Impact of laparoscopic cystectomy of endometriotic and non-endometriotic cysts on ovarian volume, antral follicle count (AFC) and ovarian doppler velocimetry

Influence of ovarian cysts on ovarian reserve and fertility: A case-control study

OBJECTIVE

The aim of this study was to evaluate the impact of having an ovarian cyst and undergoing cystectomy on the expression of ovarian reserve markers among adolescent females who live in Armenia.

METHODS

We conducted a prospective case-control study. Cases were arranged into two groups. The postoperative group (POG) included those who underwent unilateral ovarian cystectomy, and those in the benign ovarian cyst group (BOCG) had complex ovarian cysts with a diameter of 5 cm or more. Adolescents without ovarian pathologies were included in the reference group (RFG). Levels of anti-Mullerian hormone (AMH) and follicular stimulating hormone (FSH) were measured, and an ultrasound investigation of antral follicular count (AFC) was also done.

RESULTS

Mean differences between baseline and 6-month follow-up levels of AMH, AFC significantly decreased in both the POG and BOCG compared to the RFG. However, the decrease was more significant in the POG: a decrease of 0.86 ng/mL for AMH and 3.11 ng/mL for AFC versus decreasing by 0.61 ng/mL for AMH and 1.68 ng/mL for AFC. Meanwhile, in the BOCG, 6-month FSH levels did not show any significant changes compared to the baseline measurement. In comparison with the reference group, there was a significant decrease in the levels of AMH and AFC among participants who had endometriomas and cystadenomas.

CONCLUSION

Benign ovarian cysts 5 cm or more in diameter, as well as cystectomy, statistically affect OR after 6 months. Therefore, adolescents with ovarian cyst or cystectomy need individualized support to maintain reproductive age fertility.

Long-term therapy with dienogest or other oral cyclic estrogen-progestogen can reduce the need for ovarian endometrioma surgery

BACKGROUND

Almost 10% of women in reproductive age are diagnosed with ovarian endometriomas and can experience symptoms and infertility disorders. Ovarian endometriomas can be treated with medical or surgical therapy.

OBJECTIVE

To assess whether long-term therapy with dienogest or oral cyclic estrogen-progestogens is effective in reducing the size of ovarian endometriomas, alleviating associated symptoms, and reducing the requirement for surgery.

DESIGN

Prospective non-interventional cohort study.

METHODS

We enrolled childbearing women diagnosed with ovarian endometriomas. We collected demographic, clinical, and surgical data, including the evaluation of ovarian endometrioma-associated symptoms and pain using the visual analog scale. We grouped the women according to treatment regimen into dienogest, estrogen-progestogens, and no-treatment. Patient's assessment was performed at baseline and after 12 months evaluating the largest ovarian endometrioma diameter (in millimeters) and the associated symptoms. Furthermore, we analyzed the impact of hormonal treatment in a sub-group of women fulfilling at baseline the criteria for a first-line surgical approach (ovarian endometrioma > 30 mm with visual analog scale > 8 or ovarian endometrioma > 40 mm before assisted reproductive treatments or any ovarian endometrioma(s) > 60 mm).

RESULTS

We enrolled 142 patients: 62, 38, and 42 in dienogest, estrogen-progestogens, and no-treatment groups, respectively. No significant differences were found regarding baseline characteristics. After 12 months, the mean largest ovarian endometrioma diameter increased in the no-treatment group (31.1 versus 33.8; p < 0.01), while a significant reduction was registered in the dienogest (35.1 versus 25.8; p < 0.01) and estrogen-progestogens (28.4 versus 16.7; p < 0.01) groups; no significant difference in ovarian endometrioma diameter reduction between these two latter groups was noted (p = 0.18). Ovarian endometrioma-associated symptoms and pain improved in dienogest and estrogen-progestogens groups, with a significantly greater effect for dienogest than for estrogen-progestogens for dysmenorrhea (74% versus 59%; p < 0.01). In the sub-group of women eligible for first-line surgery at baseline, long-term treatment with dienogest and estrogen-progestogens reduced surgical eligibility by 30%.

