{"paper_id":"5d5a9268-6250-42e4-b236-ae9b81ddee35","body_text":"The prevalence of endometriosis is approximately 10%\noverall among reproductive age women, whose most\ncommon symptoms are infertility and pelvic pain. However, the prevalence of endometriosis in infertile women\nis about 20-50% ( 1 ). Although the relationship between\nendometriosis and infertility has been well-established,\nthe precise association between the two is not well-known\n( 2 ,  3 ). The connection between endometriosis and infertility is multifactorial, being the result of a series of events.\nEndometriosis not only affects the fallopian tubes, but\nalso the quality and number of oocytes, and endometrial\nreceptivity ( 4 ). Since minimal forms of the endometriosis disease, such as tubal factor infertility, have limited impact in women under 35, researchers mainly focus on\nmoderate to severe cases like endometrioma (OMA) and\ndeep infiltrating endometriosis (DIE), due to their significant effects on reducing fertility and ovarian reserve ( 5 ).\nOMA plays a role in reducing the ovarian reserve in women with endometriosis compared to their healthy peers.\nOMA surgery reduces the ovarian reserve and fertility and\nthis post-surgical decrease in ovarian reserve persists regardless of the techniques used to minimise damage to\nthe ovarian tissue during surgery. Therefore, it is recommended that patients with infertility save an appropriate\nnumber of embryos prior to OMA surgery to prevent reductions in ovarian reserve ( 6 - 10 ).\nThere are numerous studies on OMA; however, studies that pertain to DIE and its surgical effects on ovarian\nreserve are limited, and the results are unclear. The prevalence of DIE is 6.5%. Its associations with superficial\nendometriosis, OMA, and pelvic adhesion are reported to\nbe 61.3, 50.5, and 74.2%, respectively, in the literature\n( 11 ). Pre-surgical data about these lesions are obtained\nfrom imaging methods, which exhibit significant heterogeneity. Of note, ultrasound is operator-dependent and\ndifferent operators may use different terms for the same\nstructures and locations. Therefore, the most reliable data\nin the DIE group are based on intra-operative findings.\nAdditionally, DIE surgeries are extensive procedures that\nhave more complications, particularly in cases of colorectal involvement compared to other gynaecologic pelvic\nsurgeries ( 12 ).\nAlthough it is reported that surgery for DIE lesions is\nassociated with an increased chance of spontaneous pregnancy, it is important to point out the limitations with these\nstudies that include the absence of a control group; data\nobtained from more than one surgeon, which may cause\nvariations in the surgical procedures; not all patients were\ninfertile; simultaneous examination of spontaneous and\n in vitro  fertilisation (IVF) pregnancies within the same\ngroup; and lack of mention regarding the decrease in\novarian reserve following these extensive pelvic surgeries, which is a significant outcome. Limited data exists\non spontaneous pregnancy and infertility with DIE, and\nno reliable information or evidence-based protocols exist for the management of DIE lesions in infertile women\n( 13 - 15 ).\nIn this single-centre study, we investigated the rate of\ndecreased ovarian reserve based on anti-Müllerian hormone (AMH) levels in three groups (OMA, OMA+DIE,\nand DIE) - prior to endometriosis surgery, and at four and\neight months after surgery. The results of this case-control\nstudy could assist with more informed decisions in terms\nof surgery and preoperative fertility preservation in women with simultaneous infertility and DIE involvement.\n\nThis cross-sectional study was conducted in the Obstet\nrics and Gynaecology's Department of Shiraz University\nof Medical Sciences (Shiraz, Iran) after receiving approval from the Ethics Committee of Shiraz University of\nMedical Sciences (IR.SUMS.MED.REC.1398.580). The\nstudy population consisted of women who were referred\nto the tertiary care centre for laparoscopic endometriosis\nsurgery from June 2018 to December 2022. Participants\nsigned an informed consent form prior to entering the\nstudy. The inclusion criteria comprised women with confirmed cases of endometriosis based on histopathological\nsamples who underwent surgery for the following indica\ntions: endometriosis-related pain unresponsive to medication; tubal involvement in cases of infertility; complete\nfamily planning; inability to use hormonal drugs; need\nfor pathology samples; unwillingness to receive medical\ntreatment; or preference for treatment with the lowest recurrence rate.