Direct proportional relationship between endometrioma size and ovarian parenchyma inadvertently removed during cystectomy, and its implication on the management of enlarged endometriomas

Is There an Association Between Endometriosis, Early Menopause, and Cardiovascular Disease?

Large-scale studies show endometriosis linked to earlier menopause onset. Recent research targeting women with laparoscopically diagnosed endometriosis found an increase in cases of early natural menopause. Furthermore, recent large-scale cohort studies have found a correlation between endometriosis and an increased risk of cardiovascular disease (CVD). Understanding the causality of early menopause, particularly natural menopause, and cardiovascular risks in women with endometriosis could help medical professionals develop effective strategies for early prevention and new therapies. Endometriosis, early menopause, and cardiovascular risks may be linked by primary or secondary mechanisms. Primary mechanisms involve shared pathways that can lead to all morbidities, while secondary occur due to delayed consequences of management strategies. In these large-scale cohort studies, relevant risk and confounding factors, such as oophorectomy, were considered to refine estimates of associations. However, none of the studies considered endometriotic cystectomy, a globally accepted treatment for endometriosis-associated pelvic pain and infertility, as a mediating factor. There is substantial evidence to indicate that endometriotic cystectomy harms ovarian reserve and may lead to early menopause in cases of multiple surgeries or bilateral cases. Early menopause is a well-established risk factor for CVD. To thoroughly examine the link between endometriosis and early menopause, particularly natural menopause, and their connection with cardiovascular risks, it is imperative to consider all the possible factors that may affect the results, such as endometriotic cystectomy. This will enable us to obtain the most accurate and adjusted hazard ratio.

Reproductive outcome after laparoscopic ovarian cystectomy using barbed sutures versus conventional smooth sutures: A retrospective cohort study

OBJECTIVE

To investigate the effects of barbed and conventional sutures on reproductive outcomes and ovarian reserve after laparoscopic treatment for benign non-endometrioma ovarian cysts.

METHODS

This retrospective study was conducted at an affiliated women's hospital between May 2017 and December 2019. Patients with benign non-endometriotic ovarian cysts undergoing laparoscopic cystectomy were included.

RESULTS

Patients received barbed sutures (221 patients) or conventional smooth sutures (203 patients) intraoperatively. The two groups had comparable baseline characteristics. The surgical duration and ovarian suturing time were significantly shorter in the barbed suture group than in the conventional smooth suture group (P < 0.001 and P = 0.002, respectively). The rate of postoperative hemoglobin decline and serum anti-Müllerian hormone decline were similar between the two groups (P > 0.05). A total of 316 (74.53%) patients experienced at least one pregnancy postoperatively: 170 (76.92%) and 146 (71.92%) patients in the barbed suture and conventional smooth suture groups, respectively (χ2 = 1.395, P = 0.238). Multivariate Poisson regression demonstrated that barbed sutures had no significant effect on the overall postoperative pregnancy rate (adjusted incidence rate ratio, 1.10; 95% confidence interval, 0.93-1.36; P = 0.382).

CONCLUSION

In patients with benign non-endometriotic ovarian cysts undergoing laparoscopic ovarian cystectomy, barbed sutures had a reproductive outcome similar to that of conventional smooth sutures while providing higher surgical efficiency without adverse effects on the postoperative ovarian reserve. Barbed sutures are probably a viable option to conventional smooth sutures.

Hormonal Therapies before in vitro fertilization in women with endometriosis: The Minotaur's Labyrinth and the Ariadne's Thread

Endometriosis-related infertility is one of the most debated topics in reproductive medicine. In recent years, prolonged pre-cycle hormonal regimens gained attention as a mean of improving the assisted reproduction technologies (ART) success rates in endometriosis patients. GnRH agonists, dienogest, medroxyprogesterone acetate, and aromatase inhibitors are the most studied medications. Conflicting results and a high risk of bias exist in almost all of the conducted studies in the field. However, current evidence suggests that pre-cycle treatment with GnRH agonists may be beneficial for patients with stage III/IV endometriosis. Dienogest and medroxyprogesterone acetate-based progestin-primed ovarian stimulation protocol was shown to be comparable to the prolonged GnRH agonists protocol. Finally, aromatase inhibitors seem to be of limited benefit to the assisted reproductive outcomes of endometriosis patients. Although it is challenging to draw any clinical conclusions, pre-cycle hormonal treatments seem to be best indicated in endometriosis patients who had previously failed ART treatment.

Ethanol Sclerotherapy in the Management of Ovarian Endometrioma: Technical Considerations for Catheter- and Needle-Directed Sclerotherapy

PURPOSE

To provide technical guidance on applying catheter-directed and needle-directed ethanol sclerotherapy for endometriomas and present the results of these sclerotherapy methods.

MATERIALS AND METHODS

From January 2015 to March 2021, the results of the patients with symptomatic ovarian endometriomas who underwent needle-directed or catheter-directed sclerotherapy were evaluated, retrospectively. The decision to apply which sclerotherapy technique was made during the procedure for each patient considering the following factors: cyst size, cyst location, cyst viscosity, and tissue rigidity.

RESULTS

Both needle-directed (n = 34 cysts) and catheter-directed (n = 34 cysts) sclerotherapy techniques were effective, with a 100% technical success rate and a 97% clinical success rate. In two of 34 cysts (6%) treated with needle-directed sclerotherapy, recurrence was detected and successfully retreated with catheter-directed sclerotherapy. Significant reductions in cyst size, pain, and serum cancer antigen 125 levels (p < 0.05) were noted. Serum anti-Müllerian hormone levels remained unaffected, indicating preserved ovarian reserve (p > 0.05). Among those treated for infertility, the pregnancy rate was 54% (n = 6/11). The mean ± SD cyst size decline was greater in catheter-directed sclerotherapy than needle-directed sclerotherapy (5.5 ± 3.1 cm vs. 4.0 ± 2.1 cm, p < 0.05). However, the pretreatment cyst volumes were considerably higher in catheter-directed sclerotherapy group (202.0 ± 233.5 mL vs. 78.8 ± 59.7 mL, p < 0.05) and were associated with significant post-treatment volume decrease (p < 0.05).

CONCLUSION

The choice between catheter-directed and needle-directed ethanol sclerotherapy should be determined during the procedure, with a preference for catheter-directed sclerotherapy when feasible. Crucial factors in making this decision include cyst size, cyst location, cyst viscosity, and tissue rigidity. Level of evidence Level 3, non-controlled retrospective cohort study.