CONCLUSIONS

Decreased mean largest ovarian endometriomas'diameter after 12 months and reduction of the need for surgical treatment by 30% were observed in dienogest and estrogen-progestogens groups. Long-term treatment with dienogest had a greater effect in alleviating dysmenorrhea and pain.

Effect of salpingectomy on ovarian reserve: A systematic review and meta-analysis

AIM

To determine the effect of salpingectomy on ovarian reserve.

METHODS

PubMed, EMBASE, Web of Science, Dynamed plus, and Cochrane Controlled Trials Register databases were searched from their inception to December 2020 to identify relevant studies, including cross-sectional studies, retrospective studies, and randomized controlled trials. Studies that compared anti-Müllerian hormone (AMH) levels and/or antral follicle count (AFC) between the control and salpingectomy groups or before and after surgery were included.

RESULTS

Twenty-one articles were included in the systematic review. Meta-analyses were performed on 16 studies in which data were presented as mean ± SD values. A meta-analysis comparing AMH levels before and after surgery in the same patients showed no significant decrease in all cases, irrespective of whether it was unilateral or bilateral salpingectomy. There was no significant decrease in the AFC in the meta-analysis comparing levels before and after bilateral salpingectomy, either. In contrast, in the case-controlled study the salpingectomy group had significantly lower levels of AMH in all meta-analyses of unilateral and bilateral surgery (mean difference: -0.31, 95% confidence interval [CI]: -0.55, -0.07), only unilateral cases (mean difference: -0.28, 95% CI: -0.50, -0.06), and only bilateral cases (mean difference: -0.71, 95% CI: -1.19, -0.23). The salpingectomy group that included unilateral and bilateral cases had significantly lower AFC compared with no-surgery controls (mean difference: -1.31, 95% CI: -2.13, -0.48).

CONCLUSION

Although not conclusive, it does appear that patients who underwent salpingectomy (either unilateral or bilateral) have a decreased ovarian reserve.

Evaluation of Serum AMH, INHB Combined with Basic FSH on Ovarian Reserve Function after Laparoscopic Ovarian Endometriosis Cystectomy

Objective

The value of serum AMH, INHB, and bFSH levels in assessing postoperative ovarian reserve function was analyzed by measuring serum anti-Mullerian hormone (AMH), inhibin B (INHB), and basal follicle-stimulating hormone (bFSH) levels in patients after laparoscopic cystectomy for endometrioma.

Methods

From June 2019 to December 2021, 124 patients underwent laparoscopic cystectomy for endometrioma in our hospital were selected, and the serum AMH, INHB, bFSH level, antral follicle count (AFC) of all patients before and after operation were detected and compared. According to the results of postoperative testing, all the patients were divided into normal group (n = 86), diminished ovarian reserve (DOR) group (n = 27), and premature ovarian failure (POF) group (n = 11). Pearson correlation model and subject operating characteristic curve (ROC) were used to analyze the correlation and diagnostic value of serum AMH, INHB and bFSH levels with postoperative ovarian reserve function, respectively.

Results

After operation, the levels of serum AMH, INHB and AFC in the DOR group and POF group decreased compared with those before the operation, and the serum bFSH levels increased (p < 0.05). After operation, the levels of serum AMH, INHB and AFC in DOR group and POF group were lower than those in normal group,and the serum bFSH levels were higher than the normal group; the levels of serum AMH, INHB and AFC in POF group were lower than those in DOR group, and the serum bFSH levels were higher than the DOR group (p < 0.05). Pearson analysis showed that serum AMH and INHB levels were negatively correlated with bFSH, and positively correlated with the number of AFC, the serum bFSH level was negatively correlated with the number of AFC (p < 0.05). The diagnostic values of serum AMH, bFSH, INHB and the combination of the three tests for postoperative abnormal ovarian reserve function were 0.866 (95% CI, 0.801–0.923), 0.810 (95% CI, 0.730–0.890), 0.774 (95% CI, 0.687–0.860) and 0.940 (95% CI, 0.900–0.981), respectively.