\nThe exclusion criteria consisted of women over the age\nof 40 with a previous history of endometriosis surgery,\nany history of chemotherapy or radiotherapy, autoimmune diseases, simultaneous adenomyosis, or uterine\nleiomyoma.\nWe gathered clinical and biological data from all patients admitted to the operation room for their endome\ntriosis surgery. General information and medical history\nwere recorded through face-to-face interviews conducted\nby a specialist physician during the initial visit. The diagnosis of endometriosis was confirmed through surgical\ndetection and histological analysis. Serum samples were\ncollected during the month prior to the surgery, as well\nas four and eight months after surgery to measure AMH\nlevels. A commercial ELISA kit (AMH Gen II ELISA;\nBeckman Coulter, Inc., Brea, CA, USA) was utilised for\nthis measurement. Each calibrator, control or test sample\nwas prepared by mixing one part of the sample with five\nparts of AMH Gen II assay buffer, with no dilution factor required for this preparation method. Samples that ex\nceeded the highest calibrator were diluted using a sample\ndiluent and retested according to the kit’s instructions.\nThe intra-assay and inter-assay coefficients of variation\nwere 5.4% and 5.6%, respectively.\nThe interventions were performed by a physician with\nextensive expertise in endometriosis management. Additionally, the conservative laparoscopy was performed\nusing mechanical instruments and electrosurgery. Surgery for DIE was performed according to previously\nreported surgical procedures ( 12 ). The adhesions were\nsectioned with micro scissors. For OMA, the ovaries\nwere completely mobilised, the cysts were evacuated\nand rinsed with normal saline, and excised by countertraction applied to the pseudocapsule and normal gonadal cortex with atraumatic micro-forceps. Hemostasis\nwas achieved using selective bipolar coagulation. The\ndisease was staged according to the American Society\nfor Reproductive Medicine (ASRM) classification ( 3 ).\nThe patients were divided into three groups according\nto localisation of the endometriosis during surgical staging ( 16 ): (I) OMA (n=156), (II) OMA+DIE (n=235), and\n(III) DIE (n=117). For OMA, the recorded surgical data included size, number, and location (unilateral or bilat\neral) of the endometriosis. DIE included ureteral endometriosis, rectovaginal endometriosis, and rectosigmoid\nendometriosis. The baseline AMH levels of all the patients were compared to 50 healthy women of the same\nage (control group).\nThe normality of quantitative variables was assessed\nusing the Kolmogorov-Smirnov test. Quantitative vari\nables were reported as mean ± standard deviation (SD;\nmedian and interquartile range), and qualitative vari\nables were reported as numbers and percentages. The\nKruskal-Wallis test was utilised to assess the relationship between quantitative and qualitative (multivariate) variables. The Freidman test was used to evaluate\nquantitative variables over time. Data normality were\nchecked using the Kolmogorov-Smirnov and Shapiro\nWilk tests. The data were analysed using the Statistical\nPackage for the Social Sciences 20.0 (SPSS, IBM Corp.,\nArmonk, NY, USA).\n\nThe AMH levels of 508 patients in the three groups\n(OMA, OMA+DIE, and DIE) were examined and\ncompared to 50 healthy controls prior to surgical in\ntervention, and at four and eight months after surgery.\nOut of 508 patients, 27.5% (156) were in the OMA\ngroup, 42.11% (235) in the OMA+DIE group, and\n20.96% (117) in the DIE group. Table 1 shows the demographic data of the patients and the healthy group.\nThere is no significant difference between the patients\nand the control group in terms of age (P=0.076) and\nbody mass index (BMI) (P=0.109). Data normality\nwere checked using the Kolmogorov-Smirnov and\nShapiro-Wilk tests.\nRelationship between age and BMI with group\nData are presented as mean ± SD and median (IQR). OMA; Endometrioma, DIE; Deep\ninfiltrating endometriosis, BMI; Body mass index, SD; Standard deviation, IQR; The interquartile range, and *; Kruskal-Wallis test.\nASRM scoring for all three groups and patients’ fertility\nstatus are mentioned in Table 2.\nThere is no significant difference in the size of the OMA\nbetween groups one and two ( Table 2 ). The ASRM score\nin group two was higher than the other groups (P<0.001).\nAll patients belonged to stage three or four endometriosis\naccording to the ASRM scoring system for endometriosis.