Laparoscopic ovarian drilling is a second-line option, not a first step. International PCOS guidance (2023) says laparoscopic ovarian surgery could be second-line treatment for people with PCOS who are not ovulating despite oral ovulation drugs and who have no other fertility problems, alongside injectable gonadotropins. It avoids the higher multiple-pregnancy and OHSS risk of injectables, but it is surgery, and the guideline lists adhesions and reduced ovarian reserve among the risks to weigh.
PCOS or PMOS? A note on the name
In May 2026, an international consensus renamed polycystic ovary syndrome as polyendocrine metabolic ovarian syndrome (PMOS), to reflect that the condition is metabolic and hormonal, not just about ovarian “cysts.” The diagnosis and treatments discussed here are the same; you will see both names on clinic paperwork for some time. HowToHaveABaby explains what the name change means. This guide uses “PCOS” when quoting guidelines written before the change.
Where drilling sits on the treatment ladder
For people with PCOS who do not ovulate regularly, ovulation induction follows a familiar order, set out in the 2023 International Evidence-based Guideline for the Assessment and Management of PCOS:
- First line: oral ovulation induction. Letrozole is generally preferred, with clomiphene as an alternative. Our comparison of letrozole vs Clomid covers the differences, and our guide to a monitored ovulation induction cycle explains how response is tracked.
- Second line, for people who do not ovulate on oral drugs: injectable gonadotropins, clomiphene combined with metformin, or laparoscopic ovarian surgery.
- Third line: IVF, when other approaches have not worked or other fertility factors are present.
A practice-point summary of the 2023 guideline puts it this way: laparoscopic ovarian surgery “could be the second-line treatment,” particularly for those resistant to clomiphene or who have failed oral ovulation drugs, and who have no other infertility factors. FertileStart’s step-by-step PMOS plan walks through the same ladder from the trying-to-conceive side.
What the surgery involves
Ovarian drilling is done by laparoscopy, through small incisions under general anesthesia. The surgeon uses electrocautery or a laser to make a small number of punctures in the surface of each ovary. The procedure is thought to work by destroying some of the hormone-producing ovarian tissue, which lowers androgen levels and can allow normal ovulation to resume.
Because it is laparoscopy, the surgeon can also look at the tubes, uterus and pelvis at the same time, and check tubal patency with dye. That combined look is one reason drilling is sometimes chosen when a laparoscopy is being considered anyway. Our guide to laparoscopy for infertility explains when surgery adds answers and when it usually does not.
Drilling vs injectable gonadotropins
| Laparoscopic ovarian drilling | Injectable gonadotropins | |
|---|---|---|
| What it is | One surgical procedure | Daily injections each treatment cycle, with ultrasound monitoring |
| If it works | Ovulation may resume on its own, allowing natural attempts each month | Ovulation in treated cycles only |
| Multiple pregnancy and OHSS | Avoids the stimulation-related risks of injectables | Higher risk of OHSS and multiple pregnancy, as the guideline notes |
| Main risks | Surgical and anesthesia risks, adhesions, reduced ovarian reserve | OHSS, multiples, cycle cancellation for overresponse |
| Expertise needed | Surgeon experienced in the technique | Close monitoring by a fertility team |
| Cost pattern | One upfront surgical cost | Per-cycle cost of drugs and monitoring |
The 2023 guideline’s considerations when choosing surgery are cost compared with other ovulation induction options, the expertise needed to do it safely, and intraoperative and postoperative risks, including “ovarian adhesions and diminished ovarian reserve.” For OHSS risks with injectables, see our OHSS guide.
Who it may suit
- People with PCOS/PMOS who have not ovulated on letrozole or clomiphene at the doses their doctor considers appropriate.
- No other fertility factor: open tubes (or tubes to be checked at the same surgery), and a normal semen analysis.
- Someone who cannot attend frequent monitoring visits for injectable cycles, or wants to avoid the multiple-pregnancy risk of injectables.
- Someone for whom laparoscopy is already being considered for another reason.
Who it usually does not suit
- People who have not yet tried oral ovulation induction properly.
- Couples with male-factor infertility or blocked tubes, for whom IVF addresses more of the problem.
- People with low ovarian reserve.
- Those who need to move quickly because of age; ask whether IVF is a better use of time.
Consider drilling after oral drugs fail, if nothing else is wrong and injectables are a poor fit.
