{"paper_id":"74cb359c-deac-472f-8110-f8635f30202c","body_text":"~ 228 ~ \nInternational Journal of Clinical Obstetrics and Gynaecology 2023; 7(2): 228-233 \n \nISSN (P): 2522-6614 \nISSN (E): 2522-6622 \n© Gynaecology Journal \nwww.gynaecologyjournal.com \n2023; 7(2): 228-233 \nReceived: 11-01-2023 \nAccepted: 20-02-2023 \n \nMona Zaghloul Kandeel \nDepartment of Obstetrics and \nGynecology, Faculty of Medicine, \nTanta University, Tanta, Egypt \n \nMohamed Ahmed Talat El Sharawy \nDepartment of Obstetrics and \nGynecology, Faculty of Medicine, \nTanta University, Tanta, Egypt \n \nNaglaa Ali Hussein \nDepartment of Obstetrics and \nGynecology, Faculty of Medicine, \nTanta University, Tanta, Egypt \n \nMostafa Zein Al Abidean Mohamed \nDepartment of Obstetrics and \nGynecology, Faculty of Medicine, \nTanta University, Tanta, Egypt \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \nCorresponding Author: \nMona Zaghloul Kandeel \nDepartment of Obstetrics and \nGynecology, Faculty of Medicine, \nTanta University, Tanta, Egypt \n \nUse of Oxidized Regenerated Cellulose (ORC) in \ntreatment of ovarian endometriomas to prevent \nrecurrence and preserve ovarian reserve \n \nMona Zaghloul Kandeel, Mohamed Ahmed Talat El Sharawy, Naglaa Ali \nHussein and Mostafa Zein Al Abidean Mohamed \n \nDOI: https://doi.org/10.33545/gynae.2023.v7.i2d.1309 \n \nAbstract \nBackground: Oxidized Regenerated Cellulose (ORC) is used in  the treatment of Endometriosis to \neliminate or postpone endometriomas’ recurrence and to preserve ovarian reserve subsequently increasing \npregnancy rate. The aim of this research was to evaluate the benefit  of ORC in surgical management of \novarian endometriomas to reduce the rate of recurrence while preserving ovarian reserve.  \nMethods: This prospective randomized controlled research was carried out on 60 cases, divided into two \ngroups: Group A (drainage and ablation): 30 cases had laparoscopic drainage of ovarian endometrioma \nwith electrocautery of the endometriomal cyst wall. Group B (drainage and ORC): 30 cases had \nlaparoscopic drainage of ovarian endometrioma with insertion of ORC inside the cyst cavity. \nResults: There was a statistically significant difference according to 3 and 6 months  in anti-mullerian \nhormone ( AMH) (ng/ml) and Antral Follicular Count (AFC) being higher in ORC group compared to \nablation group while the reduction in AMH (change) was significantly lower in ORC group  (P values< \n0.001). The recurrence rate of ovarian endometrioma was comparable between both groups . AMH and \nAFC was significantly associated with the recurrence of ovarian endometrioma 3 and 6 months.  \nConclusions: ORC reduces effectively the recurrence risk of endometriomas following laparoscopic \ndrainage. \n \nKeywords: Oxidized Regenerated Cellulose (ORC), ovarian endometriomas, ovarian reserve \n \nIntroduction \nEndometriomas is defined as the presence of endometrial glands and stroma like lesions outside \nthe uterine cavity including the Ovaries, Douglas pouch, Uterosacral ligaments, vulva, bladder \nand rectum. The endometrium undergoes cyclic changes [1]. In spite of analgesics and cyclic oral \ncontraceptive pill treatment, it is linked to persistent pelvic discomfort, painful periods \n(dysmenorrhea), painful sexual activity (dyspareunia), painful bowel movements (dyschezia), \nand painful bladder emptying (dys uria). It is also associated with Inf ertility and intermenstrual \nbleeding [2].  \nEndometriosis is managed by:  Symptomatic treatment: as Anti -Prostaglandin, Oral \nContraceptive Pills. Medical treatment: as Progestrone, Gonadotropin Releasing Hormone, Oral \nContraceptive Pills and Androgen analogue.  Surgical treatment: cystectomy or drainage of \nendometriomas either by laparoscopy or laparot omy and then ablation of cyst wall using \nelectrocautry [3].  \nAs an efficient measure for haemostasis, especially for gushing surf aces, oxidized regenerated \ncellulose (ORC) has been used in surgical sectors as a topical absorbable substance. ORC works \nas a physical barrier that encourages platelet aggregation and clotting in addition to the \nmechanical compression (tamponade -like) at the bleeding sites. In addition, ORC's acidic pH \n(between 2 and 4) aids haemostasis through vasoconstriction,  denaturation of blood proteins, \nand the development of a gel-like artificial clot [4, 5].  \nIn most cases, ORC products are tolerated well and safe since they are quickly eliminated from \nthe body after insertion  [4]. Nowadays, ORC is used in treatment of Endometriosis to eliminate \nor postpone endometriomas’ recurrence and to preserve Ovarian reserve subsequently increasing \npregnancy rate [4, 5].\n\n\nInternational Journal of Clinical Obstetrics and Gynaecology http://www.gynaecologyjournal.com \n~ 229 ~ \nThe aim of this work was to evaluation of benefit of ORC in \nsurgical management of ovarian endometriomas to reduce the \nrate of recurrence while preserving ovarian reserve. \n \nPatients and Methods \nThis prospective, randomized, controlled research was carried \nout on 60 cases aged from 20 to 35 years with clinical criteria of \nendometriosis-related clinical manifestations (infertility, pelvic \npainorpelvicmass), unilateral and unilocular endometrioma \n(≥5 cm), good ovarian reserve (antimullerian hormone \n(96) > 1 ng/ mlandantral follicular count AFC> 4) and candidate \nfor conservative laparoscopic treatment of ovarian \nendometriomas at Tanta University Hospital – Obstetrics and \nGynaecology department over 1 year from March 2021 to July \n2022. \nThe research was done after approval from the Ethical \nCommittee Tanta University Hospitals. An informed written \nconsent was obtained from the case or their relatives. \nExclusion criteria were recurrent and bilateral case s, s uffers \nchronic diseases (e. g., cardiac disease ordiabetes) and h as any \ncontraindication for laparoscopic surgery (excessiveanterior \nabdominal wallscarring). \nCases were categorized into two equal groups: Group A \n(drainage and ablation): had laparoscopic drainage of ovarian \nendometrioma with electrocautery of the endometriomacyst \nwall. Group B (drainage and ORC): had laparoscopic drainage \nof Ovarian Endometrioma with insertion of ORC inside the \ncystcavity. \nAll cases were subjected to: Full History, Complete Physical \nExamination: w omen had a clinical examination, including \ngeneral, abdominal, and pelvic examinations, and vaginal \nspeculum examination to e xclude loca l causes of infertility. \nLaboratory Investigations : Serum antimullerian hormone  \n(AMH) was assayed by ELISA (enzyme linked immunosorbent \nassay) technique (Expected Values: 0.9–9.5 ng/ml).  \n \nImaging techniques \nTransvaginal ultrasound: Samsung H60 color Doppler \n(SAMSUNG MEDISON CO., LTD.42, Teheran -ro 108 -gil, \nGangnam-gu, Seoul, Korea) with a transvaginal 6.5 MHz probe \nused for:  Visualisation of uterine cavity, adnexa, and ovaries \nSince endometriomas can present themselves in a wide ran ge of \nways, it's important to confirm their presence and determine \ntheir size and location. Unilocular cysts are a classic case of \nacoustic enhancement due to hemorrhagic debris, manifesting as \ndiffuse homogenous ground-glass echoes. Antral follicular count \n(AFC) is the total number of follicles, in  both the diseased and \nhealthy ovaries. Both the pre -op evaluation and the post -op \nfollow-up ultrasounds were performed by the same doctor. \n \nCase preparation for laparoscopy \nThese guidelines were instructed befor e coming to the hospital \nfor the laparoscopy and the cases were informed by the surgical \nprocedure. The surgery was done during proliferative phase of \nthe menstrual cycle to exclude current pregnancy and to \nminimize