\nIn the OMA group, 76.3% of the patients had a unilat\neral cyst; in the OMA+DIE group, 53.2% had unilateral\nOMA (P<0.001).\nTable 3 shows the changes in AMH levels in the groups\nbefore surgery, and at four and eight months after surgery\ncompared to the control group. The DIE group had lower\nbaseline AMH levels compared to groups I and III, and the\ncontrol group (P<0.0001). Serum AMH levels significantly\ndecreased after surgery in all three groups (P<0.001).\nThere were no significant differences in AMH levels at\nfour and eight months after surgery in all three groups of\npatients (Tables 3 ,  4 ,  Fig .1 , P=0.202).\nRelationship between fecundity variables with groups\nData are presented as mean ± SD and median (IQR). OMA; Endometrioma, DIE; Deep infiltrating endometriosis, SD; Standard deviation, IQR; The interquartile range, *; Kruskal-Wallis\ntest, and **; Mann-Whitney U test,\nThe trend in reduction in AMH levels in the groups before surgery, and four and eight months after surgery. AMH; Anti-Müllerian hormone, OMA;\nEndometrioma, and DIE; Deep infiltrative endometriosis.\nComparison of AMH levels in the study groups to the control group before surgery, and four and eight months after surgery\nData are presented as mean ± SD and median (IQR). AMH; Anti-Müllerian hormone, OMA; Endometrioma, DIE; Deep infiltrating endometriosis, SD; Standard deviation, IQR; The interquar\ntile range, *; Kruskal-Wallis test, and **; Freidman’s test.\nThe decrease in serum AMH levels after surgery was\n49.84% in the OMA group, 62.20% in the OMA+DIE\ngroup, and 43.46% in the DIE group. The OMA+DIE\ngroup had the most significant decrease (Tables 3 ,  4 ).\nIn the OMA and OMA+DIE groups, larger cyst sizes\ncorrelated with a greater decrease in AMH levels by month\neight in the OMA (r=-0.23, P=0.071) and OMA+DIE (r=\n0.14, P=0.087) groups.\nComparison of decrease in AMH levels at different time points after surgery\nData are presented as mean ± SD. AMH; Anti-Müllerian hormone, OMA; Endometrioma, DIE; Deep infiltrating endometriosis, SD; Standard deviation, and *; Kruskal-Wallis test. P value\nwithin groups: <0.0001.\n\nThe effects of OMA surgery on reduction of ovarian\nreserve and the need for fertility preservation in these\npatients, especially in cases of simultaneous infertility,\nis well-documented. Nonetheless, there are no definitive\nrecommendations for patients with DIE in this regard\n( 17 ).\nThe management of severe DIE in patients who desire\nto become pregnant is a focus of recent studies. However, most research is retrospective and non-comparative;\nhence, the role of fertility preservation before endome\ntriosis surgery in women with DIE is not clear. Furthermore, the removal of DIE before an assisted reproductive\ntechnique procedure in patients with endometriosis-relat\ned infertility has not been well established ( 17 ). Although\nsome researchers reported a beneficial effect of DIE surgery on pregnancy outcomes with a 45% improvement in\nIVF results, there is no randomised study that confirms\nthis improvement or the effect of surgery on spontane\nous pregnancy rate in these patients ( 14 ,  15 ). DIE surgery\nrequires a highly skilled surgeon and cannot be routinely\noffered to all patients because of the inevitable complications.\nWe divided 508 endometriosis patients into three groups\n(OMA, OMA+DIE, and DIE) and compared them with 50\nhealthy women. Based on our findings, the baseline AMH\nlevels in the DIE and OMA+DIE groups were much lower than the OMA and control groups. The baseline AMH\nin the OMA and control groups was similar. The decrease\nin AMH levels in all three groups after surgery was statistically significant. There was no evidence of AMH recov\nery in any of the surgical groups at four and eight months\nfollowing surgery.\nBased on an extensive literature search, our study is the\nlargest to date, involving the highest number of endometriosis cases, and uniquely investigates AMH as a marker\nto assess ovarian reserve both before and after surgery\nacross three different groups of endometriosis patients.\nThis study was conducted on a homogeneous population\nin terms of age and BMI. All surgeries were performed by\na skilled surgeon, which eliminated the bias of the surgical technique.\nLimitations of this study include not utilising the ENZI\nAN classification system for imaging and operation note\nreports; this classification can determine the severity of the\ndisease better than the ASRM scoring system. In addition,\nwe did not assess fertility outcomes in all three surgical\ngroups and compare them with the normal population ( 18 ).