Surgical management of polycystic ovary syndrome: A contemporary viewpoint on place of ovarian surgery in PCOS management

Polycystic ovary syndrome (PCOS) is the most common cause of ovulatory dysfunction and resultant infertility. Although the mainstay in management is predominantly medical therapy directed at overcoming diverse symptomatology, surgical management of PCOS was one of the earliest therapeutic options available to treat the disease. Soon after their original description of the disorder, Stein and Leventhal serendipitously discovered that ovarian wedge resection resulted in symptomatic improvement and correction of ovulatory defect of PCOS. The initial enthusiasm soon dampened and ovarian wedge resection subsequently fell into disfavor secondary to sequelae of ovarian cortical trauma that included pelvic adhesions and detriment to ovarian reserve. Recent innovations in the surgical approach, however, offer a potential for benefit for patients unresponsive to conventional medical therapy; focal targeted theca cell destruction utilizing laparoscopic ovarian drilling (LOD) or ultrasound-guided ovarian follicle aspiration, can correct the endocrine milieu of PCOS, albeit transiently, while mitigating serious adverse effects that were common with the conventional wedge resection approach. These beneficial endocrine effects usually result in amelioration of ovulatory dysfunction and infertility. Minimally invasive surgical management of PCOS in the appropriately selected patient is a cost-effective therapeutic option that has comparable success rates to ovulation induction in the management of infertility without incurring any additional treatment related risk of multiple pregnancy. Alongside thecal decompression, interventions such as LOD, bariatric surgical procedures are increasingly being utilized to address obesity and accompanying co morbidities that are highly prevalent in populations of women with PCOS. This chapter focuses on ovarian surgical interventions that can be of relevance to the management of PCOS in a subgroup of patients, whereas Chapter 16 addresses the relevance of bariatric surgical interventions in PCOS.