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Daniilidis A, Grigoriadis G, Kalaitzopoulos DR, Angioni S, Kalkan Ü, Crestani A, Merlot B, Roman H. Surgical Management of Ovarian Endometrioma: Impact on Ovarian Reserve Parameters and Reproductive Outcomes. J Clin Med 2023; 12:5324. [PMID: 37629367 PMCID: PMC10455819 DOI: 10.3390/jcm12165324] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 08/08/2023] [Accepted: 08/14/2023] [Indexed: 08/27/2023] Open
Abstract
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.
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Affiliation(s)
- Angelos Daniilidis
- 1st Department in Obstetrics and Gynaecology, Papageorgiou General Hospital, School of Medicine, Aristotle University of Thessaloniki, 54643 Thessaloniki, Greece;
| | - Georgios Grigoriadis
- 2nd Department in Obstetrics and Gynecology, Hippokratio General Hospital, School of Medicine, Aristotle University of Thessaloniki, 56429 Thessaloniki, Greece;
| | | | - Stefano Angioni
- Department of Obstetrics and Gynecology, University of Cagliari, Monserrato, 09042 Cagliari, Italy;
| | - Üzeyir Kalkan
- Department of Obstetrics and Gynecology, Koç University, 34010 Istanbul, Turkey;
| | - Adrien Crestani
- Institut Franco-Europeen Multidisciplinaire d’Endometriose (IFEMEndo), Endometriosis Centre, Clinique Tivoli-Ducos, 33000 Bordeaux, France; (A.C.); (B.M.)
| | - Benjamin Merlot
- Institut Franco-Europeen Multidisciplinaire d’Endometriose (IFEMEndo), Endometriosis Centre, Clinique Tivoli-Ducos, 33000 Bordeaux, France; (A.C.); (B.M.)
- Franco-European Multidisciplinary Endometriosis Institute (IFEMEndo), Middle East Clinic, Burjeel Medical City, Abu Dhabi 7400, United Arab Emirates
| | - Horace Roman
- Institut Franco-Europeen Multidisciplinaire d’Endometriose (IFEMEndo), Endometriosis Centre, Clinique Tivoli-Ducos, 33000 Bordeaux, France; (A.C.); (B.M.)
- Franco-European Multidisciplinary Endometriosis Institute (IFEMEndo), Middle East Clinic, Burjeel Medical City, Abu Dhabi 7400, United Arab Emirates
- Aarhus University, 8000 Aarhus, Denmark
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Selcuk S, Kucukbas M, Koc N, Cam C, Ozkaya E, Eser A, Karateke A. Tumour markers and histopathologic features of ovarian endometriotic cysts. J OBSTET GYNAECOL 2020; 41:763-768. [PMID: 33054460 DOI: 10.1080/01443615.2020.1791060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Endometriosis is one of the most common benign gynaecologic diseases and its clinical presentation is generally ovarian endometrioma. We aimed to assess the association of tumour markers with histopathological structure of ovarian endometriomas to assess their roles in clinical management. Data from 86 women who underwent laparoscopic surgery for ovarian endometrioma were evaluated. The possible risk factors for inadvertently removed normal ovarian parenchyma (IRNOP) during laparoscopic cystectomy and the relationship between tumour markers and histopathologic parameters of ovarian endometrioma were assessed. Age and the depth of penetration of endometrial tissue into the cyst wall showed a significant positive correlation with thickness of IRNOP. There was a significant negative correlation between IRNOP and the thickness of fibrosis on cyst wall. Thickness of fibrosis and the depth of penetration represented significant positive correlations with tumour markers (CA 125, CA 15-3, and CA 19-9), respectively. This is the first study that reveals the association between tumour markers and the histopathologic features of ovarian endometrioma. The outcome of the present study indicated that lower levels of tumour markers may permit a conservative management, rising levels may help in timing of a possible surgical intervention and high levels may help in counselling postoperative outcomes.Impact statementWhat is already known on this subject? Endometriosis is defined as a benign gynaecologic disease, and the vast majority of women who suffer from endometriosis are of reproductive age. Ovarian endometriotic cysts are found in one-fifth to one-half of patients with endometriosis. Laparoscopic cystectomy is accepted as the gold standard for the surgical management of ovarian endometriotic cysts because of the procedure's several clinical advantages, such as lower recurrence and higher pregnancy rates. However, studies have indicated that laparoscopic excision of an ovarian endometrioma capsule could be associated with a reduction in both the ovarian volume and the follicle count.What do the results of this study add? Our retrospective data indicate that tumour markers may have role in planning the management of ovarian endometriomas.What are the implications of these findings for clinical practice and/or further research? Low tumour markers levels may permit a conservative management, elevating levels may help in timing of a possible surgical intervention and finally high levels may help in counselling the patient about her possible postoperative outcomes.
