Laparoscopic ovarian drilling (LOD) is a second-line treatment for infertility in polycystic ovary syndrome (PCOS) patients who do not respond to clomiphene citrate. Adjusting the number of punctures and thermal dose based on individual ovarian volume improves outcomes and reduces risks of damage to ovarian reserve compared to fixed dosing protocols. While LOD improves ovulation and pregnancy rates, it is not a first-line or permanent treatment, and repeated drilling is not recommended. Oral and gonadotropin therapies are preferable first-line options before considering LOD or in vitro fertilization.

1. Prof. Mahmoud Zakherah
Prof of Obstetrics and Gynecology,
Women’s Health Hospital Assiut University
Egypt
mszakhera@gmail.com
22-12-17

3.  A “stepwise approach” to the management
of infertility in PCOS
Ovarian Drilling in PCOS: Is it Really
Useful?

4. 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, particularly in those with hypersecretion
(LH), normal body mass index, needing
laparoscopic assessment of the pelvis or who live
too far away from the hospital for the intensive
monitoring required during gonadotropin
therapy.

5. Ovarian Drilling in PCOS: Is it
Really Useful?
This implies that LOD
is a valid, but not the
sole option for CC-
resistant PCOS
Mitra et al ,2015

6. All meta-analysis confirmed
that LOD is a second-line
treatment in PCOS patients,
especially those with CC
resistance.
 Mayenga et al Gynecol Obstet Fertil (2011) .
 Farquhar et al Cochrane Database Syst
Rev (2012).

7. How many punctures?
How many punctures

8. Four Facts

9. You are lucky
PCOS patient has the
advantage of being have
a good ovarian reserve
than their peers who are
NON PCOS

11. Infertility
with increased risk of
Metabolic syndrome
➢ Type II diabetes
➢ Cardiovascular disease.
➢Endometrial cancer

12. PCO not equal PCOS
Polycystic-
appearing ovaries
on ultrasound
examination are a
nonspecific
finding in PCOS.

13. Criteria of diagnosis of PCOS

14. PCO not equal PCOS
Rotterdam criteria 2004 ,entails the
presence of ≥12 follicles within the
ovary with a diameter of 2-9 mm and/or
ovarian volume ≥10 cm.
Polycystic ovaries may present in
healthy women, s0 the inclusion of this
sign to the diagnostic criteria of
polycystic ovary syndrome is still
questioned.

15. PCO not equal PCOS
Sonographically diagnosed polycystic
ovaries by Rotterdam Criteria increase in
the percentage of polycystic
ovary syndrome .
Recently , 26 versus 12 follicles-is required
to distinguish among women with PCOS and
healthy women from the general population
(Lujan et al. Hum Reprod. 2013)

16. PCOS imitators
The most important step to
diagnose PCOS to exclude
other conditions of
CA/Hyperandrogenism

17. PCOS imitators
 NC CAH 17 hydroxyprogesterone
 Hypothyrodism TSH
 Hyperprolacinemia prolactin
 Adrenal tumors DHES
 Ovarian tumors total testosterone
 Cushing’s syndrome cortisol

18. How many punctures?
How many punctures

20. How many punctures?
Too little is insufficient
Too much is harmful
The solution is : Adjust

21. How many punctures?
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).

22. How many punctures?
 Most surgeons 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
➢40 W
➢4 seconds
➢4 puncture points

23. How many punctures?
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

24. How many punctures?
In earlier studies there was an
assumption that the greater the
amount of energy, the more
effective the procedure.
(Gjonnaess,1989)
May be too much

25. How many punctures?
 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 still perform bilateral
over unilateral drilling.
(Roy et al,2009 , Farquhar et al,2012).

26. Unilateral versus Bilateral
Unilateral as effective as bilateral (Balen
and Jacob,1994).
Contralateral ovary may ovulate first
(Al-Mizyen and Grudzinskas 2007)

27. How many punctures?
Adjusted laparoscopic
ovarian drilling of PCOS

28. Adjusted LOD
 New terminology
 Means tailoring the number of
punctures according to Ovarian Volume
(Zakherah et al ,2011)

29. Ovarian Volume
Ovarian volume is calculated by the
measurement of the length, width and
the thickness and use of the classical
formula for a prolate ellipsoid: L × W × T ×
0.5 (Adams et al ,1985 Chen et al ,2008).
 The volume of each ovary was calculated as follows: length ×
width × height × 0.523 (Higgins et al ,1990).
Three-dimensional ultrasound is a recognized
diagnostic modality to assess ovarian volume

