Ovarian Surgery For PCOS

If medication and lifestyle changes have done little to manage your polycystic ovary syndrome (PCOS) symptoms, your doctor may suggest surgery as a last resort to help with your situation.

Here is an overview of surgery for PCOS, who it might be suitable for, what it involves, and the potential risks you need to consider.

What is PCOS?

Polycystic ovary syndrome, or PCOS, is an endocrine condition that affects around 4–20% of women of reproductive age. It can cause a range of symptoms, many related to hyperandrogenism, meaning excess levels of androgen hormones. These symptoms include acne and excess hair growth (hirsutism).¹

Besides other symptoms, like irregular or painful periods, the condition causes infertility in as many as 70–80% of cases.²

Untreated PCOS can eventually lead to heart disease, type 2 diabetes, and other serious health complications.

Diagnosis criteria for PCOS include the following:³

1. Symptoms of hyperandrogenism and/or high androgen levels detected in blood tests

2. Irregular periods (oligoovulation) or lack of periods (anovulation)

3. Polycystic ovaries (the ovaries are enlarged and contain fluid-filled follicles)

Causes and risk factors

Due to the complexity of the various elements contributing to the development of this hormonal condition, it’s impossible to nail down a single specific cause.

However, a combination of genetic, lifestyle, and environmental factors is linked to PCOS, including the following:⁴

• Obesity

• Diabetes (type 1, 2, or gestational)

• Family history

• Genetics

• Sedentary lifestyle

• Insulin resistance or metabolic syndrome

Symptoms

PCOS manifests with various symptoms that may differ in severity from person to person. The symptoms you experience depend on several factors.

Not everyone struggling with PCOS will experience all the symptoms below. However, the three main characteristics mentioned above are common in most cases.

Symptoms include the following:

• Irregular or no periods

• Excess body and/or facial hair

• Painful periods

• Unexplainable weight gain

• Acne

• Oily skin

• Hair loss (baldness) or thinning of the hair that often follows male pattern baldness

• Difficulty getting pregnant

Treatment options for PCOS

There is currently no cure for PCOS, but your doctor will recommend a treatment plan to help manage your symptoms.

Lifestyle changes

Making healthy lifestyle changes is the first-line treatment for PCOS.

Your doctor will encourage you to adopt healthy behaviors to improve your general health and reach and maintain a healthy body weight. If you are carrying excess weight, losing as little as 5% of your original body weight could improve your PCOS symptoms.⁵

Healthy lifestyle changes may include making changes to your diet — particularly by reducing your consumption of processed foods, sugar, and foods high in saturated and trans fat — and doing more light to moderate exercise.

Medications

Your doctor may also prescribe medication to ease your PCOS symptoms. The medication you take will depend on your unique symptoms and whether or not you want to become pregnant.

If you do not want to become pregnant, your doctor may recommend the combined hormonal birth control pill (containing both estrogen and progesterone) to ease your menstrual irregularity and hyperandrogenism-related symptoms, such as hirsutism and acne.⁶

Metformin, a medication that improves how your body uses insulin, is sometimes recommended for people with PCOS who have glucose intolerance and obesity. The drug reduces insulin resistance, which can improve PCOS symptoms.⁷

People wishing to become pregnant may be prescribed clomiphene citrate or letrozole. If these medications don’t stimulate ovulation, your doctor may recommend gonadotrophins or other medicines that stimulate ovulation. However, these medications are not always successful in achieving ovulation and pregnancy.⁸

Surgery

Surgery for PCOS is only recommended if lifestyle changes and medications haven’t improved your symptoms or established regular ovulation/pregnancy if that was your concern.

The surgery recommended in this instance is laparoscopic ovarian drilling (LOD).

In some cases, this surgery may be carried out before you start taking gonadotropins. The aim would be to achieve a normal regulatory cycle and improve the medication’s efficiency while lowering its side effects.⁹

Laparoscopic ovarian drilling for PCOS

Laparoscopic ovarian drilling is a type of keyhole surgery performed under general anesthesia. The medical team will drill holes in each ovary using an electrical current or laser.

Micro-laparoscopic ovarian drilling technique (MLOD) can be carried out under local anesthesia.

