Laparoscopic ovarian drilling (LOD) in patients with polycystic ovary syndrome (PCOS): an alternative approach to medical treatment?
© Springer-Verlag Berlin / Heidelberg 2005
Received: 21 October 2004
Accepted: 14 March 2005
Published: 13 May 2005
The operative treatment of polycystic ovary syndrome (PCOS) patients by laparoscopic ovarian drilling (LOD) is a widely used technique. However, the indication remains unclear. Excellent results with ovulatory cycles up to 9 years after surgery have been described. Nevertheless, pregnancy rates are not superior to a course of three to six treatment cycles with gonadotrophins in low-dose protocols.
KeywordsPCOS Infertility Ovarian drilling
Polycystic ovary syndrome (PCOS) is a common endocrine disorder in up to 10% of women in the reproductive age. It comprises a heterogenous mixture of clinical and diagnostical findings, including oligo-/amenorrhoea, oligo-/anovulation, hirsutism, hyperandrogenaemia, a typical ovarian morphology and insulin resistance. Diagnostic criteria were defined by the ESHRE-ASRM consensus meeting in Rotterdam 2003 . The main criteria are oligo- or anovulation, clinical and/or biochemical signs of hyperandrogenism and polycystic ovaries by ultrasound. At least two out of these three criteria must be present. Furthermore, other aetiological factors, like M. Cushing, androgen-producing tumours or congenital adrenal hyperplasia must be excluded.
The aetiology of the PCOS is based on two major concepts; hyperandrogenism and insulin resistency. The classical hypothesis as proposed by Yen  postulates an initial androgen excess. Androgens are aromatised in peripheral tissue to oestrogens, resulting in an imbalance of luteinizing hormone (LH) and follicle stimulating hormone (FSH) secretion on the pituitary level with endogenous hypersecretion of LH. The LH strongly stimulates the intraovarian androgen production. This classical concept has been extended by the role of hyperinsulinaemia in PCOS patients. Insulin resistance can be found in up to 50% of women with PCOS . Insulin, like LH, stimulates directly the ovarian biosynthesis of steroid hormones, in particular, of ovarian androgens. Furthermore, insulin decreases the sex-hormone-binding globulin (SHBG) production in the liver, thus, further elevating free androgen levels [4–8]. Therefore, both pathways end in the stimulation of ovarian theca cells with elevated ovarian androgen production, resulting in disturbed folliculogenesis, cycle disorders and chronic oligo-/anovulation. This pivotal role of the ovary for the aetiology of the PCOS has favoured therapeutical concepts, which might directly correct the intraovarian pathology.
Besides these leading concepts, PCOS might be caused by enzymatic defects of steroidogenesis, for example, an increased activity of 5α-reductase , an increased adrenal corticoid secretion or a dysregulation of the ovarian cytochrome-P450C17α-enzyme complex .
Current therapeutic concepts are mainly based on correction of the hyperinsulinemic state, direct ovarian stimulation or treatment of hyperandrogenemia by oral contraceptives with antiandrogenic gestagen components.
Similar to metformin treatment, operative procedures aim to restore spontaneous ovulatory cycles. The first invasive approach to treat polycystic ovaries was performed by ovarian wedge resection, described as early as 1935 by Stein and Cohen . Although followed by severe de novo adhesion formation, this technique has been used successfully in many studies [12–14]. In a series of 173 wedge resections, Buttram and Vaquero were able to perform a second-look laparoscopy or laparotomy in 34 patients. None of these patients showed ovaries free of adhesions . Lunde et al.  examined 149 patients 10–15 years after previous wedge resection. Kaplan–Meier evaluation revealed a cumulative pregnancy rate of 76% (69.5% patients suffered from postoperative adhesions, counting for an infertility rate of 13.4%). However, most of the patients still reported regular menstrual cycles after a period of up to 25 years.
Technique of laparoscopic ovarian drilling
Results of laparoscopic ovarian drilling in PCOS patients
No. of patients
Pregnancy rate spontaneous
Live birth rate
No. of holes
Unipolar electrocautery, 200–300 W
Abdel Gadir et al. 