\nIn line with our results, Ashrafi et al. ( 19 ) conducted a\nstudy on 125 patients who underwent endometriosis sur\ngery. Their patients were divided into three groups [OMA\n(n=40), DIE (n=58), and OMA+DIE (n=27)]. The results\nshowed a decrease in ovarian reserve, with an increase in\nseverity and ASRM score. In their study, the lowest post\noperative AMH level was observed in the OMA+DIE\ngroup (1.4 ± 1.4 ng/dl). Their study aimed to investigate\nthe number of retrieved oocytes from all three endometriosis groups. They observed the lowest reserve in the\nOMA+DIE group (P<0.001); however, AMH levels be\nfore and after surgery were not compared. The ASRM\nscores in the groups were much less than our current study\n( 19 ).\nPapaleo et al. ( 20 ) investigated the ovarian reserve in\n51 patients after endometriosis surgery. The patients were\ndivided into two groups: OMA (n=27) and OMA+DIE\n(n=24), all of whom had ASRM stages 3 and 4 endometriosis. Despite the similar size of OMA in both groups\n(4.6 ± 2.1 cm versus 4.2 ± 2.0 cm, P=0.04), the number of\nantral follicles under the monitor on the third day of the\nmenstrual cycle for performing intracytoplasmic sperm\ninjection was significantly lower in the second group.\nHowever, they did not mention the ovarian reserve prior\nto the surgery.\nGoodman et al. ( 21 ) compared AMH levels in 58 patients who underwent OMA surgery to 58 healthy con\ntrols. They concluded that the reduced AMH levels after\nsurgery depended on the initial AMH level as well as\nthe size and laterality of the OMA. They reported a 52%\nAMH drop in case of bilateral OMA versus a 17.5% decline in unilateral ovarian involvement with OMA after\nsurgery. This decrease continued up to six months after\nsurgery, but it was not significant. There was no evidence\nof recovery in AMH levels during the follow-up period.\nDIE cases were not investigated in this study ( 21 ).\nSarbazi et al. ( 22 ) examined 174 endometriosis patients\nin three groups: OMA (n=33), DIE (n=6), and OMA+DIE\n(n=135). They observed a general decrease in AMH levels compared to the baseline value of 2.8 ± 1.86 (ng/dl)\nbefore surgery to 1.76 ± 1.40 (ng/dl) after surgery; the\nresults were not separately reported for each group ( 22 ).\nConsidering the 6.5% prevalence of DIE, as the only form\nof the endometriosis disease in the literature, the number\nof articles is much lower than OMA and OMA+DIE.\nNevertheless, in our study, we had an adequate number of\ncases that presented with DIE.\nThe burnout theory in endometriosis was proposed for\nthe first time in 2007 by Dolmans et al. ( 23 ) According\nto this theory, ovarian homeostasis is very important in\ncausing follicle loss in cases of iatrogenic ovotoxicity.\nThis theory also notes that any imbalance in ovarian homeostasis, even during normal and physiological condi\ntions, can lead to follicular burnout ( 23 ,  24 ). Any process\nthat accelerates follicle activation and reduces in follicle\ninhibition can lead to loss of ovarian reserve (e.g., the aging process). These processes include those causing toxicity in the ovary (OMA), either directly or through an\nindirect mechanism, and contribute to vascular infarction,\nhypoxia, increased oxidative stress, increased oxygen\nspecies in the pelvic environment, and even induction of\nthe short term PTEN inhibition or PI3K activation in the\ngenes of cortical ovarian neurons that lead to apoptosis\nof ovarian cells ( 25 - 27 ). According to the burnout theory,\nthe presence of endometriosis lesions in the pelvis with an increase in pro-inflammatory cytokines and adhesion\nmolecules, such as nitric oxide, tumour necrosis factor,\ninterleukin (IL) 6, IL8, and interferon gamma, as well as\nproliferation and fibrosis induction, would lead to disruption of the blood supply to the ovaries. Simultaneously,\nwith an increase in reactive oxygen species in the pelvis,\nthese processes can lead to ovarian aging and rapid follicular activation and loss. This phenomenon occurs not\nonly in the presence of OMA, but also in the presence of\nDIE, and leads to a decrease in ovarian reserve prior to\nsurgery in these patients ( 28 - 31 ).\n\nAlthough the presence of OMA is a pivotal factor for\npredicting reduced ovarian reserve in endometriosis patients, the role of DIE should not be ignored. It is important to diagnose DIE in patients with infertility who\ndo not have OMA. Conducting target ultrasonography to\ndetect pelvic DIE lesions and fertility preservation before\nsurgery in these patients is of utmost importance.","source_license":"CC0","license_restricted":false}