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Affiliation(s)
- Selcuk Selcuk
- Department of Obstetrics and Gynecology, Istanbul Medeniyet University Goztepe Training and Research Hospital, Istanbul, Turkey
| | - Mehmet Kucukbas
- Department of Obstetrics and Gynecology, Istanbul Medeniyet University Goztepe Training and Research Hospital, Istanbul, Turkey
| | - Nermin Koc
- Department of Pathology, Zeynep Kamil Training and Research Hospital, Istanbul, Turkey
| | - Cetin Cam
- Department of Obstetrics and Gynecology, Usak University Hospital, Usak, Turkey
| | - Enis Ozkaya
- Department of Pathology, Zeynep Kamil Training and Research Hospital, Istanbul, Turkey
| | - Ahmet Eser
- Department of Pathology, Zeynep Kamil Training and Research Hospital, Istanbul, Turkey
| | - Ates Karateke
- Department of Obstetrics and Gynecology, Istanbul Medeniyet University Goztepe Training and Research Hospital, Istanbul, Turkey
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Abstract
Aims The aim was to evaluate the association between oxidative stress with the severity of endometriosis in blood and peritoneal fluid. Settings and Design This study was a prospective observational study conducted in the department of obstetrics and gynecology in a tertiary center over 2 years in patients with endometriosis requiring laparoscopy. Methodology Patients diagnosed with endometriosis and undergoing laparoscopy for infertility and/or chronic pelvic pain were included in the study. Out of the 64 patients recruited, only 55 patients formed the part of our study. Blood and peritoneal fluid was evaluated for oxidative stress parameters such as glutathione peroxidase, superoxide dismutase (SOD), and lipid peroxides. Results The severity of endometriosis was assessed intraoperatively by the revised American Society for Reproductive Medicine scoring in all 55 patients who underwent laparoscopy into minimal (n = 3), mild (n = 7), moderate (n = 32), and severe (n = 17). Median activity of SOD and glutathione peroxidase was lowest in the severe stage of endometriosis, whereas the median activity of lipid peroxide was highest in the severe stage of endometriosis in both blood and peritoneal fluid samples. There was a statistically significant increase in oxidative stress with the severity of endometriosis. Conclusions Oxidative stress might play a role in the disease process of endometriosis. Control of oxidative stress can be used as the latest treatment option for the management of endometriosis.
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Affiliation(s)
- Shaiesta Amreen
- Department of Obstetrics & Gynaecology, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Pratap Kumar
- Department of Obstetrics & Gynaecology, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Priyanka Gupta
- Department of Biochemistry, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Pragna Rao
- Department of Biochemistry, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
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Endometrioma in Adolescents and Future Reproductive Health. JOURNAL OF ENDOMETRIOSIS AND PELVIC PAIN DISORDERS 2017. [DOI: 10.5301/je.5000267] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
There continues to be debate over the nature and progression of ovarian endometriomas in adolescence due to the possibility that they may have a different origin and to the impossibility to be able to predict progress. The hypothesis of a different origin traces its roots in the phenomenon called “neonatal menstruation” (NUB), occurring in approximately 5% of newborn. The retrograde shedding of neonatal endometrium may contain progenitor cells and stroma that may lie dormant under the peritoneal surface until being activated when estrogens begin to rise. In teenagers, ovarian endometriomas are often preceded by highly angiogenic implants in the fossa ovarica, with adhesion formation resulting in the invagination of the ovarian cortex and the creation of a pseudocyst. Use of imaging techniques makes it possible to diagnose even small endometriomas. This is vital to their management, since there is evidence that the disease in an adolescent represents a severe condition, with tendency to progression. In addition, if intervention is decided, the first surgical procedure can determine the ultimate outcome of her reproductive life, because there is a significantly higher risk of inadvertently removing ovarian tissue in the presence of an endometrioma than of other ovarian pathologies. For this reason, techniques avoiding additional trauma to the ovary should be preferred and those who wish to become pregnant should attempt conception as soon as possible; if pregnancy is not sought, hormonal therapy is strongly advised. Finally, young age at diagnosis may constitute a pivotal factor in considering fertility preservation.
