Serum anti-Müllerian hormone levels decrease after endometriosis surgery

Risk factors associated with changes in serum anti-Müllerian hormone levels before and after laparoscopic cystectomy for endometrioma

Background

The objective of our study was to investigate the risk factors for a decrease in ovarian reserve in patients with endometriomas after standardized laparoscopic procedures and evaluation to provide corresponding clinical guidance for patients with fertility requirements.

Methods

Anti-Müllerian hormone (AMH) levels and other clinical data from 233 patients with endometriomas and 57 patients with non-endometrioma ovarian cysts admitted to the Peking Union Medical College Hospital between January 2018 and September 2023 were prospectively analysed. The pretreatment AMH levels of the study groups were compared to assess the impact of endometrioma on ovarian reserve, and the decrease in AMH after treatment was analysed to determine potential risk factors contributing to this change.

Results

Pretreatment AMH levels did not significantly differ between patients with endometriomas and those with non-endometrioma ovarian cysts. Within the endometrioma group, older age, higher body mass index (BMI), and shorter menstrual cycles were found to be associated with decreased AMH levels prior to treatment (p<0.05). Participants presenting with bilateral cysts, advanced surgical staging, or a completely enclosed Douglas pouch demonstrated significantly lower levels of AMH prior to treatment compared to those without these conditions (p<0.05). Furthermore, their AMH levels further declined within one year after undergoing laparoscopic cystectomy (p<0.05). However, there was no difference in AMH levels after surgery between patients who successfully became pregnant and those who did not (p>0.05).

Conclusion

Laparoscopic removal of endometriomas can adversely affect ovarian reserve, especially during bilateral cysts removal and when patients are diagnosed as having a higher stage of endometriosis, further impacting ovarian function. It should be noted that a decrease in AMH levels may not necessarily indicate an absolute decline in fertility. Therefore, it is crucial to conduct thorough patient evaluations and provide comprehensive patient education to offer appropriate guidance for fertility preservation.

Management of a Nulliparous IVF Patient with a Declined Ovarian Reserve After Discovery of an Atypical Ovarian Endometriotic Cyst

Purpose

Endometriosis (EM) is a common cause of infertility, and an ovarian endometriotic cyst may affect the ovarian reserve, ovulation, and endometrial receptivity. The majority of EM cases are benign; however, EM may also be prone to malignant transformation, associated with infiltrative growth, and recurrent or distant metastasis. In this study, we report the management of an atypical cyst discovered through ovarian endometriotic cyst puncture prior to controlled ovarian stimulation (COS).

Case Presentation

The patient required in vitro fertilization treatment due to EM and bilateral fallopian tube obstruction. Prior to initiating gonadotropin (Gn) treatment, the right ovarian EM cyst was punctured; cytological pathology of the obtained fluid revealed an atypical morphology. Subsequently, the case was discussed with the patient and ethically reviewed. Gn was initiated according to the patient's wishes, and six day-3 embryos were finally obtained and cryopreserved. Afterwards, laparoscopic cystectomy of the ovarian endometrioma revealed no malignant transformation. The patient achieved clinical pregnancy after resuscitation and transplantation of the embryo.

Conclusion

In summary, patients with EM-associated infertility are at risk of ovarian cancer formation when undergoing assisted reproduction treatment; therefore, this risk should be evaluated and minimized before initiating such treatment.

The Risk of Infertility After Surgery for Benign Ovarian Cysts

Background: There is a growing body of evidence that ovarian cystectomy may negatively impact ovarian reserve. However, it is unclear whether ovarian cyst surgery puts women at risk of future infertility. This study investigates whether surgery for benign ovarian cysts is associated with long-term infertility risk. Methods: Women aged 22-45 years (n = 1,537) were invited to participate in an interview about their reproductive histories, including whether they ever had infertility or ovarian cyst surgery. Each woman reporting cyst surgery was randomly matched to a comparison woman, who was assigned an artificial surgery age equal to that of her match. Matching was repeated 1,000 times. Adjusted Cox models were fit to examine time to infertility after surgery for each match. A subset of women was invited to participate in a clinic visit to assess markers of ovarian reserve (anti-Müllerian hormone [AMH], antral follicle count). Results: Approximately 6.1% of women reported cyst surgery. Infertility after surgery was more common for women reporting cyst surgery than those without surgery after adjusting for age, race, body mass index, cancer history, parity before assigned surgery age, history of infertility before surgery age, and endometriosis (median-adjusted hazard ratio 2.41, 95% simulation interval 1.03-6.78). The estimated geometric mean (95% confidence interval [CI]) AMH levels of those who reported a history of ovarian cyst surgery were 1.08 (95% CI: 0.57-2.05) times those of women who reported no history of surgery. Conclusions: Those with a history of ovarian cyst surgery were more likely to report having a history of infertility compared with age-matched women who reported no history of cyst surgery. It is possible that both ovarian surgery to remove cysts and the conditions that lead women to develop cysts requiring surgery may affect subsequent successful conception.

