Laparoscopic management of endometriomas using a combined technique of excisional (cystectomy) and ablative surgery

The Impact on Ovarian Reserve of CO2 Laser Fiber Vaporization in the Treatment of Ovarian Endometrioma: A Prospective Clinical Trial

Background

In recent years, excisional surgery has been questioned as an ideal surgical approach for endometriomas because it is associated with potential removal of healthy ovarian tissue and loss of ovarian follicles with subsequent reduction of ovarian reserve. The aim of our study was to evaluate the benefits of CO2 laser vaporization through a clinical trial assessing the postoperative changes in ovarian reserve as indicated by antral follicle count (AFC) and anti-Müllerian hormone (AMH).

Materials and Methods

Fifteen patients undergoing surgery for primary unilateral or bilateral symptomatic endometriomas were enrolled in the study. During surgery, the cystic lining was completely vaporized with CO2 laser fiber (AcuPulse Duo system, Lumenis); before surgery and at 1 and 3 months after surgery, ovarian reserve was evaluated by pelvic ultrasound to determine the AFC, and blood sample to determine AMH levels.

Results

The AFC of the operated ovary was significantly increased after treatment at 1 and 3 months' follow-up (p = 0.0021; p = 0.005, respectively); the increase is particularly significant in women younger than 35 years (p = 0.012). No statistically significant changes were reported in serum AMH concentrations at 1 or 3 months' follow-up. No recurrences of symptoms and no recurrences of endometrioma were reported.

Conclusions

These data support the hypothesis that endometrioma vaporization with CO2 laser fiber may be a valid method to preserve ovarian function; however, further studies are required before advocating the routine use of CO2 laser vaporization for the management of ovarian endometriosis.

Endometriosis and Infertility: A Systematic Review

Endometriosis is one of the most common gynaecological conditions affecting 6% to 12% of women in the reproductive age group. It can be found in 35% to 45% of women who are trying to conceive and are infertile. Infertility is one of the most common problems associated with endometriosis. This review will look at the evidence that endometriosis may lead to infertility and the data looking at whether surgical correction of endometriosis may improve fertility outcomes.

Management of Endometriomas Prior to IVF

Endometriosis causes a decrease in fertility in affected patients. The different forms of the disease, peritoneal, ovarian, deep infiltrating and adenomyosis, are often present in varying degrees in the same patient, either together or individually, and cause infertility through a pathogenesis that is not yet clear. A significant number of women with endometriosis and endometriomas will eventually seek assisted reproductive technology (ART) for conception. The specific impact of endometriomas alone and the impact of surgical intervention for endometriomas on the reproductive outcome of women undergoing in vitro fertilization/intra-cytoplasmic sperm injection (IVF/ICSI) are areas that need further clarification and, for this reason, the management of endometriomas before clinical IVF is a very complex topic.

In order to provide useful information for the clinical management of patients with endometriomas having IVF, in this review we investigated: the impact of the presence of endometriomas, both individually and associated with other types of the disease, on IVF techniques; the possible role of surgery and its possible negative effects; the risks and difficulties related to conservative management during IVF procedures.

Impact of surgery for endometriomas on pregnancy outcomes following in vitro fertilization-intracytoplasmic sperm injection. Who should be the preferred laparoscopists: gynecologists or reproductive surgeons?

OBJECTIVE

To investigate whether laparoscopic excision of ovarian endometriomas pretreated with operation by gynecologists or reproductive surgeons exerts different effects on in vitro fertilization-intracytoplasmic sperm injection results.

MATERIALS AND METHODS

Retrospective case control study. Relevant information was collected from the electronic records of women who underwent IVF/ICSI from 01/01/2013 to 30/12/2015 in our unit. The study group consisted of 35 women who previously had laparoscopic endometrioma excision by reproductive surgeons in our unit; the control group included 36 patients who underwent surgery for endometriomas by gynecologists in our hospital.

