Introduction

The aims of treatment for polycystic ovarian disease involve correction of the essential endocrinopathy, reduction in the risk of chronic hyperoestrogenism, treatment of hyperandrogenism and associated hirsuitism, the correction of the underlying anovulatory infertility, or any combination of the above.

Laparoscopic approaches to treatment of polycystic ovarian disease have focused upon ovulation induction and improvement in fertility rates, but other benefits continue to be described. This review will focus upon fertility considerations, but other endpoints will be considered.  

The history of polycystic ovarian disease

Stein and Levinthal (1935) first described the surgical treatment of polycystic ovaries in 1935. They described wedge resection of the ovaries in seven women, all of whom were restored to normal menstrual patterns and two of whom subsequently conceived. Stein (1964) reported on 108 women treated by bilateral ovarian wedge resection, with restoration of normal menstruation in 94%, and conception in 86% of those who desired pregnancy.

In 1960, the isolation of human gonadotrophin presented an alternative therapeutic option for the treatment of anovulatory infertility associated with polycystic ovarian disease (Gemzell et al, 1960). Clomiphene citrate became available for the first time in 1961 (Greenblatt et al, 1961), simplifying the therapeutic options for ovulation induction.

Adhesion formation, chronic pelvic pain and iatrogenic infertility became increasingly associated with bilateral ovarian wedge resection, prompting Kirstner to state in 1968 that surgical approaches to patients with polycystic ovarian disease should take a minor position in patients care. Toaff et al supported this in 1976 after performing laparoscopy on seven women with persisting infertility after bilateral ovarian wedge resection, and finding all patients to have extensive tubal and ovarian adhesions. Over this decade, surgical approaches to anovulatory infertility were convincingly replaced by developing medical therapies.

In 1969, the problem of multiple pregnancy after gonadotrophin treatment was highlighted by Goldfarb and Crawford, and again by Kovacs in 1989 when he reported a multiple pregnancy rate of 20%. The cost of gonadotrophin therapy, the requirement for intensive monitoring and the serious risk of ovarian hyperstimulation continued to be reported in the medical literature. Down-regulation of pituitary function with gonadotrophin releasing hormone (GnRH) followed by treatment with gonadotrophin held hope, but was found to be unrewarding for patients with polycystic ovarian disease (Kovacs et al., 1989).

In 1981, Adashi reported restoration of ovulation in 91% of women and a crude pregnancy rate of 48% in women with polycystic ovarian disease treated surgically, rekindling interest in this approach.

The major stimulus for re-exploration of the surgical approach resulted from the work of Gjönnaess in 1984, when he reported a 92% ovulation rate and an 80% conception rate following laparoscopic electrosurgical drilling of the ovaries in clomiphene citrate resistant patients. While Campo’s results in the previous year were less encouraging - with an ovulation rate of 45% and a pregnancy rate of 42% in 12 women treated, the impetus for exploration of surgical approaches to this disease was established. 

Greenblatt & Casper (1987) reported an 83% ovulation rate following laparoscopic ovarian drilling, and Kovacs reported a 90% ovulation rate in 1991. Kovacs supported Dabirashrafi (1989) in providing evidence that adhesion formation after laparoscopic approaches to ovarian cyto-reduction was significantly less than previously described for open procedures. The return to a surgical approach for polycystic ovarian disease was thus established.

This return to operative management lead to an exploration for the optimal energy source. This has still not been resolved. In 1988, Huber et al proposed advantages in the use of CO² laser, Daniell and Miller (1989) reported on 85 women treated by either CO² laser or KTP laser with favorable results. Argon and Nd:YAG lasers have also been used, with lasers in general offering the theoretical benefit of precise destruction with little lateral thermal effect. However, I am not aware of any randomized controlled data demonstrating clear superiority of one energy source over another.

Incidence of polycystic ovarian disease

Polycystic ovarian disease has been increasingly recognized as a clinical entity over the last decade, with the true incidence dependent upon the criteria used to establish the diagnosis, for which there remains no consensus. Polsen (1988) reported that polycystic ovarian disease diagnosed by ultrasound assessment in healthy volunteers may occur in as many as 23% of the female population. Farquhar reported a similar incidence in 1994.

Management of polycystic ovarian disease

Medical approaches

The non-surgical management of polycystic ovarian disease is well known and includes weight reduction in obese women with this condition. This alone will initiate spontaneous ovulation without the use of ovulation induction agents in some individuals. Clomiphene citrate remains as the first-line treatment for the induction of ovulation in others. Response to clomiphene citrate is variable in women with polycystic ovarian disease, ranging from an exaggerated response to clomiphene resistance. Overall about an 80% ovulation rate and a 40% pregnancy rate can be expected.