Randomised LOD versus HMG versus FSH
Keckstein et al. 
19 CO2 laser
CO2: 20–30 W continuous mode
Nd:YAG: 45–70 W defocussed laser beam
Armar et al. 
Kovacs et al. 
Gürgan et al. 
Unipolar electrocautery 70 W
Nd:YAG laser 30–60 W
Gürgan et al. 
Nd:YAG laser 50 W
Armar and Lachelin 
n.a. after LOD only
Greenblatt und Casper 
Naether et al. 
Unipolar electrocautery 400 W/s
Balen and Jacobs 
Unipolar diathermy 40 W
Heylen et al. 
Prospective two-laser techniques
47.2% incl. clomiphene
Argon, continuous 8–12 W
72.7% (total incl. clomiphene)
Liguori et al. 
Unipolar electrocautery 4 mA
Lazovic et al. 
Unipolar diathermy and CO2 laser
28 low-dose FSH
13 low-dose FSH
Muenstermann and Kleinstein 
CO2 laser 105 W/cm2
8 GnRH-a followed by FSH
Felemban et al. 
72% (cumulative probability after 24 months)
Unipolar electrocautery 40 W
Zullo et al. 
Kriplani et al. 
Fernandez et al. 
Transvaginal hydrolaparoscopy bipolar versapoint device
Amer et al. 
Retrospective longitudinal follow-up
Electric diathermy 30 W
Argon laser 12–14 W continuous mode
Farquhar et al. 
19 patients 3 cycles HMG/FSH
81% per cycle
Takeuchi et al. 
17 harmonic laser
Harmonic scalpel laser
Neodyn YAG laser
Casa et al. 
76% (cumulative after 6 months)
Transvaginal hydrolaparoscopy bipolar versa spring electrode
Malkawi et al. 
Bayram et al. 
Randomised controlled trial
Bipolar needle electrode
Fernandez et al. 
39.7% (drilling alone) 60% (incl. stimulation)
35.6% (total incl. stimulation)
Transvaginal, coaxial bipolar
Palomba et al. 
Monopolar 40 W
53.3% per cycle
13.4% per cycle
36% per patients
The initial technique described by Gjönnaess  used a unipolar biopsy or sterilisation forceps. Penetration of the ovarian capsule was reached by pressing the electrode on the ovarian surface for 2–4 s, using a power of 200–300 W. Each hole had an average diameter of 3 mm and a depth of 2–4 mm. Three to eight holes were created in each ovary. In most studies, a three-puncture technique was used [26, 46, 30]. Liguori et al.  described the same size of drilled holes by unipolar electrocautery, but a higher number of 5–20 sites per ovary. Amer et al.  used a specially designed diathermy probe with a distal stainless steel needle measuring 8 mm in length and 2 mm in diameter, projecting from an insulated solid cone of 6 mm maximum diameter. Monopolar coagulation was reached with 30 W power and 3–10 punctures were made in each ovary, each measuring 4 mm in diameter and 5–7 mm in depth.
A bipolar insulated needle has been described as well . In this study, each ovary was punctured 5–10 times, depending on its size.
The CO2 laser technique reduces the number of subcapsular small follicles and should destroy androgen-producing tissue. Usually, a power of 10–20 W in continuous mode is used with a power density of up to 105 W/cm2 . The laser beam opens 10–30 subcapsular small follicles per ovary. The Nd:YAG laser is equipped with a sterile quartz glass fibre of 0.6-mm core diameter, the power ranges between 30 and 60 W. The focussed laser beam is used at a distance of 5–10 mm from the ovary . This laser type coagulates tissue without vaporisation at low powers in a non-contact mode. Penetration depth depends on the applied energy and application time. The argon laser allows good vaporisation and coagulation effects . When an argon laser technique is used, the power setting is 12–14 W in continuous mode using a disposable sapphire tip connected to a 600-mm flexible fibre . Ten to 40 holes are drilled.
