{"paper_id":"a2a11fb0-8faf-4da3-8157-124c9a5dd93b","body_text":"Turk J Obstet Gynecol \nClinical Investigation / Araştırma\nCopyright© 2025 The Author. Published by Galenos Publishing House on behalf of Turkish Society of Obstetrics and Gynecology.\nThis is an open access article under the Creative Commons AttributionNonCommercial 4.0 International (CC BY-NC 4.0) License.\nPRECIS: Three-dimensional laparoscopic cystectomy significantly reduces ovarian reserve in endometrioma and dermoid cysts but not in serous-\nmucinous cysts, highlighting cyst-type-specific impacts on ovarian function.\nCorresponding Author/Sorumlu Yazar: Assoc. Prof. Sabahattin Anıl Arı, MD,\nİzmir Bakırçay University Faculty of Medicine, Department of Obstetrics and Gynecology, İzmir, Türkiye\nE-mail: s.anil.ari.md@gmail.com ORCID ID: orcid.org/0000-0002-2526-6986\nReceived/Geliş Tarihi: 14.02.2025 Accepted/Kabul Tarihi: 10.05.2025 Epub: 15.05.2025 \nCite this article as: Arı SA, Şahin Ç, Akdemir A, Ergenoğlu AM, Yeniel AÖ, Terek MC, et al. Effects of ovarian cyst types on ovarian reserve after three-dimensional laparoscopic cystectomy. Turk \nJ Obstet Gynecol. [Epub Ahead of Print]\nÖz\nAmaç: Çalışmamızın amacı, farklı kist tipleri açısından üç boyutlu (3D) laparoskopik over kistektomisinin over rezervi üzerindeki etkisini karşılaştırmaktır.\nGereç ve Yöntemler: Çalışmamıza 2018-2020 yılları arasında over kistleri nedeniyle cerrahi tedavi görecek katılımcılar dahil edildi. Katılımcıların anti-\nmüller hormon (AMH) ve folikül uyarıcı hormon (FSH) düzeyleri ameliyat öncesi ve ameliyattan 6 ay sonra ölçüldü. Tüm ameliyatlar genel anestezi altında \nve 3D laparoskopi ile gerçekleştirildi. Histopatolojik değerlendirmeden sonra katılımcılar üç gruba ayrıldı; grup 1: Endometrioma, grup 2: Olgun kistik \nteratom (dermoid kist) ve grup 3: Seröz veya müsinöz kistadenom.\nAbstract\nObjective: This study aims to compare the effects of three-dimensional (3D) laparoscopic ovarian cystectomy on ovarian reserve according to different \ntypes of ovarian cysts.\nMaterials and Methods:  Participants who underwent surgical treatment for ovarian cysts between 2018 and 2020 were included in this study. Anti-\nmüllerian hormone (AMH) and follicle-stimulating hormone (FSH) levels were measured before surgery and six months postoperatively. All procedures \nwere performed under general anesthesia using 3D laparoscopy. Participants were classified into three groups based on histopathological findings:  \ngroup 1, endometriomas; group 2, mature cystic teratomas (dermoid cysts); and group 3, serous or mucinous cystadenomas.\nResults: A total of 51 women were included in the study. No significant differences were observed between the groups in terms of perioperative variables \nsuch as operation time, intraoperative blood loss, postoperative hemoglobin decrease, and maximum cyst diameter. There were also no significant differences \namong the groups in preoperative AMH (p=0.97) and FSH (p=0.22) levels. Postoperative AMH levels were significantly lower than preoperative values in \nboth the endometrioma group (p<0.001) and the dermoid cyst group (p=0.004). The reduction in AMH levels was more pronounced in the endometrioma \ngroup compared to the other groups. Postoperative FSH levels tended to increase in all groups compared to preoperative levels; however, this increase was \nnot statistically significant (p=0.092).\nConclusion: 3D laparoscopic cystectomy for the removal of endometriomas and dermoid cysts significantly reduces ovarian reserve. In contrast, laparoscopic \ncystectomy for serous or mucinous cysts appears to have no significant impact on ovarian reserve.