Effect of laparoscopic excision of endometriomas on ovarian reserve: serial changes in the serum antimüllerian hormone levels

Live Birth Rate after Surgical and Expectant Management of Endometriomas after In Vitro Fertilization: A Systematic Review, Meta-Analysis, and Critical Appraisal of Current Guidelines and Previous Meta-Analyses

Controversy exists regarding surgical management of endometriomas in infertile women before in vitro fertilization (IVF) because growing evidence indicates that surgery may impair the ovarian response. The objective of the present systematic review and meta-analysis was to compare surgical and expectant management of endometriomas regarding IVF outcomes. Prospective and retrospective controlled studies were found via the Cochrane Library, Embase, and MEDLINE databases. Thirteen studies (1 randomized controlled trial and 12 observational studies, N = 2878) were pooled, and similar live birth rates were observed in the surgically and expectantly managed groups (odds ratio = 0.83; 95% confidence interval [CI], 0.56-1.22; p = .98). The clinical pregnancy rates (odds ratio = 0.83; 95% CI, 0.66-1.05; p = .86), the number of mature oocytes retrieved, and the miscarriage rates were not statistically different between study groups. However, the total number of oocytes retrieved was lower in the surgery group (mean difference = -1.51; 95% CI, -2.60 to -0.43; p = .02). Findings suggest that surgical management of endometriomas before IVF therapy yields similar live birth rates as expectant management. However, future properly designed randomized controlled trials are warranted.

Do ovarian reserve markers predict the subsequent pregnancy outcomes in women with recurrent pregnancy loss?

Objective(s):

Chromosomal abnormalities are more commonly seen in embryos with decreased oocyte quality. Therefore aneuploidy due to diminished ovarian reserve may be one of the causative reasons of RPL. We investigated the relationship between ovarian reserve markers especially serum antimullerian hormone (AMH) level and antral follicle count (AFC) and recurrent pregnancy loss (RPL).

Materials and methods:

This prospective cross-sectional clinical trial including 88 women with RPL and 84 age-matched women without RPL.

Results:

There were statistically significant differences in body mass index, live birth number, menstrual cycle length, AFC and serum AMH level between groups. There was no statistically significant difference between groups regarding age, menstrual cycle regularity and serum follicle stimulating hormone (FSH) and estradiol (E2) levels. The percentage of women with levels of AMH<1 was 21.4% in the RPL group and 11.4% in the control group. AFC <7 in both ovaries was lower in the RPL group when compared with the control group (73.8% vs 44.3%, respectively).

Conclusion(s):

Serum AMH levels and AFC can be assessed in patients with RPL as a part of the work up parameters. Lower Serum AMH levels and AFC especially may predict the quantity of oocytes that may be consequently be related with RPL.

Serum anti-Müllerian hormone concentration before and after salpingectomy for ectopic pregnancy

RESEARCH QUESTION

Does salpingectomy for ectopic pregnancy affect the ovarian reserve measured by changes in pre- and post-operative levels of anti-Müllerian hormone (AMH)?

DESIGN

This is a prospective observational multicentre study of 64 women treated with salpingectomy for an ectopic pregnancy. AMH was measured in serum samples collected at admission before salpingectomy and at follow-up (median time to follow-up [interquartile range] was 3 [3-4] months). Changes in serum AMH levels were investigated using Wilcoxon signed-rank test and the relationship between changes in AMH and age, time to follow-up, and pre-operative serum AMH level was investigated using linear regression analysis. The biological variation of AMH was also calculated.

RESULTS

Serum AMH levels did not differ significantly before and after salpingectomy (median ∆AMH [follow-up value minus admission value] 0.40 pmol/l, interquartile range -2.0 to 4.0 pmol/l). ΔAMH was independent of age, time to follow-up and pre-operative serum AMH level. The intra-individual biological variation for AMH ranged from 12.1% to 26.3%, depending on time between the two samples.

CONCLUSIONS

This is the first paired study to investigate serum AMH values before and after salpingectomy in an unselected population of women presenting with an ectopic pregnancy, including both patients who conceived naturally and following fertility treatment. It was found that salpingectomy for ectopic pregnancy had no short-term effect on serum AMH levels, and changes in AMH levels were independent of age, time to follow-up, and pre-operative serum AMH level. Furthermore, the study demonstrated a 6-month biological variation of AMH of less than 30%.

Ovarian Reserve Following Laparoscopic Ovarian Cystectomy vs Cyst Deroofing for Endometriomas

STUDY OBJECTIVE

Because laparoscopic ovarian cystectomy of endometriomas is known to adversely impact patient ovarian reserve, the search for other techniques of surgical management is ongoing. The present study was undertaken to evaluate laparoscopic cyst deroofing as a feasible alternative.

STUDY DESIGN

Prospective, randomized clinical trial (Canadian Task Force classification I).

SETTING

University maternity hospital.

PATIENTS

Women diagnosed with unilateral or bilateral ovarian endometriomas.

INTERVENTIONS

Patients were managed with either laparoscopic ovarian cystectomy or cyst deroofing.

