Effect of Surgery for Endometrioma on Ovarian Function

Does Robot Assisted Laparoscopy (RAL) Have an Advantage in Preservation of Ovarian Reserve in Endometriosis Surgery? Comparison of Single-Port Access (SPA) RAL and SPA Laparoscopy

The purpose of this study was to compare single-port access (SPA) laparoscopy and SPA robot assisted laparoscopy (RAL) for endometriosis with respect to ovarian reserve preservation and surgical outcomes. Clinical factors affecting any reduction in ovarian function after surgery were also evaluated. Patients with endometriosis who underwent SPA laparoscopy (n = 87) or RAL (n = 78) were retrospectively reviewed. Patients' baseline characteristics, including the severity of endometriosis and surgical outcomes including surgical complexity, were collected. To assess the preservation of ovarian reserve after surgery, serum anti-Müllerian hormone (AMH) levels before surgery, at two weeks, and at three months after surgery were collected. Age, ovarian cyst size, location of cyst, complexity of surgery, and the severity of endometriosis were associated with the reduction in AMH levels after surgery. The severity of endometriosis was higher in the RAL group than in the SPA group. There were no significant differences in other clinical baseline characteristics, including preoperative AMH levels. For surgical outcomes, radical surgery was more frequently performed in the RAL group. In univariate and multivariate linear regression analyses, age, ovarian cyst size, location of cyst, complexity of surgery, and the severity of endometriosis were associated with the reduction in AMH levels after surgery. Incorporating surgical approaches and risk factors for postoperative ovarian function decrease, RAL was more beneficial than SPA laparoscopy for the preservation of ovarian reserve in patients with mild endometriosis (stage I/II) (postoperative 3 month AMH reduction rate (%), SPA laparoscopy vs. RAL, 33.51 ± 19.98 vs. 23.58 ± 14.98, p = 0.04) and in patients who underwent non-complex surgery (postoperative 3 month AMH reduction rate (%), SPA laparoscopy vs. RAL, 37.89 ± 22.37 vs. 22.37 ± 17.49, p = 0.022). SPA RAL may have advantages over SPA laparoscopy in ovarian function preservation, especially in patients with mild endometriosis and patients who have undergone a non-complex surgery.

Effect of laparoscopic cystectomy on ovarian reserve in patients with ovarian cyst

OBJECTIVE

This study aimed to evaluate the effect of laparoscopic cystectomy on ovarian reserve in patients with ovarian cysts.

MATERIAL AND METHODS

This prospective study was performed on 113 women with ovarian cysts in a tertiary referral teaching hospital. All patients underwent laparoscopic cystectomy. Serum levels of antimüllerian hormone (AMH) were measured pre-and, 3 months postoperatively. The primary outcome of the study was to assess the effect of laparoscopic cystectomy on ovarian reserve based on alterations in serum AMH levels. The secondary outcome of the present study was to evaluate the impact of the number of cauterizations, size and type of cysts, bilaterality (bilateral or unilateral), age, and body mass index (BMI) on the ovarian reserve after laparoscopic excision.

RESULTS

Laparoscopic cystectomy reduced the serum AMH levels preoperatively (1.32 ± 4.48 ng/ml) to postoperatively (3.2 ± 1.93 ng/ml) and the difference (- 1.28 ng/ml) was statistically different (0.001 >P). There was a negative significant relationship between the number of cauterizations used and postoperative serum AMH levels (p ≤ 0.001). There was a significant relationship between the location (p ≤ 0.01), type of cyst (p ≤ 0.001) and the serum AMH levels reduction.

CONCLUSION

The number of cauterizations used during surgery, the type of cyst, and bilaterality can affect AMH levels that need to be addressed.

Endometriosis-associated infertility: surgery or IVF?

Endometriosis is a chronic disease frequently associated with female infertility. The choice of treatment in case of endometriosis is one of the most discussed topics in Reproductive Medicine. The approach to the patient with endometriosis and infertility should be tailored based on different parameters. The localization of the disease, the severity of symptoms and the age of the patient are just some of them. Management options include surgery, in-vitro fertilization (IVF), or a combination of both. Data, mostly uncontrolled, would favor surgery at any stage of endometriosis, increasing the chances of natural conception compared to expectant management. Laparoscopic excision of the ovarian endometrioma should be the treatment of choice when there is associated pain. Surgery should be performed following appropriate techniques to reduce the possible damage to the ovarian reserve. Pregnancy rates around 50% have been consistently reported after surgery, which compare favorably with those obtained with IVF. IVF, on the other hand, may be preferred in case of associated male or tubal factor, in case of a reduced ovarian reserve, or if previous surgery has failed, particularly if there is no associated pain, and when the ultrasonographic features of the ovarian cyst are reassuring. Sometimes IVF may be preceded by surgery, when a difficult access to follicles at pick-up, due to the size and location of the ovarian cyst, or to severe adhesions, is anticipated. Due to the lack of solid evidence in the scenario of endometriosis-associated infertility, robust data from randomized clinical trials (RCTs) are strongly needed.

