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530
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ev
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ras
2015; 61(6):530-535
REVIEW ARTICLE
Drilling: medical indications and surgical technique
C
ristina
K
allás
H
ueb
1
*, J
oão
A
ntônio
D
ias
J
únior
2
, M
aurício
S
imões
A
brão
3
, E
lias
K
allás
F
ilho
4
1
PhD – Specialist in Gynecology and Obstetrics, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
2
PhD – Medical Coordinator at Centro de Reprodução Assistida, Hospital Sírio Libanês, São Paulo, SP, Brazil
3
Habilitation (BR: Livre Docência) – Associate Professor at Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
4
Postdoctor – Full Professor at Faculdade de Direito do Sul de Minas, Pouso Alegre, MG, Brazil
S
ummary
Studed conducted at Instituto
Sírio-Libanês de Ensino e Pesquisa,
São Paulo, SP, Brazil
Article received:
8/8/2014
Accepted for publication:
10/21/2014
*Correspondence:
Address: Rua Cel. Nicolau dos Santos, 69
Bela Vista
Postal code: 01308-060
São Paulo, SP – Brazil
kallashueb@uol.com.br http://dx.doi.org/10.1590/1806-9282.61.06.530Financial support:
none
Introduction:
anovulation is a major cause of female infertility, and polycystic
ovary syndrome (PCOS) is the leading cause of anovulation. While undergoing
drug-induced ovulation, women with PCOS usually have a satisfactory response
recruiting follicles, but some are unable to recruit follicles or often produce an
excessive number of follicles, which can result in ovarian hyper-stimulation syn-
drome and/or multiple pregnancy. Surgical laparoscopy with ovarian “drilling”
may prevent or reduce the need for drug-induced ovulation.
Objective:
to identify the current indications of laparoscopic ovarian drilling
and the best surgical technique.
Method:
a review of the medical literature based on systematic search in the Med-
line, Lilacs and Cochrane databases, using as keywords laparoscopy, polycystic ova-
ry syndrome, and drilling.
Results:
we found 105 articles in the literature, 27 of these highly relevant, describ-
ing findings on ovarian drilling.
Conclusion:
laparoscopic drilling is indicated for patients with polycystic ova-
ry syndrome with ovulatory resistance to the use of clomiphene citrate, body
mass index less than 30 kg/m² and preoperative luteinizing hormone above 10
IU/L. The preferred surgical technique should be the realization of 5 to 10 per-
forations on the surface of each ovary bilaterally using monopolar energy.
Keywords:
clomiphene, laparoscopy, anovulation, polycystic ovary syndrome,
percussion drilling.
I
ntroduction
Anovulation is a major cause of female infertility, and
polycystic ovary syndrome (PCOS) is the leading cause of
anovulation.
1
A wedge resection of the ovaries was the first surgical
treatment aimed at correcting anovulation in patients
with PCOS.
1
Described by Stein and Leventhal in 1935
and performed via laparotomy, it was abandoned, despite
the promising results of the first series.
2
This is due to the
substantial loss of ovarian tissue and the formation of
postoperative adhesions.
2
The surgical procedure was re-
placed by the use of drugs for induction of ovulation, such
as clomiphene citrate (CC) and gonadotropins.
2
Howev-
er, PCOS women treated with clinical induction of ovula-
tion with gonadotropins may fail to recruit follicles, or
present excessive development of follicles and ovarian hy-
per-stimulation with a risk of multiple pregnancies. De-
spite being very effective, the use of gonadotropins is ex-
pensive, time-consuming and requires intensive
monitoring.
1
Therefore, a modern and less traumatic sur-
gical version compared with wedge resection of the ova-
ries has been developed using laparoscopy. This procedure
known as laparoscopic drilling (LD) of the ovaries prob-
ably reduces the need for clinical induction of ovulation,
or facilitates its use.
1
The procedure can be performed
with admission in “day hospitals”, with very little surgi-
cal trauma compared to the initial laparotomy technique.
Laparoscopic drilling is a minimally invasive surgery in
which the ovaries are treated with small perforations us-
ing heat or laser.
1
The mechanism by which partial de-
struction results in ovarian follicular development and
ovulation is unknown. Despite the contribution of hor-
monal changes caused by the procedure, such as the re-
duction of serum androgens, it is not clear whether this