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Fertility outcome after laparoscopic treatment of advanced endometriosis in two groups of infertile patients with and without ovarian endometrioma. Eur J Obstet Gynecol Reprod Biol 2016; 201:46-50. [DOI: 10.1016/j.ejogrb.2016.03.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Revised: 02/29/2016] [Accepted: 03/04/2016] [Indexed: 11/24/2022]
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Selcuk S, Cam C, Koc N, Kucukbas M, Ozkaya E, Eser A, Karateke A. Evaluation of risk factors for the recurrence of ovarian endometriomas. Eur J Obstet Gynecol Reprod Biol 2016; 203:56-60. [PMID: 27240262 DOI: 10.1016/j.ejogrb.2016.05.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2015] [Revised: 05/07/2016] [Accepted: 05/13/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To evaluate the risk factors for the recurrence of ovarian endometrioma after laparoscopic cystectomy. STUDY DESIGN Reproductive aged patients who underwent laparoscopic ovarian endometriotic cystectomy and with histopathologically confirmed diagnosis of ovarian endometrioma were evaluated retrospectively. Histopathologic specimens were reevaluated and histopathologic characteristics of ovarian endometriotic cysts (thickness of cyst wall, thickness of fibrosis [ToF], thickness of ovarian tissue, the number of follicles per cyst, the depth of penetration [DoP] of endometrial tissue into the cyst wall) were determined. Along the determined histopathologic findings, demographic characteristics (age at surgery, number of pregnancies), clinical symptoms (dysmenorrhea, infertility), intraoperative findings (revised American Society for Reproductive Medicine [rASRM] stage), imaging features (bilaterality, cyst diameter), and biochemical parameters (Ca125, Ca19.9, Ca15.3) were evaluated as possible risk factors for the recurrence of endometrioma. The variables with p<0.2 in univariate analysis were introduced into regression analysis to determine the risk factors for recurrence. RESULTS There were statistically significant differences in age group (≤35 years and >35 years), the ToF and DoP between patients with recurrence and those with no recurrence. In Cox regression analysis, age ≤35 years and DoP were significant risk factors for presence of recurrence. DoP, ToF, preoperative cyst diameters in ultrasonographic examination were inversely correlated with recurrence interval. In multivariate regression analysis, the DoP was found the only significant risk factor for the recurrence interval. 1.2mm of DoP was found as the optimum cut off value for presence of recurrence according to Youden index criteria in ROC curve analyze. The sensitivity (62.9%), specificity (75%) were obtained at the cut off value of 1.2mm for DoP. CONCLUSION Histopathological features of ovarian endometriotic cyst may have important roles on predicting the recurrence of the endometrioma. Predicting the recurrence risk of particular patient is very important in future management of the disease. Knowing the recurrence risk of an endometrioma will help in deciding the optimal treatment modalities for each individual patient. High risk patients should be offered appropriate treatments according to the clinical status without delay and low risk patients should be protected from overtreatment.
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Affiliation(s)
- Selcuk Selcuk
- Zeynep Kamil Training and Researching Hospital, Department of Obstetrics and Gynecology, Opr. Dr. Burhanettin Ustunel St., No: 10, Uskudar/Istanbul, Turkey.
| | - Cetin Cam
- Zeynep Kamil Training and Researching Hospital, Department of Obstetrics and Gynecology, Opr. Dr. Burhanettin Ustunel St., No: 10, Uskudar/Istanbul, Turkey.
| | - Nermin Koc
- Zeynep Kamil Training and Researching Hospital, Department of Pathology, Opr. Dr. Burhanettin Ustunel St., No: 10, Uskudar/Istanbul, Turkey.
| | - Mehmet Kucukbas
- Zeynep Kamil Training and Researching Hospital, Department of Obstetrics and Gynecology, Opr. Dr. Burhanettin Ustunel St., No: 10, Uskudar/Istanbul, Turkey.
| | - Enis Ozkaya
- Zeynep Kamil Training and Researching Hospital, Department of Obstetrics and Gynecology, Opr. Dr. Burhanettin Ustunel St., No: 10, Uskudar/Istanbul, Turkey.
| | - Ahmet Eser
- Zeynep Kamil Training and Researching Hospital, Department of Obstetrics and Gynecology, Opr. Dr. Burhanettin Ustunel St., No: 10, Uskudar/Istanbul, Turkey.
| | - Ates Karateke
- Zeynep Kamil Training and Researching Hospital, Department of Obstetrics and Gynecology, Opr. Dr. Burhanettin Ustunel St., No: 10, Uskudar/Istanbul, Turkey.
