Ultrasound ovarian assessments after endometrioma ablation using plasma energy

Surgical Management of Ovarian Endometrioma: Impact on Ovarian Reserve Parameters and Reproductive Outcomes

Ovarian endometriomas have a negative impact on a patient's reproductive potential and are likely to cause a reduction in ovarian reserve. The most commonly employed ovarian reserve parameters are anti-Müllerian hormone (AMH) and antral follicular count (AFC). Surgical management options of endometrioma include cystectomy, ablative methods, ethanol sclerotherapy and combined techniques. The optimal surgical approach remains a matter of debate. Our review aimed to summarize the literature on the impact of surgical management of endometrioma on AMH, AFC and fertility outcomes. Cystectomy may reduce recurrence rates and increase chances of spontaneous conception. However, a postoperative reduction in AMH is to be anticipated, despite there being evidence of recovery during follow-up. The reduction in ovarian reserve is likely multi-factorial. Cystectomy does not appear to significantly reduce, and may even increase, AFC. Ablative methods achieve an ovarian-tissue-sparing effect, and improved ovarian reserve, compared to cystectomy, has been demonstrated. A single study reported on AMH and AFC post sclerotherapy, and both were significantly reduced. AMH levels may be useful in predicting the chances of conception postoperatively. None of the aforementioned approaches has a clearly demonstrated superiority in terms of overall chances of conception. Surgical management of endometrioma may, overall, improve the probability of pregnancy. Evidence on its value before medically assisted reproduction (MAR) is conflicting; however, a combination of surgery followed by MAR may achieve the optimal fertility outcome. In view of the complexity of available evidence, individualization of care, combined with optimal surgical technique, is highly recommended.

Assisted reproductive technology for women with endometriosis, a clinically oriented review

PURPOSE OF REVIEW

To discuss optimal management of an assisted reproductive technology (ART) cycle in women with endometriosis.

RECENT FINDINGS

New studies involving euploid embryo transfers provide more insight on the etiology of endometriosis-associated infertility. Oocyte competence to reach live birth seems unlikely to be affected by the disease. Routine medical or surgical treatment prior to an ART cycle does not appear beneficial. Short gonadotropin releasing hormone (GnRH) antagonist or progestin primed ovarian stimulation protocols seem to be proper first choices, depending on the intention for a fresh embryo transfer. Low-quality evidence supports frozen thawed over fresh embryo transfer. Ovarian stimulation for ART does not seem to be associated with symptom progression or recurrence.

SUMMARY

How endometriosis affects fertility is still unclear, but ART is an effective pragmatic treatment. Each woman with endometriosis must be assessed with a holistic approach, and in the absence of an indication for otherwise, ART cycles can be kept simple with patient-friendly protocols. Whether a frozen embryo transfer is better than a fresh one should be investigated.

Appropriate surgical management of ovarian endometrioma: excision or drainage?

Endometriosis negatively impacts the lives of countless women around the world. When medical management fails to improve quality of life often women are left making a decision whether or not to proceed with surgery. With endometriomas, patient's surgical options include complete surgical removal or drainage via laparoscopy. Here, we review the literature to discuss both techniques, excision and drainage of endometriomas, and what the research supports for endometrioma management.

Impact of endometrioma surgery on ovarian reserve: a prospective, randomized, pilot study comparing stripping with CO2 laser vaporization in patients with bilateral endometriomas

Objective

To assess ovarian reserve through antral follicle count (AFC) and ovarian volume (OV) determination after decapsulation (stripping technique) or CO₂ laser vaporization in the surgical treatment of patients with bilateral ovarian endometriomas.

Methods

This prospective, randomized, blinded, self-controlled pilot study was set in a tertiary university hospital between January 2017 and December 2017, and included consecutive patients with bilateral ovarian endometriomas ≥3 cm. The study was registered with ClinicalTrials.gov under the title ‘Impact on ovarian reserve according to the type of ovarian endometrioma excision: laser versus conventional cystectomy’; NCT 03826355. For each patient, the endometrioma on one side was randomly selected to undergo CO₂ laser vaporization and the contralateral endometrioma to undergo laparoscopic decapsulation.

Results

A total of 16 patients were included. There were no statistically significant between-group differences in OV and AFC levels at baseline. At the 6-month follow-up, OV and AFC levels were significantly higher in the laser-treated group versus the stripping technique.

