Polycystic Ovarian Disease (PCOD), also referred to as Polycystic Ovary Syndrome (PCOS), is one of the most common endocrine disorders affecting women of reproductive age. It is characterized by chronic anovulation, hyperandrogenism, and the presence of multiple small cysts on the ovaries. Women with PCOD often present with menstrual irregularities, infertility, obesity, hirsutism, and metabolic disturbances such as insulin resistance. While lifestyle modification and medical therapy are the first lines of management, some women with infertility caused by PCOD may not respond adequately to medications such as clomiphene citrate, letrozole, or gonadotropins. In such cases, laparoscopic ovarian drilling (LOD) has emerged as a valuable surgical option to restore ovulation and improve fertility outcomes.

Understanding PCOD and Its Challenges

The hallmark of PCOD is the failure of ovulation due to increased androgen production and altered hormonal regulation within the ovaries. The ovarian surface is often thickened, and multiple small cystic follicles accumulate under the capsule, preventing the release of a dominant follicle. This leads to irregular menstrual cycles, subfertility, and metabolic consequences.

First-line therapy includes weight management, insulin-sensitizing agents, and ovulation induction drugs. However, in a subset of women who are resistant to medical therapy, surgical management through laparoscopy provides an effective alternative.

Principle of Laparoscopic Management

Laparoscopic management of PCOD primarily involves ovarian drilling, a procedure where multiple small punctures are created in the thickened ovarian capsule and stroma. This reduces androgen-producing tissue, restores normal hormonal balance, and facilitates ovulation. Unlike older techniques such as wedge resection, laparoscopic drilling is less invasive, causes fewer adhesions, and preserves ovarian tissue.

Indications for Laparoscopic Ovarian Drilling (LOD)

Women with PCOD-related infertility not responding to medical ovulation induction (clomiphene-resistant PCOD).

Women with contraindications to or failure of gonadotropin therapy.

Patients with high risk of ovarian hyperstimulation syndrome (OHSS) from gonadotropins.

Those desiring a minimally invasive, fertility-enhancing procedure without long-term medications.

Surgical Technique

Anesthesia and Positioning
The procedure is performed under general anesthesia. The patient is placed in lithotomy position with a Trendelenburg tilt to allow pelvic exposure.

Port Placement
A standard laparoscopic setup is used, usually with a 10-mm umbilical port for the laparoscope and two 5-mm accessory ports.

Inspection
Both ovaries are inspected. Typically, in PCOD, ovaries appear enlarged, pearly white, and thickened with multiple subcapsular follicles.

Drilling Procedure
A monopolar electrocautery needle, laser, or harmonic scalpel is used to make 4–10 punctures in each ovary, penetrating approximately 3–4 mm deep. Care is taken not to damage the ovarian hilum to preserve vascular supply. Each puncture delivers controlled thermal energy, destroying androgen-producing stromal tissue.

Hemostasis and Completion
Minimal bleeding is usually observed. Irrigation may be performed to cool the ovarian surface and reduce adhesion formation. Ports are removed, and the patient is awakened from anesthesia.

Mechanism of Action

Laparoscopic drilling reduces ovarian androgen production and luteinizing hormone (LH) levels, which helps restore normal follicular maturation. By breaching the thickened ovarian capsule, it also facilitates follicle rupture and ovulation. The overall effect is improved hormonal balance and spontaneous ovulation in many women.

Postoperative Care and Recovery

Patients recover quickly, with most discharged within 24 hours. Mild abdominal discomfort is managed with oral analgesics. Normal activities can usually be resumed within a week. Ovulation typically resumes within 4–6 weeks, and many women achieve spontaneous conception within six months. Follow-up includes monitoring menstrual cycles, ovulation, and fertility outcomes.

Advantages of Laparoscopic PCOD Management

Restoration of Ovulation – High rates of spontaneous ovulation in women resistant to medications.

Reduced Need for Drugs – Decreases reliance on ovulation-inducing medications, lowering risks of OHSS and multiple pregnancies.

Fertility Preservation – Provides a safe surgical option while maintaining ovarian tissue.

Minimally Invasive – Small incisions, faster recovery, minimal pain, and excellent cosmetic results.

Durable Effect – Many women maintain regular cycles and ovulation long after the procedure.

Risks and Limitations

While laparoscopic ovarian drilling is safe, some risks exist:

Adhesion formation around the ovaries or pelvic structures.

Reduced ovarian reserve if excessive drilling is performed.

Incomplete response in some women, particularly with severe metabolic PCOD.

Rare complications such as bleeding, infection, or injury to adjacent organs.

Careful patient selection, limiting the number of punctures, and precise energy application minimize these risks.

Outcomes and Fertility Benefits

Studies show that 60–80% of women resume ovulation after laparoscopic ovarian drilling, and pregnancy rates are significantly improved. In clomiphene-resistant women, this procedure offers an effective alternative before advancing to assisted reproductive technologies like IVF. Long-term metabolic improvements are also observed, though lifestyle modification remains essential for overall health.

Conclusion

Laparoscopic management of PCOD through ovarian drilling is a safe, effective, and fertility-enhancing option for women unresponsive to medical therapy. By restoring ovulation and reducing dependence on hormonal medications, it offers new hope for women struggling with infertility due to PCOD. With careful patient selection, expert surgical technique, and ongoing lifestyle management, laparoscopic ovarian drilling can significantly improve reproductive outcomes and quality of life for women with this challenging condition.