MEASUREMENTS AND MAIN RESULTS

A total of 122 women with endometriomas were randomized to either laparoscopic cystectomy (group 1) or laparoscopic cyst deroofing (group 2). The primary endpoint was the effect on ovarian reserve based on changes in anti-Müllerian hormone (AMH) values. At 1 month postsurgery, anti-Müllerian hormone values were significantly decreased (p < .001) from preoperative values, from 4.25 ± 0.87 ng/mL to 1.66 ± 1.02 ng/mL in group 1 and from 4.2 ± 1.69 ng/mL to 2.15 ± 1.48 ng/mL in group 2. In addition, antral follicle count and ovarian volume decreased significantly (p < .001) in both groups by 1 month postsurgery. The decreases in these 3 parameters were more significant (p < .001) in group 1 than in group 2.

CONCLUSION

Laparoscopic cyst deroofing of endometriomas appears to be a promising alternative to laparoscopic cystectomy, with less postoperative decrease in ovarian reserve; however, the higher rate of endometrioma recurrence warrants future clinical research to determine the optimal surgical management of endometriomas.

Transplantation of cryopreserved ovarian tissue in a patient affected by metastatic struma ovarii and endometriosis

In this case report, the outcomes of cryopreserved ovarian tissue transplantation performed in a patient affected by struma-ovarii associated with mature cystic teratoma, recurrent endometriotic cysts and diffuse peritoneal malignant struma-ovarii implants were described. Before cryopreservation, the patient underwent two left ovarian surgeries for enucleation cysts 8 years after righ salpingo-oophorectomy for struma-ovarii. Ovarian biopsy was collected in another hospital and transported to our laboratory for cryopreservation. The patient was submitted to radioiodine-therapy for metastases from malignant struma-ovarii. After treatment she experienced premature ovarian failure. Ten years after cryopreservation, a first orthotopic transplantation was performed in the left ovary and in a peritoneal pocket. Before transplantation, ovarian samples were analyzed to assess neoplastic contamination and tissue quality. Three years later, a second transplantation was heterotopically performed in abdominal subcutaneous sites. The analysis on thawed ovarian tissue did not reveal micrometastasis and they showed follicle and stroma damages. After transplantation few small follicles were observed at ultrasound examination and hormonal levels remained at menopausal values. To date no ovarian function recovery has been observed. The report highlights that ovarian tissue cryopreservation after multiple ovarian surgery may have some limitations. An accurate counseling should be offered to patients who wish to preserve fertility.

Endometrioma-related reduction in ovarian reserve (ERROR): a prospective longitudinal study

OBJECTIVE

To evaluate whether endometrioma is associated with a progressive decline in ovarian reserve, and to compare the rate of decline with natural decline in ovarian reserve.

DESIGN

Prospective, observational study.

SETTING

Tertiary university hospital, endometriosis clinic.

PATIENT(S)

Forty women with endometrioma and 40 age-matched healthy controls.

INTERVENTION(S)

Women with endometriomas who did not need hormonal/surgical treatment at the time of recruitment and were expectantly managed. Controls were age-matched, healthy women. All participants underwent serum antimüllerian hormone (AMH) testing twice, 6 months apart. Sexually active patients with endometrioma also underwent antral follicle count.

MAIN OUTCOME MEASURE(S)

Change in serum AMH levels.

RESULT(S)

Median (25th-75th percentile) serum AMH level at recruitment was 2.83 (0.70-4.96) ng/mL in the endometrioma group and 4.42 (2.26-5.57) ng/mL in the control group. The median percent decline in serum AMH level was 26.4% (11.36%-55.41%) in the endometrioma group and 7.4% (-11.98%, 29.33%) in the control groups. Twenty-two women with endometrioma who had antral follicle count (AFC) had median AFC of 10 (8-12) at recruitment and 8 (6.3-10) at 6 months.

CONCLUSION(S)

Women with endometrioma experience a progressive decline in serum AMH levels, which is faster than that in healthy women.

CLINICAL TRIAL REGISTRATION NUMBER

NCT02438735.

Systematic review and meta-analysis of the effect of bipolar electrocoagulation during laparoscopic ovarian endometrioma stripping on ovarian reserve

BACKGROUND

Laparoscopic stripping is the gold-standard treatment for ovarian endometriosis. The choice of hemostasis method might affect ovarian reserve.

OBJECTIVES

To determine whether bipolar electrocoagulation is more detrimental to ovarian reserve than non-thermal hemostasis methods.

SEARCH STRATEGY

Entry terms associated with the MeSH terms "endometrioma," "laparoscopy," and "ovarian reserve" were used to search databases for articles published up to April 3, 2017, in English, Spanish, Portuguese, French, and Italian.

SELECTION CRITERIA

Randomized controlled trials comparing the 3-month postoperative serum anti-Müllerian hormone (AMH) level in premenopausal women undergoing laparoscopic stripping with bipolar hemostasis or non-thermal hemostasis methods were selected.

DATA COLLECTION AND ANALYSIS

Data were extracted by two independent reviewers and a meta-analysis was performed.

MAIN RESULTS

Three studies met the inclusion criteria; overall, 105 patients underwent surgery with bipolar electrocoagulation and 105 patients underwent surgery with an alternative hemostasis method. The AMH level 3 months after surgery was decreased in the bipolar electrocoagulation group (mean difference -0.79 ng/mL, 95% confidence interval -1.19 to -0.39).

CONCLUSIONS

Bipolar electrocoagulation negatively impacts ovarian reserve and should be avoided, especially for patients with reproductive goals.

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.