bleeding at operative laparoscopy accord ing to \nAmerican Fertility Society classification. \n \nProcedure \nUnder general anaesthesia, cases were put in the lithotomy \nposition and Trendelenburg position. Small vertical umblical \nincision was performed by scalpel  under aspect conditions . \nPneumoperitoneum was performed by a Veress needle  and \ntested by injection of saline and aspiration  then, insufflation of \nperitoneal cavity by carbon dioxide gas to provide a working \nand viewing space for the surgeon. \nOnce Pneumoperitoneum was established, Veress needle was \nremoved, and trocar 10 mm was introduced instead.  30 D or 0 \nLens with One -chip Full HD camera frame rate 50/60 HZ \n(KARL STORZ GmbH and Co., Germany) on the end and a \nlight source was introduced throu gh trocar.  The laparoscope \n(KARL STORZ GmbH and Co., Germany) transmitted images \nfrom the abdominal and pelvic cavity to high resolution video \nmonitors in  the operating room. After exploration of all \nabdominal cavities and when the cyst was visualized, one or two \nmore incisions 5mm were made. Each incision was a port, where \na trocar 5mm was inserted. \nIf any adhesion or band was found between ovary and other \npelvic organs, adhesiolysis was performed.  Grasping of ovary \nand ovarian ligament by Maryland graspe r introduced through \nthe trocar 5mm. A small window 1cm was done in the cyst wall \nusing monopolar diathermy. The window  was made on the \nthinnest part of the cyst. Avoid making the incision close to the \nfallopian tube or fimbrial end.  Aspiration of the choc olate \nmaterial from the cyst and then irrigation of the cyst cavity with \nnormal saline solution till complete elimination of the chocolate \nmaterial. \n In ablation group, haemostasis and ablation of the remaining \nendometriotic cyst wall was done by 60Welectr odes (Erbe REF \n20195-145 max. 250Vp) of bipolar electrocautery \n(ErbeElektromedizin GmbH Waldhoernlestr. 1772072 \nTuebingen, Germany). In ORC-treated group, each ORC knitted \nfabric with area measuring 5 × 10 cm (SURGICEL® –Ethicon \nUS, LLC.) It was separated into quarters. Depending on the size \nof the endometrioma,  four to eight  surgical parts were placed \ninside the cyst's interior. Sutures of 4/0 polydioxanone (PDS® \nSuture-Ethicon US, LLC) were used to approximate the ovarian \nmargins if they were gapping . During the procedure tissue may \nbe removed for histopathology.  \nAll cases were followed up after 3 months and 6 months \nfollowing the laparoscopic surgery by:  Serum antimullerian \nhormone (AMH) was assayed by ELISA (enzyme linked \nimmunosorbent assay) technique ( ExpectedValues: 0.9 –\n9.5 ng/ml). Transvaginal ultrasound: Samsung H60 color \nDoppler (SAMSUNG MEDISON CO., LTD.42, Teheran -ro \n108-gil, Gangnam -gu, Seoul, Korea) with a transvaginal 6.5 \nMHz probe used for  identification of recurrence of \nendometrioma in the sa me ovary (ovarian cyst with \nhomogeneous low-level ground glass echogenicity of the cystic \nfluid) and for a ntral Follicular Count (AFC): Number of visible \nfollicles from 2 to10 ml in the same ovary. \nOne doctor performed both the pre -op assessment and the post -\nop follow -up ultrasounds. During the postoperative follow -up \nperiod, no subjects received any hormonal therapies.  \nPrimary outcome was the presence of sonographically confirmed \nendometrioma-like cysts in the ipsilateral ovary (recurrence was \ndefined as the occurrence of such cysts) at a size of more than \none centimeter. As a secondary endpoint, we reevaluated \novarian reserve (AMH and day 2 AFC) after the laparoscopy. \n \nStatistical analysis  \nSPSS v28  (IBM Inc., Chicago, IL, USA) was used for the \nstatistical analysis. Quantitative variables were compared \nbetween the two groups using unpaired Student's t - test and \nfollowed-up measurements were compared to baseline \nmeasurements within the same group usin g paired Student's t - \ntest. When applicable, the Chi -square test or Fisher's exact test \nwas used to analyze qualitative variables provided as \n\nInternational Journal of Clinical Obstetrics and Gynaecology http://www.gynaecologyjournal.com \n~ 230 ~ \nfrequencies and percentages. In this study, statistical \nsignificance was defined as a two-tailed P value below 0.05. For \nthis reason, we analyzed the diagnostic efficacy of each marker \nusing a Receiver Operating Characteristic (ROC) curve. The \narea under the curve (AUC) is a statistical measure used to \nassess test efficacy (with an AUC of 50% indicating satisfactory \nresults and an AUC of 100% indicating optimal results). \n \nResults \nRegarding Age, BMI, Manifestations, side, and size of \nendometrioma of the studied groups, there was no statistically \nsignificant difference between research groups. Table 1 \n \nTable 1: The demographic characteristics, Manifestations, Side, and size of endometrioma of the studied groups \n \n ORC group (n= 30) Ablation group (n= 30) 95% CI P \nAge (years) 29.33 ± 3.133 30.00 ± 2.613 -2.2, 0.8 0.374 \nBMI (kg/m2) 26.39 ± 2.298 27.02 ± 2.016 -1.7, 0.5 0.268 \nManifestations \nPrimary Infertility 26.7% (8) 26.7% (8) - 0.224 \nSecondary infertility 13.3% (4) 33.3% (10) \n  Pelvic Pain 43.3% (13) 23.3% (7) \nPelvic Mass 16.7% (5) 16.7% (5) \nSide \nRight 60.0% (18) 53.3% (16) - 0.602 \nLeft 40.0% (12) 46.7% (14)   Size (cm) 6.58 ± 1.566 6.60 ± 1.552 -0.8, 0.8 0.967 \n \nData is expressed as mean and standard deviation. 95% CI: 95% \nconfidence interval of the mean difference between both groups. \nBMI: Body mass index ; ORC: oxidized regenerated cellulose; P \nis significant when ˂ 0.05.  \nThere was a statistically significant difference according to 3 \nand 6 months AM H (ng/ml) being higher in ORC group \ncompared to ablation group as the reduction in AMH (change) \nwas significantly low er in ORC group . There was a statistically \nsignificant higher count of Antral Follicular Count in ORC group \nafter 3 and 6 months of laparos copy compared to ablation group \nas the AFC reduction (change) was significantly lower in ORC \ngroup (P values  < 0.001).  The recurrence rate of ovarian \nendometrioma was comparable between both groups. Table 2 \n \nTable 2: Basal and follow-up of Anti Mullerian hormone (ng/ml), Antral Follicular Count and recurrence in the studied groups \n \n ORC group (n= 30) Ablation group (n= 30) 95% CI P value \nAMH \nBasal AMH (ng/ml) 6.16 ± 1.04 5.77 ± 0.97 -0.124: 0.915 0.133 \nThree months 6.05 ± 1.06 4.83 ± 0.95 0.696: 1.737 <0.001* \nSix months 6.04 ± 1.07 4.6 ± 0.98 0.903: 1.966 <0.001* \nAMH change -0.13 ± 0.41 -1.16 ± 0.44 0.818: 1.259 <0.001* \nComparison of follow up to basal AMH P1= 0.129 \nP2= 0.107 \nP1<0.001* \nP2<0.001* --- --- \n95% CI -0.036: 0.266 \n-0.029: 0.279 \n0.803: 1.074 \n1: 1.319 --- --- \nAFC \nAntral Follicular Count 7.57 ± 0.86 7.33 ± 0.96 -0.237: 0.704 0.325 \nThree months 7.2 ± 1.27 5.73 ± 1.72 0.684: 2.25 <0.001* \nSix months 7.1 ± 1.47 4.77 ± 2.01 1.423: 3.244 <0.001* \nAFC change -0.47 ± 1.28 -2.57 ± 1.74 1.312: 2.888 <0.001* \nComparison of follow up to basal AFC P1= 0.054 \nP2= 0.055 \nP1<0.001* \nP2<0.001* --- --- \n95% CI -0.007: 0.74 \n-0.011: 0.944 \n1.091: 2.071 \n1.921: 3.175 --- --- \nRecurrence \nRecurrence 9 (30%) 4 (13.3%) --- 0.209 \n \nData is expressed as mean and standard deviation. 95% CI: 95% \nconfidence interval of the mean difference between both groups. \nP1: comparison between basal and three months values, P2: \ncomparison between basal and six months values. P is \nsignificant when ˂ 0.05.  P is significant when ˂ 0.05.  