The impact of ovarian endometrioma and endometriotic cystectomy on anti-Müllerian hormone, and antral follicle count: a contemporary critical appraisal of systematic reviews

Currently, three crucial questions regarding the reliability of ovarian reserve measures in women with ovarian endometrioma during the reproductive age are being discussed. Firstly, the effects of endometriotic cystectomy on short and long-term ovarian reserve. Secondly, the accuracy of serum anti-Müllerian hormone (AMH) and antral follicle count (AFC) in estimating ovarian reserve in these cases. Thirdly, the impact of endometrioma itself on the ovarian reserve over time in such cases. The purpose of the present review is to critically assess available systematic reviews and meta-analyses that have explored these questions. Nine eligible reviews were found following a systematic search on PubMed.com and similarly assessed. These reviews varied considerably regarding the level of evidence, as per an identical comprehensive scoring system. Moderate to high-quality evidence demonstrates that endometriotic cystectomy, by the stripping technique, adversely affects ovarian reserve in the short and long term, up to 9-18 months post-surgery. Damage to ovarian reserve was considerable but more pronounced in bilateral cases than unilateral cases, equivalent to 39.5% and 57.0%, respectively. Repeat endometriotic cystectomy is detrimental to ovarian reserve. The impact of endometrioma diameter on ovarian reserve before or after surgery is still unclear. Moderate to high-quality evidence, relying on simultaneous assessment of both ovarian reserve measures, shows that AMH is sensitive while AFC is not in cases undergoing ovarian cystectomy. AMH should be the biomarker of choice for counseling and managing women with endometrioma in their reproductive age, especially before surgery. While there is some evidence to show that endometrioma per se may harm ovarian reserve, this evidence is not robust, and there is good-quality evidence to challenge this notion. It is necessary to conduct further targeted RCTs, systematic reviews, and meta-analyses based on solid methodological grounds to increase the level of evidence, refine quantitative estimates, investigate open questions, and decrease heterogeneity.

The Effect of Hormonal Treatment on Ovarian Endometriomas: A Systematic Review and Meta-Analysis

OBJECTIVE

To evaluate the effect of hormonal suppression of endometriosis on the size of endometriotic ovarian cysts.

DATA SOURCES

The authors searched MEDLINE, PubMed, Cochrane Central Register of Controlled Trials, Embase, and ClinicalTrials.gov from January 2012 to December 2022.

METHODS OF STUDY SELECTION

We included studies of premenopausal women undergoing hormonal treatment of endometriosis for ≥3 months. The authors excluded studies involving surgical intervention in the follow-up period and those using hormones to prevent endometrioma recurrence after endometriosis surgery. Risk of bias was assessed with the Newcastle-Ottawa Scale and Cochrane Risk of Bias Tool. The protocol was registered in PROSPERO (CRD42022385612).

TABULATION, INTEGRATION, AND RESULTS

The primary outcome was the mean change in endometrioma volume, expressed as a percentage, from baseline to at least 6 months. Secondary outcomes were the change in volume at 3 months and analyses by class of hormonal therapy. The authors included 16 studies (15 cohort studies, 1 randomized controlled trial) of 888 patients treated with dienogest (7 studies), other progestins (4), combined hormonal contraceptives (2), and other suppressive therapy (3). Globally, the decrease in endometrioma volume became statistically significant at 6 months with a mean reduction of 55% (95% confidence interval, -40 to -71; 18 treatment groups; 730 patients; p <.001; I2 = 96%). The reduction was the greatest with dienogest and norethindrone acetate plus letrozole, followed by relugolix and leuprolide acetate. The volume reduction was not statistically significant with combined hormonal contraceptives or other progestins. There was high heterogeneity, and studies were at risk of selection bias.

CONCLUSION

Hormonal suppression can substantially reduce endometrioma size, but there is uncertainty in the exact reduction patients may experience.

Laparoscopic Cystectomy for a 20-Centimetre Ovarian Endometrioma in a Subfertile Patient: Α Case Report

Large ovarian endometriomas may cause severe pressure symptoms and often require surgical management. The laparoscopic approach, although challenging, is feasible and safe when performed by surgeons with advanced minimal access skills, provided that certain rules are respected. We report a case of a 40-year-old, nulliparous patient with a history of endometriosis, low ovarian reserve, and subfertility who presented with a 20-cm left ovarian endometrioma and associated symptoms, managed successfully by laparoscopic cystectomy. Compared to non-excisional surgical methods, endometrioma cystectomy likely causes a more profound decline in post-operative ovarian reserve, which is particularly important in the context of subfertility. We discuss the technical aspects of this challenging procedure, potential alternative approaches, and clinical decision-making as to why cystectomy was preferred.

Effect of hormonal treatment on evolution of endometriomas: An observational study

OBJECTIVE

To evaluate the evolution of endometriomas with or without medical treatment.

METHODS

This retrospective observational study was performed at the Gynaecological Center, Hôpital La Conception (Assistance Publique Hopitaux de Marseille). We reviewed clinical data of patients with at least one endometrioma diagnosed by magnetic resonance imaging (MRI) and at least one other MRI exam after more than three months. Patients were divided into groups receiving medical treatment and without medical treatment (high-dose progestins, low-dose progestins or combined contraceptives). The primary objective was to evaluate the evolution of endometriomas with or without hormonal treatment. The primary evaluation criterion was the diameter of the endometriomas, and the secondary evaluation criterion was the number of endometriomas for each patient observed. The secondary objective was to evaluate whether different categories of hormonal treatment have different efficacity in the evolution of endometriomas.

RESULTS

We included 68 patients, 39 (57,4%) with hormonal treatment and 29 (42,6%) without hormonal treatment. There were 105 total endometriomas identified at the first MRI, 52 in patients with hormonal treatment and 53 in patients without treatment. The mean diameter of the endometriomas in patients with hormonal treatment was 31,48 ± 18,1 mm at the first MRI and 23,60 ± 15,3 mm at the second MRI. The mean diameter of the endometriomas in patients without treatment was 33,57 ± 19,7 mm at the first MRI and 40,11 ± 25,7 mm at the second MRI (statistically significant difference, p = 0.01). The mean number of endometriomas in patients with treatment was 1,79 ± 1,1 at the first MRI and 1,18 ± 0,9 at the second MRI, while the mean number of endometriomas in patients without hormonal treatment was 1,38 ± 0,6 at the first MRI and 1,97 ± 1,5 at the second MRI (difference not statistically significant, p = 0.38). The subgroup analysis differentiated by category of hormonal treatment did not show statistically significant results.

CONCLUSIONS

The present study shows that there is a positive effect of hormonal treatment on reducing the diameter of endometriomas and also a significative increase in endometrioma size in the absence of treatment. There is no evidence of an advantage of a single category of hormonal treatment on this effect on endometriomas. Thus, any medical treatment could be proposed as a first-line therapy for endometriomas that would reduce the size of the endometrioma and thereby help to avoid surgical intervention.

Oocyte Cryopreservation in Women with Ovarian Endometriosis

Ovarian endometriosis is a gynecological condition that is closely associated with infertility-from its pathogenesis to treatment modalities, this condition presents a challenge both for patients and clinicians alike when seeking conception, due to low AMH levels, peritoneal inflammation, and the inadvertent removal of healthy ovarian parenchyma at surgery. In fact, around half of endometriosis patients seeking fertility require tertiary-level assisted reproduction techniques to achieve a live birth. Oocyte cryopreservation, a procedure initially designed for oncology patients, has emerged over recent years as a very promising treatment strategy for patients who have been diagnosed with ovarian endometriosis in order to preserve their fertility and obtain a live birth at a later stage in their lives. Counseling patients about oocyte preservation techniques at an early stage in the diagnosis, ideally before the age of 35 and especially prior to any surgical treatment, provides an excellent opportunity to discuss future fertility and the benefits associated with oocyte cryopreservation.

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.

The optimal time for laparoscopic excision of ovarian endometrioma: a prospective randomized controlled trial

OBJECTIVE

This study aimed to explore the optimal time of laparoscopic cystectomy for unilateral ovarian endometrioma patients and evaluate the influence on ovarian reserve.