The impact of laparoscopic cystectomy on ovarian reserve in patients with unilateral and bilateral endometrioma

OBJECTIVE

To evaluate the effects of laparoscopic cystectomy on serum anti-Müllerian hormone (AMH) level as a marker of ovarian reserve in patients with endometrioma.

METHODS

A prospective observational study enrolled patients aged younger than 40 years who were referred to a tertiary center in Tehran, Iran, between January 1, 2013 and December 31, 2014 to undergo laparoscopic cystectomy for ovarian endometriomas at least 30 mm in diameter, or regardless of size for patients with infertility, dysmenorrhea, dyspareunia, or dyschezia. Baseline and 6-month post-operative AMH levels were compared.

RESULTS

Data from 70 patients were included in the analyses. Among patients with unilateral endometriomas, lower pre-operative AMH levels were observed in patients with endometriomas at least 50 mm in diameter (P=0.027), whereas cyst size was not associated with differences in pre-operative AMH level in patients with bilateral endometriomas (P=0.227). Across the entire study population, post-operative AMH levels were lower than the baseline (P=0.008). Greater post-operative decreases in AMH were associated with bilateral cysts compared with unilateral cysts (P=0.046), cysts being at least 50 mm in diameter among patients with unilateral cysts (P=0.028), and both cysts being at least 50 mm in diameter among patients with bilateral cysts (P=0.025).

CONCLUSION

Laparoscopic cystectomy was associated with post-operative decreases in serum AMH, particularly with bilateral involvement and endometriomas at least 50 mm in diameter.

Effect of surgery on ovarian reserve in women with endometriomas, endometriosis and controls

BACKGROUND

Many women who experience endometriosis and endometriomas also encounter problems with fertility.

OBJECTIVE

The purpose of this study was to determine the impact of surgical excision of endometriosis and endometriomas compared with control subjects on ovarian reserve.

STUDY DESIGN

This was a prospective cohort study of 116 women aged 18-43 years with pelvic pain and/or infertility who underwent surgical treatment of suspected endometriosis (n=58) or endometriomas (n=58). Based on surgical findings, the suspected endometriosis group was further separated into those with evidence of peritoneal disease (n=29) and those with no evidence of endometriosis (n=29). Ovarian reserve was measured by anti-Müllerian hormone and compared before surgery and at 1 month and 6 months after surgery.

RESULTS

Baseline anti-Müllerian hormone values were significantly lower in the endometrioma vs negative laparoscopy group (1.8 ng/mL [95% confidence interval, 1.2-2.4 ng/mL] vs 3.2 ng/mL [95% confidence interval, 2.0-4.4 ng/mL]; P<.02), but the peritoneal endometriosis group was not significantly different than either of these groups. Only patients with endometriomas had a significant decline in ovarian reserve at 1 month (-48%; 95% confidence interval, -54 to -18%; P<.01; mean anti-Müllerian hormone baseline value, 1.77-1.12 ng/mL at 1 month). Six months after surgery, anti-Müllerian hormone values continued to be depressed from baseline but were no longer significantly different. The rate of anti-Müllerian hormone decline was correlated positively with baseline preoperative anti-Müllerian hormone values and the size of endometrioma that was removed. Those with bilateral endometriomas (n=19) had a significantly greater rate of decline (53.0% [95% confidence interval, 35.4-70.5%] vs 17.5% [95% confidence interval, 3.2-31.8%]; P=.002).

CONCLUSION

At baseline, patients with endometriomas had significantly lower anti-Müllerian hormone values compared with women without endometriosis. Surgical excision of endometriomas appears to have temporary detrimental effects on ovarian reserve.

Involvement of mesosalpinx in endometrioma is a possible risk factor for decrease of ovarian reserve after cystectomy: a retrospective cohort study

BACKGROUND

Serum anti-Müllerian hormone (AMH) concentration has been used to assess ovarian reserve in patients with endometriosis, especially when endometrioma surgery is involved. Previously, we reported that decreased serum AMH levels after cystectomy for endometriomas can recover to preoperative levels in some cases. In this present study, we assessed the sequential changes in serum AMH levels before and after cystectomy in terms of the state of the mesosalpinx prior to surgery.

METHODS

The retrospective cohort study recruited 53 patients from a series of prospective studies conducted from 2009 to 2015. All patients underwent laparoscopic cystectomy for endometriomas. If either mesosalpinx was involved in the endometrioma or adnexal adhesion before cystectomy, the case was defined as 'involved mesosalpinx' (n = 14). If both mesosalpinx remained anatomically correct, the case was classified as 'intact mesosalpinx' (n = 39). Blood samples were obtained from the patients 2 weeks before surgery, and at 1 month and 1 year after surgery to assess serum AMH levels.

RESULTS

The serum AMH levels (the involved group vs. the intact group) were 1.92 vs. 0.98 (P = 0.552) preoperatively, 0.59 vs. 1.99 (P = 0.049) at 1 month postoperatively, and 0.48 vs. 2.37 ng/mL (P = 0.007) at 1 year postoperatively. The involved mesosalpinx group showed a further decrease in serum AMH levels at 1 year postoperatively, while serum AMH levels in the intact mesosalpinx group tended to recover.

CONCLUSION

These results suggest that pre-existing mesosalpinx disturbance, in combination with adhesiolysis, may be involved in the medium- and long-term decrease in ovarian reserve after endometrioma surgery. A disturbance in ovarian blood supply via the mesosalpinx may underlie this.

