Oligo-anovulatory state and infertility often accompany the polycystic ovary syndrome (PCOS), due in large part to increased androgen production from the stromal component of the ovary. Bilateral ovarian wedge resection (BOWR) by laparotomy as treatment for PCOS was first described by Stein-Leventhal in 1935, who noted restoration of menses and occasional spontaneous conceptions subsequent to the procedure. However, given the risk of postsurgical adnexal adhesions and ovarian failure, and in light of the introduction of pharmacotherapeutic agents used to induce ovulation, the procedure has generally fallen into disuse. Gonadotropin administration, however, poses increased risks for ovarian hyperstimulation syndrome (OHSS) and multiple gestations for patients with PCOS. A potential indication for surgical intervention, then, may be therapeutic failure to standard ovarian stimulation cycles.

Unlike BOWR performed via laparotomy, laparoscopic ovarian diathermy (i.e., “ovarian drilling”) results in fewer postoperative adverse outcomes such as ovarian failure, trauma, surgical dead space, hematoma formation, and adhesions. Furthermore, an effective alternative to ovarian drilling, which may unduly compromise healthy ovarian cortex, is the laparoscopic BOWR, which has a lesser risk of postoperative periovarian adhesions than classic BOWR via laparotomy.

The exact mechanisms of action of this procedure on ovulatory function are unclear. Laparoscopically performed ovarian wedge resection focuses on debulking the hyperplastic theca-stromal portion of the ovarian mass, generally sparing the ovarian cortex. Alternatively, bilateral ovarian diathermy focuses on destroying discrete and relatively limited areas of the ovarian cortex. Nonetheless, studies evaluating the success of either procedure have reported similar success with either ovarian wedge resection or ovarian diathermy, with spontaneously occurring ovulatory cycles in up to 90% of women treated. The endocrine changes found after ovarian surgery in PCOS women seem to be governed by the ovaries themselves, and simply put, seem to stem from any type of ovarian damage.

A recent Cochrane analysis indicated that laparoscopic ovarian diathermy is as successful as and more cost effective than gonadotropin therapy for ovulation induction, without the added risk of OHSS and multiple gestations. An economic evaluation demonstrated that treating women with laparoscopic ovarian diathermy results in a significant reduction in both direct and indirect costs. Overall, for women with PCOS-related anovulatory infertility and who cannot tolerate the risks or costs of gonadotropin ovulation induction, laparoscopic ovarian wedge resection or diathermy (drilling) may represent a viable option.

Patients who are candidates for bilateral ovarian diathermy are typically young and healthy, although some may be glucose intolerant or overtly diabetic and may require preoperative assessment by their internist. Not uncommonly do patients have lipid disorders or
fatty liver disease, but these typically do not preclude an outpatient surgical procedure.

Commonly accepted surgical indications include patients who have normal pelvic anatomy, normal male factor, and have either not responded to clomiphene citrate or gonadotropin ovulation induction, or have not conceived after three to six ovulation induction cycles with either medication. Patients should also be counseled concerning the potential of postoperative periadnexal adhesions affecting fertility and the concept that the procedure itself will not generally be curative.