RESULT(S)

There were slightly higher numbers of AFC and higher pregnancy rate in the study group, although differences did not reach statistical significance. For patients over 35 years old, there were more oocyte retrieved, mature oocytes and two pronucei (2PN) in the study group than the control group although observed differences did not reach statistical significance.

CONCLUSION(S)

Electrocautery is more deleterious on ovarian reserve than hemostatic suture. In procedure of patients who wish to conceive, surgeons should use hemostatic suturing technique preferentially.

Analyzing the risk factors for a diminished oocyte retrieval rate under controlled ovarian stimulation

Aim

To investigate which risk factors contribute to a lower oocyte retrieval ratio in women who are receiving controlled ovarian hyperstimulation.

Methods

The authors retrospectively analyzed 329 in vitro fertilization (IVF) cycles under controlled ovarian hyperstimulation by using a gonadotropin‐releasing hormone antagonist or agonist at Osaka Medical College, Japan. The patients were classified into five groups: advanced age, male infertility, severe endometriosis, tubal infertility, and unexplained infertility. The primary outcomes were the patients’ age, oocyte retrieval ratio, serum basal follicle‐stimulating hormone, total dose of gonadotropin, and the clinical outcome. A secondary outcome was the stepwise multivariate logistic regression analysis to assess the factors associated with the failure of oocyte retrieval.

Results

The oocyte retrieval ratio declined significantly with the patient's age. The ratio of endometriosis in unsuccessful cases was significantly higher than that in successful cycles. Advanced age and endometriosis were the factors that were significantly associated with a lowered oocyte retrieval rate.

Conclusion

Advanced age and endometriosis are high‐risk factors that contribute to oocyte retrieval failure in infertile patients who are receiving IVF treatment.

Which Should Be the Preferred Technique During Laparoscopic Ovarian Cystectomy

The aim of the present study was to determine the long-term effects of different laparoscopic hemostatic techniques on ovarian reserve after ovarian cystectomy. Ninety patients with unilateral ovarian cysts were recruited and randomly distributed into 2 groups. Laparoscopic stripping cystectomy was performed in all patients. Afterward, cystectomy hemostasis was achieved via hemostatic suture or bipolar electrocoagulation. Serum levels of anti-Müllerian hormone (AMH) were determined preoperatively and postoperatively at 1, 3, and 12 months, and patients were evaluated for residual ovarian volume, antral follicle count, and pregnancy. The statistical difference was determined between the 2 groups in terms of AMH levels at 3 months (hemostatic suture group = 3.17 ± 3.40 vs bipolar electrocoagulation group = 2.38 ± 2.57, P = .006) and 12 months (hemostatic suture group = 3.71 ± 3.09 vs bipolar electrocoagulation group = 2.78 ± 2.85, P = .005). In addition, in the hemostatic suture group, there was no statistically significant difference between preoperative and postoperative AMH levels ( P = .165) and between the postoperative antral follicle count ( P = .779) and the residual ovarian volume ( P = .248), whereas in the bipolar electrocoagulation group, postoperative AMH levels were lower than preoperative levels ( P = .028) and postoperative residual ovarian volumes at 3 and 12 months were lower than those at 1 month ( P = .001). Nonetheless, pregnancy rates were not significantly different ( P = .546). Bipolar electrocoagulation is more destructive compared with hemostatic suture. However, the ovarian reserve does not decrease further during the follow-up period.

Evaluation of factors predicting diminished ovarian reserve before and after laparoscopic cystectomy for ovarian endometriomas: a prospective cohort study

Background

Ovarian endometriomas affect a substantial proportion of women of reproductive age who may have a potential risk of diminished ovarian reserve (DOR) after ovarian cystectomy. Here, we investigated the risk factors for pre-surgical DOR in patients with ovarian endometriomas and for DOR after laparoscopic ovarian cystectomy for endometriomas and evaluated the feasibility of the pre-surgical prediction of post-surgical DOR based on the Bologna criteria.