Impact of Laparoscopic Sclerotherapy for Ovarian Endometriomas on Ovarian Reserve

STUDY

Objective: To evaluate the impact of laparoscopic sclerotherapy on the management of endometrioma during surgery for deep infiltrative endometriosis (DIE).

DESIGN

Observational study.

SETTING

Tivoli-Ducos Clinic, Bordeaux.

PATIENTS

Sixty-nine patients underwent laparoscopic sclerotherapy for endometrioma during surgery for DIE.

INTERVENTIONS

Laparoscopic sclerotherapy with 95% ethanol solution and DIE surgery.

MEASUREMENTS AND MAIN RESULTS

Antimüllerian hormone (AMH) levels before and at least 6 months after surgery, recurrences, and pregnancies. Mean AMH (ng/mL) levels were 3.4 (2.3) before surgery and 2 (1.7) after surgery (p <.001). Mean difference was 1.29 ng/mL. Preoperative AMH level was the only variable independently associated with an additive decrease in AMH. Mean (standard deviation) follow-up period was 17.5 months (4.6) (range 9-26 months); 18 of 44 patients (40.1%) with pregnancy intent conceived. Of 51 patients who underwent postoperative pelvic ultrasound, 6 (6 of 51, 11.8%) had a recurrence of endometrioma.

CONCLUSION

Laparoscopic sclerotherapy for endometrioma >40 mm during surgery for DIE sclerotherapy has a low impact on AMH, preserves fertility, and prevents recurrence.

Efficacy of ablation and sclerotherapy for the management of ovarian endometrioma: A narrative review

Ovarian cystectomy is the preferred technique for the surgical management of ovarian endometrioma. However, other techniques such as ablation or sclerotherapy are also commonly used. The aim of this review is to summarize information regarding the efficacy of ablation and sclerotherapy compared to cystectomy in terms of ovarian reserve, the recurrence rate, and the pregnancy rate. Several studies comparing ablation versus cystectomy or sclerotherapy versus cystectomy in terms of the serum anti-Müllerian hormone (AMH) decrement, endometrioma recurrence, or the pregnancy rate were identified and summarized. Both ablation and cystectomy have a negative impact on ovarian reserve, but ablation results in a smaller serum AMH decrement than cystectomy. Nonetheless, the recurrence rate is higher after ablation than after cystectomy. More studies are needed to demonstrate whether the pregnancy rate is different according to whether patients undergo ablation or cystectomy. The evidence remains inconclusive regarding whether sclerotherapy is better than cystectomy in terms of ovarian reserve. The recurrence rates appear to be similar between sclerotherapy and cystectomy. There is not yet concrete evidence that sclerotherapy helps to improve the pregnancy rate via in vitro fertilization in comparison to cystectomy or no sclerotherapy.

Relationship between bone mineral density and ovarian function and thyroid function in perimenopausal women with endometriosis: a prospective study

BACKGROUND

In women with endometriosis, the association between ovarian function, hormones, and bone mineral density (BMD) is unclear. Therefore, this study aimed to elucidate the association between changes in bone mineral density (BMD) and clinical data, such as ovarian reserves, in perimenopausal women with endometriosis.

