Polycystic Ovary Syndrome (PCOS) is a group of signs caused by a hormonal imbalance. It is very common, affecting between 5 and 10% of women and can be characterized by an unusual increase in the production of androgens (male hormones) in the ovaries. This syndrome impairs the growth of ovarian follicles and disrupts the production of eggs. It can increase the size of the ovaries [1].

PCOS arises from a hormonal imbalance. Two hormones called FSH and LH (secreted by a gland at the base of the brain) regulate the ovarian cycle: their levels vary throughout the cycle, leading to ovulation.

In f PCOS, the level of LH often increases, which causes stimulation of the ovaries that produce excess androgens and impede the growth of follicles. The result: menopause. In addition, the level of testosterone rises in the blood, causing an increase in body hair and acne [2]. Finally, the level of insulin in the blood - a hormone used to regulate blood sugar levels - also tends to increase. However, if there is an overproduction of insulin, the body will secrete additional male hormones [3].

Polycystic Ovary Syndrome (PCOS) is one of the most common causes of infertility in women of reproductive age (up to 5-15% of cases). The main clinical manifestations of the disease are characterized by disorders of menstrual function of the type of oligomenorrhea, secondary amenorrhea, in some cases - menometrorrhagia as a result of endometrial hyperplasia, manifestations of androgenization of varying severity, overweight. Currently, there is a rethinking of the place of PCOS in the structure of endocrine pathology, considering it as a socially significant disease, given the direct connection between it with metabolic disorders (dyslipidemia, hyperinsulinism, insulin resistance, impaired glucose tolerance), leading to the development of arterial hypertension, abdominal-visceral obesity, early atherosclerosis, coronary artery disease hearts. Indeed, numerous epidemiological studies in various countries of the world have shown a high prevalence of PCOS among women of reproductive age up to 3-10% of the population [4]. The risk of developing myocardial infarction and ischemic heart disease in hyperandrogenism of non-neoplastic genesis is 7 times higher than in the general population of 40% of women.

There is increasing interest in the development of combined PCOS treatment regimens in which metformin a significant role is assigned [5]. Thus, it has been shown that the combined use of metformin (1500-1700 mg/day) and clomiphene citrate (100 mg/day) is highly effective by the method of induction of ovulation in PCOS This combination is prescribed in case of patient resistance to clomiphene, as well as the first stage of therapy in the presence of obesity, severe dyslipidemia, impaired glucose tolerance in PCOS. Another rational combination is the combination of metformin 1500-1700 mg/day and antiandrogen flutamide (125-500 mg /days), which leads to a synergistic effect about the normalization of the menstrual cycle, decrease in hirsutism, decrease in blood testosterone levels, decrease the amount of visceral fat, an increase in HDL levels Additional appointment to these drugs of low-dose oral contraceptives led to an additional increase in the level of CVH, which further reduced the index free androgens [6-10]. Thus, the use of metformin in the treatment of PCOS is a pathogenetic agent therapy aimed at correcting hyperinsulinism and insulin resistance, which leads to a significant effect about almost all clinical components of the disease (restoration of the menstrual cycle, induction of ovulation, reduction of hirsutism) and laboratory parameters [11,12].

Conventional treatment for PCOS includes:

• Take contraceptives, which are usually recommended for women who are not planning to become pregnant. This approach is not a cure for PCOS, it masks symptoms and helps preserve fertility if a woman desires to have children in the future

• Taking diabetes medications: Metformin, used to treat type 2 diabetes, maybe excellent for treating symptoms of PCOS. However, the use of this drug to treat PCOS has not been approved by the Ministry of Health

• Preparations for infertility treatment (clomiphene (Clomid) injection, Gonadotropin) for women who want to become pregnant. Infertility problems in women with PCOS are associated with a lack of ovulationand taking these medications helps restore them

Patient and Method 

About 125 samples were collected from Bint Al-Huda Maternity and Children Hospital, Thi-Qar, Iraq of patients and private clinics with polycystic ovaries, where standard endoscopic treatment was performed. Isolated needle electrode treatment on both ovaries [13-15].

The needle was inserted as perpendicular to the surface of the ovary as possible:

• The current used is 100 watts

• The activation used to the current and 40 watts

• Using a crystal solution to wash bleach

• The incisions are made on the ovarian cortex and are usually 4–10 mm deep and 3 mm wide

• Ovarian drilling is performed laparoscopically and either via the navel (laparoscopy) 

The main cause of PCOS is hyperandrogenism, which is responsible for hirsutism and indirectly, for irregular ovulation and irregular menstruation [16].