Methods

A total of 143 patients with ovarian endometriomas who underwent laparoscopic cystectomy from January 2009 to May 2015 at our hospital were prospectively enrolled and evaluated. Serum anti-Müllerian hormone (AMH) concentrations were measured pre-surgically and at 3 and 6 months after surgery. In accordance with the Bologna criteria, the patients whose AMH concentrations were <1.1 ng/mL before surgery and 3 or 6 months after surgery were classified into pre- and post-surgical adverse DOR (aDOR) groups, respectively.

Results

Thirty-one (21.7 %) of 143 patients were classified as pre-surgical aDOR. Patient age and serum follicle-stimulating hormone level were significantly positively correlated with pre-surgical aDOR [odds ratios (ORs), 1.26 and 1.16; p < 0.001 and p = 0.003, respectively]. Among the remaining 112 patients, 38 patients (33.9 %) had post-surgical aDOR 3 and 6 months after surgery. Bilateral cystectomy was positively correlated with post-surgical aDOR (at 3 months: OR, 4.7; p = 0.001; at 6 months: OR, 3.71; p = 0.006); conversely, pre-surgical serum AMH concentrations were negatively correlated with post-surgical aDOR (at 3 months: OR, 0.65; p = 0.005; at 6 months: OR, 0.43; p < 0.001). The optimal cut-off point of pre-surgical AMH concentrations for predicting aDOR at 3 and 6 months in the patients undergoing unilateral cystectomy was 2.1 ng/mL. In contrast, the optimal cut-off points at 3 and 6 months in the patients undergoing bilateral cystectomy were 3.0 and 3.5 ng/mL, respectively.

Conclusions

Our data suggest that the pre-surgical serum AMH concentrations and bilateral cystectomy are significant factors for the risk of aDOR following surgery and that predicting post-surgical aDOR according to the Bologna criteria could be feasible using pre-operative measurements of serum AMH concentrations.

Modern Management of Endometrioma-Associated Infertility: in Favor of ART

Introduction

Endometrioma is present in 17% to 40% of women with endometriosis. Since it has been traditionally believed that the presence of an endometrioma adversely affects the outcome of assisted reproductive technology (ART), surgery has been suggested by many practitioners before advancing to ART, in the hope of improving results.

Scientific Evidence

In the present article, we outline the impact of an endometrioma on the ovarian reserve and describe how surgical resection of an endometriotic cyst affects ovarian reserve, ovarian response after stimulation and ART outcome. Several studies suggest that the sole presence of an endometrioma may have a negative impact on ovarian reserve of the affected ovary, and surgery (particularly cystectomy) has been the choice of treatment in ovarian endometriosis for many years. However, detrimental effects of laparoscopic surgical removal on ovarian reserve and responsiveness to hyperstimulation has made that ART practices are shifting towards a more conservative approach: experimental and clinical data supporting this shift are thoroughly reviewed here.

Clinical Implications

Opposed to the conventional criteria of performing cystectomy when ovarian endometrioma is observed, careful consideration of patient symptoms as well as her age and ovarian reserve will help to select the patients that require surgery prior to ART, whereas the majority will not need surgery prior to ART; even more, surgery may compromise ovarian reserve in most cases even if performed by careful surgeons.

Conclusions

Individualization of the treatment is imperative. Each case should be thoroughly assessed, looking at both the advantages and complications of cyst removal prior to ART. Surgery should be approached with caution in women with endometriomas, especially if the woman has had previous ovarian surgery. In the presence of infertility, we recommend generally sparing surgical treatment and proceeding directly to ART. This reduces the time to achieve a pregnancy, avoids potential surgical risks and limits patient costs.