MATERIALS AND METHODS

This prospective randomized controlled study included 88 women with unilateral ovarian endometrioma at a tertiary teaching hospital. All patients received their first identified diagnosis of ovarian endometrioma by ultrasound (> 4 cm and ≤ 10 cm) and were administered an oral contraceptive pill (OC) for one cycle before laparoscopy. They were randomly divided into two groups: laparoscopy at the late luteal phase (group LLP) (n = 44) (termination of OC for two days) and laparoscopy at the early follicular phase (group EFP) (n = 44) (day 3 after menstruation). Basic clinical characteristics were recorded. Serum Anti-Müllerian hormone (AMH) levels were measured at various times to predict ovarian reserve. Serum levels of Anti-Müllerian hormone (AMH) were measured at several time sites to predict the ovarian reserve; AMH and leukocyte esterase (LE) levels of the endometrioma wall were measured.

RESULTS

Before surgery, serum AMH levels decreased in both groups from preoperative to one week and six months postoperatively. In contrast, the difference values of group EFP were larger than those of group LLP at postoperative one week and postoperative six months (1.87 ± 0.97 vs. 1.31 ± 0.93, P = 0.07; 1.91 ± 1.06 vs. 1.54 ± 0.93, P = 0.001). The mean rates of postoperative serum AMH decline were 37.92% and 46.34% in group EFP, significantly higher than those in group LLP (25.83% vs. 31.43%, P < 0.001). Ovarian endometrioma wall AMH of group LLP was significantly lower than that of group EFP ([22.86 ± 3.74] vs. [31.02 ± 5.23], P < 0.001). Meanwhile, ovarian endometrioma LE concentration of group LLP was significantly higher than that of group EFP ([482.83 ± 115.88] vs. [371.68 ± 84.49], P<0.001). There was also a significant inverse correlation between leukocyte esterase and AMH concentration in an ovarian endometrioma cyst wall (r=-0.564, P<0.001).

CONCLUSION(S)

The optimal time for laparoscopic cystectomy for patients with first identified unilateral ovarian endometrioma is the late luteal phase, which reduces ovarian tissue loss and preserves ovarian reserve effectively and safely.

Minimally invasive surgery for ovarian endometriosis as a mean of improving fertility: Cystectomy vs. CO2 fiber laser ablation what do we know so far?

Minimally invasive surgery emerged in the 1980s as a safe and effective technique which requires smaller incisions and, usually, a shorter hospital stay compared to traditional surgery. Since then, minimally invasive surgery has expanded in many surgical specialties. One of its newest application in gynecology stands in the infertility management of young women with unexplained infertility or suspected endometriosis. In these cases, laparoscopy allows to diagnose and treat the disease aiming to increase at best the chances of spontaneous pregnancy or trough assisted reproductive technology. Nowadays, minimally invasive surgical approach of ovarian endometriosis consists of either laparoscopic cystectomy or ablative techniques such as laparoscopic CO2 fiber laser vaporization. Although cystectomy represents the gold standard according to the latest Cochrane review, some endometriosis experts are worried about its detrimental effect on healthy ovarian parenchyma and suggest preferring a less aggressive approach such as CO2 fiber laser vaporization. The aim of this review is to give an overview of the available evidences about the impact of the two surgical procedures on ovarian reserve markers and pregnancy outcome.

Combining Sclerotherapy with CO2 Laser Ablation for the Laparoscopic Management of Large Endometrioma: Advantages and Pitfalls

STUDY OBJECTIVE

To demonstrate the feasibility of management of large endometrioma laparoscopically.

DESIGN

Stepwise demonstration with narrated video footage of the laparoscopic 2-step procedure starting with alcohol sclerotherapy of the large endometrioma followed by CO₂ laser ablation and 6-month follow-up.

SETTING

The debate surrounding the best approach for the management of large endometriomas has been ongoing. Cystectomy especially when treating large endometriomas has been shown to decrease ovarian reserve proportionally to the endometrioma's size.^2,4 This is why 2-step approaches have been considered to preserve the ovarian reserve.^1,3 We present the case of a 22-year-old nulliparous woman who has primary severe dysmenorrhea resistant to medical treatment. Magnetic resonance imaging shows uterine adenomyosis and a 10 cm large endometrioma of the left ovary and no signs of deep infiltrative endometriosis. She has a desire for pregnancy in the distant future.

INTERVENTION

The first step is the laparoscopic ethanol sclerotherapy. After emptying and rinsing the endometrioma's cavity through a 5 mm suction cannula, it is then filled with ethanol through a 14 French Foley catheter to avoid any overflow.^5,6 After a time exposure of 10 minutes, the ethanol is withdrawn and the cavity rinsed (Figure 2). The second step of the surgery is performed 12 weeks later (Figure 3). Using CO₂ laser, the untreated portion of the inner wall of the remaining endometrioma is vaporized along with remaining superficial endometriosis lesions (Figure 1).

CONCLUSION

Laparoscopy sclerotherapy combined to CO₂ laser ablation is a feasible technique for the management of a large endometrioma. Further research is still required to evaluate the benefit of a 2-step surgery approach over standard cystectomy and to understand the long-term effects of ethanol-induced ovarian fibrosis.

Diagnosis and treatment of early-stage endometriosis by Transvaginal Hydro laparoscopy

Background: Transvaginal Hydro Laparoscopy (THL) is known as a minimal invasive procedure allowing endoscopic exploration of the female pelvis. Objective: To evaluate the possibilities of the THL as a tool for early diagnosis and treatment of minimal endometriosis. Materials and methods: A retrospective study of a consecutive series of 2288 patients referred for fertility problems to a tertiary centre for reproductive medicine was undertaken. Mean duration of infertility was 23.6 months (SD ±11-48), mean age of patients was 31.25 (SD± 3.8y). With normal findings at clinical and ultrasound examination patients underwent, as part of their fertility exploration, a THL. Main outcome measures: Evaluation of feasibility, identified pathology and pregnancy rate. Results: Endometriosis was diagnosed in 365 patients (16%); the localisation was higher on the left side (n=237) than on the right side (n=169). Small endometriomas, with diameters between 0.5 and 2 cm, were present in 24.3% (right side in 31, left side 48 and bilateral 10). These early lesions were characterised by the presence of active endometrial like cells and a pronounced neo-angiogenesis. Destruction of the endometriotic lesions with bipolar energy resulted in an in vivo pregnancy rate (spontaneous/IUI) of 43.8% (CPR after 8 months: spontaneous 57.7%; IUI/AID 29.7%). Conclusion: THL allowed in a minimally invasive way an accurate diagnosis of the early stages of peritoneal and ovarian endometriosis with the possibility of offering treatment with minimal damage. What is new? This is the largest series reporting the usefulness of THL for the diagnosis and treatment of peritoneal and ovarian endometriosis in patients without obviously visible preoperative pelvic pathology.