TRIAL REGISTRATION

UMIN-CTR UMIN000019369 . Retrospectively registered October 15, 2015.

[Surgical management of endometrioma: Result of French practice survey]

OBJECTIVES

There are many national and international recommendations and guidelines for the management of patients with endometrioma. In this study, we aimed to evaluate the impact of these recommendations on the practice of French surgeons, and to assess their knowledge about the management of endometriomas.

MATERIALS AND METHODS

A self-questionnaire has been sent to the French members of the Society of Gynecologic Surgery and Pelvic (SCGP) in May 2015.

RESULTS

One hundred and forty-four members of the society (36 %) participated in the survey. Most of the practitioners (71 %) followed recommendations of the Collège National des Gynécologues Obstétriciens (CNGOF), 38 % followed the guidelines of European Society of Human Reproduction and Embryology (ESHRE). One hundred percent of the surgeons declared that they practice laparoscopy when a surgical removal of the endometrioma is indicated. About treatment with GnRH analogue, 38 % of the practitioners declared that they prescribe an add back therapy immediately after the surgery, 43 % at 3 months, and 14 % declared that they never prescribe this treatment.

CONCLUSIONS

French surgeons consider the recommendations are useful in their clinical practice; they primarily apply the guidelines of the CNGOF.

Controversies in the Management of Endometrioma: To Cure Sometimes, to Treat Often, to Comfort Always?

Endometriomas are common in reproductive-aged women, but controversy exists regarding their management. PubMed was searched to identify pertinent studies on outcomes of medical and surgical management of endometrioma, with focus on randomized controlled trials and meta-analyses. Surgical excision is more effective than fenestration/coagulation of endometrioma for pelvic pain but decreases antimullerian hormone. It may modestly improve the chances of spontaneous pregnancy, but does not impact chances of success with in vitro fertilization. Oral contraceptive pills improve dysmenorrhea but not dyspareunia or noncyclic pelvic pain. Management of the patient with endometrioma should be individualized based on each patient's particular symptoms and short-term and long-term fertility goals.

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.

Risks of tubo-ovarian abscess in cases of endometrioma and assisted reproductive technologies are both under- and overreported

OBJECTIVE

To study possible associations among endometriosis, pelvic infectious disease, and ART.

DESIGN

Retrospective cohort analysis over 4 consecutive years, based on medical records and insurance coding in a tertiary endometriosis reference center.

SETTING

Tertiary university-based reference center for endometriosis.

PATIENT(S)

We retrieved all charts carrying the diagnoses infectious process and endometriosis in 2009-2012. Each chart was individually analyzed for categorization of the infectious episode and determining whether ART had been performed.

MAIN OUTCOME MEASURE(S)

Hospitalization for acute infection in women with known endometriosis and possible past ART.

INTERVENTION

Retrospective insurance codes-triggered chart analysis.

RESULT(S)

Ten patients were admitted for an acute infection with fever, acute abdomen syndrome, elevated white blood cell count, and adnexal mass. Three women had oocyte retrieval, and an endometrioma was present 16, 57, and 102 days earlier. In one patient, the complication occurred 37 days after a cesarean section without prior ART. In the remaining six cases tubo-ovarian abscesses (TOAs) occurred spontaneously in endometriosis women who never had ART. Medical treatment succeeded in only two patients, and the remaining eight needed laparoscopic drainage. In 6 out of those 8 cases, laparoscopic drainage was a second-stage measure justified by failure to respond to antibiotic therapy.

CONCLUSION(S)

Our data indicate that some putative complications of ART and endometrioma may actually not be linked to ART, but rather constitute sporadic occurrences in endometriosis. Furthermore, TOAs occurring in women with endometriosis are best treated by early surgical drainage together with intravenous antibiotics.

Antimullerian hormone level and endometrioma ablation using plasma energy

Objective:

To investigate the impact of ovarian endometrioma vaporization using plasma energy on antimullerian hormone (AMH) level.

Method:

We report a prospective, noncomparative series (NCT01596985). Twenty-two patients with unilateral ovarian endometriomas ≥30 mm, with no surgical antecedent and no ongoing pregnancy, underwent vaporization of ovarian endometriomas using plasma energy during the period of November 29, 2010 to November 28, 2012. We assessed AMH levels before surgery, 3 months postoperatively, and at the end of follow-up.

Results:

The mean length of postoperative follow-up was 18.2 ± 8 months. AMH level significantly varied through the 3 assessments performed in the study, as the mean values ± SD were 3.9 ± 2.6 ng/mL before the surgery, 2.3 ± 1.1 ng/mL at 3 months, and 3.1 ± 2.2 ng/mL at the end of the follow-up (P = .001). There was a significant increase from 3 months postoperatively to the end of follow-up (median change 0.7 ng/mL, P = .01). Seventy-one percent of patients had an AMH level >2 ng/mL at the end of the follow-up versus 76% before the surgery (P = 1). During the postoperative follow-up, 11 patients tried to conceive, of whom 8 (73%) became pregnant.

Conclusions:

The ablation of unilateral endometriomas is followed in a majority of cases by a significant decrease in AMH level 3 months after surgery. In subsequent months, this level progressively increases, raising questions about the real factors that impact postoperative ovarian AMH production.