METHODS

In this prospective study, we evaluated 207 female patients who visited the Department of Obstetrics and Gynecology at the University of Tokyo Hospital between December 2015 and December 2020. We included patients aged ≥ 40 years with a history of endometriosis or who presented with endometriosis lesions. Patients with a history of smoking, steroid administration, autoimmune diseases, dyslipidaemia, and heart disease were excluded. During the study period, patients who underwent two tests, an initial and a follow-up test (n = 142, average age: 45.02 years, average BMD: 1.16 g/cm2), were evaluated at regular intervals based on the annual rate of change in BMD.

RESULTS

There was a weak negative correlation between the follicle-stimulating hormone (FSH) and BMD and a weak positive correlation between the anti-Müllerian hormone (AMH) and BMD. The annual rate of change in BMD showed a very weak correlation with thyroid-stimulating hormone (TSH) levels. A large decline in BMD was associated with high TSH levels and higher average age at menopause. Patients with higher TSH exhibited a higher rate of decrease in BMD than those without.

CONCLUSIONS

High FSH or low AMH levels are associated with decreased BMD. Decreased ovarian reserve is associated with decreased BMD in perimenopausal women with endometriosis. High TSH levels increase the risk of BMD loss. This finding may suggest that women with endometriosis should undergo bone scanning to rule out the possibility of reduced bone mass and subsequent increased risk of fracture.

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.

Increasing trend of serum antimullerian hormone level after long term follow up of endometrioma resection

Background:

Endometriosis is a chronic disease mostly affecting women at reproductive age. Some evidence suggests that surgery of ovarian endometrioma may have a detrimental effect on ovarian reserve. The aim of this study was to evaluate the changes of serum antimullerian hormone (AMH) levels in patients with endometrioma after cystectomy.

Methods:

A prospective study was performed at Nikan hospital on 58 patients with endometrioma who underwent laparoscopic cystectomy. Of them, 30 had unilateral endometrioma and 28 had bilateral endometrioma. Complete excision was done, pelvic endometriosis implants as well as deep infiltrative endometriosis was resected. Sutures were made for the closure of ovarian parenchyma and bleeding control. We did not use any hot energy devices such as cautery on ovaries for ablation, coagulation or resection of endometrioma. Serum AMH levels were measured preoperatively, 3, 9, and 15 months postoperatively.

Results:

Serum AMH levels decreased significantly from the preoperative sample (2.98 ± 2.47 ng/ml) to 3 months after laparoscopy (1.07 ± 1.06 ng/ml), then gradually increased 9 months (1.47 ± 1.16 ng/ml) and 15 months (1.95 ± 1.85 ng/ml) after surgery, without returning to the preoperative levels during the follow-up time of study.

Conclusion:

There is a fluctuation pattern in AMH levels from preoperative to 15-month follow-up after endometrioma surgery using only suture for ovarian hemostasis. Firstly, there is decline in AMH level 3 months after surgery, then an increasing trend was observed gradually up to 15 months after surgery. Controlled studies are needed to compare the effects of various cystectomy methods on the ovarian reserve after endometrioma surgery

Impact of Surgical Management of Endometrioma on AMH Levels and Pregnancy Rates: A Review of Recent Literature

Ovarian endometrioma are found in up to 40% of women with endometriosis and 50% of infertile women. The best surgical approach for endometrioma and its impact on pregnancy rates is still controversial. Therefore, we conducted a literature review on surgical management of ovarian endometrioma and its impact on pregnancy rates and ovarian reserve, assessed by anti-Müllerian hormone (AMH) serum levels. Ovarian cystectomy is the preferred technique, as it is associated with lower recurrence and higher spontaneous pregnancy rate. However, ablative approaches and combined techniques are becoming more popular as ovarian reserve is less affected and there are slightly higher pregnancy rates. Preoperative AMH level might be useful to predict the occurrence of pregnancy. In conclusion, AMH should be included in the preoperative evaluation of reproductive aged women with endometriosis. The surgical options for ovarian endometrioma should be individualized. The endometrioma ablation procedure seems to be the most promising treatment.

Practical Recommendations for the Management of Benign Adnexal Masses

OBJECTIVE

 To perform a comprehensive review to provide practical recommendations regarding the diagnosis and treatment of benign adnexal masses, as well as information for appropriate consent, regarding possible loss of the ovarian reserve.

METHODS

 A comprehensive review of the literature was performed to identify the most relevant data about this subject.