Effect of salpingectomy, ovarian cystectomy and unilateral salpingo-oopherectomy on ovarian reserve

Pelvic surgery can affect ovarian reserve, but estimates of the potential effect of different surgical procedures are lacking. This study examines the markers of ovarian reserve after different procedures in order to help the provision of informed consent before surgery. Anti-Müllerian hormone (AMH), antral follicle count (AFC) and follicle-stimulating hormone (FSH) of women with a history of salpingectomy, ovarian cystectomy or unilateral salpingo-oophorectomy were compared to those without history of surgery using cross-sectional data adjusting for patient and clinical factors in multivariable regression model. There were 138 women who had had salpingectomy, 36 unilateral salpingo-oopherectomy, 41 cystectomy for ovarian cysts that are other than endometrioma and 40 women had had excision of endometrioma. There was no significant difference in AMH (9 %; p = 0.33), AFC (-2 %; p = 0.59) or FSH (-14 %; p = 0.21) in women with a history of salpingectomy compared to women without surgery. Women with a history of unilateral salpingo-oophorectomy were found to have significantly lower AMH (-54 %; p = 0.001). These women also had lower AFC (-28 %; p = 0.34) and higher FSH (14 %; p = 0.06), the effect of which did not reach statistical significance. The study did not find any significant associations between a history of cystectomy, for disease other than endometrioma and AMH (7 %; p = 0.62), AFC (13 %; p = 0.18) or FSH. (11 %; p = 0.16). Women with a history of cystectomy for ovarian endometrioma had 66 % lower AMH (p = 0.002). Surgery for endometrioma did not significantly affect AFC (14 %; p = 0.22) or FSH (10 %; p = 0.28). Salpingo-oopherectomy and cystectomy for endometrioma cause a significant reduction in AMH levels. Neither salpingectomy nor cystectomy for cysts other than endometrioma has appreciable effects on ovarian reserve.

[Fertility preservation in women of the childbearing age: Indications and strategies]

Advances on cryopreservation techniques now allow considering oocyte, embryo or ovarian tissue freezing for female fertility preservation. Originally developed for patients suffering from cancer, fertility preservation has rapidly invaded others medical fields, and represents now the standard of care for all young patient diagnosed with a disease that could impair fertility or having to receive possibly gonadotoxic treatment. As a result, autoimmune diseases, some genetic pathologies or iterative pelvic surgeries, at risk of premature ovarian failure, have become common indications of fertility preservation. In addition, the social egg freezing aiming at preventing the age-related fertility decline is still debated in France, although authorized in numerous countries. This review will discuss the different strategies of fertility preservation in young girls and women of reproductive age, regarding different medical or non-medical indications.

When helping hurts: the effect of surgical interventions on ovarian reserve

This commentary reviews some of the major papers that have been published on the effect of ovarian reserve after surgical interventions. At the end, the authors outline a summary on the effect of these interventions, in terms of future fertility and menopause.

Treatment of endometrioma for improving fertility

Endometrioma is a frequent clinical manifestation of endometriosis. It is controversial how endometriomas may affect women's fertility. This review addresses: the impact of the endometrioma per se and of its surgical treatment on ovarian physiology, on the ovarian reserve, on spontaneous conception and pregnancy outcomes, and on IVF/ICSI outcomes. Based on current evidence, although there are plausible biological detrimental effects on the ovarian cortex surrounding the endometrioma and an impairment of the normal ovarian physiology, the clinical impact of the endometrioma per se is not significantly altered. There is a negligible detrimental effect on ovarian reserve with spontaneous ovulation not being impaired. Conversely, surgical excision of an endometrioma reduces ovarian reserve as measured by AMH levels. Studies investigating the impact of the endometrioma per se and of its surgical treatment in women requiring IVF/ICSI show similar implantation rates, clinical pregnancy rates and live birth rates between women with endometrioma and controls.

The Presence of Endometrioma Does Not Impair Time-Lapse Morphokinetic Parameters and Quality of Embryos: A Study On Sibling Oocytes

OBJECTIVE

To see whether the oocytes retrieved from an ovary with an endometrioma would develop into embryos with aberrant timings of cleavage as assessed using time-lapse monitoring (TLM) and poorer morphologic quality compared with sibling oocytes from the contralateral ovary with no endometrioma in the same patient after intracytoplasmic sperm injection.