Endometriosis-associated infertility: From pathophysiology to tailored treatment

Despite the clinically recognized association between endometriosis and infertility, the mechanisms implicated in endometriosis-associated infertility are not fully understood. Endometriosis is a multifactorial and systemic disease that has pleiotropic direct and indirect effects on reproduction. A complex interaction between endometriosis subtype, pain, inflammation, altered pelvic anatomy, adhesions, disrupted ovarian reserve/function, and compromised endometrial receptivity as well as systemic effects of the disease define endometriosis-associated infertility. The population of infertile women with endometriosis is heterogeneous, and diverse patients' phenotypes can be observed in the clinical setting, thus making difficult to establish a precise diagnosis and a single mechanism of endometriosis related infertility. Moreover, clinical management of infertility associated with endometriosis can be challenging due to this heterogeneity. Innovative non-invasive diagnostic tools are on the horizon that may allow us to target the specific dysfunctional alteration in the reproduction process. Currently the treatment should be individualized according to the clinical situation and to the suspected level of impairment. Here we review the etiology of endometriosis related infertility as well as current treatment options, including the roles of surgery and assisted reproductive technologies.

Effect of Surgical Findings on Prediction of Postoperative Ovarian Reserve in Patients with Ovarian Endometrioma

Objective

Revised American Society for Reproductive Medicine (rASRM) classification for endometriosis is considered to have limited ability to predict fertility after surgery. This study evaluated the effect of surgical findings described by the rASRM classification on postoperative change in serum Anti-Müllerian hormone (AMH) in endometriosis.

Study Design

We retrospectively analyzed 112 patients with endometrioma who underwent laparoscopic ovarian cystectomy. The ovarian score was defined as the sum of the endometrioma score from the size and depth of endometrioma and the adhesion score from the extent and types of ovarian adhesion described in the rASRM classification. The ovarian score was correlated with the AMH levels before surgery (AMH0), 3 (AMH3), and 6 months (AMH6) after surgery. To design a model for predicting AMH6, using ovarian score and AMH0, we calculated the unstandardized predictive value of AMH6/AMH0 (UPV) by linear regression analysis. The predicted AMH6 (pAMH6) could be calculated by multiplying the UPV by AMH0. When AMH6 is less than 1.0 ng/mL, it was defined as a poor ovarian reserve group (PORG), and the accuracy of the predictive model was validated.

Results

The level of AMH declined more in rASRM stage IV compared to stage III after surgery. The ovarian score had a significant variable in the linear regression analysis with the ratio of AMH6/AMH0 (p = 0.001). The UPV was correlated with ovarian score negatively. The pAMH6 correlated with AMH6 positively and with age negatively. The pAMH6 showed sensitivity 0.564, specificity 0.909, positive predictive rate 0.786, and negative predictive rate 0.800 in the prediction of PORG (p < 0.001).

Conclusion

The pAMH6 predicted the PORG at 6 months after surgery. Based on the results of our study, the surgical findings, including the size and depth of the endometrioma and extent and types of adhesion could be useful indicators for ovarian reserve after surgery.

Endometrioma surgery-a systematic review and meta-analysis of the effect on antral follicle count and anti-Müllerian hormone

OBJECTIVE

Accurate preoperative counseling about whether an endometriotic cystectomy has a detrimental effect on the ovarian reserve has been a considerable challenge, because studies assessing the postoperative antral follicle counts and anti-Müllerian hormone levels have reported conflicting results. Our objective was to explore the impact of endometriotic cystectomy on both the anti-Müllerian hormone levels and antral follicle counts, with focus on prospective studies in which both variables were measured for each woman concurrently (overcoming unmeasured confounding), in the same setting (overcoming surgical technique differences), and at the same 3 postoperative time points, namely early (1-6 weeks), intermediate (2-6 months) and late (9-18 months), to overcome time-sensitive changes.

DATA SOURCES

Databases of PubMed, ClinicalTrials.gov, the Cochrane Library, Web of Science, and EBSCO were searched between January 2000 and October 2020.

STUDY ELIGIBILITY CRITERIA

Only prospective cohort studies that evaluated the impact of endometriotic stripping cystectomy on anti-Müllerian hormone levels and antral follicle counts in the same women, at matching time points, and in the same setting were eligible.

STUDY APPRAISAL AND SYNTHESIS METHODS

Two authors performed the screening and data extraction independently.

RESULTS

A total of 14 prospectively designed studies were eligible for the meta-analysis and included 650 women. The included studies had a low risk of bias. The postoperative weighted mean differences in serum anti-Müllerian hormone levels dropped significantly when compared with the preoperative levels by an estimated 1.77 ng/mL (95% confidence interval, 0.77-2.77; P<.001), 1.17 ng/mL (95% confidence interval, 0.66-1.67; P<.001), and 2.13 ng/mL (95% confidence interval, 1.61-2.65; P<.001) at the early (1-6 weeks), intermediate (2-6 months), and late (9-18 months) time points, respectively. This corresponded to a mean reduction in serum anti-Müllerian hormone levels at each of the 3-time points of 44.4%, 35.1%, and 54.2%, respectively. Conversely, the postoperative weighted mean difference in the antral follicle count estimates did not change significantly at any of the 3 time points; the early antral follicle count was 0.70 (95% confidence interval, -2.71 to 3.56; P=.63), the intermediate count was -0.94 (95% confidence interval, -2.53 to 0.65; P=.25), and the late count was 2.58 (95% confidence interval, -0.43 to 5.58; P=.09). Overall, high levels of heterogeneity were encountered (I² ranging between 92% and 94% for the anti-Müllerian hormone levels and between 94% and 98% for the antral follicle counts at the 3 time points), which were attenuated when similar anti-Müllerian hormone assays were compared, and the meta-regression suggested that age did not contribute to heterogeneity.

CONCLUSION

Endometriotic cystectomies are associated with a significant reduction in the serum anti-Müllerian hormone levels but not in the antral follicle counts, with the detrimental effects on the anti-Müllerian hormone levels consistently detectable at the early-, intermediate-, and late-postoperative time points. In women with endometrioma, the anti-Müllerian hormone level may provide a more accurate assessment of the risk for iatrogenic depletion of the ovarian reserve.

Effects of intravenous tranexamic acid on ovarian reserve and intra-operative blood loss during laparoscopic cystectomy of endometriotic cyst: a pilot randomized controlled trial

Background

Strategies to preserve ovarian function after ovarian endometriotic cyst removal have been reported in many studies; however, no study has evaluated tranexamic acid administration during surgery.

Objective

To evaluate feasibility of conducting a definitive trial and assessing the potential efficacy of tranexamic acid on ovarian reserve and intra-operative blood loss by comparing mean differences in anti-Müllerian hormone (AMH) levels following laparoscopic ovarian cystectomy between tranexamic acid and control groups.

Materials and methods

A parallel two-arm pilot trial was conducted with 40 participants with endometriotic cysts who underwent laparoscopic ovarian cystectomy. They were randomized 1:1 to either 1 g tranexamic acid (TXA) or no TXA (n = 20 per group). TXA was administered to the participants immediately after induction of general anesthesia and intubation. The primary outcome was the feasibility of conducting a definitive trial in terms of design and procedures (such as recruitment rate, retention, safety of intravenous 1 gm of TXA, sample size verification) and assess the efficacy of TXA on the ovarian reserve and intra-operative blood loss by comparing mean difference of AMH levels between TXA and control groups at pre- and 3 months post-surgery.