Impact of endometriomas and their removal on ovarian reserve

PURPOSE OF REVIEW

The effect of endometrioma on ovulatory function and ovarian reserve was unclear. Conflicting opinions exist regarding effect of endometrioma excision on ovarian reserve.

RECENT FINDINGS

Endometriomas do not seem to affect ovulatory function. Women with endometrioma have lower antral follicle count and serum anti-Müllerian hormone levels than age-matched healthy controls. There is high-quality evidence suggesting a significant decline in serum anti-Müllerian hormone levels following endometrioma excision. However, a similarly significant decline in antral follicle count is not demonstrated. Cauterization seems to be a contributing factor to ovarian damage and suturing the cyst bed could perhaps be a better alternative.

SUMMARY

It seems prudent to warn patients regarding loss of ovarian reserve following endometrioma excision. Surgeons should cautiously limit the use of cauterization following stripping of endometrioma. Well designed studies comparing effect of various haemostatic measures on ovarian reserve are needed.

The role of fertility preservation in patients with endometriosis

Patients affected with severe endometriosis are at significant risk for ovarian tissue damage, which may lead to infertility, reduced response to ovarian stimulation, and occasionally, premature ovarian failure. The risk for a compromised ovarian reserve in young patients is especially high following repeated surgical intervention and in the presence of bilateral endometriomas. In many cases, enhanced loss of ovarian reserve may also result from the damaging effect of the pathologic process on follicle reservoir even without surgical interventions. Women diagnosed with severe endometriosis and those designated for extensive ovarian surgical intervention are frequently not planning to conceive. In light of recent advances in fertility preservation techniques (FPT), such as oocytes and ovarian tissue freezing, as well as their increasing success rates, we critically evaluate the options for FPT in patients suffering from endometriosis. Personalized counseling should be offered to all patients with endometriosis taking into account age, extent of ovarian involvement, current ovarian reserve, previous and impending surgeries for endometriosis, along with current success rates and possible risks associated with FPT.

Anti-Müllerian hormone levels after laparoscopic cystectomy for endometriomas as a possible predictor for pregnancy in infertility treatments

We assessed the associations between preoperative and postoperative serum anti-Müllerian hormone (AMH) levels and parameters of endometriosis and endometriomas surgery with the success of infertility treatments after cystectomy. Seventeen out of 54 patients got pregnant during the infertility treatments. In these patients, the median interval from surgery to conception was 16.3 months. The serum AMH levels 1-year postoperatively were significantly higher in the pregnant group compared to the non-pregnant group (3.44 ± 1.78 versus 2.17 ± 2.24 ng/ml, p = 0.049). The median interval from surgery to recurrence was 34.4 months, and no significant differences were found in the serum AMH levels at any time point between the recurrence and non-recurrence groups. Serum AMH levels 1 year after laparoscopic cystectomy for endometriomas may predict the success of postoperative infertility treatments, but not a recurrence of endometriomas.

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.

The effect of bipolar electrocoagulation during ovarian cystectomy on ovarian reserve: a systematic review

The aim of the present systematic review was to study the effect of bipolar electrocoagulation during ovarian cystectomy on ovarian reserve. We searched Medline (1966-2015), Scopus (2004-2015), ClinicalTrials.gov (2008-2015), and Cochrane Central Register (CENTRAL) databases along with reference lists of electronically retrieved studies. The levels of antimullerian hormone (AMH) and antral follicle count (AFC) at 1, 3, 6, and 12 months following the excision of the benign ovarian cyst were defined as primary outcomes. Eight studies were finally included in our systematic review, which recruited 545 women. A metaanalysis was precluded because of significant heterogeneity in the methodological characteristics of the included studies. Data from the included studies suggest that the use of bipolar coagulation compared with ovarian sutures seems to result in significantly lower AMH and AFC during the first 3 months following the excision of the ovarian cyst. Two studies reported that this effect seems to persist at 6 and 12 months postoperatively. Bipolar electrodiathermy seems to be accompanied by increased damage to ovarian reserve, which is indicated by the lower levels of AMH and AFC. However, definitive results are precluded because of the significant heterogeneity of included studies and the potential bias.

Effects of transcutaneous electrical acupoint stimulation on ovarian reserve of patients with diminished ovarian reserve in in vitro fertilization and embryo transfer cycles

AIM

The aim of this study was to investigate the effect of transcutaneous electrical acupoint stimulation (TEAS) on ovarian reserve in patients with diminished ovarian reserve undergoing in vitro fertilization and embryo transfer.

MATERIAL AND METHODS

A total of 240 patients were randomly divided into the Han's acupoint nerve stimulator TEAS treatment (TES), comforting false Han's placebo (FHP), artificial endometrial cycle treatment (AEC), and control (CON) groups.

RESULTS

Fifty-six patients in TES, 56 in FHP, 54 in AEC, and 60 in CON fulfilled the study, respectively. Antral follicle count and anti-Müllerian hormone levels were increased, whereas the estradiol level, follicle-stimulating hormone level, and follicle-stimulating hormone/luteinizing hormone ratio were significantly decreased after treatment in the TES and AEC groups. After treatment, the number of oocytes retrieved and average number of embryos transferred were higher in the TES and AEC than in the CON and FHP groups. Clinical pregnancy rate in the TES group was markedly higher than values obtained for the other three groups.