METHODS

This was an observational prospective study at an in vitro fertilization (IVF) center of a private hospital. It included analysis and comparison of 128 embryos (69 embryos developed from the ovary with endometrioma and 59 embryos from the contralateral ovary without endometrioma serving as controls from a total of 20 women with infertility). Morphology of the embryo was assessed twice (days 3 and 5), again by capturing images with the TLM system. Morphokinetic parameters of embryos and clinical pregnancy rates were recorded separately from ovaries with and without endometrioma and were the primary outcomes of the study. Secondary outcomes included number of retrieved oocytes, number of metaphase II (MII) oocytes, fertilization rates, and conventional morphological classification of embryos.

RESULTS

There were no differences in terms of the following time-lapse morphokinetic parameters of embryos. The mean numbers of oocytes and MII oocytes collected from the ovary with the endometrioma were similar to those collected from the contralateral ovary without endometrioma. Fertilization rates and the percentage of embryos with top morphologic quality were also similar.

CONCLUSIONS

According to the morphokinetic parameters, this study further strengthens the notion that removal of endometriomas before IVF is not a necessity in terms of better oocyte quality and development.

Anti-Mullerian hormone trend evaluation after laparoscopic surgery of monolateral endometrioma using a new dual wavelengths laser system (DWLS) for hemostasis

Operative laparoscopy is the gold standard in the treatment of endometriotic ovarian cysts. Excisional surgery is the best technique to prevent recurrences and improve symptoms but it may result in ovarian reserve damage due to the removal of healthy ovarian cortex. The aim of this study was to assess the impact on ovarian reserve of the use of dual wavelengths laser system (DWLS) hemostasis after stripping technique of monolateral endometrioma, by dosing the anti-Mullerian hormone (AMH). This prospective study was conducted at the Institute of Obstetrics and Gynecology, University of Foggia, from December 2013 to January 2015. Forty-five women underwent excision of monolateral endometriotic ovarian cyst by stripping without using a bipolar coagulation and performing hemostasis with a DWLS. The AMH serum levels were estimated before the surgery (T0), 4-6 weeks (T1) and 6-9 months (T2) after surgery. Our results suggest that an appropriate surgical technique with the use of laser hemostasis does not determine a significant reduction of ovarian reserve. Laser hemostasis could prevent follicular reserve loss after ovarian endometrioma surgery.

Robotic single-site excision of ovarian endometrioma

BACKGROUND

Conventional single-incision laparoscopic surgery has been successfully employed for treatment of ovarian endometriomas. However, this technique presents surgeons with formidable ergonomic challenges, that make its widespread adoption unlikely. Robotic assistance in single-incision laparoscopic surgery provides adequate instrument triangulation through a single fulcrum, while eliminating ergonomic challenges to the surgeon. The objective of this video is to describe a novel technique of laparoscopic excision and ablation of ovarian endometriomas with single-site robotic assistance. Footage from a single surgical case is shown in our video. The da Vinci Si surgical system with da Vinci Single-Site platform was utilized. A flexible CO2 laser fiber was employed as the main energy tool. To describe a technique of single-incision laparoscopic excision and ablation of endometriomas with robotic assistance. Footage from a single surgical case is shown in this video. The da Vinci Si surgical system with da Vinci Single-Site platform was utilized. A flexible CO2 laser fiber was employed as the main energy tool.

RESULTS

Our technique achieved excellent surgical, clinical and cosmetic results, with complete excision and ablation of the endometriomas and no complications. The procedure was completed in day-surgery setting.

CONCLUSION

Our step-by-step video tutorial shows how the dedicated single incision laparoscopy technology for the da Vinci Si surgical system can be safely and effectively applied to the excision and ablation of ovarian endometriomas.

Recurrence of endometriosis: risk factors, mechanisms and biomarkers

While the incidence of endometriosis is up to 40-60% in women with severe dysmenorrhea/chronic pelvic pain, patients with subfertility carries a risk up to 20-30%. In symptomatic patients, although medical therapy is preferred in women with endometriosis, surgery might be needed in nonresponders or patients with an endometrioma. Following the surgery, recurrence of the disease and/or symptoms might be still noticed which will progressively increase as times goes by. Nevertheless, some risk factors have been identified for the risk of recurrence that decreases the success of the procedure. Those risk factors might be classified as patient-disease related and surgery-associated variables. Herein, we will address about the management of endometriosis regarding the risk factors for relapse, mechanisms of recurrence and potential biomarkers to predict the event.