Conclusion

Serum AMH and INHB levels decreased and bFSH levels increased in patients after laparoscopic cystectomy for endometrioma, both of which were closely related to postoperative ovarian reserve function, and both could evaluate ovarian reserve function after ovarian cyst debulking, and the combined test could significantly improve the detection rate.

Ovarian function following use of various hemostatic techniques during treatment for unilateral endometrioma: A randomized controlled trial

OBJECTIVE

To compare the effect of hemostatic techniques (bipolar energy versus hemostatic sealants versus suture) on the ovarian reserve of patients submitted to laparoscopic cystectomy for the surgical excision of unilateral endometrioma.

METHODS

A randomized controlled trial conducted in a teaching hospital included 84 patients with unilateral endometrioma. The patients underwent laparoscopic stripping for excision of the unilateral endometrioma between March 2018 and February 2020. Three different hemostatic techniques-bipolar energy (Group 1), hemostatic sealants (Group 2), and suture (Group 3)-were compared. Anti-Müllerian hormone (AMH) levels were measured before, and 1 and 6 months after surgery to determine changes in ovarian function.

RESULTS

Following surgery, AMH levels decreased in all the groups; however, this decrease was not statistically significant. Comparison between groups showed no statistically significant differences in AMH levels between the three hemostatic techniques used. Six months after surgery, median AMH levels were: 1.65 ng/mL (interquartile range [IQR] 0.62-2.08 ng/mL) in Group 1, 1.87 ng/mL (IQR 1.27-2.97 ng/mL) in Group 2, and 1.53 ng/mL (IQR 1.18-2.44 ng/mL) in Group 3.

CONCLUSION

The present study suggests that there is no difference between the different hemostatic techniques used in laparoscopic cystectomy for the treatment of unilateral endometriomas. Registered at ClinicalTrials.gov: NCT03430609. https://clinicaltrials.gov/ct2/show/NCT03430609.

Effects of environmental, social and surgical factors on ovarian reserve: Implications for age-relative female fertility

OBJECTIVE

To investigate new risk factors for female fertility by analyzing the effects of environmental, social, and surgical factors on antral follicle counts (AFC) and anti-Müllerian hormone (AMH) levels.

METHODS

A total of 1513 women aged 20-47 years who underwent in vitro fertilization/intracytoplasmic injection treatment in Southwest Hospital from December 2017 to December 2019 were included. Women were assessed for AFC and AMH levels, and completed a questionnaire. Ordinal logistic regression analyses with generalized linear mixed models were used to calculate the adjusted odds ratio (OR) for diminished ovarian reserve.

RESULTS

Adnexal surgery was the only risk factor associated with low AFC in women aged 20-30 years. Younger age at menarche, alcohol drinking, and adnexal surgery are three independent risk factors for AMH decline in women aged 20-30 years. Intense exercise, sleep quality, and adnexal surgery are three independent risk factors for a low AFC in women aged 31-36 years. Alcohol drinking and adnexal surgery are two independent risk factors for AMH decline in women aged 31-36 years.

CONCLUSION

With age, female fertility becomes sensitive to high-intensity exercise and poor sleep quality. Adnexal surgery and alcohol drinking are two important risk factors for female fertility in women under age 37 years.

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

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

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.