\nKeywords: 3D laparoscopy, AMH, dermoid cyst, endometrioma ovarian cyst, ovarian reserve\n Sabahattin Anıl Arı1,  Çağdaş Şahin2,  Ali Akdemir2,  Ahmet Mete Ergenoğlu2,  Ahmet Özgür Yeniel2, \n Mustafa Coşan Terek2,  İsmail Mete İtil2,  Teksin Çırpan2\n1İzmir Bakırçay University Faculty of Medicine, Department of Obstetrics and Gynecology, İzmir, Türkiye\n2Ege University Faculty of Medicine, Department of Obstetrics and Gynecology, İzmir, Türkiye\nDOI: 10.4274/tjod.galenos.2025.38259\nÜç boyutlu laparoskopik kistektomi sonrası yumurtalık kisti \ntiplerinin yumurtalık rezervi üzerindeki etkileri\nEffects of ovarian cyst types on ovarian reserve after \nthree-dimensional laparoscopic cystectomy\n\n Arı et al. Ovarian reserve post-3D cystectomy\nIntroduction\nOvarian cysts affect approximately 7% of women during their \nlifetime and are particularly common during the reproductive \nyears(1). Given that ovarian cysts often become symptomatic \nduring the reproductive years, fertility preservation is a primary \nconcern in their management. For clinicians, this concern is \ntypically assessed through evaluation of ovarian reserve (OR).\nWhile age remains the leading factor influencing OR, medical \ninterventions like surgery, radiation, and chemotherapy can \nalso have a negative impact on its status(2). Several biochemical \nand ultrasonographic markers are used to assess OR. Among \nthese, anti-müllerian hormone (AMH) stands out as a reliable \nand practical indicator(3). Moreover, AMH serves as a sensitive \nmarker for assessing iatrogenic damage to ovarian function (4). \nIn addition, the measurement of basal follicle-stimulating \nhormone (FSH) levels is a well-established, straightforward, \nand reliable method for assessing OR (5). FSH is a glycoprotein \npolypeptide hormone produced by the gonadotropic cells of \nthe anterior pituitary gland(6).\nAlthough simple functional cysts are typically managed \nconservatively to preserve OR during reproductive age, \nsurgical intervention is often indicated for cyst types such \nas endometriomas and mature cystic teratomas, which are \nunlikely to resolve spontaneously, particularly in the presence \nof suspicious ultrasonographic findings.\nLaparoscopic ovarian cystectomy is the preferred surgical \nmethod for ovarian cysts suspected to be benign. Although this \nprocedure is typically regarded as fertility-preserving, recent \nconcerns have arisen about its possible effects on OR. During \ncyst enucleation, there is a risk of unintentionally removing \nhealthy ovarian tissue or causing mechanical or thermal damage \nto the ovarian cortex(1). Literature presents conflicting evidence, \nand no definitive conclusions have been reached regarding this \nissue.\nAnother unresolved question in the literature concerns the \ncomparative advantages of two-dimensional (2D) versus \nthree-dimensional (3D) laparoscopy. 3D laparoscopy offers \nenhanced depth perception and spatial orientation compared \nto conventional 2D laparoscopy, potentially enabling greater \nsurgical precision. This improved precision may enhance the \nsurgeon’s performance during laparoscopic ovarian procedures \nand help mitigate the negative impact on OR. Several studies \nhave demonstrated the specific advantages of 3D laparoscopy, \nparticularly during the dissection and laparoscopic suturing \nphases(7).\nThis study was designed to evaluate the impact of cystectomy \nperformed using 3D laparoscopy on OR across different cyst \ntypes, with the aim of contributing to the clinical management \nof such cases.\nMaterials and Methods\nPatients who presented to the Department of Obstetrics and \nGynecology at Ege University Faculty of Medicine between \n2018 and 2020, and underwent surgical treatment for ovarian \ncysts were evaluated for inclusion in this prospective cohort \nstudy based on predefined inclusion and exclusion criteria. \nAll participants were informed about the study both verbally \nand in writing, and written informed consent was obtained \nprior to enrollment. The study protocol was approved by the \nEthics Committee of Ege University Faculty of Medicine on \nApril 29, 2016 (approval number: 16-4T/56). This research \nwas supported by the Ege University Scientific Research \nProjects Coordination Unit under project number 17-TIP-056. \nAll procedures in this study were carried out in compliance \nwith the ethical guidelines established by the institutional \nresearch committee, the 1964 Declaration of Helsinki, and its \nsubsequent revisions or equivalent ethical standards. The study \nwas registered at ClinicalTrials.gov (NCT05054946).