Benefit of different laparoscopic ovarian drilling techniques
Today, there is no evidence that any one of the laparoscopic techniques should yield superior results. The studies are rather poor. Keckstein et al.  have treated 19 patients with the CO2 laser and 11 patients with the Nd:YAG laser system in a non-randomised study. In a follow-up between 18 months and 30 months, eight pregnancies in the CO2 laser group and three pregnancies after drilling with the Nd:YAG laser have been achieved (44% vs. 27%).
Takeuchi et al.  compared ovarian drilling with a harmonic scalpel laser and a Nd:YAG laser in 17 patients per group. The endocrine profile after surgery was similar, the ovulation rate was 94% in both groups and the pregnancy rate within a follow-up of 2 years was 77% and 60%, respectively, without significant differences.
Additional operative procedures
Ovaries are cooled during the procedure by rinsing with Ringer’s lactate , saline solution [30, 28], Hartmann’s solution  or 10% dextran solution with 500 ml artificial ascites . Some groups use hyaluronic acid gel as an adhesion barrier at the end of the procedure . Greenblatt and Casper have used Interceed to wrap one ovary in a comparative study .
In standard laparoscopical procedure, a CO2 pneumoperitoneum is used. Fernandez et al.  have introduced a transvaginal approach by transvaginal hydrolaparoscopy. The pouch of Douglas was punctured with a Veress needle and 300 ml of normal saline solution was instilled through the posterior vaginal fornix. Vaporisation was achieved by a bipolar electrosurgical probe called Versapoint. The conductivity of normal saline solution was used to advance the two electrodes along the axis of the device. The high energy level of 110–130 W produced steam at the distal electrode end and, thereby, vaporised the ovarian tissue.
Although the technique has been widely used in the last two decades, the underlying pathomechanism is yet unclear, but it should cause similar effects as wedge resection. Ovarian drilling might destroy tissue of the ovarian cortex and stroma and drain small, androgenic follicles, thus, leading to a decrease of intraovarian androgen levels and androgen production. Consecutively, the peripheral conversion of androgens to oestrogens should be lowered, resulting in a correction of LH hypersecretion on the pituitary level . Furthermore, lower androgen shall convert the intraovarian androgenic milieu to an oestrogenic one . This mechanism shall diminish the atresia of chronically hyperandrogenic small follicles and restore normal follicular recruitment . Drainage of small follicles with a hyperandrogenic milieu might be the most important effect . This hypothesis is underlined by a study of Ferraretti et al. , who showed comparable endocrine effects by simply aspirating small follicles by transvaginal ovarian puncture without destroying ovarian tissue. According to the proposed pathomechanism, insulin resistance and hyperinsulinaemia should not be influenced by the surgical concept.
Indeed, these effects on gonadotrophin production can be confirmed and are similar to ovarian wedge resection. The LH and FSH levels increase significantly during the first 2 days after drilling , followed by a persistent decline of LH [26, 21, 52–55]. In contrast to FSH, LH levels remain low for many years [21, 56]. Low LH levels were confirmed over a period of more than 3 years . However, secondary increasing FSH levels are discussed controversely. Amer et al.  did not find significant FSH variations after a 3-year follow-up. A normalised inhibin pulsatility further indicates normal intraovarian paracrine signalling .
Androgen levels and the free androgen index (FAI) are persistently suppressed, partially due to a significant increase of SHBG, but mainly as a result of persistently lowered LH levels. Young PCOS patients show lower androgen levels within 3 months after drilling and a significant increase of ovarian blood flow, but no effects on leptin levels . Ovarian drilling does not affect adrenal steroidogenesis, as demonstrated by adrenocorticotropic hormone (ACTH) tests in 14 voluntary patients .
At least 30% of PCOS patients show metabolic disorders, such as hyperinsulinemia and insulin resistance. Ovarian drilling displays some beneficial effects on glucose and insulin responses in an oral glucose challenge test , although these findings could not be confirmed by others . Hyperglycaemic clamping did not show any improvement in insulin sensitivity after ovarian drilling . Today, there is no evidence that ovarian drilling might positively influence insulin resistance.
