The document discusses guidelines and recommendations for ovarian drilling as a treatment for polycystic ovary syndrome (PCOS). It recommends that ovarian drilling be used as a second-line treatment in highly selected cases, such as those with clomiphene citrate resistance, a normal body mass index, or who live too far from treatment centers. The document provides guidance on patient selection, including optimal anti-Mullerian hormone levels, as well as techniques for ovarian drilling to optimize outcomes and avoid potential risks like diminished ovarian reserve. Key aspects discussed include tailoring the number of punctures and thermal dose based on individual ovarian volume.

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2. Ovarian Drilling..Do’s & Don’ts

4. • Rotterdam Criteria 2003
• The Thessaloniki ESHRE/ASRM-Sponsored
PCOS Consensus Workshop Group
March 2–3, 2007, Thessaloniki, Greece.
Human Reproduction 2008
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5. HA
PCOM
IM

6. Consensus on infertility treatment in PCOS
dr.dhorepatil
FIRST LINE
CLOMIPHENE CITRATE
SECOND LINE
LOD/GONADOTROPINS
THIRD LINE
IVF
R
E
S
I
S
T
A
N
C
E
R
E
S
I
S
T
A
N
C
E
F
A
I
L
U
R
E

7. Ovarian Drilling in PCOS: Is it Really Useful?
RCOG,[2007] ACOG,[2009] Society of Obstetricians
and Gynecologists, Canada[2010] and the PCOS
consensus working group[2008)
All recommend LOD use in highly selected cases,
Hypersecretion (LH), normal BMI, needing
laparoscopic assessment of the pelvis or who live
too far away from the hospital for the intensive
monitoring required during gonadotropin therapy.
This implies that LOD is a valid, but not the
sole option for CC- resistant PCOS
Mitra et al ,2015

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PCOS
PCOS
Which one to drill?

10. Case senario
29yrs old pt..with irregular menses, p.infertility
5ys,both tubes patent,no male factor
FSH..5.30,LH 6.7,AMH 4.5,AFC 15,ovaries PCOM
Will you Drill this Ovary?
NO

11. Is reduction of AMH level needed?
• Decrease in AMH : needed for better response
and women with the highest concentrations have
the worst outcome.
• The evidence has led us to hypothesise that there
is a subgroup of women with PCOS who have
elevated levels of AMH and who are the most
resistant to treatment.
• AMH is unlikely to be the sole cause of
anovulation, but it has effects on aromatase
expression and folliculogenesis

12. Ovarian Drilling
• When to do?
• Is all PCOS same? AMH(3.5- 5) (5-7) (>7.5 )
• Is it 3.5 to 5 group of pts .land up to POI with
drilling
• Is it going to be helpful if we drill pts > 7 value
• Can we optimise best if we select only pts
with AMH between 5 to 7ng/ml?

13. How Many Punctures,Thermal energy?
• Too little is insufficient
• Too much is harmful….
• Just appropriate ..looking at each individual
patients profile is necessary for selection of
drilling procedure

14. • The number of punctures is empirically
chosen depending on the ovarian size.
• In the original procedure, 3-8 diathermy
punctures (each of 3 mm diameter and 2-4
mm depth) per ovary were applied, using
power setting of 200-300 W for 2-4 s (
Gjönnaess ,1984).

15. • The clinical response is dose-dependent, with
higher ovulation and pregnancy rates
observed by increasing dose of thermal
energy up to 600 J/ovary,irrespective of
ovarian volume (Amer 2003).
• Most gynecologists perform bilateral over
unilateral drilling.
(Roy et al,2009 , Farquhar et al,2012).

16. Don’tToo Much..

17. • Overall consensus is perform four punctures
per ovary, each for 4 s at 40 W (rule of 4),
delivering 640 J of energy per ovary (the
lowest effective dose recommended)
(Armar et al 1990)
• Rule of Four
 Watt ..40
 seconds..4sec
 puncture points..4

18. • The aim of fixed number of puncture points
regardless of ovary size (Felemban et al,2000)
or unilateral ovary cauterization to decrease
the potential risks of ovarian failure and
adnexal adhesions (Balen and Jacob,1994).
• May be too little
• So what next..adjusted individualise LOD

19. Adjusted LOD
• New terminology
• Means tailoring the number of punctures
according to Ovarian Volume
(Fertility Sterility Zakherah et al ,2011)

21. • Thermal Dose in Adjusted LOD

22. • Suggested dose was 625 J/10.8 cm3= 60 J/cm3
of ovarian tissue.
• The required number of punctures then was
calculated by dividing total individual ovarian
dose with dose delivered in each puncture
point.
( e.g. 12 cm3 x60=720 j ÷150=4.8 punctures)

23. Word of caution..
• The impact of laparoscopic ovarian drilling on AMH &
ovarian reserve: a meta-analysis
• LOD significantly lowers circulating AMH, but this may
not necessarily reflect a real damage to ovarian
reserve.
• Given its proven efficacy and its long-term benefits,
LOD should remain as an option in the management of
anovulatory PCOS patients.
• (Saad A Amer1, Tarek T El Shamy2, Cathryn James, Ali
H Yosef , Ahmed A. Mohamed, 2017)

24. How to avoid DOR ?
Adjust your dose ALOD
Cutting mode instead of coagulating mode
Short time 5 seconds
Low wattage 30 watt
Lavage Before and After Unilateral RT ovary –
Adjusted Never drill unless indicated

25. • Avoid cauterization at
• Mesoovarium
• Hilum
• Corpus Luteum
• Ovarian ligament
• Infundibulopelvic ligament

26. Never Drill..
• Ovarian volume less than 10 cm3.
• FSH more than 9 IU/L
• Previous ovarian drilling …except pt has
conceived after previous LOD
• AMH less than 5 ng/ml or more than 8.3
ng/ml
• Only used as a 2rd line therapy

27. Take Home ..
• LOD still has a role to play in PCOS, however
selective group of pts is must
• Individualization each case must
• It is 2nd line management
• Adjust thermal dose and no of punctures with
proper technique is the need of hour to
optimize ovulation and pregnancy rate
without damaging Ovarian reserve

28. Your skills are what you put in yesterday.
Commitment is what you must put in today
in order to make today your masterpiece
and
make tomorrow a success.
John C. Maxwell, in “Make Today Count”

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