RESULTS

 In total, 48 studies addressed the necessary aspects of the review, and we described their epidemiology, diagnoses, treatment options with detailed techniques, and perspectives regarding future fertility.

CONCLUSIONS

 Adnexal masses are extremely common. The application of diagnosis algorithms is mandatory to exclude malignancy. A great number of cases can be managed with surveillance. Surgery, when necessary, should be performed with adequate techniques. However, even in the hands of experienced surgeons, there is a significant decrease in ovarian reserves, especially in cases of endometriomas. There is an evident necessity of studies that focus on the long-term impact on fertility.

Predictive value of the serum anti-Müllerian level for spontaneous pregnancy in women after endometriosis surgery

Objective

This study was performed to assess the predictive value of the anti-Müllerian hormone (AMH) serum level for spontaneous pregnancy in women after endometriosis surgery.

Methods

In total, 124 patients with suspected ovarian endometrioma planning to undergo laparoscopic ovarian cystectomy were divided into a high AMH group (AMH > 2 ng/mL) and low AMH group (AMH ≤ 2 ng/mL) according to their preoperative AMH levels. The postoperative AMH levels were also measured, and pregnancy outcomes were followed up.

Results

Twenty-one patients were excluded, and 52 pregnancies were registered in the remaining 103 patients diagnosed with endometriosis. The pregnancy rate was significantly greater in the high than low AMH group. Receiver operator characteristics analysis of preoperative AMH, postoperative AMH, and the AMH decline rate showed that preoperative AMH was associated with the greatest area under the curve. Kaplan–Meier curves showed that women in the high AMH group had a significantly higher cumulative pregnancy rate than those in the low AMH group.

Conclusion

The preoperative AMH level might be a useful marker to predict the occurrence of natural pregnancy and could be offered as part of the fertility strategy to women who desire pregnancy after endometriosis surgery.

Antimüllerian hormone is reduced in the presence of ovarian endometriomas: a systematic review and meta-analysis

OBJECTIVE

To evaluate if the presence of endometriomas impacts on the ovarian reserve as evaluated with antimüllerian hormone (AMH).

DESIGN

Systematic review and meta-analysis.

SETTING

Not applicable.

PATIENT(S)

Patients with unoperated endometriomas versus controls without endometriomas.

INTERVENTION(S)

Electronic databases searched up to June 2017 to identify articles evaluating AMH levels in patients with unoperated endometriomas versus controls without endometriomas.

MAIN OUTCOME MEASURE(S)

The primary analysis was aimed at evaluation of AMH levels (mean and SD) in patients with and without endometriomas. Secondary analyses were aimed at evaluating AMH levels in patients with ovarian endometriomas compared to patients with either non-endometriosis benign ovarian cysts or healthy ovaries.

RESULT(S)

Of the 39 studies evaluated in detail, 17 were included, for a total of 968 patients with endometriomas and 1874 without endometriomas. AMH was significantly lower in patients with unoperated endometriomas compared to patients with no endometriomas (mean difference -0.84, with 95% confidence interval [CI] -1.16 to -0.52). At secondary analyses, AMH in patients with endometriomas was significantly lower both versus non-endometriosis benign ovarian cysts (mean difference -0.85, 95% CI -1.37 to -0.32, and versus women with healthy ovaries (mean difference -0.61, 95% CI -0.99 to -0.24).

CONCLUSION(S)

Ovarian reserve evaluated with AMH is reduced in patients with ovarian endometriomas compared both to patients with other benign ovarian cysts, and to patients with healthy ovaries.

The role of antimullerian hormone in assessing ovarian damage from chemotherapy, radiotherapy and surgery

PURPOSE OF REVIEW

Iatrogenic ovarian damage can occur after chemotherapy, radiotherapy and surgery for cancer as well as for non-malignant conditions. This review describes the effects of such treatment on antimullerian hormone (AMH) and the implications of the fall in AMH in relation to ovarian function and fertility, especially in the era of improved fertility preservation strategies.