AMH: \nAnti-Mullerian Hormone; ORC: oxidized regenerated cellulose , \nAFC: Antral Follicular Count. \nAccording to ORC and ablation groups, in terms of AMH, it was \nsignificantly associated with  the recurrence of ovarian \nendometrioma 3 and 6 months after laparoscopy being lower in \ncases who suffered from recurrence than those who didn’t while \nthere was no relation between the recurrence and AMH at the \nstart of the research. Regarding AFC, there was a statistically \nsignificant relatio n between AFC 3 and 6 months after \nlaparoscopy and the recurrence of ovarian endometrioma as \nAFC was significantly lower in cases who suffered from \nrecurrence than those who didn’t. There was no relation between \nthe recurrence and AFC at the start of the research. Table 3 \n \n\nInternational Journal of Clinical Obstetrics and Gynaecology http://www.gynaecologyjournal.com \n~ 231 ~ \nTable 3: Relationship between recurrence of ovarian endometrioma and AMH, AFC in ORC group \n \n  \nRecurrence 95% CI P Yes No \nORC group \nAMH (ng/ml) \nBasal 5.67 ± 0.99 6.37 ± 1.01 -1.518: 0.125 0.094 \nThree months 5.39 ± 0.99 6.33 ± 0.98 -1.747: -0.138 0.023* \nSix months 5.37 ± 0.99 6.32 ± 0.99 -1.764: -0.145 0.022* \nAFC \nBasal 7.33 ± 0.71 7.67 ± 0.91 -1.034: 0.368 0.338 \nThree months 6.33 ± 0.71 7.57 ± 1.29 -2.178: -0.298 0.012* \nSix months 5.56 ± 0.88 7.76 ± 1.14 -3.079: -1.333 <0.001* \nAblation group \nAMH \nBasal 5.13 ± 0.55 5.9 ± 0.98 -1.809: 0.271 0.141 \nThree months 3.83 ± 0.57 5.02 ± 0.9 -2.145: -0.235 0.016* \nSix months 3.3 ± 0.57 4.84 ± 0.88 -2.474: -0.599 0.002* \nAFC \nBasal 6.75 ± 1.5 7.48 ± 0.89 -1.798: 0.335 0.171 \nThree months 3.25 ± 0.5 6.19 ± 1.52 -3.761: -2.109 <0.001* \nSix months 2 ± 1.41 5.26 ± 1.75 -5.137: -1.381 <0.001* \n \nData is expressed as mean and standard deviation. P is \nsignificant when ˂ 0.05.  AMH: Anti-Mullerian Hormone; AFC: \nAntral Follicular Count; 95% CI: 95% confidence interval of the \nmean difference between both groups; ORC: oxidized \nregenerated cellulose. \nAMH at 3 and 6 months after laparoscopy can significantly \npredict the recurrence of ovarian endometrioma with AUC of \n0.682 and 0.677, respectiv ely. At cut off ≤5.1 and ≤5.02 ng/ml, \nrespectively, with sensitivity of 69.23% and 61.54%, \nrespectively, specificity of 59.57% and 57.45%, respectively, \nPPV of 32.1% and 28.6%, respectively and NPV of 87.5% and \n84.4%, respectively. (P value of 0.038 and 0. 048, respectively). \nFigure 1 \n \n \n \nFig 1: Comparison of ROC curves of AMH measurements in predicting \nthe recurrence of ovarian endometrioma \n \nAFC at 3 and 6  months after laparoscopy is a significant \npredictor of the recurrence of ovarian endometrioma with AUC \nof 0.732 and 0.76, respectively. At cut off ≤6, with 69.23% and \n92.31%sensitivity, respectively , 61.7%  and 59.57% specificity, \nrespectively, 33.3% and 38.7% PPV , respectively  and 87.9%  \nand 96.6% NPV, respectively. (P value <0.001). Figure 2 \n \n \n \nFig 2: Comparison of ROC curves of AFC measurements in predicting \nthe recurrence of ovarian endometrioma \n \nDiscussion \nIn this research, the most common manifestation in the ORC \ngroup was pelvic pain in 43.3% of cases vs 23.3% in the ablation \ngroup, while the most common manifestation in the ablation \ngroup was secondary infertility in 33.3% of cases vs 13.3% in \nthe ORC group. The most aff ected side was the right side in \n60% of the ORC group and 53.3% of ablation group. \nShaltout et al . [6] found that the most common manifestations \nwas secondary infertility in 36 % of the ORC group and in 32 % \nof the ablation group with most affected right side in 52% of the \nORC group and 52% of ablation group. \nThis is because endometriosis is characterized by the formation \nof adhesions in ectopic endometrial tissue. Adhesions lead to \ninfertility, pelvic or abdominal pain, and bowel obstruction [7]. \nIn this research, the mean size of endometrioma was (6.58 ± \n1.566 cm) in the ORC group, and (6.60 ± 1.552 cm) in th e \nablation group, without statistically significant difference \nbetween