Frozen blastocyst transfer improves the chance of live birth in women with endometrioma

Purpose: The existing literature is scarce regarding outcomes of fresh vs frozen embryo blastocyst transfers in women with endometrioma. The goal of the study was to compare outcomes between fresh and frozen blastocyst transfers (fresh-BT vs. frozen-BT) in endometrioma-affected women. Materials and methods: This study included 315 endometrioma-affected women aged between 20 and 39 years who underwent blastocyst transfer. Primary outcome was live birth rate (an alive birth after 24 completed weeks gestation). Results: The study groups did not differ in terms of patient characteristics and treatment variables. The live birth rate was 40.7% in fresh-BT group and 56.1% in frozen-BT group (OR:1.86, 95% CI:1.18-2.92 p = .007). The approach of frozen embryo transfer was an independent factor of live birth (adjusted OR:1.83, 95% CI:1.16-2.90, p = .009). Conclusion: The approach of frozen blastocyst transfer increases the chance of live birth in endometrioma-affected patients compared with fresh blastocyst transfer. Thus, a frozen embryo transfer may be the choice of strategy in these patients.

Antral follicle count is reduced in the presence of endometriosis: a systematic review and meta-analysis

Studies suggest that the presence of endometriosis may lead to impaired ovarian reserve, while results evaluating the changes in antral follicle count (AFC) in endometriosis remain controversial. A systematic search returned 15 studies, of which nine compared AFC between patients with and without endometriosis, five articles reported differences in AFC between affected and unaffected ovaries in patients with unilateral ovarian endometriosis and one reported both of the above two situations. Overall results showed a significant decrease in AFC and anti-Müllerian hormone (AMH) and increase in serum FSH concentrations in patients with endometriosis when compared with controls. Additionally, the AFC for the ovary with the endometrioma was also significantly lower than that of the contralateral ovary in patients with unilateral ovarian endometriosis. Moreover, it appears that the AFC in patients with endometriosis where the ovaries are not affected or in early stage were not significantly different in the control group. These findings demonstrate that endometriosis is associated with reduced AFC and AMH and elevated serum concentrations of FSH, suggesting a reduction in ovarian reserve in patients with endometriosis, especially in those with ovarian endometrioma and advanced stage.

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.

Effects of laparoscopic cystectomy on ovarian reserve in patients with endometrioma and dermoid cyst

Objective:

To compare the effects of laparoscopic cystectomy on ovarian reserve between women with endometrioma and dermoid cyst.

Materials and Methods:

Thirty-six patients were diagnosed as having endometrioma (group A) and 32 patients with dermoid cyst (group B) using ultrasonography. Preoperative anti-mullerian hormone (AMH) levels were measured and unilateral antral follicle counts (AFC) were calculated for the ovary side containing the cyst. Laparoscopic cystectomy was performed using the stripping technique for all participants. After 3 months, all participants were re-evaluated between the third and sixth day of their menstrual cycle to determine AFC and AMH levels.

Results:

The mean serum preoperative AMH level and AFC level were significantly lower in group A than in group B (p=0.001, p=0.002), respectively. At 3 months after the surgery, serum AMH levels decreased significantly in group A from 2.04±0.68 to 1.47±0.55 (p=0.001), and from 2.60±0.57 to 2.17±0.56 in group B (p=0.001). In group A, unilateral (operated side) AFC levels decreased significantly from 4.05±1.24 to 2.16±0.94 (p=0.001), and in group B, it decreased significantly from 4.93±0.94 to 3.40±0.87 (p=0.001). The decrease in AMH levels was significantly higher in group A than in group B (p=0.033). The decrease in AFC levels was also significantly higher in group A than in group B (p=0.044).

Conclusion:

Laparoscopic stripping has destructive effects on serum AMH levels and the operated side AFC levels after surgery for patients with endometrioma and dermoid cysts, and laparoscopic excision of endometrioma has more destructive effects on ovarian reserve than dermoid cysts.

Total Circulating Microparticle Levels After Laparoscopic Surgical Treatment for Endometrioma: A Pilot, Prospective, Randomized Study Comparing Stripping with CO2 Laser Vaporization

STUDY OBJECTIVE

To evaluate serial generation of microparticles (MPs) after laparoscopic stripping or CO₂ laser vaporization in the surgical treatment of patients with ovarian endometrioma (OE).