Conclusion

Lower OV and AFC levels following excisional surgery for endometrioma versus CO₂ laser vaporization suggest a higher impact on ovarian reserve after the stripping procedure.

[Management of endometrioma]

Preoperative evaluation: clinical examination, and research for associated lesions. Laparoscopic approach. Cystectomy: gold standard, conformed to the endometrioma pathophysiology (3 zones). Laser CO₂ Plasmajet^® vaporisation: important data lead to legitimate utilisation. Haemostasis: be patient! Use of bipolar energy sparingly. Look for other endometriotic lesions, and systematic treatment. Preoperative medical treatment not always useful. Postoperative treatment: decrease recurrence. Especially for patients with no immediate pregnancy desire.

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.

A Prospective Experimental Study to Investigate the Peritoneal Adhesion Formation of Argon Plasma Coagulation (APC) Versus a Novel Aerosol Plasma in a Rat Model

Background. This is a prospective, randomized, controlled, single-blinded study to investigate peritoneal adhesion formation of standard argon plasma coagulation (APC) versus aerosol plasma coagulation in a rat model. Methods. Bilateral lesions were created on the abdominal wall of 16 female Wistar rats with standard and aerosol plasma coagulation APC energy in a standard fashion. After 10 days, the rats were killed humanely to evaluate the peritoneal trauma sites. Adhesion incidence, quantity, and quality were scored 10 days postoperatively and studied histopathologically. Results. Average energy intake was 97.7 ± 3.1 J for APC and 93.8 ± 4.2 J for aerosol plasma coagulation. Incidence of adhesion formation was 74.2% for standard APC and 16.1% for aerosol plasma coagulation ( P < .0001). Standard APC mainly results in dense adhesions. Histological evaluation revealed no significant difference with regard to the average depth of lesions created by APC and aerosol plasma coagulation ( P = 0.21) at day 10; both groups showed an identical morphology of necrosis and granulation tissue formation. Conclusions. This study compares adhesion formation of standard APC versus aerosol plasma coagulation in a rat model. Standard APC produced significantly more adhesions. Aerosol plasma coagulation creates fewer adhesions, which are of lower grade, which seems to be achieved mainly by improved peritoneal conditioning in this animal model.

Postoperative recurrence and fertility after endometrioma ablation using plasma energy: retrospective assessment of a 3-year experience

STUDY OBJECTIVE

To assess recurrence and pregnancy rates in women with ovarian endometrioma treated via ablation using plasma energy.

DESIGN

Retrospective non-comparative pilot study including 55 patients treated during 28 months, with prospective recording of data (Canadian Task Force classification II-2).

SETTING

Tertiary referral center.

PATIENTS

Fifty-five consecutive women with pelvic endometriosis in whom ovarian endometriomas were managed solely via ablation using plasma energy. The minimum follow-up was 1 year.

INTERVENTION

Endometrioma ablation using plasma energy.

MEASUREMENTS AND MAIN RESULTS

Information was obtained from the database of the North-West Inter Regional Female Cohort for Patients with Endometriosis, based on self-questionnaires completed before surgery, surgical and histologic data, and systematic recording of recurrences, pregnancy, and symptoms. Recurrences were assessed using pelvic ultrasound examination. Mean (SD) follow-up was 20.6 (7.2) months (range, 12-39 months). In 75% of patients, deep infiltrating endometriosis was treated, and 40% had colorectal involvement. Preoperative infertility was recorded in 42% of patients. The rate of postoperative recurrence was 10.9% for the entire series. Of 33 women who wished to conceive, 67% became pregnant, spontaneously in 59%. Time from surgery to the first pregnancy was 7.6 (4.3) months. After discontinuation of postoperative hormone therapy, the probability of not conceiving at 12 months was 0.36 (95% confidence interval, 0.19-0.53), and at 24 months was 0.27 (95% confidence interval, 0.12-0.44).

CONCLUSIONS

Recurrence and pregnancy rates are encouraging in that they seem comparable to the best reported results after endometrioma cystectomy. Plasma energy may have an important role in the management of ovarian endometrioma in women seeking to conceive. Patients most in need of surgical procedures that can spare ovarian parenchyma, such as those with bilateral endometriomas or a history of ovarian surgery, may particularly benefit from ablation using plasma energy.