The aim of this surgery is to destroy some of the ovarian tissue that produces androgens, which leads to a reduction in androgen and luteinizing hormone (LH) levels. This raises levels of follicle-stimulating hormone, which kickstarts ovulation.

The operation may also increase blood flow to the ovaries, which carries more gonadotropins and further aids in achieving ovulation.

How effective is laparoscopic ovarian drilling?

3–8 punctures made in each ovary has been shown to stimulate normal ovulation in 74% of cases in 3–6 months after surgery.¹⁰

The procedure has been found to restore fertility in 20–64% of women with PCOS. These women were infertile because they did not ovulate and they did not respond to clomiphene citrate medication. However, other analyses have reported a narrower range of success rate — 44–50%.¹¹

Unlike some ovulation-stimulating medications like gonadotropins, LOD does not increase your risk of ovarian hyperstimulation — an effect that causes multiple pregnancies.

It’s worth noting that many studies have reported that LOD results are not superior to the use of clomiphene citrate as a first-line treatment to induce ovulation.

Additionally, when comparing LOD to six cycles of clomiphene citrate as a first-line approach, the rate of pregnancy and live birth per woman is not significantly different. However, if 6–9 cycles of clomiphene citrate don’t achieve the desired results, LOD is considered the best choice to induce ovulation and possibly achieve pregnancy.

Before recommending this surgery, your doctor will consider the following factors as they can increase the efficacy of LOD:¹²

• A body mass index (BMI) in the normal range

• High concentration of luteinizing hormone (>10UI/L)

• Being aged under 35 years

• Short duration of infertility

Here are some possible predictors of poor outcomes of LOD:

• Very high BMI

• Hyperinsulinemia (excess insulin in the blood)

• Elevated anti-Müllerian hormone (AMH) levels

• High testosterone serum levels

Possible complications

LOD is considered a safe and effective surgery. It only takes around half an hour, and many people return home the same day as the procedure.

However, as with any surgery, LOD carries risks of infection and bleeding. Undergoing general anesthesia also carries risks. Many individuals who have this surgery are obese and potentially have other comorbidities that could increase all these surgery-related risks, such as cardiovascular issues or diabetes.

The procedure also carries the risk of causing pelvic adhesions. This situation can occur as a normal response to injury where the body attempts to repair itself, causing it to form scar tissue that can lead to organs being stuck together. In other cases, adhesions can form as a result of infection. 

Another specific risk is ovarian failure, where the ovaries stop working properly. However, this is very rare. The risk increases if the blood supply to the ovary is accidentally damaged or if the medical team makes too many punctures.

The lowdown

There is currently no cure for PCOS, so treatment is aimed at improving symptoms. Another main goal is to achieve fertility in those who want to become pregnant. Treatment options are highly individual and depend on your symptoms, wider health issues, and fertility preferences.

Treatment options for PCOS fall into three main categories: lifestyle changes, medication, and surgery.

Surgery — laparoscopic ovarian drilling — is a last resort option for women who want to become pregnant or those with severe symptoms for whom lifestyle changes and medications, such as clomiphene citrate, have not been effective.

The surgery is carried out under general anesthetic and typically only lasts 30 minutes. Around three-quarters of people recover ovulation. The success rate in terms of fertility is thought to range from 40%, with some researchers reporting lower success rates.

As with any surgery, LOD carries risks. Speak to your doctor about the PCOS treatment options that are available to you and their potential benefits and risks.¹³

Frequently asked questions

Will PCOS go away with a hysterectomy?

It’s a myth that having a hysterectomy — a procedure that involves the partial or total removal of the uterus and, in some cases, the ovaries — will cure PCOS. It will not.

Removing the uterus and ovaries won’t ease symptoms as the condition is related to hormone imbalances and metabolism problems.

Can ovarian drilling cure PCOS?

Ovarian drilling is not a cure for PCOS, but it can ease symptoms and improve fertility in many cases.

Can PCOS come back after surgery?

For some women, laparoscopic ovarian drilling won’t lead to resumed ovulation and pregnancy — even temporarily. For others, the effects may fade over time.

A long-term follow-up study found that while 67% of women with PCOS resumed regular ovulation in the year after surgery, by the mid-term follow-up (1–3 years), only 37% had regular ovulation. Interestingly, this figure rose again to 55% by the long-term follow-up (4–9 years).¹⁴