DESIGN

A prospective, randomized, blinded, pilot study (Canadian Task Force classification I).

SETTING

Tertiary care university hospital from December 2014 to July 2016.

PATIENTS

Thirty women with unilateral OE undergoing laparoscopic surgery.

INTERVENTION

Patients were randomly selected to undergo either CO₂ laser vaporization (L group) or laparoscopic stripping (S group) of OE.

MEASUREMENTS AND MAIN RESULTS

Blood samples were collected before surgery and at 2 hours, 24 hours, 1 month, and 3 months after surgery. An MP generation curve after OE surgery was created. MP generation was greater in the S group than in the L group at all time points evaluated. The MP generation curve showed a significantly higher area under the curve after excisional surgery (p <.05).

CONCLUSION

The higher MP levels in the S group suggest an increased inflammation and procoagulant response after this procedure.

Diet and endometriosis-revisiting the linkages to inflammation

Endometriosis is a chronic inflammatory condition that may cause pelvic pain, dysmenorrhea, and/or infertility in women of reproductive age. While treatments may include medical or surgical management, the majority of therapeutic options are non-curative, and women may experience longstanding pain and/or disability. In general, chronic diseases are believed to result from modifiable risk factors, including diet. In this review, we discuss recent data on evidence-based associations between diet and endometriosis and the mechanistic points of action of constituent dietary factors with emphasis on inflammatory events that may contribute to the promotion or inhibition of the disease. Understanding the convergence of diet and endometriosis may lead to the development of clinical strategies to improve the quality of life for symptomatic women.

Ovarian Damages Produced by Aerosolized Fine Particulate Matter (PM2.5) Pollution in Mice: Possible Protective Medications and Mechanisms

Background:

Ambient aerosol fine particulate matter (PM_2.5) is associated with male reproductive toxicity in experiments and may have adverse effects in the female. However, studies evaluating the protective effects and precise mechanisms of aspirin, Vitamin C, Vitamin E, or ozone against toxic effects of PM_2.5 are sparse. This study was conducted to investigate the possible protective effects and mechanisms of aspirin, Vitamin C, Vitamin E, or ozone on fertility in female mice treated with PM_2.5.

Methods:

Eighty-four ICR mice were divided into six groups: control group, PM_2.5 group, PM_2.5 + aspirin group, PM_2.5 + Vitamin C group, PM_2.5 + Vitamin E group, and PM_2.5 + ozone group. PM_2.5 was given by intratracheal instillation every 2 days for 3 weeks. Aspirin, Vitamin C, and Vitamin E were given once a day by oral gavage for 3 weeks, and ozone was administered by intraperitoneal injection once a day for 3 weeks. The levels of anti-Müllerian hormone (AMH), interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-α), and 8-hydroxy-2’-deoxyguanosine (8-OHdG) were measured using enzyme-linked immunosorbent assay. Western blotting analysis was used to analyze the expressions of Bcl-2, Bax, and caspase-3 in ovaries. Changes in histological structure were examined by light microscope and electron microscopy was used to detect ultramicrostructure.

Results:

The results demonstrated that PM_2.5 decreased AMH levels (P < 0.001); however, aspirin (P < 0.001), Vitamin C (P < 0.001), Vitamin E (P = 0.001), and ozone (P = 0.002) alleviated the decrease. Changes of IL-6, TNF-α, 8-OHdG, Bax/Bcl-2, and caspase-3 in PM_2.5 group were increased compared to control group (P < 0.001), while in PM_2.5 + aspirin, PM_2.5 + Vitamin C, PM_2.5 + Vitamin E, and PM_2.5 + ozone groups, they were statistically decreased compared to PM_2.5 group (P < 0.001 or P < 0.05).

Conclusions:

PM_2.5 cause the damage of ovaries, and aspirin, Vitamin C, Vitamin E, and ozone antagonizes the damage. The protective mechanism is probably due to its ability to blunt the inflammatory and oxidative stress caused by PM_2.5, which subsequently suppressing the expression of apoptotic regulatory protein and reducing the incidence of ovary apoptosis.

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

Background

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

Materials and Methods

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

Results

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

Conclusions

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

Weigh the pros and cons to ovarian reserve before stripping ovarian endometriomas prior to IVF/ICSI: A meta-analysis

PURPOSE

To explore the effects of conservative surgery for endometriomas on ovarian responsiveness during assisted reproductive technology (ART) and provide reproductive and gynecological doctors with a more reliable reference program for the treatment of endometriomas.