Endometriosis and ovarian reserve

Endometriosis is characterized by development of the endometrial tissue outside the uterus like ovary, pelvic peritoneum, pelvic organs, and affects 6-10% of reproductive-aged women. The prevalence of endometrioma is 17-44% of women with endometriosis. Since endometriosis is mainly a disease for the women at their reproductive ages, it is important to consider ovarian reserve when managing the cases with ovarian endometriosis. There has been a long debate whether the endometrioma per se decreases the ovarian reserve and/or surgery for endometrioma - either by laparoscopy or by laparotomy - decreases it. Although the dispute for these questions is not totally settled down, in this article, we would like to give some clues for the answers in view of the literature.

Complications and their management in endometriosis surgery

Endometriosis is a common chronic disease mostly seen in young women. Endometriosis surgery may be considered as rather challenging in gynecology. In this article, we tried to emphasize on basic concepts of endometriosis surgery, the best surgical method that should be applied and the complications and the management of the complications.

An Update on Surgical versus Expectant Management of Ovarian Endometriomas in Infertile Women

Ovarian endometriomas are a common manifestation of endometriosis that can represent a more severe stage of the disease. There is much debate over the treatment of these cysts in infertile women, particularly before use of assisted reproductive technologies. Evidence exists that supports surgical excision of ovarian endometriomas, as well as evidence that cautions against surgical intervention. Certain factors need to be examined closely before proceeding with surgery or continuing with expectant management. These include the patient's symptoms, age, ovarian reserve, size and laterality of the cyst, prior surgical treatment, and level of suspicion for malignancy. The most recent evidence appears to suggest that certain patient profiles may benefit from proceeding directly to in vitro fertilization (IVF). These include symptomatic infertile patients, especially those that are older, those that have diminished ovarian reserve, those that have bilateral endometriomas, or those that have had prior surgical treatment. Although endometriomas can be detrimental to the ovarian reserve, surgical therapy may further lower a woman's ovarian reserve. Nevertheless, the presence of an endometrioma does not appear to adversely affect IVF outcomes, and surgical excision of endometriomas does not appear to improve IVF outcomes. Regardless of treatment plan, infertile patients with endometriomas must be counseled appropriately before choosing either treatment path.

Surgical technique of endometrioma excision impacts on the ovarian reserve. Single-port access laparoscopy versus multiport access laparoscopy: a case control study

Several recent studies report the detrimental effect of endometrioma excision on the ovarian reserve. Surgical technique and the excessive use of bipolar coagulation could be the key factors. Single-port access laparoscopy (SPAL) ovarian cystectomy has been reported as a comparable procedure to conventional laparoscopy in terms of operative outcomes. The aim of this study was to evaluate whether the single-port surgery affects the ovarian reserve whilst performing laparoscopic ovarian cystectomy for unilateral endometrioma. This was a prospective, case-control study of 99 women with unilateral endometrioma. Forty-nine women underwent single-port cystectomy and 50 women underwent multiport laparoscopic (MPL) conventional cystectomy. The primary outcome was the assessment of the ovarian reserve. We evaluated the serum anti-Mullerian hormone (AMH) levels before, 4-6 weeks and 3 months after surgery. At T2 we performed an ultrasound assessment of the antral follicular count (AFC). We have drawn attention to a statistically significant decrease of the mean AMH value and AFC in the SPAL group at the 4-6-week and 3-month follow-up compared to the conventional laparoscopy group. In conclusion, our results suggest that SPAL cystectomy should not be recommended to patients undergoing surgery for endometrioma excision who want to preserve their fertility.

Fertility preservation in women with endometriosis: for all, for some, for none?