Ovarian drilling significantly reduces the ovarian volume [55, 62]. Furthermore, ovarian vascularisation is increased, with a significantly higher pulsatility index and resistance index . Data concerning the number of drilling holes needed to achieve positive effects on hormonal profiles, ovulation rate and pregnancy is limited. In a rather small prospective, randomised study, Balen and Jacobs  performed unilateral LOD in four patients and bilateral LOD in six patients. They could not demonstrate the occurrence of pregnancies, but patients after unilateral LOD ovulated from both sides and they discussed that correction of the disturbed ovarian–pituitary feedback might be the most important effect of LOD.
Ovulation and pregnancy rate
Reports on ovarian drilling reveal excellent results. Even clomiphene-resistant patients show a high rate of spontaneous ovulations after the laparoscopic procedure . The original work by Gjönnaess  describes an ovulation rate of 92% and a pregnancy rate of 80%. Six months after drilling, standard ovulation rates are between 63% and 81% [31, 32, 43]. Ovulation seems to be independent of the drilling technique [23, 24]. Results of the studies are given in Table 1.
In 57 patients, Cleeman et al.  have shown that the average time to pregnancy was 135 days, leading to an overall pregnancy rate of 61%. Therefore, these authors consider laparoscopic ovarian drilling as first-line treatment in anovulatory PCOS patients.
Randomised controlled trials in laparoscopic ovarian drilling (no abstracts)
No. of patients
Abdel Gadir 
Balen and Jacobs 
Farquhar et al. 
Three cycles HMG/FSH
81% per cycle
Münstermann and Kleinstein 
6 months GnRH analogues followed by three cycles low-dose FSH
67% (FSH stimulat.)
Takeuchi et al. 
Harmonic scalpel laser
Bayram et al. 
Six cycles FSH
Palomba et al. 
53.3% per cycle
13.4% per cycle
The duration of drilling effects on cycle length and ovulation rate is still under debate. Whereas some authors describe only transient beneficial results of approximately 1 year [16, 20, 25], the positive effects might last much longer, for a number of years [56, 65, 38].
A long-term follow-up by Naether et al.  reported a number of 211 pregnancies, including 50% spontaneous pregnancies. Another study compared a follow-up of 8 years after ovarian drilling by thermocoagulation in 116 patients, with 34 patients after hormonal treatment . About 31 patients after drilling and seven of the control group were lost to follow-up, the others were studied between 3 and 9 years. At the end of the observation time, patients after drilling showed ovulatory cycles in 55% compared to 8% before surgery, ovulatory cycle rate of the control was 26%. During the first postoperative year, 49% of the patients became pregnant. In total, 56% of patients after surgery had a live birth compared to 44% after hormonal treatment.
To summarise, an average pregnancy rate of 50% after drilling can be assumed, although most studies show methodological flaws and are uncontrolled. The multiple pregnancy rate should not exceed 4–5%, most pregnancies occur within 1 year after surgery.
Comparison to hormonal stimulation
The most widely used standard treatment in infertile PCOS patients is low-dose gonadotrophin stimulation, in particular with FSH. These stimulation protocols were introduced in the early nineties and have a low hyperstimulation rate with monofollicular cycles in at least 50% of stimulation cycles . Nevertheless, these protocols yield a higher multiple pregnancy rate compared to ovarian drilling . On the contrary, a certain disadvantage of ovarian drilling is the need of an invasive surgical procedure and a 20% risk of de novo adhesion formation . Vegetti et al.  randomised 16 patients to LOD and 13 patients to receive low-dose FSH treatment. The spontaneous ovulation rate after LOD was 81.2% and there was a 25% pregnancy rate per patient. The ovulation rate after FSH treatment was 84%, unifollicular development occurred in 63% of patients and a pregnancy rate of 38% per patient was achieved. This data were reported as abstract only. Abdel Gadir et al.  compared electrocautery with low-dose HMG or FSH stimulation and found that electrocautery was equally effective as HMG or FSH treatment after six cycles. Lazovic et al.  chose a randomised crossover design in 56 patients of LOD with a CO2 laser versus six cycles of HMG or FSH. The number of drilled holes was not stated. The data were available as abstract only. In a follow-up of 6 months after drilling or three cycles of gonadotrophins, there was no difference concerning rates of ovulation and pregnancy.