Results

The recruitment and successful completion rates were 95% and 100%. Baseline characteristics were similar in the two groups. The mean difference of serum AMH levels (pre- and 3 months post-surgery) between the TXA and control groups was not significantly different. When performing a subgroup analysis, the mean difference of AMH levels (pre- and 3 months post-surgery) seemed to be higher in the bilateral than in the unilateral ovarian cyst group but not significantly different. Operating time was significantly longer in bilateral than in unilateral cysts. No post-operative complications or adverse effects were found.

Conclusion

The full randomized controlled trial for evaluating effects of TXA administration during laparoscopic cystectomy for endometrioma on ovarian reserve was shown to be feasible. Several modifications should be added for improving feasibility, for example, increasing the TXA dose, modifying TXA administration, focusing on either patients with unilateral or bilateral ovarian cysts, and exploring other outcome measures, e.g., surgeons’ satisfaction.

Trial registration

Thai Clinical Trials Registry, TCTR20190424002, Registered 24 April 2019.

Oocyte accumulation for fertility preservation in women with benign ovarian tumours with a history of previous surgery, multiple or large cysts

RESEARCH QUESTION

What are ovarian stimulation cycle outcomes and acceptance rates of an oocyte accumulation programme in young women with benign ovarian tumour (BOT)?

DESIGN

Retrospective cohort study conducted at the Academic Assisted Reproductive Technology and Fertility Preservation Centre, Lille University Hospital, between January 2016 and December 2019. The number of metaphase II oocytes per cycle and per patient after accumulation were evaluated. Two groups were identified for the analysis: endometrioma ('endometrioma') and dermoid, mucinous or serous cyst ('other cysts').

RESULTS

A total of 113 fertility-preservation cycles were analysed in 70 women aged 27.9 ± 4.8 years. Almost all women had undergone previous ovarian surgery before fertility preservation (89%). Mean anti-Müllerian hormone levels before ovarian stimulation was 12.5 ± 8.7 pmol/l. A total of 6.4 ± 3.4 oocytes were retrieved, and 4.3 ± 3.4 metaphase II (MII) oocytes were vitrified per cycle. All agreed to the oocyte accumulation programme and all underwent at least one cycle. To date, 36 (51%) patients achieved two or three fertility- preservation cycles. After accumulation, 7.0 ± 5.23 MII oocytes were vitrified per patient. No difference was found in ovarian response and oocyte cohort between the 'endometrioma' and 'other cysts' groups. Questionnaires completed after oocyte retrieval revealed abdominal bloating and pelvic pain in most patients, with no difference according to the type of cyst. No serious adverse events occurred.

CONCLUSIONS

Oocyte accumulation should be systematically offered to young women with BOT irrespective of histological type, as it seems to be well-tolerated. Long-term follow-up is needed to assess the efficiency of oocyte accumulation to optimize the chances of subsequent pregnancies.

Role of surgical treatment in endometriosis

Endometriosis can take one of three forms depending on its clinical presentation and management: endometriotic ovarian cyst (ovarian endometrioma), superficial or peritoneal endometriosis and deep infiltrating endometriosis (DIE).¹Among them, DIE is considered the most aggressive, and the patient is often affected by more than one type together. The therapeutic methodology should not be influenced by a combination of different types of endometriotic lesion. According to the clinical context and the patient's needs, the treatment of this pathology can be medical or surgical. Although medical therapy could improve endometriosis-associated symptoms, it never offers a definite treatment for symptomatic patients, who often require surgical treatment. The rationale behind endometriosis surgical treatment is to achieve the complete removal of all lesions through a one-step surgical procedure; to obtain promising long-term results for pelvic pain, recurrence rate, and fertility; and to protect the functionality of the involved organs. Achieving these results depends on the total removal of the pathology from the pelvis, in an attempt to preserve, as much as possible, the healthy tissues surrounding the site of the disease. The choice of a surgical approach rather than medical therapy is subject to the patient's expectations, such as pregnancy desire, the effectiveness of treatment compared to possible complications, the type of pain and its intensity, and the location and severity of the disease. In this context, surgical management using a multidisciplinary endometriosis team is an important factor for achieving good outcomes.

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.

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

Does large endometrioma per se increase AMH level?

Women with endometriosis, especially those with endometrioma, present a considerable challenge for ovarian reserve appraisal. This diagnostic difficulty arises from several fundamental questions inherently linked to patient management: the potential influence of endometrioma on ovarian reserve; the adverse effect of ovarian surgery on ovarian reserve; and the adequacy of the established ovarian reserve biomarkers, anti-Müllerian hormone and antral follicle count, to appraise ovarian reserve accurately in these women. Until recently, a key argument was that the development and growth of endometriomas is associated with a progressive damage to normal ovarian tissue, resulting in a concomitant reduction in serum AMH levels. Contrary to this widely accepted position; recent studies have reported that, in women with no previous history of ovarian surgery, AMH levels were increased in women with large endometriomas. These findings are surprising and, if replicated, would have substantial clinical implications. In this commentary, we would, however, urge caution before these reports lead to systematic changes in clinical practice, and recommend urgent replication as the finding linking large endometrioma to high serum AMH levels seems to be biologically implausible, and contradicts the existing extensive body of research.

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.

The Endometrioma Treatment Paradigm when Fertility Is Desired: A Systematic Review

OBJECTIVE

To establish an endometrioma treatment paradigm (decision tree) in the treatment of an ovarian endometrioma through the review of current literature.

DATA SOURCES

A thorough literature search, including PubMed, Google Scholar, and the Cochrane Library, was performed from April 2020 to July 2020. The review was completed by using the following keywords: METHODS OF STUDY SELECTION: Articles published in English that addressed the endometrioma in regard to the following were included: (1) diagnosis, (2) treatment of pain on the basis of size and/or surgical intervention, (3) treatment of fertility on the basis of size and/or surgical intervention, (4) surgical technique, (5) in vitro fertilization success on the basis of size and/or surgical intervention, (6) risk of rupture at the time of egg retrieval, (7) impact on the antimüllerian hormone and antral follicle count postsurgery, and (8) impact on implantation.

TABULATION, INTEGRATION, AND RESULTS

Fifty-six articles were included in this systematic review. While conducting this literature review, several themes were noted. In general, the literature on the ovarian endometrioma seems to be homogeneous in regard to imaging the endometrioma, excision rather than desiccation for an endometrioma ≥3-cm causing pain and/or infertility, minimal use of bipolar energy at the time of ovarian surgery, and risk of severe infection secondary to inadvertent rupture of cysts during egg retrieval. Conversely, studies on the ovarian endometrioma are much more heterogeneous in terms of surgery and assisted reproductive technology, that is, whether surgery should be performed. Certainly, an endometrioma ≥5-cm should be excised before assisted reproductive technology. Moreover, it seems that the antral follicle count and implantation may be enhanced with surgery.

CONCLUSION

By completing an extensive literature review, an easy-to-use algorithm for the diagnosis, evaluation, and treatment of endometriomas was developed to help clinicians in their treatment of patients with endometriosis in the short and long terms.

Tumour markers and histopathologic features of ovarian endometriotic cysts

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.