Hyperandrogenism is caused by several hormonal changes' characteristic of PCOS, such as increased levels of the hormone Luteinizing Hormone (LH) and increased ovarian production of the hormone's estrogen and androgen. In particular, it is the abnormal secretion of LH that overly stimulates the ovaries and produces large amounts of these hormones.

In PCOS, concentrations of FSH, a follicle-stimulating hormone secreted by the pituitary gland, are very low and the secretory contrast between LH and FSH associated with menstruation and ovulation is suppressed [17-19].

In 30% of patients with PCOS, an increase in prolactin up to twice the level of prolactin is observed in healthy women [20].

Through the use of the statistical analysis program, it was observed that there was an inverse relationship before and after drilling through the p-value, which was larger than 0.01 (Table 1).

Table 1: Effect of surgical intervention on patients

Figure 1: p-value of parameter                                                                                                                                                       

Figure 2: Explain Menstrual pattern

Figure 3: Ovulatory status

Figure 4: Quantity women Pregnancy and not Pregnancy

Reducing androgen levels in the blood After destroying the androgen-producing stroma of Ovaries may reduce the amount of substrate available Peripheral aromatization of estrogens. After the patient is submerged in anesthesia, the doctor makes several small incisions (holes) in the abdomen, into which trocars are inserted-special ports through which the endoscope, camera and light are inserted into the abdominal cavity. Because the abdominal wall              rises, carbon dioxide is injected into the cavity and the surgeon gets an overview of the area of ​​the upcoming operation.

Ovarian drilling involves making small (up to 2 mm) holes in the thick ovarian capsule. For this, a laser Due to the drilling, the volume of the androgen-producing luteal tissue decreases. This stimulates the start of ovulation.

After drilling, the surgeon reviews the abdominal cavity, then removes the tools and sutures the puncture sites with one or two stitches.

Polycystic ovaries are therefore diagnosed to include at least one of the following either 12 or more follicles with a diameter of 2-9 mm, or an increased ovarian size (>10 cm*). If there is a bulb with a diameter greater than 10 mm.

Ovarian drilling has lower rates of ovarian hyperstimulation syndrome and multiple fetus pregnancy. The advantages of the procedure also include its treatment, unlike many trials of ovulation induction. Other benefits of this technique include its cost-effectiveness and can be performed as an outpatient procedure.

1. Abdelhafeez, M.A. Forn et al. "Unilateral versus Bilateral Laparoscopic Ovarian Drilling in Clomiphene Citrate Resistant Polycystic Ovary Syndrome." Life Sciences, vol. 10, no. 1, 2013, pp. 3057-60.

2. Ashrafinia, M. Forn et al. "Comparison of Metformin Treatment and Laparoscopic Ovarian Diathermy in Patients with Polycystic Ovary Syndrome." International Journal of Obstetrics and Gynaecology, vol. 107, 2009, pp. 236-9.

3. Badawy, A. Forn et al. "Ultrasound‐Guided Transvaginal Ovarian Needle Drilling (UTND) for Treatment of Polycystic Ovary Syndrome: A Randomized Controlled Trial." Fertility and Sterility, vol. 91, no. 4, Apr. 2009, pp. 1164-7.

4. Elgafor, A. "Efficacy of Combined Metformin‐Letrozole in Comparison with Bilateral Ovarian Drilling in Clomiphene‐Resistant Infertile Women with the Polycystic Ovarian Syndrome." Archives of Gynecology and Obstetrics, vol. 288, no. 1, 2013, pp. 119-23.

5. Farquhar, C. Forn et al. "A Randomized Controlled Trial of Laparoscopic Ovarian Diathermy versus Gonadotrophin Therapy for Women with Clomiphene Citrate‐Resistant Polycystic Ovary Syndrome." Fertility and Sterility, vol. 78, no. 2, 2002, pp. 404-11.

6. Giampaolino, P. Forn et al. "Post‐Operative Ovarian Adhesion Formation after Ovarian Drilling: A Randomized Study Comparing Conventional Laparoscopy." Archives of Gynecology and Obstetrics, vol. 294, no. 4, 2016, pp. 791-6.

