Polycystic Ovary Syndrome (PCOS) is one of the most common endocrine disorders affecting women of reproductive age, characterized by irregular menstruation, anovulation, hyperandrogenism, and polycystic ovarian morphology. It is a leading cause of infertility, not only due to anovulation but also because it may coexist with other factors such as tubal blockage. Laparoscopy plays a dual role in these cases, serving as both a diagnostic tool to assess tubal patency and as a therapeutic intervention through ovarian drilling to induce ovulation. This combined approach can significantly improve fertility outcomes in women with PCOS.

Importance of Tubal Patency Testing

For successful conception, both fallopian tubes must be open to allow the egg and sperm to meet. Tubal blockages contribute to nearly 30–40% of female infertility cases, often caused by pelvic infections, endometriosis, or adhesions from previous surgeries. In women with PCOS, who already face challenges with ovulation, unrecognized tubal blockages further reduce the chances of pregnancy.

Testing for tubal patency is therefore a crucial step in infertility evaluation. While non-invasive methods like hysterosalpingography (HSG) and sonohysterography exist, laparoscopy with chromopertubation remains the gold standard, as it not only confirms tubal status but also allows simultaneous treatment of pelvic pathologies.

Laparoscopic Tubal Patency Test

Procedure:

The patient is placed under general anesthesia and a pneumoperitoneum is created with CO₂ insufflation.

A laparoscope is introduced through the umbilicus for visualization. Accessory ports may be placed for instruments.

A uterine manipulator or cannula is inserted into the cervix.

A colored dye, usually methylene blue or indigo carmine, is injected into the uterine cavity.

The surgeon observes whether the dye spills freely from the fimbrial ends of both fallopian tubes.

Interpretation:

Free bilateral spill → Both tubes patent.

Unilateral spill → One tube patent, one blocked.

No spill → Bilateral blockage, requiring further intervention.

In addition to assessing tubal patency, laparoscopy allows identification of adhesions, endometriosis, or pelvic inflammatory disease that may affect fertility.

Ovarian Drilling for PCOS

Background:
In PCOS, the ovaries are often enlarged with thickened capsules and multiple small follicles that fail to mature. This results in chronic anovulation. Medical treatments such as clomiphene citrate, letrozole, and gonadotropins are first-line therapies. However, some women are resistant to medication or experience side effects like ovarian hyperstimulation syndrome. In such cases, laparoscopic ovarian drilling (LOD) becomes a valuable option.

Procedure:

After diagnostic laparoscopy and tubal patency testing, the ovaries are visualized.

Using a monopolar electrocautery needle or laser, 4–10 punctures are made on the ovarian surface.

Each puncture penetrates 3–4 mm into the ovarian cortex, targeting the thickened capsule and underlying stroma.

Care is taken to avoid excessive cautery to prevent adhesion formation and preserve ovarian reserve.

Mechanism:

Reduces the ovarian androgen-producing tissue, lowering testosterone levels.

Decreases luteinizing hormone (LH) hypersecretion, restoring normal hormonal balance.

Facilitates the growth of a dominant follicle, thereby promoting ovulation.

Advantages of Combining Both Procedures

Comprehensive Infertility Evaluation – Laparoscopy allows direct assessment of tubes, ovaries, and pelvis in one sitting.

Dual Benefit – Tubal testing diagnoses blockages, while ovarian drilling corrects anovulation.

Minimally Invasive – Both procedures can be done laparoscopically, reducing hospital stay and recovery time.

Improved Fertility Outcomes – Many women resume regular ovulation and achieve spontaneous conception within months after surgery.

Alternative to Long-Term Medications – Reduces dependence on ovulation-inducing drugs, lowering the risks of hyperstimulation and multiple pregnancies.

Risks and Considerations

While effective, these procedures carry certain risks:

For tubal patency test: Rare risks include allergic reaction to dye, infection, or injury to pelvic organs.

For ovarian drilling: Risks include adhesion formation, diminished ovarian reserve if excessive cautery is used, and occasional recurrence of PCOS symptoms.

General surgical risks such as bleeding, infection, or anesthesia-related complications are also possible.

Careful patient selection and surgical expertise are crucial to minimize these risks.

Success Rates and Outcomes

After ovarian drilling, 70–80% of women resume spontaneous ovulation, and 40–60% achieve pregnancy within a year.

When combined with tubal patency testing and correction of associated pelvic pathologies, overall fertility outcomes improve significantly.

The recurrence rate of PCOS symptoms is lower compared to medical management alone, though long-term monitoring is still essential.

Conclusion

Laparoscopic tubal patency testing and ovarian drilling represent an integrated approach to infertility management in women with PCOS. While chromopertubation accurately assesses the openness of the fallopian tubes, ovarian drilling addresses the underlying anovulation associated with PCOS. Together, they provide both diagnostic clarity and therapeutic benefit in a single minimally invasive procedure. When performed with precision, these techniques not only enhance fertility outcomes but also improve the quality of life for women struggling with PCOS-related infertility.