- Usually discussed when
- Anovulation persists on letrozole or clomiphene and other fertility tests are normal.
- Main upside
- One procedure may restore ovulation without the OHSS and multiples risk of injectables.
- Main tradeoff
- Surgical risks, possible adhesions and reduced ovarian reserve; not everyone responds.
Cost and insurance: compare the whole path
The guideline lists cost as one of the factors to weigh, and the comparison is not straightforward. Drilling is a single upfront surgical bill, while injectable gonadotropins are paid cycle by cycle, with medication and monitoring each time. Insurance can tip the balance either way: some plans cover laparoscopic surgery as a medical procedure but exclude fertility medications, while others cover ovulation induction but scrutinize surgery done mainly for fertility. Ask your plan how it would treat each option before deciding, and compare the realistic total, for example one surgery plus a few months of trying, against the number of injectable cycles your doctor expects you might need. Our fertility financing hub covers how to approach those conversations with insurers.
Metabolic care still matters
The renaming to PMOS underlines that this is a metabolic condition. Whatever ovulation treatment you choose, the 2023 guideline emphasizes lifestyle and metabolic care as the base. Metformin is sometimes added, and you may see claims about supplements; LifeFertile compares berberine and metformin for PMOS, with the caveat that supplements are not a substitute for prescribed treatment. Our PCOS and fertility hub and PMOS clinical update cover the wider picture.
After surgery: what to expect
Recovery from laparoscopy is usually a matter of days to a couple of weeks, depending on what else is done. Your doctor will usually track whether you start ovulating on your own over the following months. If you do not, oral ovulation drugs are sometimes tried again, since some people respond to them after drilling when they did not before. If there is still no ovulation, or no pregnancy despite ovulation, the next conversation is usually about gonadotropins or IVF. Tracking your cycles after surgery, with dates of periods and any ovulation test results, gives your doctor the information needed to make that call sooner.
- Have I had an adequate trial of letrozole or clomiphene, at doses you consider appropriate?
- Why drilling rather than injectables or metformin combined with oral drugs for me?
- How many drilling procedures do you perform, and how do you limit damage to ovarian reserve?
- Will you check my tubes and pelvis during the same surgery?
- How long should I wait to see if I ovulate, and what is the plan if I do not?
- Given my age and AMH, is IVF a better use of time and money?
When to see a doctor: irregular or absent periods are a reason to seek a fertility evaluation without waiting the usual 6 or 12 months, according to ASRM’s evaluation guidance.
- Getting Pregnant With PMOS (Formerly PCOS): A Realistic Step-by-Step Plan (FertileStart)
- PCOS Is Now PMOS: What the Name Change Means for You (HowToHaveABaby)
- Berberine vs Metformin for PMOS: What’s the Real Difference? (LifeFertile)
Frequently asked questions
Is ovarian drilling still used for PCOS?
Yes, but as a second-line option. The 2023 international PCOS guideline lists laparoscopic ovarian surgery among second-line treatments for people who do not ovulate on oral drugs and have no other fertility factors.
Does ovarian drilling reduce egg reserve?
It can. The guideline lists diminished ovarian reserve and ovarian adhesions among the risks to weigh, which is why technique and patient selection matter.
Is drilling better than gonadotropin injections?
Neither is better for everyone. Injectables carry a higher risk of OHSS and multiple pregnancy; drilling carries surgical risks and possible effects on ovarian reserve.
Is PCOS now called PMOS?
Yes. In May 2026 an international consensus renamed it polyendocrine metabolic ovarian syndrome (PMOS). Diagnosis and treatment options remain the same.
Can I try letrozole again after ovarian drilling?
Sometimes. If ovulation does not resume after drilling, doctors may retry oral ovulation drugs before moving to injectables or IVF.
Sources & guidance
- Teede HJ et al. Recommendations from the 2023 International Evidence-based Guideline for the Assessment and Management of Polycystic Ovary Syndrome. Hum Reprod. 2023;38(9):1655-1679
- FOGSI Focus: PCOS practice points, PCOS and infertility (2024), summarizing the 2023 international guideline on laparoscopic ovarian surgery
- Endometriosis UK: PCOS officially renamed Polyendocrine Metabolic Ovarian Syndrome (PMOS), May 2026
- ASRM: Fertility evaluation of infertile women (2021)