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Bhat RG, Dhulked S, Ramachandran A, Bhaktha R, Vasudeva A, Kumar P, Rao ACK. Laparoscopic cystectomy of endometrioma: Good surgical technique does not adversely affect ovarian reserve. J Hum Reprod Sci 2014; 7:125-9. [PMID: 25191026 PMCID: PMC4150139 DOI: 10.4103/0974-1208.138871] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Revised: 01/14/2014] [Accepted: 06/16/2014] [Indexed: 11/22/2022] Open
Abstract
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.
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Affiliation(s)
- Rajeshwari G Bhat
- Department of Obstetrics and Gynecology, Kasturba Medical College, Manipal University, Manipal, Karnataka, India
| | - Sushma Dhulked
- Department of Obstetrics and Gynecology, Kasturba Medical College, Manipal University, Manipal, Karnataka, India
| | - Amar Ramachandran
- Department of Obstetrics and Gynecology, Kasturba Medical College, Manipal University, Manipal, Karnataka, India
| | - Rajesh Bhaktha
- Department of Obstetrics and Gynecology, Kasturba Medical College, Manipal University, Manipal, Karnataka, India
| | - Akhila Vasudeva
- Department of Obstetrics and Gynecology, Kasturba Medical College, Manipal University, Manipal, Karnataka, India
| | - Pratap Kumar
- Department of Obstetrics and Gynecology, Kasturba Medical College, Manipal University, Manipal, Karnataka, India
| | - Anuradha C K Rao
- Department of Pathology, Kasturba Medical College, Manipal University, Manipal, Karnataka, India
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Ramachandran A, Dhulkhed S, Bhakta R, Bhat RG, Rao AC, Vasudeva A, Vishalakshi A, Kumar P. Influence of endomeriotic cyst diameter and the severity of endometriosis on the ovarian parenchyma excised during laparoscopic cystectomy. J Clin Diagn Res 2013; 7:2241-3. [PMID: 24298486 DOI: 10.7860/jcdr/2013/5730.3481] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2013] [Accepted: 06/11/2013] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Endometrioma is a common form of endometriosis and it is represented by endometriotic deposits within the ovaries which accounts for upto 17-44% of cases. Laparoscopic stripping of ovarian endometriotic cysts is an accepted technique owing to low recurrence rates. Decrease in residual ovarian tissue volume was noted in many studies followed cystectomy. This study aims at estimating whether the size of endometriotic cyst is related to ovarian parenchyma excised along with cyst wall. MATERIAL AND METHODS Prospective study was done at University teaching hospital for one year. A total of 56 women underwent laparoscopic endometriotic cystectomy. Cystectomy was done by stripping method and endometriosis was staged according to revised American Society of Reproductive Medicine classification (rASRM). The endometrioma wall was evaluated histologically and were categorised into 2 groups based on semi- quantitative scale of 0-4. Group 1 and 2 showed grade 0, 1, 2 and 3, 4 in the cyst wall respectively. RESULTS Mean age of patients was 31.4 years, duration of infertility was 4.1 years and cyst diameter measured 6.3 cm. 73.2% (n=41) were in Group 1 and 26.8% (n=15) were in Group 2 , mean cyst diameter was being 4.3 cm and 5.0 cm respectively. There was no significant statistical correlation between preoperative cyst diameter and ovarian parenchyma removed (p=0.15). 93.3% (n=14) of group 2, and only 65.8% (n=27 ) of group 1 were found to have moderate to severe endometriosis, indicating there is correlation between disease severity and loss of ovarian tissue (p= 0.04). CONCLUSION Endometriotic cystectomy when performed with accurate surgical technique leads to no significant ovarian tissue removal. However, disease severity significantly determines the loss of normal ovarian parenchyma.
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Affiliation(s)
- Amar Ramachandran
- Associate Professor, Department of Obstetrics & Gynaecology, Kasturba Medical College , Manipal, Manipal University, Karnataka, India
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Surgical excision of endometriomas and ovarian reserve: a systematic review on serum antimüllerian hormone level modifications. Fertil Steril 2012; 98:1531-8. [DOI: 10.1016/j.fertnstert.2012.08.009] [Citation(s) in RCA: 262] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Revised: 07/17/2012] [Accepted: 08/03/2012] [Indexed: 11/21/2022]
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