In women resistant to clomiphene citrate, or metformin combined with clomiphene, the next step has been gonadotropin therapy. While this treatment causes ovulation in most women, it has several potentialclomiphenemetformin problems: ● It can be very difficult to titrate the dose of gonadotropins to achieve monofollicular ovulation. ● The high frequency of multifollicular ovulation results in multiple gestations in 30 percent or more of women [4].4 ● The risk of ovarian hyperstimulation syndrome (OHSS) during gonadotropin administration is substantial, necessitating careful monitoring during treatment. ● The costs of therapy are high, especially considering that only one ovulatory event will occur with each course of treatment. ● For those women who do become pregnant, the frequency of spontaneous abortion appears to be higher than when conception occurs after spontaneous ovulation

The literature now contains reports of over 1000 women in whom partial ovarian resection or ablation was done via a laparoscopic approach in the hope of restoring some ovulatory function. Pregnancy has occurred in approximately 55 percent of women undergoing this procedure, a figure that compares favorably with conception rates after three to six cycles of gonadotropin therapy

After laparoscopic surgery to restore ovulation, serum androstenedione concentrations fall transiently and serum LH, testosterone, and inhibin concentrations fall more permanently. Conversely, serum FSH concentrations rise. The net effect is normalization of some of the endocrine abnormalities associated with the polycystic ovary syndrome

The more popular method at this time is the use of a unipolar needle electrode that is insulated proximal to the distal 1 or 2 centimeters. Four to six punctures of each ovary can produce substantial thermal damage to the stromal compartment while, in theory, producing minimal surface damage, and a minimal amount of adhesion formation.

Of 15 women who underwent a second-look laparoscopy, 11 women were found to be free of adhesions. Four women had periadnexal adhesions that were filmy, minimal, and found on the ovarian surface only.

important considerations for laparoscopic surgery include: ● Patients should be of normal weight, because the procedure is often unsuccessful in obese women (body mass index >30 kg/m2 body surface area) ● Women should have no additional infertility factors. When PCOS is the only cause of infertility, 80 to 87 percent become pregnant after surgery.In contrast, the pregnancy rates are only 14 to 29 percent in women who also have an additional tubal factor, endometriosis, or an oligospermic male partner..

Laparoscopic ovarian drilling Gonadotropin ovulation induction Advantages One-time, minimally invasive procedure Normalizes endocrinologic and ultrasonographic abnormalities Restores ovulatory cycles for many years Pregnancy and live birth rates are comparable to gonadotropin ovulation induction with no increase in multiple pregnancy or OHSS Improves response to gonadotropin superovulation for IVF May improve acne and hirsutism Comparable pregnancy and live birth rates to ovarian drilling without surgery Widespread availability Comparison between laparoscopic ovulation induction and gonadotropin ovulation induction

Disadvantages Surgical risks inherent with laparoscopy Postoperative adhesions Diminished reserve ovarian Few clinicians in the United States offer it Significantly higher risk for multiple pregnancy Higher risk of OHSS Greater cost compared with ovarian drilling High patient inconvenience due to daily injections and frequent visits for monitoring No benefit beyond the treatment cycle