Farquhar et al.  have published a controlled randomised trial of 28 patients after electrocautery and 19 patients after three cycles of low-dose HMG/FSH. Initially, one patient in the electrocautery group and two patients of the hormonal treatment group had been excluded. The pregnancy rate did not show a significant difference. Interestingly, 19 patients underwent both treatments after the end of the follow-up. About 17 patients returned a questionnaire and 15 of them preferred laparoscopic ovarian diathermy instead of ovarian stimulation.
In a multicentre study comparing low-dose FSH stimulation and electrocautery in a total of 168 PCOS patients, Bayram et al.  reported a 67% cumulative pregnancy rate after stimulation, compared to only 34% after electrocautery. In the 83 patients of the electrocautery group, 45 patients had persistent anovulatory cycles and received clomiphene during follow-up. However, when hormonal stimulation with clomiphene or FSH was used during the follow-up additionally, the cumulative pregnancy rate after 12 months was exactly the same (67%), with a lower number of multiple pregnancies after electrocautery compared to FSH stimulation only.
To date, there is no data available which could give evidence that operative techniques are superior to hormonal stimulation. A second Cochrane analysis on this topic showed no difference between ovarian drilling over a 12-month follow-up period and a course of 3–6 hormonal stimulation cycles in a low-dose FSH protocol , including four studies with direct comparison of ovarian drilling and low-dose FSH. No studies are published showing a possible benefit of ovarian drilling after a longer follow-up. Bearing in mind that the majority of pregnancies after drilling will occur during the first year, this seems to be rather unlikely.
Comparison to metformin
There is no data available on the possible beneficial effects of combined ovarian drilling and metformin . In a recent prospective parallel randomised double-blind placebo-controlled trial, Palomba et al.  compared metformin treatment for a maximum of 6 months, together with a 6 month follow-up after LOD. No difference in the bleeding pattern was observed. At the end of the study, the total ovulation rate was not different. The pregnancy rate was significantly higher in the metformin group (18.6% vs. 13.4%), as well as with a significantly lower abortion rate. In contrast, Malkawi et al.  could not demonstrate any significant difference between the treatment with metformin 2×850 mg daily and laparoscopic ovarian drilling concerning ovulation rate (70.7% vs. 83.5%) and pregnancy rate (64.1% vs. 59.8%).
Combined effects of laparoscopic ovarian drilling and hormonal stimulation
Ovarian reaction to FSH stimulation in in vitro fertilisation (IVF) cycles might improve after ovarian drilling. Ovarian drilling followed by IVF should lead to a higher number of oocytes retrieved and a significantly improved embryonic development . However, these results must be interpreted with caution, since the authors have used a significantly higher FSH dosage in IVF cycles after ovarian drilling.
Farhi et al.  compared the results of HMG stimulation before and after LOD. If no spontaneous pregnancy occurred within 6 months after LOD HMG or FSH, stimulation was initiated again. The ovulation rate per cycle increased significantly from 48% to 71% after HMG and from 50% to 71% after FSH treatment. The LOD before hormonal stimulation should reduce the rate of multiple follicular growth and, therefore, multiple pregnancies. However, ovarian down regulation for 6 months before low-dose FSH stimulation is equally effective in order to avoid multiple pregnancies . In a prospective, randomised study, the authors used three FSH stimulation cycles after electrocautery or after 6 months of GnRH analogue ovarian suppression. In both groups, 30% of stimulated cycles were persistently anovulatory. The pregnancy rate of 36% was exactly the same. In a recent study by Bayram et al. , a quintuplet pregnancy with low-dose FSH after electrocautery has been described. However, it remains unclear whether a correct low-dose protocol was applied in this individual case.
Consecutive indications for laparoscopic ovarian drilling
Subgroups of patients who could have a primary advantage from ovarian drilling are yet not adequately defined. Low-dose FSH stimulation in poor responders might be more successful after ovarian drilling, although the pregnancy rate did not improve significantly . On the contrary, patients with hyperstimulation, even in a low-dose protocol, might benefit from electrocautery, only without hormonal treatment, thus, avoiding multifollicular development. Some negative predictive factors for successful ovarian drilling were postulated by Amer et al. : BMI>35, testosterone>4.5 nmol/l, FAI>15, infertility>3 years. In these groups, the indication for electrocautery should be made with caution.