The increasing confidence with the techniques of oocyte and ovarian cortex freezing has prompted their potential use for patient categories other than those at risk of early menopause due to cancer treatments. Women affected by every iatrogenic or pathologic condition known to compromise ovarian function severely have been considered as potential candidates for fertility preservation. Among them, women with endometriosis may represent a particularly suitable group since they are at increased risk of premature ovarian exhaustion and about half of them will experience infertility. Based on the currently available notions on the intricate relationships between endometriosis, infertility and damage to the ovarian reserve, we speculate that fertility preservation may be of interest for women with endometriosis, in particular for those with bilateral unoperated endometriomas and for those who previously had excision of unilateral endometriomas and require surgery for a contralateral recurrence. Young age at diagnosis may be an independent but pivotal additional factor to be taken into consideration in the balance of the pros and cons of fertility preservation. On the other hand, we argue against the introduction of fertility preservation for endometriosis in routine clinical practice. To date, only few cases have been reported and there are insufficient data for robust cost-utility analyses. It is noteworthy that endometriosis is a relatively common disease and systematically including affected women in a fertility preservation program would have profound clinical, logistic and financial effects. More clinical data and in-depth economic analysis are imperative prior to recommending its routine use.

Exploring the Relationship between Endometriomas and Infertility

Several clinical and epidemiological studies demonstrated an association between endometriosis and infertility. A role in the genesis of infertility may be played by endometriomas, which may interfere with ovulation or damage ovarian tissue. Unlike peritoneal implants, the availability of an accurate noninvasive sonographic diagnosis facilitates the investigation of endometrioma associated infertility. The laparoscopic excision of an endometrioma relieves the ovary from the damage caused by the cyst itself, which may be progressive over time, but at the same time is associated with a detrimental effect on ovarian reserve and with high rates of postoperative endometrioma recurrence. Therefore, the management of endometrioma-related infertility should not be based upon surgery alone, but upon a combination of surgery, with a refinement of the operating technique, long-term oral contraceptive, in vitro fertilization and oocyte cryopreservation.

Second surgery for recurrent unilateral endometriomas and impact on ovarian reserve: a case-control study

OBJECTIVE

To investigate the impact on ovarian reserve of second laparoscopic surgery for recurrent unilateral endometriomas.

DESIGN

Case-control study.

SETTING

University teaching hospital.

PATIENT(S)

This study included patients who underwent stripping of endometriomas (diameter ≥4 cm) and were followed-up at our institution. Case subjects had second surgery for recurrent unilateral endometriomas (n = 18); control subjects had no recurrence and no second surgery (n = 18).

INTERVENTION(S)

This case-control study was based on a retrospective analysis of a prospectively collected database including patients who underwent surgery for endometriomas at our institution.

MAIN OUTCOME MEASURE(S)

The primary outcome of the study was to assess the changes in antimüllerian hormone (AMH) levels in each study group and between the two study groups. The secondary outcomes of the study were to assess the changes in basal FSH, antral follicle count (AFC), and ovarian volume in each study group and between the two study groups.

RESULT(S)

In both study groups, primary surgery decreased AMH, increased basal FSH, and decreased the AFC of the operated ovary. Before second surgery, case subjects had AMH, basal FSH, and AFC similar to control subjects. After second surgery, case subjects had lower AMH, higher basal FSH, and lower AFC of the affected ovary than before surgery; the volume of the operated ovary was lower than that of the contralateral ovary.

CONCLUSION(S)

The laparoscopic stripping of recurrent ovarian endometriomas is associated with a high risk of ovarian reserve damage and ovarian failure.

CLINICAL TRIAL REGISTRATION NUMBER

NCT02047838.