Endometrioma and reproductive issues: a well-informed patient may be the driver for change

Endometriosis affects a great proportion of women during their reproductive years and may impair female fertility in several ways. Ovarian endometrioma (OE) is the most frequent phenotype and growing evidence suggest an endometrioma-mediated damage to the ovary, ovarian reserve and oocyte quality. Traditionally, surgery has been the first-line treatment in cases of OE. Great advances in assisted reproduction and fertility preservation techniques opened new possibilities towards a more conservative approach. Herein we discuss multiple mechanisms responsible for the deterioration of the reproductive capacity in cases of OE as well as the pros and cons of different treatment options. The management of endometrioma-related subfertility remains controversial and it will depend on patient's intentions and priorities. In the "internet era" patients tend to be hyper-informed and more participative, but they are often misguided and misinformed. Thus, doctors should be able to convert these individuals into well-informed patients in order to facilitate the process of shared decision making, which is extremely relevant in the context of OEs.

Effect of endometrioma and its surgical excision on fertility (Review)

Endometrioma is the cystic lesion of ovaries originating from endometrial glands and stroma; it is identified in 17-44% of patients with endometriosis. Numerous existing studies have reported the association between endometrioma and infertility. However, an absolute cause-effect association requires further confirmation. Available evidence has suggested that ovarian reserve may be impaired by spatial occupation influences, local reaction or both, affecting the reproductive health of females. Given the increased focus on the pathophysiological mechanisms of endometrioma, surgical excision has commonly been considered to avoid further ovarian damage. However, the potential adverse effect of this surgery on the ovarian reserve has recently become a focal point. Whether or not surgical excision can facilitate subsequent conception in young females planning to be pregnant is controversial. As shown in the present review on the effects of endometrioma and its removal in females requiring assisted reproductive technology, prior surgery for endometrioma may not improve assisted fertility results and may further decrease the number of oocytes retrieved in the affected females. Subsequent studies are needed to ascertain the optimal management of infertility in the setting of endometriomas.

Oocyte vitrification offers more space for a tailored surgical management of endometriosis

Oocyte vitrification is an attractive and efficient option in the long-term management of endometriosis patients. Which women would benefit from banked oocytes when pregnancy is attempted, and whether oocyte vitrification should be carried out before or after the surgical management of endometriosis, is still debated. On the basis of recent data, and in the absence of cost-effective modelling, a personalized strategy should assess crucial variables, such as type of surgery, effect on oocyte yield and the huge heterogeneity of the clinical scenarios possibly requiring surgery. Research into a more tailored approach to maximize the result of each available intervention, e.g. hormones, surgery, assisted reproductive technology or their combination to prevent infertility and reduce the actual burden of personal and societal cost of the disease, is recommended.

Comparison of serum antimüllerian hormone levels after robotic-assisted vs. laparoscopic approach for ovarian cystectomy in endometrioma

OBJECTIVE

Serum antimüllerian hormone (sAMH) is regarded as a useful marker in predicting for ovarian functional reserve. To evaluate whether postoperative change in ovarian reserve differs between robotic-assisted and laparoscopic single-site ovarian cystectomy in patients with ovarian endometrioma by comparing sAMH levels.

STUDY DESIGN

The perioperative outcomes in 94 patients with ovarian endometrioma who underwent robotic assisted (n = 40) or laparoscopic (n = 54) cystectomy were compared retrospectively. The sAMH levels were measured by enzyme immunoassay preoperatively and at 3 months and 6 months after surgery. The difference and ratio of sAMH levels between preoperative and 3 months, 6 months after cystectomy were compared between robotic-assisted and laparoscopic approach for predicting which method is better for preservation of ovarian function.

RESULT(S)

The sAMH levels were obviously decreased after the surgery (ratio of sAMH levels between preoperative and 3 months, 0.49 ± 0.46 versus 0.52 ± 0.28 ng/mL, mean ± standard deviation) in both groups. There was no difference of the recovery sAMH level at 6 months (ratio of 6 months sAMH to preoperative sAMH level) after cystectomy in unilateral ovarian cystectomy. However, in patients with bilateral endometrioma, the recovery of sAMH level was higher in robotic assisted approach than those of laparoscopic surgery (0.40 ± 0.24 versus 0.21 ± 0.23, p = 0.009). In multivariate linear regression analysis, the coefficient of robot surgery was 0.442 (p = 0.028).

CONCLUSION(S)

In our study, robotic-assisted cystectomy had higher preservation of ovarian function than the laparoscopic approach for bilateral ovarian endometrioma, but not for unilateral endometrioma. The robotic-assisted approach could be considered for preserving ovarian function in patients with bilateral ovarian endometrioma.

[Early postoperative complications in a multidisciplinary surgical center exclusively dedicated to endometriosis: A 491-patients series]

OBJECTIVE

The objective of our study is to present the activity volume and postoperative complications in a center exclusively destined to endometriosis surgery.

METHODS

Retrospective mono-centric study analyzing data collected prospectively in patients surgically managed for endometriosis from September 2018 to August 2019.

RESULTS

Four hundred and ninety-one patients underwent surgery for endometriosis during 12 consecutive months: 268 for colorectal localizations (54.6%), 51 for endometriosis of the urinary tract (10.4%), 17 for nodules of ileum and right colon (3.5%), 43 for nodules of parametriums (8.8%), 12 for nodules of sacral roots and sciatic nerves (2.4%), 7 for diaphragmatic localizations (1.4%). Among 268 patients with colorectal endometrioses, of which 48.1% concerned the low and mid rectum, shaving was performed in 102 cases, disc excision in 96 cases and colorectal resection in 100 cases. Stoma was performed in 13.1% of the cases. Patients could have 2 different procedures for multiple colorectal nodules. One hundred and ninety-nine ovarian endometriomas were managed by plasma energy ablation in 64.8%, sclerotherapy in 11.1%, cystectomy in 13.1%, oophorectomy in 11.1%. Major postoperative complications included 12 rectovaginal fistulas, while 18 other surgical procedures were carried out for various complications. In all, 38.1% of procedures involved a general surgeon and 5.3% an urologist.

CONCLUSION

The creation of centers exclusively destined to endometriosis surgery allows the multidisciplinary management of a high number of patients, with an over-representation of severe forms and rare locations of the disease, followed by satisfactory complication rates.

Pelvic endometriosis: Refer to the surgeon at the right moment: Pelvic endometriosis: When refer to the surgeon?

BACKGROUND

As endometriosis is not a single condition but different morphological types, it is easy to conceive that its management allow for a diversity of approaches. The objective of this literature review is about a simplified pathway through care for patients with endometriosis, and to target the right time for surgical treatment.

METHODS

Through a literature and references review, the different surgical care arrangements according to attainment, to symptoms and to the patients demands and expectations are reviewed.

RESULTS

An existing literature and recommendations synthesis has been done, and it was found that an optimum medical or surgical care rely on a multidisciplinary approach. Asymptomatic patients should not have surgery, and the medical treatment precede surgical treatment in numerous indications. In case of a surgical need, the right moment is determined by the recommendations, as noted in this article. Different aspects are necessary, the symptomatology, the intend to be pregnant and the recurrence of lesions in particular, but also the use of medically assisted reproduction or not.

CONCLUSION

In order to optimize the surgical treatment of patients with endometriosis, it is advisable to not refer these patients to the surgeon not too soon and not too late, furthermore if he's an expert. In all cases the treatment is multidisciplinary, and the most difficult cases are referred to multidisciplinary consultative reunion. The surgical treatment relies on "centre of expertise's" existence for some specific forms of deep endometriosis. The surgical treatment is a question of both pathology and timing.

