Prospective assessment of the impact of endometriomas and their removal on ovarian reserve and determinants of the rate of decline in ovarian reserve
ABSTRACT STUDY QUESTIONDo the presence of endometriomas and their laparoscopic excision lead to a decrease in ovarian reserve as assessed by serum anti-Müllerian hormone (AMH) levels?SUMMARY ANSWERBoth the presence and excision of endometriomas cause a significant decrease in serum AMH levels, which is sustained 6 months after surgery.WHAT IS KNOWN ALREADYNo previous comparison of serum AMH levels between women with and without endometrioma has been reported. However, studies have suggested a decline in serum AMH levels 1-3 months after endometrioma excision but long-term data are needed.STUDY DESIGN, SIZE, DURATIONA prospective cohort study including 30 women with endometrioma >2 cm were age matched with 30 healthy women without ovarian cysts.PARTICIPANTS/MATERIALS, SETTING, METHODS
Women with endometrioma underwent laparoscopic excision with the stripping technique. Serum AMH level and antral follicle count (AFC) were determined preoperatively, 1 and 6 months after surgery. Correlation analyses were undertaken in order to identify determinants of surgery-related change in ovarian reserve.MAIN RESULTS AND THE ROLE OF CHANCECompared with controls at baseline, women with endometrioma had lower AMH levels (4.2 ± 2.3 versus 2.8 ± 2.2 ng/ml, respectively, P = 0.02) and AFC (14.7 ± 4.1 versus 9.7 ± 4.8, respectively, P < 0.01). Serum AMH levels were further decreased 6 months after surgery (2.8 ± 2.2 versus 1.8 ± 1.3 ng/ml, P = 0.02), while AFC remained unchanged (9.7 ± 4.8 versus 10.4 ± 4.2, P = 0.63). The rate of decline in AMH was not correlated with age, laterality of endometrioma, cyst diameter or the number of primordial follicles on the surgical specimens. The preoperative serum AMH level was positively correlated with the rate of decline in serum AMH after surgery (r = 0.47, P = 0.02).LIMITATIONS, REASONS FOR CAUTIONThe absence of a non-treated group of women with endometriomas as a further control prevents comment on the presence of a progressive decline in ovarian reserve related to endometrioma per se. The sample size may be too small for detection of factors correlated with the extent of ovarian damage.WIDER IMPLICATIONS OF THE FINDINGSWhile the findings are mostly in agreement with previous studies, the present study is the first to show that the presence of endometrioma per se is associated with a decrease in ovarian reserve. The extent of surgery-related decline in ovarian reserve is not predictable using preoperative or perioperative factors. It may be prudent to measure AMH levels preoperatively and delay/avoid surgical excision as far as is possible if subsequent fertility is a concern. Additional studies are required to further investigate whether the endometrioma-related decline in ovarian reserve per se is progressive in nature and whether it exceeds the surgery-related decline.STUDY FUNDING/COMPETING INTEREST(S)This study was funded by the Research Fund of the Uludag University School of Medicine. The authors have no conflict of interest associated with this study.
- SourceAvailable from: Ludovico Muzii
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- "A retrospective, non-comparative study (Auber et al., 2011), where a non-excisional technique was used, was considered separately at data pooling from studies in which cyst excision was performed. Nine of the 13 included studies (Tsolakidis et al., 2010; Biacchiardi et al., 2011; Ercan et al., 2011; Var et al., 2011; Celik et al., 2012; Uncu et al., 2013; Urman et al., 2013; Zaitoun et al., 2013; Alborzi et al., 2014) reported data on the preoperative and post-operative values of AFC, with a total of 511 patients included for the evaluation of the primary outcome. As for the secondary analyses, two studies (Biacchiardi et al., 2011; Ercan et al., 2011) reported data on the AFC for the ovary with the endometrioma and the contralateral, unaffected ovary before surgery, with a total of 69 patients. "
ABSTRACT: Does surgical treatment of endometriomas impact on the ovarian reserve as evaluated with antral follicle count (AFC)?Human Reproduction 08/2014; 29(10). DOI:10.1093/humrep/deu199 · 4.59 Impact Factor
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ABSTRACT: Endometriosis is one of the most common disorders encountered in surgical gynaecology. The laparoscopic technique, the planning of the surgical intervention, the extent of information provided to patients and the interdisciplinary coordination make it a challenging intervention. Complete resection of all visible foci of disease offers the best control of symptoms. However, the possibility of achieving this goal is limited by the difficulty of detecting all foci and the risks associated with radical surgical strategies. Thus, the excision of ovarian endometrioma can result in a significant impairment of ovarian function, while damage to nerve structures during resection of the uterosacral ligaments, the parametrium, the rectovaginal septum or the vaginal cuff to treat deep infiltrating endometriosis can lead to serious functional impairments such as voiding disorders. A detailed risk-benefit analysis is therefore necessary, and patients must be treated using an individual approach.Geburtshilfe und Frauenheilkunde 09/2013; 73(9):918-923. DOI:10.1055/s-0033-1350890 · 0.96 Impact Factor
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ABSTRACT: Endometriosis affects a significant proportion of reproductive-aged women. The impact of the disease on ovarian function is an important consideration when planning treatment in women who want to retain the potential of future childbearing. This review will specifically address the association between endometriomas and diminished ovarian reserve, with a particular focus on the impact of surgical endometrioma resection on ovarian function. The existing literature supports an adverse effect of ovarian endometriomas on spontaneous ovulation rates, markers of ovarian reserve, and response to ovarian stimulation, although data on clinical pregnancy and live birth rates remain inconsistent. Surgical removal of endometriomas may worsen ovarian function by removing healthy ovarian cortex or compromising blood flow to the ovary. It is evident that surgical excision of endometriomas acutely impairs ovarian function as measured by ovarian reserve markers; whether this represents progressive or long term impairment remains the subject of ongoing investigation.Journal of Minimally Invasive Gynecology 10/2013; 21(2). DOI:10.1016/j.jmig.2013.09.012 · 1.58 Impact Factor