Risks of laparoscopic ovarian drilling
The main risk besides the general risks of laparoscopic surgery is the formation of de novo adhesions. In an experimental study performed on rabbits, Keckstein et al.  could not demonstrate a high grade of adhesions. Adhesion rate was independent from the type of laser used, after Nd:YAG laser 1 of 19, argon laser 1 of 10 and CO2 laser 3 of 13. In humans, eight of eight patients showed ovarian adhesions, which were removed in a second-look laparoscopy . Nevertheless, all patients experienced ovulatory cycles and seven patients conceived. Interestingly, there was no difference between ovaries wrapped with Interceed or without an adhesion barrier. In a very limited study in 17 patients, Gürgan et al.  described adhesions in six out of seven patients after electrocautery and in eight out of ten patients after Nd:YAG laser. However, a second-look laparoscopy is not mandatory. In studies by Gürgan et al. [23, 24], pregnancy rates in 19 patients with and 20 patients without second-look laparoscopy were not different after 6 months. Liguori et al.  performed 30 second-look laparoscopies after 90 cases of ovarian drilling and found minimal to moderate adhesions in seven cases only. In a study by Felemban et al. , a rate of 27% postoperative adhesions was reported in a total of 17 patients. To summarise, the grade of adhesions after LOD varies substantially and is described as between 0% and 70% . Today, there is no sufficient evidence that the laparoscopic technique influences the grade of adhesion formation .
Although general risks are rare, one case of pelvic infection following LOD has been reported . In transvaginal hydrolaparoscopy, Casa et al.  have described bleeding complications in one case requiring conversion to classical laparoscopy.
Future development of laparoscopic ovarian drilling
Currently, laparoscopic ovarian drilling is performed by standard laparoscopic techniques using general anaesthesia. Zullo et al.  compared classical laparoscopic ovarian drilling with ovarian drilling by mini-laparoscopy under local anaesthesia, and found no differences concerning endocrine postoperative parameters, ovulation rates and pregnancy rates. Classic laparoscopy was complicated by a greater need of postoperative analgetic treatment and longer hospitalisation.
Furthermore, a new transvaginal approach by hydrolaparoscopy could facilitate the procedure. Transvaginal hydrolaparoscopy requires a high training level. The technique has already been performed in 13 clomiphene-resistant PCOS patients with a coaxial bipolar electrode . Six of 13 patients achieved normal ovulatory cycles within 6 months. Six pregnancies were reported; three spontaneous pregnancies, two pregnancies after hormonal stimulation and consecutive intrauterine insemination and one IVF pregnancy. The same technique was used by Casa et al. , giving a 66% ovulation rate and a cumulative pregnancy rate of 76% after 6 months, although 5 of 13 pregnancies needed additional hormonal stimulation . Ramzy et al.  treated 52 patients by ultrasound-guided transvaginal injection of warm saline (75°C) transvaginally into the ovarian stroma. Ovulation could be achieved in 73.1% of patients, resulting in a pregnancy rate of 26.9%.
Laparoscopic ovarian drilling is an interesting alternative approach to treat anovulatory polycystic ovary syndrome (PCOS) patients, although its indications are yet not well defined. The results are not superior to direct hormonal stimulation, but yield a lower multiple pregnancy rate and avoid the risk of ovarian hyperstimulation. Furthermore, laparoscopic ovarian drilling (LOD) normalises the hormonal environment, provides long-term effects and might improve the ovarian reaction to hormonal treatment. The need of a surgical approach and the formation of de novo adhesions is a major disadvantage of the method. In hyperinsulinemic patients, metformin treatment seems to offer higher pregnancy rates. Therefore, ovarian drilling must not be considered as the treatment of first choice. Patients with poor response to hormonal stimulation or disagreement with repeated multifollicular reaction to gonadotrophin stimulation might benefit from the surgical approach.
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