CONCLUSION

TEAS and AEC treatments could improve basal endocrine levels in patients, and increase the number of oocytes retrieved and high-quality embryos. TEAS treatment could improve the clinical pregnancy rate in patients with decreased ovarian reserve during in vitro fertilization and embryo transfer cycles.

The impact of previous ovarian surgery on ovarian reserve in patients with endometriosis

BACKGROUND

To investigate the impact of previous ovarian surgery on ovarian reserve in patients with endometriosis.

METHODS

A total of 829 female patients were recruited. Their medical records were reviewed retrospectively. Patients who had diagnoses of endometriosis or endometrioma were defined as the endometriosis group, and those without endometriosis were as the control group. We further divided these patients into four groups according to whether they had received ovarian surgeries before. Group 1: control group without previous surgery; Group 2: control group with previous surgery; Group 3: endometriosis group without previous surgery; Group 4: endometriosis group with previous surgery. The subgroups with endometrioma or not and different operative procedures were also analyzed. The parameters for comparison included age, body mass index, serum estradiol, follicle-stimulating hormone, luteinizing hormone, cancer antigen 125, and anti-Müllerian hormone (AMH) level.

RESULTS

The level of serum AMH was highest in group 1 and lowest in group 4. The decline was significant between group 1 and group 4 (p < 0.05). The serum AMH level was lower in group 4 than in group 3 but no significant difference. Serum estradiol level was significantly higher in group 3 than in group 2 (p < 0.05). Cancer antigen 125 levels were both significantly higher in group 3 and group 4 as compared with group 1 and group 2 (p < 0.05).

CONCLUSIONS

Performing repeated ovarian surgery in patients with recurrent endometriosis needs careful consideration and adequate patient counselling because of the predictable deteriorating ovarian reserve.

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.

Reduction in Endometrioma Size with Three Months of Aromatase Inhibition and Progestin Add-Back

The purpose of this study was to assess the impact of 3 months of aromatase inhibition together with progestin add-back on ovarian endometrioma size. This prospective cohort study was performed at University Medical Center (UC San Diego). Women trying to conceive were excluded. After informed consent, all women were treated with the aromatase inhibitor letrozole (5 mg/d) with norethindrone acetate (5 mg/d) add-back for 3 months. Pre- and posttreatment assessments of endometrioma sizes were performed by ultrasound. The impact of treatment on pain was determined using the patient assessed endpoints of the Biberoglu and Behrman scale. These included assessing dysmenorrhea, dyspareunia, and nonmenstrual pelvic pain each on a scale from 0 to 3. The primary endpoint of this study was the change in ultrasound documented endometrioma size. Fourteen endometriomas in 8 consecutive women were treated for 3 m. Mean endometrioma diameter decreased 50% from 4.6 ± 1.6 cm to 2.3 ± 1.6 cm (mean ± SD). This represents a 75% decrease in endometrioma volume. Endometriosis symptoms of dysmenorrhea, dyspareunia, and nonmenstrual pelvic pain also improved with treatment. In conclusion, a 3-month course of high dose aromatase inhibition with progestin add-back significantly reduces ovarian endometrioma size and warrants further investigation.

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.

Effect of two laparoscopic techniques for treatment of ovarian endometrioma on ovarian reserve

Introduction:

Operative laparoscopy is the most common used technique for treatment of patients with ovarian endometriomas, because of many positive effects in comparison with laparotomy. There are many laparoscopic techniques, but most used are cystectomy and puncture with endocoagulation (ablation) of the cyst’s capsule. The aim of this study was to evaluate the effect of two laparoscopic techniques for treatment of ovarian endometriomas on ovarian reserve. We used two ultrasonographic markers for ovarian reserve: ovarian volume and antral follicle count (AFC).

Materials and Methods:

Sixty patients in reproductive age (18-42 years) were treated for a chronic pelvic pain or infertility in a tertiary hospital (University Clinic for Gynecology and Obstetrics in Skopje, R. Macedonia). The study was prospective and two laparoscopic techniques were used. All patients were with confirmed ultrasound diagnosis for ovarian endometriomas with diameter between 3 and 8 cm. Complete cystectomy was done in 30 patients (group A) and puncture with endocoagulation was done in other 30 patients (group B). Ovarian reserve was analyzed before surgery and was controlled one and three months after laparoscopic surgery.

Results:

In group A (operated with cystectomy) ovarian volume was 53.46±29.97 cm³ before surgery, which fell to 13.06±7.34 cm³ after one month, and 13.28±7.17 cm³ after three months. Statistical analysis showed a significant reduction in ovarian volume one and three months after surgery (p≤0.01). In group B (operated with puncture and endocoagulation) the ovarian volume was 58.34±37.99 cm³ before surgery, which fell to 18.96±7.90 cm³ one month and 17.38±6.86 cm³ three months after surgery. In both groups there was a significant reduction in ovarian volume one and three months postoperatively (p≤0.01). In the first group AFC was 3.03±1.27 before surgery, 4.8±1.30 one month after surgery and 6.23±1.57 after three months. Statistical analysis showed a significant increase in AFC after laparoscopic cystectomy (p≤0.01). In the second group AFC was 3.07±1.05 before surgery, 5.33±1.60 after one month and 7.0±1.62 after three months. The comparison of AFC showed high statistically significant difference (p≤0.001), e.g. increase of AFC after one and three months in comparison with AFC before surgery.