Modification of endometrioma size during hormone therapy containing dienogest

The aim of the present study was to evaluate whether hormone therapy containing dienogest is effective in reducing endometrioma size. A retrospective observational study was conducted on 116 women with endometrioma which was evaluated after 6 and 12 months of either no treatment (n = 46), or hormonal therapy containing dienogest (n = 70), without (DNG; n = 34) or with ethinylestradiol (DNG/EE; n = 36). Median (interquartile range) cyst diameter (23.0 mm (21.0 mm)) and volume (9941.2 mm³ (14240.1 mm³)) of untreated were similar to cyst diameter (25.0 mm (14.5 mm) and volume (7587.7 mm³ (13806.2 mm³)) of treated women. After 12 months, endometrioma volume did not vary in untreated women (-34.0 mm³ (55595.0 mm³); -0.77% (93.9%)) while it significantly decreased (-5400 mm³ (15378.7 mm³); -100.0% (27.7%); p<.0001) during hormone therapy. Volume decrease was linearly related to endometrioma volume ([Formula: see text] R² = 0.899, p<.0001). The effect tended to be greater during DNG alone than DNG/EE (-100.0% (0.0%) vs. -87.9% (47.7%); p<.0004). Cyst disappearance was observed in 4.4% of untreated cases and in 57.1% of cases on hormone therapy (p<.0001) (38.9% with DNG/EE and 76.5% with DNG; p<.03). The early diagnosis and treatment of endometrioma with dienogest-based hormone therapy may be effective in controlling cyst growth and in reducing the need for surgery.

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

Objective:

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

Materials and Methods:

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

Results:

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

Conclusion:

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

[Borderline Ovarian Tumours: CNGOF Guidelines for Clinical Practice - Fertility]

OBJECTIVES

Borderline ovarian tumours (BOT) represent around 15% of all ovarian neoplasms and are more likely to be diagnosed in women of reproductive age. Overall, given the epidemiological profile of BOT and their favourable prognosis, ovarian function and fertility preservation should be systematically considered in patients presenting these lesions.

METHODS

The research strategy was based on the following terms: borderline ovarian tumour, fertility, fertility preservation, infertility, fertility-sparing surgery, in vitro fertilization, ovarian stimulation, oocyte cryopreservation, using PubMed, in English and French.

RESULTS AND CONCLUSIONS

Fertility counselling should become an integral part of the clinical management of women with BOT. Patients with BOT should be informed that surgical management of BOT may cause damage ovarian reserve and/or peritoneal adhesions. Nomogram to predict recurrence, ovarian reserve markers and fertility explorations should be used to provide a clear and relevant information about the risk of infertility in patients with BOT. Fertility-sparing surgery should be considered for young women who wish preserving their fertility when possible. There is insufficient evidence to claim a causal relation between controlled ovarian stimulation (COS) and BOT. However, in case of poor prognosis factors, the use of COS should be considered cautiously through a multidisciplinary approach. In case of infertility after surgery for BOT, COS can be performed without delay, once histopathological diagnosis of BOT is confirmed. There is insufficient consistent evidence that fertility drugs and COS increase the risk of recurrence of BOT after conservative management. The conservative surgical treatment can be associated to oocyte cryopreservation considering the high risk of recurrence of the disease. In women with BOT recurrence in a single ovary and in women with bilateral ovarian involvement when the conservative management is not possible, other fertility preservation strategies are available, but still experimental.

Ovarian function after the use of various hemostatic techniques during treatment for endometrioma: protocol for a randomized clinical trial

Background

Laparoscopic cystectomy is currently considered the gold standard for the treatment of ovarian endometrioma, resulting in an improvement in symptoms, a lower recurrence rate, and a higher pregnancy rate among infertile patients. However, this treatment is not free from risk, since it is associated with a reduction in ovarian reserve. There is still controversy in the literature regarding whether the cause of the reduction in ovarian reserve is due to damage caused by the coagulation energy during hemostasis or whether the procedure itself is the cause of the damage irrespective of the hemostatic method used. The aim of this study is to compare the effects of different hemostatic methods on the ovarian function of women subjected to laparoscopic surgery for ovarian endometrioma.

Methods

An open-label randomized clinical trial to be conducted at the Lauro Wanderley University Hospital between December 2017 and August 2020. Eighty-four patients will be randomly allocated to three groups according to the hemostatic technique used during laparoscopic surgery for ovarian endometrioma: bipolar coagulation; laparoscopic suture; and hemostatic matrix. Ovarian function will be assessed by serum anti-Müllerian hormone measurement and by performing an antral follicle count using ultrasound before surgery and one, three, and six months after surgery. The internal review board of the Medical Sciences Center, Federal University of Paraíba approved the study protocol under reference CAAE 71621717.9.0000.8069.