Historically second-line treatment for clomiphene citrate resistant polycystic ovarian disease has been the use of gonadotrophin therapy. This is expensive, requires intensive hormonal and sonographic monitoring, and risks high grade multiple pregnancies or the danger of ovarian hyperstimulation. Pregnancy rates range from 30 – 55%.

Down regulation of the pituitary by the use of Gonadotrophin Releasing Hormone (GnRH), has a part to play in association with gonadotrophin therapy. While pregnancy rates may be improved and early pregnancy loss associated with polycystic ovarian disease and high luteinizing hormone (LH) levels may be reduced, ovarian hyperstimulation remains a problem.

Perhaps the insulin resistance and hyperinsulinaemia associated with polycystic ovarian disease may provide therapeutic options in the future. Treatment with oral hypoglycaemics has shown some evidence of improvement in the hyperandrogenism, the altered lipid states, and the anovulation associated with polycystic ovarian disease (Donesky & Adashi, 1995)

Surgical approaches

As we have discussed, bilateral ovarian wedge resection results in normalization of the hormonal milieu, ovulation rates around 80% and pregnancy rates around 60% (Adashi et al, 1981).  Unilateral oophorectomy has also been described as restoring ovulatory function in three patients with clomiphene citrate resistant, gonadotrophin resistant and in-vitro fertilization resistant polycystic ovarian disease (Kaaijk et al, 1997).

Palmer and De Brux (1967) described laparoscopic ovarian wedge biopsy. This is not an easy procedure and seems to confer no benefit over other laparoscopic methods of inflicting injury on the ovary.

The term ovarian drilling refers to the use of either electrosurgical or laser energy to drill a hole in the ovarian cortex at multiple sites, almost invariably undertaken as a laparoscopic procedure. The development of minimal access surgery in general has led to reinterest in this procedure, and favorable results have been reported from multiple centres around the world.

Techniques of Laparoscopic Ovarian Drilling

Electrosurgery

A three-puncture laparoscopy is generally used. This allows one port for the endoscope, one for a grasping forcep to stabilize the ovary and isolate it from surrounding structures and one for the electrosurgical instrument.

Any instrument capable of providing high power density current to the ovarian surface will suffice, such as finely pointed laparoscopic scissors. The Corson cannula (Fig. 1) is probably the ideal instrument for this procedure. Power should be delivered with the instrument at right angles to the ovarian surface. If a Corson cannula is used, beware of capacitative current in the outer sheath if it is isolated from the abdominal wall. This instrument allows smoke evacuation or irrigation through the outer sheath without the need to introduce a dedicated suction – irrigation probe.

During application of energy, it is most important to avoid inadvertent injury to adjacent bowel, and to cool the surface of the ovary with irrigation fluid before allowing it to settle back into the pelvis. It is also important to avoid energy application near the hilum of the ovary, both to avoid injury to the ovarian vessels and to avoid compromise to ovarian blood supply. Dubirashafi (1989) has described vascular compromise leading to ovarian atrophy.

A wide variety of power settings and energy applications have been described. I would recommend use of an unmodulated waveform (“cut” current) to reduce peak voltage and limit lateral thermal spread of electrosurgical injury. Energy application from the tip of laparoscopic scissors will produce the required effect at around 100 watts of unmodulated current, although this would need to be reduced to around 60 watts using the Corson cannula, due to higher power density application from its fine pointed tip. I recommend activation of the electrode as it come in contact with the ovarian surface after which it is advanced into the ovarian cortex to a depth of 2- 5 mm. Lesions measuring 2 – 3 mm in width are desirable, and can be achieved with the above settings. Satisfactory ovarian drills can be produced with the above settings by energy application over 1 – 2 seconds.

The number of drills required is both an important and controversial issue. Initially around 20 – 25 drills per ovary were used, probably influenced by a perceived desire to achieve similar cyto-reduction to that of a small wedge resection. Kovacs (1993) recommends a minimum of 10 drills per ovary and Gjonnaess (1994) now recommends a minimum of 8 drills per ovary. Balen and Jacobs (1994) have produced evidence that 4 drills may be sufficient, and that unilateral drilling may be as effective as bilateral treatment. Evidence for the minimum number of drills continues to accrue, and it seems likely that this will relate to ovarian size.

Laser

CO² laser was the first to be used for ovarian drilling. This can be introduced through a coaxial operating laparoscope, or through a second puncture system. A further delivery system known as a waveguide may be used, where the laser beam is internally reflected through a fine ceramic lined tube, directly to the ovarian surface.

Recommended power settings vary widely, and my own experience has been to use 40 watts in continuous mode through a second puncture system, with a spot size of 0.6 – 1.2 mm and application duration of 2 – 3 seconds. All the same principles of electrosurgical energy application apply, such as avoiding inadvertent injury, irrigation and cooling of the ovary and avoiding energy application to the hilum of the ovary. It is thought that a larger number of drills may be required when using laser compared with electrosurgery, due to the reduced lateral thermal damage induced with this modality.