RECENT FINDINGS

The risk of gonadotoxicity differs between chemotherapy regimens. There is growing evidence that pretreatment AMH has prognostic significance for the degree of fall in AMH after treatment, the reversibility of ovarian damage and risk of premature ovarian insufficiency. The accuracy of prediction increases when age is coupled with AMH. The adverse effect of removal of endometriomas is increasingly clear, and AMH pre and post surgery useful is assessing the degree of damage to the ovary. The implications of low AMH after such treatment on natural fertility and reproductive lifespan are less clear. Apart from treatment effects, there are other coexisting conditions that can affect AMH which needs to be taken into consideration during interpretation of AMH before and after treatment.

SUMMARY

A fall in AMH in women after gonadotoxic treatment has been consistently described, with variable recovery, the accurate interpretation and clinical application of post-treatment AMH level on reproductive lifespan and fertility prediction needs to be studied in future larger prospective studies with longer follow-up.

Endometriosis and ART: A prior history of surgery for OMA is associated with a poor ovarian response to hyperstimulation

Background

Many women whose fertility may have been impaired by endometriosis require assisted reproductive technology (ART) in order to become pregnant. However, the influence of ovarian endometriosis (OMA) on ovarian responsiveness to hyperstimulation has not been clearly established.

Objective

To evaluate the risk of a poor ovarian response (POR) to stimulation and ART outcomes in women with OMA.

Materials and methods

We conducted a large observational controlled matched cohort study in a tertiary care university hospital between 01/10/2012 and 31/12/2015. After matching by age and anti-Müllerian hormone (AMH) levels, 201 infertile women afflicted with OMA (the OMA group) and 402 disease-free women (the control group) undergoing an ART procedure were included in the study. The main outcomes that we measured were a POR to hyperstimulation (i.e., ≤ 3 oocytes retrieved, or cancelled cycles), the clinical pregnancy rate, and the live birth rate.

All of the women with endometriosis underwent a pre-ART work-up, in order to obtain an accurate diagnosis and staging of their disease. An OMA diagnosis was based on published imaging criteria (obtained by transvaginal sonography or magnetic resonance imaging) or on histological analysis for patients with a prior history of endometriosis surgery. The statistical analyses were conducted using univariate and multivariate logistic regression models.

Results

The incidence of a POR to hyperstimulation was significantly higher for the OMA group than for the control group [62/201 (30.8%) versus 90/402 (22.3%), respectively; p = 0.02]. However, no significant differences were found between the OMA and the control group in terms of the clinical pregnancy rate [53/151 (35%) versus 134/324 (41.3%), respectively; p = 0.23] and the live birth rate [39/151 (25.8%) versus 99/324 (30.5%), respectively; p = 0.33]. By multivariate analysis, a prior history of surgery for OMA was found to be an independent factor associated with a POR to stimulation [OR = 2.1; 95% CI: 1.1–4.0], unlike OMA without a prior history of surgery [OR: 1.5; 95% CI: 0.9–2.2].

Conclusion

The presence of OMA during ART treatment increased the risk of a POR to hyperstimulation, although the live birth rate was not affected. Furthermore, having OMA and having previously undergone surgery for OMA was identified as an independent risk factor for a POR.

Endometriosis-associated infertility: GDF-9, AMH, and AMHR2 genes polymorphisms

PURPOSE

The purpose of this paper is to determine whether there is a correlation between polymorphisms in the growth differentiation factor-9 (GDF-9) gene and anti-Müllerian hormone (AMH) gene and its receptor, AMHR2, and endometriosis-associated infertility.

METHODS

This is a case-control study to evaluate whether there is a correlation between polymorphisms in the GDF-9 gene (SNPs determined by direct sequencing), AMH gene, AMHR2 (both SNPs determined by genotyping using TaqMan Allelic Discrimination), and endometriosis-associated infertility. The study included 74 infertile women with endometriosis and 70 fertile women (tubal ligation) as a control group.

RESULTS

Patient age and the mean FSH levels were similar between the infertile with endometriosis and fertile without endometriosis groups. The frequency of genotypes between the groups for GDF-9 gene polymorphisms did not show statistical significance, nor did the AMHR2 gene polymorphism. However, the AMH gene polymorphism did show statistical significance, relating the polymorphic allele with infertility in endometriosis.

CONCLUSIONS

We demonstrate that an SNP in the AMH gene is associated with infertility in endometriosis, whereas several SNPs in the GDF-9 gene and the - 482A G SNP in the AMHR2 gene were found to be unrelated.