Discussion

Bearing in mind the need for more randomized clinical trials to clarify this issue, we hope to contribute with data that will determine whether there is any difference between hemostatic methods despite the rational use of bipolar energy or whether the procedure itself explains the ovarian damage irrespective of the hemostatic technique used.

Trial registration

ClinicalTrials.gov, NTC03430609. Registered on XX.10/31/2017.

ISRCTN Registry, ISRCTN11469394. Registered on XX.17/12/2017.

Unique Protocol ID: U1111–1203-2508.

Hormonal contraception in women with endometriosis: a systematic review

OBJECTIVE

A systematic review was carried out of studies of women with endometriosis, to examine the evidence for efficacy of the use of hormonal contraception to improve disease-related pain and decrease postoperative risk of disease recurrence.

METHODS

A search of the Medline/PubMed and Embase databases was performed to identify all published English language studies on hormonal contraceptive therapies (combined hormonal contraceptives [CHCs], combined oral contraceptives [COCs], progestin-only pills [POPs] and progestin-only contraceptives [POCs]) in women with a validated endometriosis diagnosis, in comparison with placebo, comparator therapies or other hormonal therapies. Main outcome measures were endometriosis-related pain (dysmenorrhoea, pelvic pain and dyspareunia), quality of life (QoL) and postoperative rate of disease recurrence during treatment.

RESULTS

CHC and POC treatments were associated with clinically significant reductions in dysmenorrhoea, often accompanied by reductions in non-cyclical pelvic pain and dyspareunia and an improvement in QoL. Only two COC preparations (ethinylestradiol [EE]/norethisterone acetate [NETA] and a flexible EE/drospirenone regimen) demonstrated significantly increased efficacy compared with placebo. Only three studies found that the postoperative use of COCs (EE/NETA, EE/desogestrel and EE/gestodene) reduced the risk of disease recurrence. There was no evidence that POCs reduced the risk of disease recurrence.

CONCLUSIONS

CHCs and POCs are effective for the relief of endometriosis-related dysmenorrhoea, pelvic pain and dyspareunia, and improve QoL. Some COCs decreased the risk of disease recurrence after conservative surgery, but POCs did not. There is insufficient evidence, however, to reach definitive conclusions about the overall superiority of any particular hormonal contraceptive.

Modern Management of Endometrioma-Associated Infertility: in Favor of ART

Introduction

Endometrioma is present in 17% to 40% of women with endometriosis. Since it has been traditionally believed that the presence of an endometrioma adversely affects the outcome of assisted reproductive technology (ART), surgery has been suggested by many practitioners before advancing to ART, in the hope of improving results.

Scientific Evidence

In the present article, we outline the impact of an endometrioma on the ovarian reserve and describe how surgical resection of an endometriotic cyst affects ovarian reserve, ovarian response after stimulation and ART outcome. Several studies suggest that the sole presence of an endometrioma may have a negative impact on ovarian reserve of the affected ovary, and surgery (particularly cystectomy) has been the choice of treatment in ovarian endometriosis for many years. However, detrimental effects of laparoscopic surgical removal on ovarian reserve and responsiveness to hyperstimulation has made that ART practices are shifting towards a more conservative approach: experimental and clinical data supporting this shift are thoroughly reviewed here.

Clinical Implications

Opposed to the conventional criteria of performing cystectomy when ovarian endometrioma is observed, careful consideration of patient symptoms as well as her age and ovarian reserve will help to select the patients that require surgery prior to ART, whereas the majority will not need surgery prior to ART; even more, surgery may compromise ovarian reserve in most cases even if performed by careful surgeons.

Conclusions

Individualization of the treatment is imperative. Each case should be thoroughly assessed, looking at both the advantages and complications of cyst removal prior to ART. Surgery should be approached with caution in women with endometriomas, especially if the woman has had previous ovarian surgery. In the presence of infertility, we recommend generally sparing surgical treatment and proceeding directly to ART. This reduces the time to achieve a pregnancy, avoids potential surgical risks and limits patient costs.