Nd:YAG laser has been used in both non-contact and contact mode. Contact mode applications require sculptured quartz fibres or sapphire tips. While there is perhaps less smoke and improved haemostasis, Nd:YAG offers no major advantage over electrosurgical drilling.

KTP and Argon lasers have the advantage of using cheaper bare fibres in contact mode. While lasers are theoretically more precise, there is no evidence that this translates into any clinical advantage over electrosurgery.

Results of Ovarian Drilling

The reported conception rates following laparoscopic ovarian drilling varies enormously between authors. This no doubt relates to variable case selection, variation in technique and variation in the use of postoperative clomiphene citrate or gonadotrophin therapy.

Table 1 shows the crude pregnancy rate in published series with greater than 20 patients.  Ovulation rates have not been analyzed, as there is great variation in the definition of ovulation, whether this is sustained and whether clomiphene citrate has been given post-operatively.

Pregnancy rates range from 27 – 73%. Pregnancies are more likely to occur in non-clomiphene citrate resistant patients (Daniell & Miller, 1989), although improved responsiveness to clomiphene citrate or gonadotrophin may be found after surgery. Pregnancies are most likely to occur within 6 months of surgery.

Campo (1998) undertook a large meta-analysis of 1803 anovulatory polycystic ovarian disease patients, with 679 treated by wedge resection at laparotomy, 720 by laparoscopic electrosurgery, 322 by laser vaporization and 82 by laparoscopic multiple biopsy – finding no significant difference in the outcome by surgical technique.  The average ovulation rate was 78.8%, the cumulative pregnancy rate was 58.5%, the miscarriage rate was 15.9%, the twin pregnancy rate was 2.1% and the ectopic pregnancy rate was 1.6%.

In this same study he found hormonal changes after surgery to consist of a marked fall in androgen levels, an increase in follicle stimulating hormone (FSH) level, reduced amplitude of LH pulses and an LH/FSH ratio tending towards normal levels. Gjonnaess in 1998, looked at the duration of these endocrine changes resulting from ovarian electrocautery, and found evidence of normalized ovarian function lasting for up to 20 years.

Factors associated with pregnancy outcome from ovarian drilling

Short duration infertility is associated with a significantly improved outcome from ovarian drilling (Li et al, 1998, Saravelos et al, 1997). Age of the patient does not appear to be of significant predictive value (Saravelos et al, 1997).

High pre-operative LH levels are predictive of a better outcome (Abdel Gadir et al, 1993). The LH/FSH ratio, in contrast to the absolute LH level, is not predictive of the outcome.

Interestingly body weight seems to be independent of pregnancy rates after ovarian drilling (Gjönnaess, 1994, Li et al, 1998), although there is some evidence that ovulation rates are higher in slimmer subjects (Gjönnaess, 1994).

Smoking seems to exert a profound effect upon outcome after ovarian drilling. Naether (1993) reported a pregnancy rate of 70% in 104 patients undergoing ovarian drilling. However, the pregnancy rate was 94% in non-smoking couples, 53% when the male partner smoked, 45% when the patient smoked and 27% when both partners smoked.

Potential complications of Ovarian Drilling

Apart from all the usual complications associated with laparoscopic surgery, adhesion formation around adnexal structures may result. This development may adversely affect short and long term fertility, or cause chronic pelvic pain.

Reported adhesion rates vary from 0 – 100%. Perhaps Campo’s meta-analysis (1998) of 1803 patients provides the most useful information. He reports an adhesion rate of 90% after wedge resection at laparotomy, 30% after laparoscopic electrosurgical drilling and 50% after laparoscopic laser vaporization.

Greenblatt and Casper (1993) found no benefit from Interceed, an absorbable adhesion barrier used to cover the ovary at the end of a procedure, and this was supported by Saravelos and Li (1996)

Most adhesions following ovarian drilling are minor and do not cause problems with fertility or pain (Greenblatt & Casper, 1993).

Conclusions & recommendations

Ovarian drilling is a powerful tool in the treatment of polycystic ovarian disease. Treatment with clomiphene citrate remains as first line treatment for anovulatory infertility associated with this disease.

Laparoscopic ovarian drilling should probably become second-line treatment for those with clomiphene resistant disease, rather than recourse to treatment with gonadotrophins. This strategy has a number of benefits as outlined in a review by Doneski and Adashi (1995). These are listed as no increase in the rate of multiple gestation, elimination of the risk of ovarian hyperstimulation, no requirement for intensive monitoring, a potentially lower rate of miscarriage, the production of multiple ovulatory cycles from a single course of treatment and finally, the lower cost of operation compared with gonadotrophin therapy.

While prospective randomized comparative data between gonadotrophin therapy and ovarian drilling is not available, there is much circumstantial evidence to recommend ovarian drilling.

Table 1. Crude conception rates following ovarian drilling in polycystic ovarian disease.

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