Conclusions:

Ovarian reserve decreases after laparoscopic surgery using both laparoscopic techniques. But, this decrease was more frequent using cystectomy in comparison with ablation of the endometriotic cyst.

Laparoscopic excision of ovarian endometrioma does not exert a qualitative effect on ovarian function: insights from in vitro fertilization and single embryo transfer cycles

PURPOSE

To evaluate whether laparoscopic excision of endometrioma exerts a qualitative effect on ovarian function.

METHODS

A retrospective analysis of oocytes retrieved in 25 cycles of 21 patients undergoing IVF treatment with controlled ovarian stimulation. The number of oocytes recovered from ovaries with a history of excision of endometrioma (E-Ov) were compared to those from contra-lateral healthy ovaries (H-Ov) as for the analysis of a quantitative effect of surgery. As for the analysis of a qualitative effect, 55 oocytes from E-Ov were compared to 128 oocytes from H-Ov in terms of normal fertilization rate and the rate of top-quality embryos per normally fertilized eggs. Furthermore, 10 embryos derived from oocytes recovered from E-Ov were compared to 24 embryos derived from oocytes from H-Ov in terms of clinical and on-going pregnancy rates per embryos in 34 single embryo transfer cycles.

RESULTS

Mean number of oocytes recovered from E-Ov was significantly smaller than that from H-Ov (2.2 ± 2.0 vs. 5.1 ± 3.3, P = 0.009). There was no difference between oocytes from E-Ov and H-Ov as for normal fertilization rate (63.6% vs. 69.5%, P = 0.43) and the rate of top-quality embryos (40.0% vs. 49.0%, P = 0.34). Clinical and on-going pregnancy rates per embryos were also similar in embryos derived from oocytes recovered from E-Ov and H-Ov (40.0% vs. 25.0%, P = 0.39 and 20.0% vs. 20.8%, P = 0.96).

CONCLUSIONS

The quality of oocytes recovered from the ovary with a history of laparoscopic excision of endometrioma is not inferior to the quality of oocytes from contra-lateral healthy ovary.

The impact on ovarian reserve of haemostasis by bipolar coagulation versus suture following surgical stripping of ovarian endometrioma: a meta-analysis

Concern is increasing that the use of bipolar coagulation or suturing to obtain haemostasis after surgical stripping of ovarian endometrioma could affect ovarian reserve. To compare the ovarian damage associated with the use of bipolar coagulation with ovarian suture as determined by anti-Müllerian hormone (AMH), FSH and antral follicle count, 21 studies were identified. Pooled analysis of 312 patients showed the average serum level of AMH was lower in the coagulation group than in the suture group (3-month follow-up: weighted mean difference (WMD) -0.75 ng/ml, 95% confidence interval (CI) -1.82 to 0.31; 6 months: WMD -1.45 ng/ml, 95% CI -2.43 to -0.47; 12 months: WMD -1.01 ng/ml; 95% CI -1.85 to -0.17), although heterogeneity was high. The weighted overall average levels of FSH between the two groups were not statistically significantly different 3 months after surgery (WMD 0.37 mIU/ml; 95% CI -1.56 to 1.30). The mean antral follicle count in the coagulation group was significantly less than in the suture group at 3 months' follow-up (WMD -2.53, with 95% CI -4.94 to -0.12). This study showed bipolar coagulation did more harm to the ovarian reserve than the suture haemostasis during excision of ovarian cyst as shown by a significant postoperative reduction in AMH.

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.

Assessment of ovarian reserve using anti-Müllerian hormone levels in benign gynecologic conditions and surgical interventions: a systematic narrative review

The usefulness of anti-Müllerian hormone (AMH) for the quantitative evaluation of ovarian reserve has been established. Therefore, serum AMH has been recently applied to the assessment of ovarian reserve outside infertility treatment. We conducted a computer-based search, using keywords, through the PubMed database from inception until May 2014 and summarized available studies evaluating ovarian damage caused by gynecologic diseases, such as endometriosis and ovarian tumor, as well as surgical interventions, such as cystectomy and uterine artery embolization (UAE), to discuss the usefulness of serum AMH. Most of the studies demonstrated a decline of serum AMH levels after cystectomy for endometriomas. It is not conclusive whether electrocoagulation or suturing is preferable. The effects of other gynecologic diseases and interventions, such as hysterectomy and UAE, on ovarian reserve are controversial. Serum AMH levels should be considered in determining the indication and selection of operative methods for benign gynecologic conditions.

The impact of endometrioma and laparoscopic cystectomy on ovarian reserve and the exploration of related factors assessed by serum anti-Mullerian hormone: a prospective cohort study

BACKGROUND

To evaluate the impact of the presence of endometrioma and laparoscopic cystectomy on ovarian reserve as assessed by serum anti-Müllerian hormone (AMH) level. In addition, factors related to the decline in ovarian reserve were analyzed.

METHODS

From June 2013 to January 2014, we prospectively included 40 women with endometriomas as the study group (group A), 36 women with tubal factor infertilities as control group 1 (group B) and 22 women with the other benign ovarian cysts as control group 2 (group C). The women with ovarian cysts underwent laparoscopic cystectomy. Serum AMH levels were determined preoperatively and at 1 month after surgery.

