Ovarian drilling, or ovarian multiperforation, is a surgical operation consisting in multiperforating the ovary in order to restore its proper functioning. It is sometimes offered to women with polycystic ovary syndrome (PCOS) for the treatment of infertility by anovulation (lack of ovulation).

From the verb “to drill”, to drill, ovarian drilling is a surgical operation consisting in piercing the ovary, or more exactly the “multiperforer”, in order to restore its proper functioning. Small perforations are made in the cortical ovary (shell of the ovaries) often thick in PCOS. This gesture makes it possible on the one hand to facilitate the access of the oocytes to the outside, on the other hand to destroy the cysts in order to restore a good hormonal balance.

The operation takes place under general anesthesia and under laparoscopy most often, sometimes under loco-regional anesthesia by culdoscopy (vaginal endoscopy), on an outpatient basis.

Different types of energy can be used to puncture the ovary:

• the laser;
• electrocoagulation.

The number of puncture points varies from 3 to more than 10 points per ovary; 5-10 points are generally recommended (1).

Ovarian drilling is for women with polycystic ovary syndrome, commonly known as PCOS. This endocrine pathology is characterized by the accumulation, around the ovaries, of multiple small follicles refusing to grow during the last stage of the follicular phase. Polycystic ovary syndrome affects more than 5% of women of childbearing age and is accompanied by infertility by anovulation (absence of ovulation) in 20 to 74% of cases (2).

The first-line treatment, namely the implementation of hygieno-dietetic rules in the event of overweight and the induction of ovulation by clomiphene citrate, makes it possible to obtain a pregnancy in 35 to 40% of the patients. In case of failure after 6 cycles, ovarian drilling, treatment with gonadotropins or metformin (in obese patients most often) may be offered to the patient.

The mechanisms are still unknown, but the realization of an ovarian drilling is accompanied by a hormonal rebalancing favorable to ovulation.

It thus leads to pregnancy in about 50% of cases (3). Studies show that a PCOS patient will respond all the more favorably to drilling if she is young, low androgynous, low insulin resistant (moderate overweight), with high LH and without other associated infertility factor (4).

In the event of pregnancy after drilling, unlike medical treatment, there is no increased risk of multiple pregnancy and hyperstimulation of the ovaries. The miscarriage rate may also be lower than that seen generally in women with PCOS (30% on average) (5). 

“If multiperforation fails, another therapeutic strategy (gonadotropins FIV) should be considered within 3 months in the event of no restoration of the cycle and in the following year in the absence of pregnancy ”, recommends the Haute Autorité de Santé (6).