METHODS

A literature search was performed by searching the PubMed, Embase, Cochrane Library, Web of Science and Science Direct databases. Studies with inter- and intra-patient comparisons of ovarian responses and oocyte quality between operated and unoperated ovaries and that met the inclusion criteria were retrieved, and the data from the outcome measures were extracted and pooled for this meta-analysis.

RESULTS

Twenty-one published studies (2649 ART cycles) were included. The total amount of gonadotropin (Gn) used (inverse variance (IV):0.48; 95% confidence interval (CI): [0.13, 1.82], P = 0.0007) was significantly increased in the women with endometriomas who had a history of cystectomy. The estrogen (E) level on the day of hCG administration (IV: -0.29; 95% CI: [-0.41, -0.17], P<0.00001), the number of mature or dominant follicles (IV: -1.17; 95% CI: [-1.51, -0.82], P<0.00001) and the total number of oocytes retrieved (IV: -1.78; 95% CI: [-2.38, -1.17], P<0.00001) were significantly decreased in the women with endometriomas who had a history of cystectomy. The duration of stimulation (IV: 0.02; 95% CI: [-0.09, 0.13], P = 0.77), the total number of formed embryos (IV: -0.06; 95% CI: [-0.17, 0.04], P = 0.25), the pregnancy rate(IV:0.98;95%CI[0.82,1.18], P = 0.83) and the live birth rate(IV:0.93;95%CI[0.70,1.23], P = 0.61)were not statistically different between the two groups. Similar intra-patient results were found in the number of mature or dominant follicles (IV: -0.88; 95% CI: [-1.25, -0.52], P<0.00001) and the total number of oocytes retrieved (IV: -3.48; 95% CI: [-4.77, -2.19], P<0.00001).

CONCLUSION

ART might be a better therapeutic method for ovarian endometrioma-related infertility than cystectomy.

Standards of Care in infertility in Europe

Evidence-based medicine is the principal approach to medical practice. There are several debatable issues in infertility, which require clarification. Over the past 20 years, reliable methodology has been developed for the management of infertile couples. This includes high quality diagnostic and therapeutic procedures, which are applied in highly specialised infertility centres. The European Board and College of Obstetrics and Gynaecology (EBCOG) has published Standards of Care for Women's Health in Europe, which should be the cornerstone for the clinicians and service providers in the European Union to establish common protocols within their centres. Each infertility treatment should result in the highest possible success rate and all appropriate measures for the patient's safety should be in place. The treatment protocols should minimise risk of complications, such as ovarian hyperstimulation syndrome (OHSS). The current use of GnRH agonists to trigger final follicle maturation has provided the means for avoiding this syndrome. Additionally, multiple pregnancy rates are still high in assisted reproductive technology (ART). These rates should be reduced by the adoption of single embryo transfer during IVF treatment and by the proper monitoring of ovulation induction protocols. EBCOG Standards of Care for infertility and assisted conception treatment derived from the best available evidence should underpin the provision of high quality infertility services in European countries.

Robotic single-site excision of ovarian endometrioma

BACKGROUND

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

RESULTS

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

CONCLUSION

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

Ovarian reserve markers and assisted reproductive technique (ART) outcomes in women with advanced endometriosis

BACKGROUND

The role of ovarian reserve markers as predictors of the controlled ovarian stimulation (COS) response in intracytoplasmic sperm injection (ICSI) cycles in women with endometriosis has been much debated. The aim of the present study is to assess the predictability of ovarian reserve markers for the number of mature oocytes (MII) retrieved and to assess the pregnancy rate and live birth rate in women with advanced endometriosis.

METHODS

Two hundred eighty-five infertile women who had laparoscopy followed by a first ICSI cycle were recruited in this prospective study. One hundred ten patients were diagnosed with endometriosis stage III-IV (group 1), and 175 patients had no endometriosis (group II). Sixty-three patients in group 1 had no history of previous endometrioma surgery (group Ia), and 47 patients had a history of previous endometrioma surgery (group Ib).

RESULTS

The number of mature oocytes retrieved was significantly lower in women with advanced endometriosis than in women with no endometriosis. The number of mature oocytes retrieved in women with and without endometriosis was best predicted by antral follicle count (AFC) and age, whereas only AFC was a predictor in women with previous endometrioma surgery (odds ratio: 0.49; 95% confidence interval: 0.13-0.60). Women with endometriosis had a lower rate of live births than the control group, but this difference was not statistically significant; the number of live births was significantly lower in those with previous endometrioma surgery.

CONCLUSIONS

The best predictor of the COS response in ICSI was AFC, followed by age. Women receiving ICSI following surgery for ovarian endometrioma had a poorer clinical outcome and lower rate of live births compared with those with endometriosis but no previous surgery and the control group.

Employing Laparoscopic Surgery for Endometriosis

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