Surgical Treatment of PCOS (Ovarian Drilling, Wedge Resection, Ovarian Diathermy).

Stein and Leventhal performed ovarian wedge resection over 80 years ago and noted ‘astonishingly good results’ of regular menses and progress in some patients. In 1935, they reported on 7 patients that regained regular menstruation after surgery. Many studies have been performed over the years, some with impressive results. Many surgeons cite personal experience as the basis for their perceived better outcomes with surgery. Rigorous scientific trails can answer the ultimate question, ‘Does surgery help?’ Unfortunately, the majority of studies have not been well controlled from a research methodology standpoint. That is, other factors than surgery may have actually caused the onset of menstruation and the statistical analysis may have been flawed. Post operatively, some of the hormonal changes were reported to be transitory. Decreases in testosterone and estradiol were seen, but no changes in FSH or LH. Often the studies did not show these changes so it is hard to be sure of the actual hormonal changes of their significance.

The issue of post-operative adhesion formation has concerned fertility specialists for many years. One study showed that all patients that had laparotomy (bikini abdominal incision) developed adhesion. In one study, the researchers expected to see a 75% cumulative pregnancy rate but actually saw only 48%, possibly due to adhesion formation after surgery. Laparoscopy (belly button incision) may also cause adhesions.

The major problem with many of these studies is lack of uniformity and in general small study sizes. One study reviewed a total of 706 patients, 83% ovulated and 55% achieved pregnancy. Still, a major concern is adhesion formation that appears to be seen in approximately 80%-100%. Yet still, conceptions occurred if the patients ovulated with or without clomid. If severe adhesions form, patients may develop pelvic pain or need IVF to conceive.

The laparoscopic approach is the preferred choice for most patients. It is less invasive and done as an outpatient. A large Cochrane Database Systematic Review that summarized the results of a number of prior randomized controlled trials found that laparoscopic ovarian drilling had the same pregnancy rates as gonadotropin therapy but was without the risk of ovarian hyperstimulation syndrome or multiple gestations. In general, the overall cost may be less with the surgical approach because of the increased cost associated with the multiple gestations. Some have compared the cost of metformin therapy to laparoscopic ovarian drilling and found that the metformin patients had a higher pregnancy rate, suggesting that medical therapy should be done instead of surgery. The concerns of surgical therapy, in addition to the operative risks of anesthesia and surgery in general, have to with the potential destruction of ovarian tissue that occurs with the procedure. Some studies have addresses the number of puncture sites and fewer may be better. The procedure destroys ovarian tissue and the hormone profile afterwards is as expected: decreased androgens, increased FSH leading to better follicle and egg production. Inhibin B decreased with bilateral drilling and the antral follicle count decreases, suggesting that ovarian function may potentially be compromised. Possibly only one ovary should be drilled. It is difficult to predict which patient would fail. In general, we expect about 2/3 to ovulate with in 2 months with or without clomid treatment. One study examined 60 non-obese primary infertile women that failed clomid and found patients that were >35v years of age and has a day #3 FSH > 10.0 did not respond as well to the drilling procedure. Technically, these patients are not the classical PCOS patients we commonly see.

It is important that we have a discussion concerning the risks and benefits of this treatment before proceeding with laparoscopic ovarian diathermy. It may be a viable treatment option for some patients.