30. The antral follicle count(AFC)
➢AFC was defined as the total number of
follicles < 9 mm in diameter in both
ovaries
➢FNPO is best predictor for diagnosis
PCOS
Christ et al , Fertil Steril,. 2014
Lie Fong et al, Hum Reprod. 2017

31. Methodology of Adjusted LOD
 We 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)

32. Thermal Dose in Adjusted LOD


33. How many punctures?
Adjusting thermal dose based on
ovarian volume (60 J/cm3 ) has
better reproductive outcomes with
similar postoperative adhesion rates
than fixed dose of 600 J/ovary
(Zakherah et al ,20011)

35. Is ovarian reserve diminished after
laparoscopic ovarian drilling?
✓The PCOS women both with and without
LOD had significantly greater ovarian reserve
than the age-matched controls having
normal ovulatory menstruation (Weerakiet et
al ,2007).
✓ LOD, if applied properly, normalizes the
exaggerated ovarian morphologic and
endocrinologic properties. (normalization of
ovarian function rather than a reduction of
ovarian reserve ) (Api,2009)

36. Adjusted bilateral ovarian
drilling based on ovarian volume
has no detrimental effect on the
ovarian reserve (Zakherah,2014).

37. Assessment of ovarian reserve after
unilateral diathermy with thermal
doses adjusted to ovarian volume .
Dose-adjusted unilateral diathermy
(60 J/cm(3)) does not have significant and
long-term effects on ovarian reserve.
 Sunj et al , Gynecol Endocrinol. 2014

38. Anti-Müllerian hormone, testosterone and free
androgen index following the dose-adjusted unilateral
diathermy in women with polycystic ovary syndrome
 The value of T is the strongest and consistent
indicator of ovulatory response after
diathermy
 Sunj et al .Eur J Obstet Gynecol Reprod Biol. 2014

39. Does unilateral laparoscopic
diathermy adjusted to ovarian volume increase the
chances of ovulation in women with polycystic
ovary syndrome?
The pregnancy rate was significantly
higher in patients with a larger right
ovary compared with those with a
smaller right ovary, regardless of the
treatment group
 Sunj et al Hum Reprod. 2013

40. .
Conclusions :Accurate and documented
diagnosis of PCOS, appropriate surgical
training, adjusted thermal injury and
adjusted number of punctures are
essential for the avoidance of excessive
damageto the ovaries.

41. 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)

42. 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

43. To Avoid DOR
Avoid cauterization at
Mesovarium
Hilum
Corpus luteum
Ovarian ligament
Infudibulopelvic ligament

44. Never Drill
Ovarian volume less than 10 cm3.
FSH more than 9 IU/L
Previous ovarian drilling .except
AMH less than 5 ng/ml or more
than 8.3 ng/ml
Only used as a 2rd line therapy

45. Repeated LOD in polycystic ovary
syndrome
✓ DO NOT Repeat
✓ You will repeat failure
✓ After 1 y follow up IVF
✓ Antagonist Vs Long protocols
✓ Repeat LOD is ONLY in women
who previously responded to the
first procedure (Amer ,et al
,2003).

46. Take home messages
Lod still has a place and still
useful .
Proper diagnosis
 Exclude PCOS imitators
 LOS is 2nd line therapy for
clomiphene resistant cases
 Adjust thermal dose

47. Take home messages
 LOD is currently recommended as a safe, efficacious
and cost-effective alternative to gonadotropins for
OI in infertile, anovulatory, CC-resistant PCOS
women without the risks of OHSS or multiple
gestation.
 Although iatrogenic adhesion formation and DOR
are potential complications, they are of little clinical
significance and can be minimized by adjusting the
number of punctures and energy applied.

48. Take home messages
 LOD improves ovarian responsiveness to
CC and gonadotropins, these may be
considered after LOD failure instead of
repeat LOD, before proceeding to the last
resort that is, IVF.
 LOD is only an alternative, not the
ultimate in management of PCOS

49. Take home messages
 LOD NOT the first NOR
last line of treatment of
PCOS.
 There are safe and efficacious oral alternatives
and relatively safe as low-dose step-up
regimen of gonadotropin therapy before
proceeding to the last resort that is, IVF.

50. If your only toy is a hammer
every problem will look like
a nail