the two groups (p= 0.967). \nOur research agrees with Shaltout et al. [6] research, in which the \nmean size of endometrioma was (6.5 ± 1.1 c m) in the ORC \ngroup, and (6.4 ± 1.1 cm) in the ablation group, without \nstatistically significant difference between the two groups. \n\nInternational Journal of Clinical Obstetrics and Gynaecology http://www.gynaecologyjournal.com \n~ 232 ~ \nSimilar to Sönmezer et al. [8] who reported that the mediansize \nof endometrioma of hemostatic matrix group was 5 cm, of the \nbipolar coagulation group it was 5.5 cm. \nLoss of ovarian reserve can be due to o varian endometriosis that \nmay reduce the amount of healthy tissue, leading researchers to \nbelieve it may have a negative effect on a woman's fertility. \nSerum AMH levels are known to drop significantly after \ninvasive procedures like ovarian cystectomy due to stress to the \novarian vasculature and excessive removal of ovarian tissue [9].  \nOur research results have revealed that th ere was a statisticall y \nsignificant difference according to 3 and 6 months in AMH \n(ng/ml) and Antral Follicular Count being higher in ORC group \ncompared to ablation group while the reduction in AMH \n(change) was significantly lower in ORC group (P values< \n0.001). The recurrence rate of ovarian endometrioma was \ncomparable between both groups . AMH and AFC was \nsignificantly associated with the recurrence of ovarian \nendometrioma 3 and 6 months.  \nWe assume in our research that laparoscopic drainage of ovarian \nendometrioma with insertion of ORC inside the cyst cavity is a \ngood alternative to laparoscopic drainage of ovarian \nendometrioma with electrocautery of the endometriomal cyst \nwall and excellent choice for cases with poor ovarian reserve. In \nour research, we choose the third and si xth month postoperative \nfollow up to assess the extent of recovery after management.  \nSharma et al. [10] concluded that the use of ORC as a hemostatic \nagent is simple and very effective. Additionally, the risk of \ncompromising ovarian reserve with use of energy sources for \nhemostasis is also minimized. \nContrary to our research results, Chung et al. [11] found that in \nboth hemostatic sealant and bipolar coagulation group, one \nmonth and three months after surgery, the AFC was higher tha n \nit had been before. The 3 -month change in AFC of the afflicted \novaries was substantially (P = 0.013) larger in the hemostatic \nsealant group (2.36±0.37) compared to the bipolar coagulation \ngroup (1.08±0.36). \nSince it takes at least three months for little  preantral and antral \nfollicles to emerge from quiescent primordial follicles, this is the \ntime point we will initially examine in our research. During \novarian surgery, it is crucial to protect the ovarian reserve. \n[8].  \nThere is a wide range of reported recurrence rates for ovarian \nendometrioma following laparoscopic ovarian cystectomy, from \n9.6 percent to 45 percent. Furthermore, up to 40 -45% of cases \nmay have a risk of symptom recurrence following initial \nsurgery, necessitating either another surgery or even more \ndrastic treatments, such as hysterectomy [12, 13].  \nAlthough Shaltout et al . [6] filling the remaining cavity with \nORC after drainage management has been shown to lower \nrecurrence risk and improve overall results compared to \ndrainage and ablation. They hypothesized that ORC (Surgicel) is \nable to exert a form of chemical destruction by creating a highly \nacidic environment (pH 2 -4) and triggering severe \nvasoconstriction within the endometrioma, killing the remaining \nendometrial cells and lowering the recurrence rate. \nChen et al . [14] cinfirmed that ORC products have been \nconfirmed safe because they are sterile and bioabsorbable. There \nhave been reports of problems (such as foreign body \ngranulomatous development, persistent inflammation, and \ninfection) that occurred on the long run. However, there is still a \nshortage of evidence -based data on the best ways to use ORC \n(surgicel) and any risks associated with doing so. \nCost of treatment is an important factor to consider from an \neconomic view. The equipment required for ORC is less \nexpensive than that required for electrocauterization. The \noperational duration can be reduced without sacrificing the \nprecision and skill required for intracorporeal suturing [6]. \nIn contrast to Pergialiotis et al . [15] research which found that \nAFC hadn’t improved following endometrioma surgery. \nIn the cu rrent research, AMH at 3 and 6 months after \nlaparoscopy can significantly predict the recurrence of ovarian \nendometrioma with AUC of 0.682 and 0.677, respectively. At \ncut off ≤5.1 and ≤5.02 ng/ml, respectively. AFC at 3 and 6 \nmonths after laparoscopy is a significant predictor of the \nrecurrence of ovarian endometrioma with AUC of 0.732 and \n0.76, respectively. At cut off ≤6. \nIn their research, Ozaki et al. [16] patients with AMH values 1.1 \nng/mL 3 or 6 months prior to surgery and 3 or 6 months after \nsurgery were reported to have an unfavorable DOR (aDOR). At \n3 months following surgery, the optimal cut -off points of the \npre-surgical AMH concentrations were 2.1 ng/mL [ 0.83 (95% \nCI, 0.68-0.97); and 3.0 ng/mL [0.72 (95% CI, 0.57- 0.87), and at \n6 months following surgery, were 2.1 ng/mL [0.85 (95% CI, \n0.73-0.97); and 3.5 ng/mL [0.80 (95% CI, 0.67-0.93). \n \nFurthermore, Tang et al. [17] noted that the AUC of the predictive \nvalue of serum AMH for postoperative abnormal ovarian reserve \nfunction was 0.866 (95% CI, 0.801 –0.923), with a sensitivity of \n88.10% and specifi city of 88.30% when the  best cut -off value \nwas 0.621. \nWe acknowledge that there are some potential pitfalls in our \nresearch, the first limitation of our analysis was that the pelvic \npain improvement  and case satisfaction rate were not in our \nscope during the follow up period. Secondly, the small sample \nsize. Thirdly, we didn’t assess the AMH and AFC, one month \npostoperative to test the effect of two methods on ovarian \nreserve. Lastly, the lack of evidence abo ut long-term recurrence \nand ovarian performance (due to the short duration of follow -\nup).  \n \nConclusions \nORC reduces effectively the recurrence risk of endometriomas \nfollowing laparoscopic drainage.  Furthermore, laparoscopic \ndrainage with filling of the remaining cyst cavity with ORC is an \neffective alternative for laparoscopic drainage of ovarian \nendometrioma with electrocautery of the endometriomal cyst \nwall that minimally impairs the case ovarian reserve as \nmeasured by AMH and AFC.  \n \nFinancial support and sponsorship: Nil \n \nConflict of Interest: Nil \n \nReferences \n1. Muzii L, Di Tucci C, Di Feliciantonio M, Galati G, Verrelli \nL, Donato VD, et al . Management of Endometriomas. \nSemin Reprod Med. 2017;35:25-30. \n2. Rizk B, Fischer AS, Lotfy HA, Turki R, Zahed HA, Malik \nR, et al . Recurrence of endometriosis after hysterectomy. \nFacts Views Vis Obgyn. 2014;6:219-27. \n3. Brown J, Farquhar C. 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Use of \nOxidized Regenerated Cellulose (ORC) in treatment of ovarian \nendometriomas to prevent recurrence and preserve ovarian reserve . \nInternational Journal of Clinical Obstetrics and Gynaecology . \n2023;7(2):228-233. \n \n \nCreative Commons (CC) License \nThis is an open access journal, and articles are distributed under the terms \nof the Creative Commons Attribution -NonCommercial-ShareAlike 4.0 \nInternational (CC BY -NC-SA 4.0) License, which allows others to remix, \ntweak, and build upon the work non -commercially, as long as appropriate \ncredit is given and the new creations are licensed under the identical terms.","source_license":"CC0","license_restricted":false}