7. Hamed, H.O. Forn et al. "Metformin versus Laparoscopic Ovarian Drilling in Clomiphene‐ and Insulin‐Resistant Women with Polycystic Ovary Syndrome." International Journal of Gynecology and Obstetrics, vol. 108, no. 2, 2010, pp. 143-7.

8. Abu Hashim, A. Forn et al. "Letrozole versus Laparoscopic Ovarian Diathermy for Ovulation Induction in Clomiphene‐Resistant Women with Polycystic Ovary Syndrome: A Randomized Controlled Trial." Archives of Gynecology and Obstetrics, vol. 282, 2010, pp. 567-71.

9. Abu Hashim, H. Forn et al. "Combined Metformin and Clomiphene Citrate versus Laparoscopic Ovarian Diathermy for Ovulation Induction in Clomiphene‐Resistant Women with Polycystic Ovary Syndrome: A Randomized Controlled Trial." Journal of Obstetrics and Gynaecology Research, vol. 37, no. 3, 2011, pp. 169-77.

10. Kaya, H. Forn et al. "Evaluation of a New Surgical Approach for the Treatment of Clomiphene Citrate‐Resistant Infertility in Polycystic Ovary Syndrome: Laparoscopic Ovarian Multi‐Needle Intervention." Journal of Minimally Invasive Gynaecology, vol. 12, no. 4, 2005, pp. 355-8.

11. Palomba, S. Forn et al. "Laparoscopic Ovarian Diathermy vs Clomiphene Citrate plus Metformin as a Second‐Line Strategy for Infertile Anovulatory Patients with Polycystic Ovary Syndrome: A Randomized Controlled Trial." American Journal of Obstetrics and Gynecology, vol. 202, no. 6, 2010, pp. e1-8.

12. Roy, K.K. Forn et al. "Evaluation of Unilateral versus Bilateral Ovarian Drilling in Clomiphene Citrate Resistant Cases of the Polycystic Ovarian Syndrome." Archives of Gynecology and Obstetrics, vol. 280, no. 4, 2009, pp. 573-8.

13. Roy, K.K. Forn et al. "A Prospective Randomized Trial Comparing the Clinical and Endocrinological Outcome with Rosiglitazone versus Laparoscopic Ovarian Drilling in Patients with Polycystic Ovarian Disease Resistant to Ovulation Induction with Clomiphene Citrate." Archives of Gynecology and Obstetrics, vol. 281, no. 5, 2010, pp. 939-44.

14. Zahiri Sorouri, Z. Forn et al. "Comparison between Unilateral and Bilateral Ovarian Drilling in Clomiphene Citrate Resistance Polycystic Ovary Syndrome Patients: A Randomized Clinical Trial of Efficacy." International Journal of Fertility & Sterility, vol. 9, no. 1, 2015, pp. 9-16.

15. Selim, M.F. "The Optimal Number of Ovarian Punctures to Be Applied during Laparoscopic Ovarian Diathermy in Women with the Polycystic Ovarian Syndrome." Journal of Gynecologic Surgery, vol. 27, no. 4, 2011, pp. 217-24.

16. Sharma, M. Forn et al. "Laparoscopic Bipolar versus Unipolar Ovarian Drilling in Infertile Women with Resistant Polycystic Ovarian Syndrome: A Pilot Study." Journal of Gynecologic Surgery, vol. 22, no. 3, 2006, pp. 105-11.

17. Takeuchi, S. Forn et al. "Polycystic Ovarian Syndrome Treated with Laparoscopic Ovarian Drilling with a Harmonic Scalpel: A Prospective Randomized Study." Journal of Reproductive Medicine, vol. 47, no. 10, 2002, pp. 816-20.

18. Taskin, O. Forn et al. "Comparison of the Effects of Ovarian Cauterization and Gonadotropin‐Releasing Hormone Agonist and Oral Contraceptive Therapy Combination on Endocrine Changes in Women with Polycystic Ovary Disease." Fertility and Sterility, vol. 65, no. 6, 1996, pp. 1115-8.

19. Youssef, H. Forn et al. "Unilateral Ovarian Drilling in Polycystic Ovarian Syndrome: A Prospective Randomized Study." Reproductive BioMedicine Online, vol. 15, no. 4, 2007, pp. 457-62.

20. Zakherah, M.S. Forn et al. "Laparoscopic Ovarian Drilling in Polycystic Ovary Syndrome: Efficacy of Adjusted Thermal Dose Based on Ovarian Volume." Fertility and Sterility, vol. 95, no. 3, 2011, pp. 1115-8.