\nThe inclusion criteria were defined as being between 18 and \n40 years of age and having no history of prior ovarian surgery, \nto standardize the cohort and eliminate potential iatrogenic \neffects on OR. Exclusion criteria consisted of the presence of \nendocrinological disorders, suspected malignancy based on \npreoperative laboratory and ultrasonographic assessments, or \nhistopathological confirmation of malignancy, as these factors \ncould influence OR. The main outcome measure was serum \nAMH levels, which were evaluated six months after surgery.\nAll participants underwent a preoperative evaluation of cyst size \nand morphology using either transvaginal or transabdominal \nultrasonography (Voluson E8, GE Healthcare, Chicago, IL, \nUSA) employing a RAB 4-8D 4D transabdominal probe \nand a multifrequency 5-7.5 MHz transvaginal probe. Cyst \nsize was calculated by averaging the maximum diameter \nand the diameter perpendicular to it as measured during \nultrasonographic examination. Blood samples were collected \nfrom all participants during the early follicular phase (days 1-5 \nof the menstrual cycle) following 8-10 hours of fasting. The \nBulgular: Çalışmaya toplam 51 kadın dahil edildi. Gruplar arasında ameliyat süresi, intraoperatif kan kaybı, postoperatif hemoglobin azalması ve maksimum \nkist çapı gibi perioperatif bulgular açısından anlamlı bir fark bulunmadı. Gruplar arasında preoperatif AMH (p=0,97) ve preoperatif FSH (p=0,22) değerleri \naçısından anlamlı bir fark yoktu. Endometrioma (p<0,001) ve dermoid kist (p=0,004) gruplarında postoperatif AMH değerleri preoperatif AMH değerlerine \nkıyasla anlamlı derecede düşüktü. Preoperatif ve postoperatif AMH azalması endometriozis grubunda diğer gruplara göre daha belirgindi. Tüm gruplardaki \npostoperatif FSH seviyeleri preoperatif seviyelere kıyasla artma eğilimindeydi, ancak artış anlamlı bir seviyeye ulaşmadı (p=0,092).\nSonuç: Endometrioma ve dermoid kistleri çıkarmak için yapılan 3D laparoskopik kistektomi over rezervini önemli ölçüde azaltır. Seröz-müsinöz kistler \niçin yapılan laparoskopik kistektomi over rezervi etkilemez.\nAnahtar Kelimeler: 3D laparoskopi, AMH, dermoid kist, endometrioma, over kisti, over rezervi\n\n Arı et al. Ovarian reserve post-3D cystectomy\nsame procedure was repeated for six months postoperatively. \nTo measure serum AMH concentrations, blood samples were \nfirst centrifuged at 1600 g for 10 minutes. The separated serum \nfractions were then preserved at -80 °C until the completion \nof sample collection from all participants. Subsequently, AMH \nlevels were analyzed in batches using the AMH Gen II ELISA kit \nprovided by Beckman Coulter Inc. (Brea, CA, USA). For FSH \nmeasurement, blood samples were collected in separator gel \ntubes, centrifuged at 1400 g for 10 minutes, and analyzed using \nthe Beckman Coulter DXI 800 immunoassay system (Beckman \nCoulter Inc., Brea, CA, USA).\nBased on histopathological findings, the participants were \nclassified into three distinct groups: Group 1 included cases \nof endometrioma, group 2 comprised mature cystic teratomas \n(dermoid cysts), and group 3 encompassed serous or mucinous \ncystadenomas. During surgery, the cyst wall was carefully \ndissected and stripped from the adjacent normal ovarian tissue. \nHemostasis was achieved by applying bipolar coagulation at \nbleeding sites. When required, ovarian reconstruction was \nperformed using a 4-0 absorbable suture (polyglycolic acid, \nVicryl Rapide™, Ethicon, Germany). To minimize the risk \nof postoperative adhesion, the surgical field was irrigated \nextensively with warm saline. All participants were discharged \non the first postoperative day following an uneventful recovery \nperiod.