RESULTS

The endometrioma group had lower AMH levels (1.53 ± 1.37 ng/ml) compared with the other benign ovarian cyst group (2.20 ± 1.23 ng/ml) and the tubal factor infertility group (2.82 ± 1.74 ng/ml). The rate of serum AMH decline 1 month after surgery in the endometrioma group (0.62 ± 0.35) was larger than the decline in the other benign ovarian cyst group (0.32 ± 0.30). The preoperative AMH level showed a significant correlation with patient age (group A, r = -0.32; group B, r = -0.54; group C, r = -0.71); there was a statistically significant correlation between the rate of serum AMH decline and endometrioma diameter as well as with the preoperative serum AMH level. In addition, the rate of serum AMH decline was larger for bilateral endometriomas than for unilateral endometriomas, but there was no similar correlation in the other benign ovarian cyst group. The rate of AMH decline after surgery in the subgroup of >7 cm was significantly higher than in the subgroup of ≤7 cm.

CONCLUSIONS

Ovarian endometriomas per se may damage ovarian reserve, and cystectomy of endometriomas may cause greater damage to ovarian reserve compared with other benign ovarian cysts. The operation-related damage to the ovarian reserve was positively related to whether the endometriomas were bilateral, as well as cyst size (especially for cysts >7 cm), but was negatively related to the preoperative serum AMH level. Age was a negative factor that affected the ovarian reserve.

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.

Validation of an immunoassay for anti-Müllerian hormone measurements and reference intervals in healthy Brazilian subjects

Background

Anti-Müllerian hormone is marker of ovarian and testicular reserve. The clinical use of this hormone requires proper standardization of reference intervals. The aims of this study were to validate the Anti-Müllerian hormone Gen II immunoassay, to establish Anti-Müllerian hormone reference intervals in healthy subjects, and to evaluate the influence of hormonal contraceptives, smoking, and body mass index on Anti-Müllerian hormone.

Methods

The validation of the Anti-Müllerian hormone Gen II assay (Beckman Coulter Company, TX, USA) was performed using a simplified protocol recommended by Clinical Laboratory Standard Institute. One-hundred and thirty-three healthy females and 120 males were prospectively selected for this study.

Results

The analytical and functional sensitivities of the Anti-Müllerian hormone Gen II immunoassay were 0.02 and 0.2 ng/mL, respectively. Intra-assay coefficients ranged from 5.2 to 9.0%, whereas inter-assay precision ranged from 4.6 to 7.8% at different concentrations. In females, Anti-Müllerian hormone showed progressive decline with increasing age (r = −0.4, p < 0.001), whereas in males, age showed no influence on Anti-Müllerian hormone concentrations. In females, Anti-Müllerian hormone concentrations did not differ between users and non-users of hormonal contraceptives, smokers, and non-smokers and obese and lean individuals. However, there was a negative and significant correlation between Anti-Müllerian hormone and body mass index in males (r = −0.3, p = 0.008).

Conclusions

Anti-Müllerian hormone Gen II assay was reliable for determining serum Anti-Müllerian hormone concentrations. Anti-Müllerian hormone concentrations declined with aging and presented a wide inter-individual variability. The lack of influence of hormonal contraceptives, smoking, and obesity on Anti-Müllerian hormone in both sexes allowed us to refine the normative concentrations for the Brazilian population.

Laparoscopic cystectomy of endometrioma: Good surgical technique does not adversely affect ovarian reserve

BACKGROUND:

The damage to ovarian reserve inflicted by surgery for endometriosis represents a major concern in the balance between reproductive benefits and risks.

AIM:

To evaluate the ovarian reserve in sub fertile women after laparoscopic endometriotic cystectomy.

SETTINGS AND DESIGN:

Prospective study, done in Department of Obstetrics and Gynecology, tertiary care hospital between August 2010-2012.

MATERIALS AND METHOD:

Laparoscopic cystectomy performed by stripping technique for endometriotic cysts. Endometriosis was staged according to revised American Society of Reproductive Medicine classification (rASRM). Ovarian reserve assessed by comparing FSH and LH levels, measurement of residual ovarian volume, antral follicle counts and stromal blood flow on second day of menses pre and postoperatively. Cyst wall was evaluated histologically to note the presence of normal ovarian tissue in resected tissue.

STATISTICAL ANALYSIS:

SPSS for Windows version 16.0 (SPSS Inc., Chicago, IL) was used for statistical calculations. Wilcoxon signed test and Pearson Chi – Square test were applied. Significance level was P < 0.05.

RESULTS:

Incidence of minimal, mild, moderate, and severe endometriosis was 4.1%, 21.9%, 28.7%, 45.3% respectively. Ovarian reserve was assessed both by ultrasound and biochemical parameters on day 2 of menses; pre and post-operatively. Preoperative and post-operative values; FSH (7.24 ± 1.21, 7.23 ± 1.51 m IU/ml), LH levels (6.37 ± 1.8, 6.6 ± 2.3 m IU/ml), residual ovarian volume (8.5 cm³ ± 5.3, 7.4 cm³ ± 5.8), antral follicle count(3.3 ± 1.9, 4.1 ± 1.5) and stromal blood flow (6.8 cm/sec ± 4.57, 7.1 cm/sec ± 3.55) were statistically not significant. Loss of follicle was seen in 27.2% cyst walls on histopathological examination while 72.73% had no loss.

CONCLUSION:

Laparoscopic cystectomy when performed for endometriotic cysts with accurate surgical technique leads to no significant ovarian tissue removal.