BRIEF SUMMARY

In order to optimize the surgical treatment of endometriosis, it is advisable to refer patients to the surgeon at the right moment.

Is dienogest the best medical treatment for ovarian endometriomas? Results of a multicentric case control study

Ovarian endometriomas are common manifestations of endometriosis. Surgical excision has been shown to potentially decrease ovarian reserves. In this prospective study, we included 81 patients with ovarian endometriosis. 40 were treated with 2 mg of dienogest daily (DNG) and 41 were treated with cyclic oral estro-progestins (ethinyl estradiol 30 mcg [EE] plus dienogest 2 mg) (DNG + EE). Aim of the study was the effect of the treatment on the size of the endometriotic cysts. Further, in the symptomatic patients, follow-up included an evaluation of chronic pain before and during treatment. Both treatments were able to significantly decrease the pain in symptomatic patients with no statistical differences. The mean visual analog scale score at enrollment was 65 ± 14 and 70 ± 18, and there was significant improvement (19 ± 15, p < .001, DNG; 18 ± 12, p < .001, DNG + EE). The size of the endometrioma cysts were significantly reduced in the DNG group. The mean cyst diameter was 52 ± 22 mm at baseline and 32 ± 12 mm after six months of treatment (p < .001), yielding a 75% volume reduction in DNG group. The decrease in the size of endometrioma cysts observed in the women treated with only progestin could be noteworthy, as it may reduce the negative impacts on the affected ovary and avoid surgery.

Surgery for endometriomas within the context of infertility treatment

BACKGROUND

The presence of an endometrioma can often be accompanied by a clinical dilemma during the course of fertility treatment. The aim of this study was to evaluate anti-Müllerian hormone (AMH) levels and spontaneous pregnancy rate in infertility patients with endometriomas depending of initial AMH levels and cyst type.

METHODS

This prospective cohort study included infertility patients with unilateral endometrioma (3-5 s m in diameter) aged 25-35. A total of them underwent laparoscopic cystectomy. All patients were divided into two groups due to AMH levels and cyst type during surgery. We investigated AMH levels and spontaneous pregnancy rate in 1,3 and 12 months after surgery.

RESULTS

The majority of patients with normal AMH level had type II endometriomas (70%) compared with low AMH level group (30%). There were no significant differences between AMH levels in all the patients with type II endometriomas after surgery. AMH level decreased significantly at 1 month in patients with normal AMH level and type I endometriomas (P = 0.018). But at 3 months the AMH level was compared with initial parameters. Women with low AMH levels before surgery and type I cysts had a significant decrease of AMH level at 1 and at 3 months after surgery. All patients with a time interval of 6 months after surgery had the best outcomes with significantly higher pregnancy rate (PR) in patients with normal AMH level and type II cysts (P = 0.036) and with AMH less than 2 ng/ml and type I cysts (P = 0.021). The group with normal AMH level and type II endometriomas had a significantly higher ongoing cumulative PR than others (59.4%).

CONCLUSIONS

Our data suggest that laparoscopic surgery could affect ovarian reserve in case of initial low AMH levels and type I of endometriomas. We believe that the good surgical technique helps to increase pregnancy rate in infertility patients with endometriomas. Good prognosis group are the infertility patients with normal AMH level and type II endometriomas.

Assessment of ovarian reserve after cystectomy versus 'one-step' laser vaporization in the treatment of ovarian endometrioma: a small randomized clinical trial

STUDY QUESTION

Does CO2 laser vaporization offer better results in treating endometrioma in terms of ovarian reserve preservation compared to traditional cystectomy?

SUMMARY ANSWER

Assessing both antral follicle count (AFC) and serum anti-Müllerian hormone (AMH) levels as measures of ovarian reserve, the results suggest that CO2 technology may be an alternative treatment for endometrioma, causing minimal damage to adjacent healthy ovarian tissue.

WHAT IS KNOWN ALREADY

Excisional surgery has been questioned as an ideal surgical approach for endometriomas because it is associated with potential reduction of ovarian reserve. Recently, vaporization with CO2 laser in-line-of-sight, according to the 'three-step procedure', has been proposed as the best method to preserve ovarian function. However, no randomized controlled trials have been conducted to compare cystectomy and 'one-step' CO2 fiber laser vaporization (without GnRH agonist therapy) with respect to the ovarian reserve.

STUDY DESIGN, SIZE, DURATION

A multicentre randomized clinical trial including 60 patients was performed between July 2017 and February 2018. Computerized randomization was conducted to allocate them in a proportion of 1:1 either to Group 1 (laparoscopic stripping: cystectomy) or Group 2 (CO2 laser vaporization). Patients in Group 1 underwent a standardized laparoscopic stripping technique; patients in Group 2 underwent drainage of the cyst content, biopsy and vaporization of the internal wall with a CO2 fiber laser. Patients underwent pelvic ultrasound examination to determine the AFC and blood sampling to determine AMH levels before surgery and at 1- and 3-month follow-up.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Patients undergoing surgery for symptomatic endometriomas (infertility and/or pelvic pain) larger than 3 cm were randomized in two groups according to the surgical technique. Patients aged ≥40 years, or with deep infiltrating endometriosis/adenomyosis, or previously submitted to surgical procedures on the ovaries or to hysterectomy were excluded from the study. The primary endpoint was the comparison of intra-group AFC changes before and after surgery (ΔAFC) between the two groups (ΔAFC Group 1 versus ΔAFC Group 2). The secondary endpoint was the modification of serum AMH before and after surgery (ΔAMH) between the two groups (ΔAMH Group 1 versus ΔAMH Group 2).

MAIN RESULTS AND THE ROLE OF CHANCE

The AFC of the operated ovary was significantly increased in Group 2 (laser vaporization) compared with Group 1 (cystectomy) after surgery (Group 1: from 4.1 ± 2.2 [mean ± SD] at baseline to 6.3 ± 3.5 at 3-month follow-up; 95% CI: 0.9-4; Group 2: from 3.6 ± 1.9 at baseline to 8.6 ± 4.2 at 3-month follow-up; 95% CI: 2.8-7.1; P = 0.016); serum AMH levels were significantly reduced at 3 months in Group 1 (from 2.6 ± 1.4 ng/mL at baseline to 1.8 ± 0.8 ng/mL at 3-month follow-up; 95% CI: -1.3 to -0.2; P = 0.012) compared with no reduction in Group 2 (from 2.3 ± 1.1 ng/mL at baseline to 1.9 ± 0.9 ng/mL at 3-month follow-up; 95% CI: -1 to -0.2; P = 0.09).

LIMITATIONS, REASON FOR CAUTION

The key limitations of the trial were the low accuracy of AFC in estimating the ovarian reserve in ovaries with endometriomas, the limited study size and the relatively short follow-up, which do not allow us to draw definitive conclusions.

WIDER IMPLICATIONS OF THE FINDINGS

The present study suggests that CO2 technology may treat endometrioma with minimal damage to the adjacent healthy ovarian tissue; however, this study should be considered as a preliminary clinical trial, intended to stimulate future larger trials to address this clinically relevant issue.