Ovarian endometrioma in the adolescent: a plea for early-stage diagnosis and full surgical treatment

The incidence and severity of endometriosis in adolescent are comparable with the incidence in adult women. The mean delay between the onset of symptoms and the final diagnosis varies between 6.4 and 11.7 years. The longer the diagnosis is delayed, the more the endometriosis can progress to a more severe stage certainly in the group of patients with pelvic pain. The evolution of endometriosis and its progressivity are not predictable, and the severity of the disease is not directly related to the degree of pain. Endometriotic cysts have a detrimental effect on the ovarian reserve by the evolution in time and the surgical excision technique. Already, in small endometriotic cysts (<4 cm), loss of follicular reserve is present together with the formation of fibrosis in the cortex of the ovary. Early diagnosis of endometriosis in the adolescent deserves our full attention. Non-invasive imaging techniques like 2-D and 3-D ultrasound are helpful in the early diagnosis. Early ablative surgery is recommendable. Although laparoscopy is traditionally recommended, transvaginal laparoscopy has been shown to be most effective in ablating endometriomas with a maximum diameter of 3 cm. Early detection and intervention will contribute to a better quality of life in these adolescents and also to a lower damage of the ovarian tissue by a less invasive ablative surgery.

Effect on ovarian reserve of hemostasis by bipolar coagulation versus suture during laparoendoscopic single-site cystectomy for ovarian endometriomas

STUDY OBJECTIVE

To compare the postoperative decrease in ovarian reserve between hemostasis by bipolar coagulation and suture during laparoendoscopic single-site cystectomy (LESS-C) for ovarian endometriomas.

DESIGN

Prospective comparative study (Canadian Task Force Classification II-1).

SETTING

University hospital.

PATIENTS

One hundred twenty-five patients with ovarian endometriomas.

INTERVENTIONS

Patients with endometrioma were managed by hemostasis with either bipolar coagulation (n = 62) or suturing (n = 63) during LESS-C. We evaluated the impact of surgery on ovarian reserve using serum anti-Müllerian hormone (AMH) levels, which were measured before surgery and 3 months after surgery in all patients.

MEASUREMENT AND MAIN RESULTS

Baseline characteristics such as age, bilaterality of endometriomas, and preoperative AMH levels were similar between the 2 study groups. There were also no differences between the 2 groups in surgical outcomes, such as operative time, operative blood loss, or operative complications. In both study groups, postoperative AMH levels were lower than preoperative AMH levels (p < .001). The decline rate of AMH levels was significantly greater in the bipolar coagulation group than in the suture group (42.2% [interquartile range, 16.5%-53.0%] and 24.6% [interquartile range, 11.6%-37.0%], respectively, p = .001).

CONCLUSION

Hemostasis by bipolar coagulation after stripping of the endometrioma during LESS-C reduces ovarian reserve more than suturing does, as determined by serial AMH levels. Therefore, suturing may be a better hemostatic choice after stripping ovarian endometriomas.

Ovarian cystectomy in endometriomas: Combined approach

Endometrioma is one of the most frequent adnexal masses in the premenopausal population, but the recommended treatment is still a subject of debate. Medical therapy is inefficient and can not be recommended in the management of ovarian endometriomas. The general consensus is that ovarian endometriomas larger than 4 cm should be removed, both to reduce pain and to improve spontaneous conception rates. The removal of ovarian endometriomas can be difficult, as the capsule is often densely adherent. While the surgical treatment of choice is surgical laparoscopy, for conservative treatment, the preferred method is modified combined cystectomy. Cystectomy can be destructive for the ovary, whereas ablation may be incomplete, with a greater risk of recurrence. To the best of our knowledge, the modified combined technique seems to be more efficient in the treatment of endometriomas.

Endometriosis and infertility: how and when to treat?

Endometriosis is defined as the presence of endometrial-like tissue (glands or stroma) outside the uterus, which induces a chronic inflammatory reaction. Although endometriosis impairs fertility, it does not usually completely prevent conception. The question of evidence based-medicine guidelines in endometriosis-associated infertility is weak in many situations. Therefore, we will highlight in this issue where the challenges are.

Employing Laparoscopic Surgery for Endometriosis

Endometriosis is a chronic, multifactorial disease, which can impact significantly on a women's quality of life. It is associated with pelvic pain, dyspareunia and intestinal disorders, and can lead to infertility. The use of laparoscopic surgery in the management of endometriosis is well documented; however, the optimal management of women with deep infiltrating disease remains controversial. This review describes the different surgical strategies for the treatment of endometriosis.