Laparoscopic Ovarian drilling

PCOS is a complex hormonal disorder that affects female fertility. In PCOS, the ovaries produce excess androgens (male hormones) either due to the release of excessive luteinising hormone (LH has an important role in sexual development and functioning) or through high levels of insulin in the blood (hyperinsulinemia).

Women with PCOS have prolonged or infrequent menstrual periods. The ovaries get enlarged and contain follicles (small cavities containing fluid) surrounding the eggs, due to which the ovaries are unable to function properly.

Ovarian drilling is one of the methods that can be used for treating infertility in women with PCOS. This is a minimally invasive surgery and involves destroying ovarian follicles, to induce a reduction of secretion of androgens and also increasing blood flow to the ovaries, which results in restoration of ovulation function.

Ovarian drilling is prescribed when the woman with PCOS is found resistant to certain oral medications (for example, clomiphene citrate – a selective oestrogen receptor modulator).

 It is found most useful for women with infertility of fewer than three years with higher concentrations of luteinising hormone.

The surgery is also helpful for women with PCOS suffering from persistent, abnormal bleeding despite hormonal treatment.

(Read more: LH Test)

In women with PCOS, the relative contraindications to ovarian drilling are:

• Infertility for more than three years
• Body mass index (BMI) greater than 35
• Testosterone level above 4.5 nmol/l
• Free androgen index (FAI) higher than 15 
• Presence of tubal diseases

This surgery is performed under general anaesthesia. So, the woman is also evaluated for any allergies for that.

The procedure is performed by an OBGyn doctor. A complete history of the patient including the symptoms experienced by the patient, pre-existing diseases, and medication history. Menstrual history and any previous treatments for PCOS are noted.

This is followed by physical examinations that involve a per vaginal and abdominal examination. Any abnormalities such as pain and tenderness are noted.

A panel of investigations are also done that includes:

• Routine blood tests: such as a complete blood count (CBC) to check for haemoglobin level
• Blood tests to assess various hormones such as testosterone, LH, FSH, prolactin, TSH, insulin, etc.
• Chest X-ray
• ECG
• USG of the pelvis and abdomen ultrasound to visualise the ovaries

The procedure is a daycare admission, i.e. the patient arrives in the morning and gets discharged by evening. The patient is advised to fast overnight before the procedure.

On the day of the procedure, the patient arrives at the hospital with all the relevant documents and changes into hospital attire. A final review is done by the doctor and nurses during which written consent is taken from the patient and the relatives. Once the patient is cleared for the procedure she is then shifted to an operating theatre.

An IV line is secured for administering fluid and medications. A monitor is attached to track the patient’s vitals (heart rate, blood pressure and oxygen saturation). The patient is placed usually in the lithotomy position (giving birth position).

The surgery is usually performed using laparoscopy with general anaesthesia. The site of the operation is cleaned followed by placing sterile surgical drapes. The surgeon then makes small incisions below the belly. Using a tiny tube, a small amount of carbon dioxide is insufflated to create sufficient space for inserting a laparoscope (a thin flexible tube with a camera attached to its end). The laparoscope is then threaded to view the pelvic organs.

This is followed by further small incisions for inserting the additional surgical instruments. During the surgery, using very fine needles typically four punctures are made per ovary with the application of diathermy current (a special heat current). After the punctures are made in the ovary, it is allowed to cool with saline to prevent heat trauma. Post this, the peritoneal cavity is washed with irrigating solutions.

Once the surgery is complete, the incisions are closed using sutures/staples and the area is covered with a bandage. Thereafter, the patient is monitored till the effect of the anaesthesia wears off. The surgery takes a few hours to perform.

The procedure can also be done via a vaginal approach also known as fertiloscopy.

The usual risks of the procedure arise from laparoscopy/fertiloscopy and anaesthesia. Some of the complications include:

• Infection or bleeding at the incision site
• Accidental injury to internal organs or major blood vessels
• Internal bleeding
• Pain after the procedure, from inflating the belly with air
• Problems due to anaesthesia: nausea, vomiting, breathing difficulties etc.
• Adhesions or scarring inside the body
• Premature ovarian failure

To check for signs of adhesion formation, a second-look laparoscopy may be performed.

Generally, the patient is discharged four to six hours after the operation on the same day and may be able to resume normal activities within 24 hours. Full recovery from this surgery can take from a few days to two to four weeks. 

Discharge advice typically includes instructions on wound care, medications including analgesics for pain relief and antibiotics for preventing infections.

Strenuous activity is not advised for a few days and physiotherapy may be given to strengthen the pelvic and abdominal muscles.

A follow-up schedule is also specified for reviewing any complaints or complications. This also includes visiting the doctor for the next few months (usually six). This is to understand the regularity of the periods, ovulation rate and pregnancy rate.

Ovarian drilling is a cost-effective minimally-invasive surgery used for treating women with PCOS for whom medicines have not been effective in conceiving. It may be performed along with other interventions such as other medications and IVF.

The surgery improves chances of success equivalent to other interventions, better response to fertility medicines and reduces the chances of multiple pregnancies. There are various surgical approaches for performing the procedure, with no major complications.