culdoscope through the posterior vaginal wall. The word culdoscopy (and culdoscope) is derived from the term cul-de ...

) or transvaginal (

fertiloscopy The fertiloscope is a type of laparoscope, modified to make it suitable for trans-vaginal application, which is used in the diagnosis and treatment of female infertility. This relatively new surgical technique is used for the early diagnosis and im ...

Risks

Though preferable to creating incisions on the ovary, ovarian drilling does have some risks. These are: pelvic adhesion formation,

hemorrhage Bleeding, hemorrhage, haemorrhage or blood loss, is blood escaping from the circulatory system from damaged blood vessels. Bleeding can occur internally, or externally either through a natural opening such as the mouth, nose, ear, urethra, v ...

gas embolism An air embolism, also known as a gas embolism, is a blood vessel blockage caused by one or more bubbles of air or other gas in the circulatory system. Air can be introduced into the circulation during surgical procedures, lung over-expansion ...

pneumothorax A pneumothorax is an abnormal collection of air in the pleural space between the lung and the chest wall. Symptoms typically include sudden onset of sharp, one-sided chest pain and shortness of breath. In a minority of cases, a one-way valve i ...

premature ovarian failure Primary ovarian insufficiency (POI) (also called premature ovarian insufficiency, premature menopause, and premature ovarian failure) is the partial or total loss of reproductive and hormonal function of the ovaries before age 40 because of fol ...

, long-term ovarian function, developing hyperstimulation syndrome, adhesion formation,

infertility Infertility is the inability of a person, animal or plant to reproduce by natural means. It is usually not the natural state of a healthy adult, except notably among certain eusocial species (mostly haplodiploid insects). It is the normal st ...

and

multiple births A multiple birth is the culmination of one multiple pregnancy, wherein the mother gives birth to two or more babies. A term most applicable to vertebrate species, multiple births occur in most kinds of mammals, with varying frequencies. Such bir ...

. Transvaginal hydrolaparoscopy (THL) ovarian drilling may minimize the risk of iatrogenic adhesion formation and decreased ovarian reserve (DOR), which can impinge upon fertility. LOD does not contribute to the risk of decreased ovarian reserve. There is risk of electrical accidents with monopoly current. A rare complication of LOD is major vascular injury, mostly on the small vessels in the anterior abdominal wall when the Veress needle and trocar are inserted at the beginning of the procedure.

Advantages

Ovarian drilling has lower rates of ovarian hyperstimulation syndrome and of multi-fetal gestation. The advantages of the procedure also include its singular treatment, as opposed to several trials of ovulation inductions. Other benefits of this technique include cost-effectiveness and that it can be performed as an

outpatient procedure A patient is any recipient of health care services that are performed by healthcare professionals. The patient is most often ill or injured and in need of treatment by a physician, nurse, optometrist, dentist, veterinarian, or other health c ...

History

Ovarian drilling was first used in the treatment of PCOS in 1984 and has evolved as a safe and effective surgery. After performing laparoscopic electrosurgical ovarian drilling in CC-resistant patients in 1984, Gjönnaess found that this technique increased ovulation rates to 45 percent and pregnancy rates to 42 percent. In 1988, laparoscopic multiple punch resection of ovaries on the hypothalamo-pituitary axis, slightly modified from Gjönnaess's operation, caused a reduction in LH pulsation and pituitary responsiveness in the treatment of PCOS. In 1989, ovarian drilling was conducted with argon, carbon dioxide (CO₂) or potassium-titanyl-phosphate (KTP) laser vaporization causing spontaneous ovulation in 71 percent of those treated. The procedure has been modified and popularized in the treatment of patients with CC-resistance.

References

{{Wound healing Physiology Infertility Women's health Gynecological surgery