STUDY FUNDING/COMPETING INTEREST(S)

None.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov NCT03227640.

TRIAL REGISTRATION DATE

9 July 2017.

DATE OF FIRST PATIENT’S ENROLLMENT

24 July 2017.

Clinical application of serum anti-Müllerian hormone in women

Anti-Müllerian hormone (AMH), a peptide growth factor of the transforming growth factor-β family, is a reliable marker of ovarian reserve. Regarding assisted reproductive technology, AMH has been efficiently used as a marker to predict ovarian response to stimulation. The clinical use of AMH has recently been extended and emphasized. The uses of AMH as a predictive marker of menopause onset, diagnostic tool for polycystic ovary syndrome, and assessment of ovarian function before and after gynecologic surgeries or gonadotoxic agents such as chemotherapy have been investigated. Serum AMH levels can also be affected by environmental and genetic factors; thus, the effects of factors that may alter AMH test results should be considered. This review summarizes the findings of recent studies focusing on the clinical application of AMH and factors that influence the AMH level and opinions on the use of the AMH level to assess the probability of conception before reproductive life planning as a “fertility test.”

Effect of laparoscopic endometrioma cystectomy on anti-Müllerian hormone (AMH) levels

OBJECTIVE

To investigate temporary or long-term changes of AMH after laparoscopic endometrioma cystectomy and its dependency on characteristics of endometriomas.

METHODS

One hundred and seventy-one women, open-labeled prospective study; five groups divided according age ≤/> 35, uni-/bilateral, cyst ≤/> 7 cm, coagulation/suture surgery, stage III/IV; between- and within-group analyses after 1, 3, 6, and 12 months.

RESULTS

After 12 months, compared to pretreament, AMH decreased significantly for patients with bilateral cysts, cyst size >7 cm and endometriosis stage IV. In the between-group analysis all comparisons were significant, with exception of the surgery type. However, this was different performing the multiple linear regression analysis suggesting lower postoperative decrease using suturing technique. This analysis also showed higher age at pretreatment and bilateral cysts as risk factor for AMH decline.

CONCLUSIONS

Effects of endometrioma cystectomy on AMH are dependent on characteristics of the endometrioma, showing long-term a decrease in patients with larger, bilateral cysts and in stage IV endometriosis, but only short-time decrease in smaller, unilateral cysts and stage III which sometimes also can fully recover in AMH production within one year. In our study suture compared to coagulation surgery was protective, i.e. may lead to lower postoperative AMH decline.

Endometrioma, fertility, and assisted reproductive treatments: connecting the dots

PURPOSE OF REVIEW

Surgery has traditionally been the primary treatment option for endometriosis-related infertility of any phenotype. However, advances and refinements of assisted reproductive technologies (ART) permit a more conservative approach in many scenarios. This review summarizes the latest findings in the field of reproductive medicine, which have supported a paradigm shift towards more conservative management of ovarian endometrioma.

RECENT FINDINGS

The presence of ovarian endometrioma per se is likely to impair ovarian reserve and alter ovarian functional anatomy. Conventional laparoscopic surgery is associated with significant risk of additional damage, and less invasive treatment approaches require further evaluation. With regard to infertile women with ovarian endometrioma who are scheduled for ART treatment, current data indicate that prior surgical intervention does not improve ART outcomes, and that controlled ovarian hyperstimulation (COH) does not affect quality of life or pain symptoms.

SUMMARY

Reproductive medicine physicians frequently encounter patients with ovarian endometrioma. The current evidence does not support the postponement of infertility treatment in favour of surgery, except in cases with severe symptoms or to improve follicle accessibility. Although these patients may exhibit diminished ovarian response to COH, their endometrial receptivity, aneuploidy rates, and fertility outcomes are similar to healthy controls. Surgery for ovarian endometrioma provides no benefits in ART treatments.

Modern approaches to surgical management of endometrioma

Formation of the ovarian endometrioma consists of implantation, invagination of the ovarian cortex, and adhesion formation. Progression is characterized by repeated injury and repair with degenerative changes. Already with a partially deprived ovarian reserve, resulting from the disease, surgical treatment carries a potential risk of further follicular deprivation. Surgery should therefore be performed with microsurgical precision by experienced hands. Early treatment can possibly prevent further progression. The adverse impact on ovarian reserve of the ablative approach has to be balanced against a lower recurrence rate of a cystectomy. Adapted surgical approaches like a two-step approach or a combination of excisional and ablative surgery has to be considered in case of a large endometrioma. Further studies on the possibility and advantages of sclerotherapy are warranted. Fertility preservation by cryopreservation of ovarian cortex should be part of the informed consent with the patient.

Endometriosis surgery and preservation of fertility, what surgeons should know

Colorectal surgeons often participate in the multidisciplinary management of young females with endometriosis. Complications of endometriosis as well as its management often result in infertility since they can involve all pelvic organs including the procreative organs: uterus, ovaries and fallopian tubes. Complete excision of all endometriotic lesions should not be performed at the expense of irreversible destruction of the procreative organs; definitive infertility should not be the price to pay in order to obtain an improvement of the painful symptoms caused by endometriosis. Surgery for ovarian endometriomas should be specifically adapted to the patient's desire for future conception and to her preoperative ovarian reserve. Two main techniques are used to treat ovarian endometriomas: ovarian cystectomy excises the wall of the cyst while ablation consists of destruction of the internal surface of the cyst. The use of mono polar or biolar coagulation for cyst ablation is strongly contra-indicated. Ablation using laser or plasma energy has resulted in comparable rates of post-operative pregnancy to those obtained by ovarian cystectomy. Patients who wish to delay their attempt to conceive for some period of time, should be placed on long-term oral contraception with prevention of menstruation to reduce the risk of recurrent endometriosis. When surgery for colorectal endometriosis is necessary, the laparoscopic approach increases the chances of spontaneous conception compared to laparotomy. Surgery for deep-seated endometriosis has been accompanied by a high rate of spontaneous conception and successful pregnancy and does not seem to decrease the chances for conception by in vitro fertilization.

Comparison of the impact of laparoscopic endometriotic cystectomy and vaporization on postoperative serum anti-Mullerian hormone levels

INTRODUCTION

The aim of this study was to investigate the effect of laparoscopic endometriotic cystectomy and vaporization on ovarian reserve.

METHODS

We prospectively analyzed the serum level of anti-Mullerian hormone (AMH) in 62 patients at four different time points- preoperatively and at 1 month, 6 months, and 1 year postoperatively. Among the 62 cases, a bilateral cystectomy was performed in 10, bilateral vaporization in 16, a unilateral cystectomy in 24, and unilateral vaporization in 12.

RESULTS

The rate of AMH decline after unilateral cystectomy or bilateral cystectomy was higher than that after unilateral vaporization or bilateral vaporization. Age and bilaterality were associated with an AMH decline at 1 month, and age alone was associated with an AMH decline at 1 year. Moreover, being older than 38 years of age and having a revised American Society for Reproductive Medicine score >80 were independent risk factors for the non-recovery of AMH.

CONCLUSION

The rate of AMH decline after laparoscopic endometriotic vaporization is significantly lower than that after cystectomy. Both methods, however, have the potential to lower ovarian reserve, especially in cases of severe endometriosis or in patients older than 38 years of age.

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.