\nStatistical Analysis\nStatistical analyses were performed using IBM SPSS Statistics \nversion 22.0 (IBM Corp., Armonk, NY, USA). The distribution of \nvariables was examined through the Kolmogorov-Smirnov test. \nFor continuous variables, descriptive statistics are presented as \nmean ± standard deviation for normally distributed data and as \nmedian (range) for non-normally distributed data. Categorical \nvariables are represented as frequencies and percentages [n \n(%)]. The chi-square test or Fisher’s exact test was used for \ncomparing categorical variables, as appropriate. For continuous \nvariables, the Student’s t-test was applied when the data \nfollowed a normal distribution, while the Mann-Whitney U test \nwas used for non-normally distributed data. A p-value of <0.05 \nwas considered statistically significant.\nResults\nAccording to the inclusion criteria, 51 participants were \ninitially enrolled in the study. However, four participants with \nhypothyroidism, three with malignancies identified through \nfrozen section and final histopathological evaluation, and one \nwho failed to attend the 6-month follow-up were subsequently \nexcluded. No participants declined to participate in the study. \nConsequently, a total of 43 participants were included in the \nfinal analysis.\nThe mean age of the participants was 28.19±6.14 years in the \nendometrioma group (n=16), 28.38±6.70 years in the dermoid \ncyst group, and 26.82±5.72 years in the serous or mucinous \ncystadenoma group. No significant differences were observed \nbetween the groups regarding age, gravidity, or parity (Table 1).\nThe mean operative times were 68.13±21.86 minutes in \nthe endometrioma group, 74.38±28.10 minutes in the \ndermoid cyst group, and 77.73±25.53 minutes in the serous/\nmucinous cyst group. There were no significant differences \nbetween the groups (p=0.56) (Table 2). Intraoperative blood \nloss and postoperative hemoglobin decrease were as follows: \n83.75±95.57 mL and 1.55±0.78 g/dL in the endometrioma \ngroup; 35.00±35.37 mL and 1.56±1.03 g/dL in the dermoid cyst \ngroup; and 71.09±58.00 mL and 1.42±0.77 g/dL in the serous/\nmucinous cyst group. There were no statistically significant \ndifferences among the groups in terms of intraoperative blood \nloss (p=0.054) or postoperative hemoglobin reduction (p=0.9) \n(Table 2).\nThe mean maximum cyst diameters were 54.65±14.91 mm in \nthe endometrioma group, 51.68±16.16 mm in the dermoid cyst \ngroup, and 56.09±8.75 mm in the serous/mucinous cyst group. \nNo significant differences were found between the groups \nregarding cyst diameter (p=0.7) (Table 2).\nPreoperative AMH levels we re 4.20±3.27 ng/mL in the \nendometrioma group, 4.40±4.28 ng/mL in the dermoid cyst \ngroup, and 4.14±3.06 ng/mL in the serous/mucinous cyst \ngroup. The mean preoperative FSH levels were 6.56±2.58 \nmIU/mL, 6.51±2.46 mIU/mL, and 7.34±0.98 mIU/mL in \nthe endometrioma, dermoid cyst, and serous/mucinous cyst \ngroups, respectively. There were no significant differences \namong the groups in terms of preoperative AMH (p=0.97) or \nFSH levels (p=0.22) (Table 3).\nTable 1. Patients’ characteristics\nEndometrioma (n=16) Dermoid cyst (n=16) Serous or mucinous cystadenoma \n(n=11)\np\nMean SD Median\n(Min-Max) Mean SD Median\n(Min-Max) Mean SD Median\n(Min-Max)\nAge (year) 28.19±6.14 27 (19-39) 28.38±6.70 29 (18-40) 26.82±5.72 25 (20-37) 0.79\nGravida 0.44±1.0 0 (0-4) 0.94±1.28 0 (0-4) 0.45±0.93 0 (0-3) 0.37\nParity 0.38±0.80 0 (0-3) 0.50±0.73 0 (0-2) 0.36±0.67 0 (0-2) 0.73\nSD: Standard deviation, Min: Minimum, Max: Maximum\n\n Arı et al. Ovarian reserve post-3D cystectomy\nGroup-wise analysis revealed a significant postoperative \ndecline in AMH levels compared to preoperative values in \nboth the endometrioma group (p<0.001) and the dermoid \ncyst group (p=0.004). In contrast, the serous/mucinous cyst \ngroup did not exhibit a statistically significant change in AMH \nlevels postoperatively (p=0.297). The reduction in AMH was \nmore pronounced in the endometrioma and dermoid cyst \ngroups compared to the serous/mucinous cyst group (Figure \n1). However, no significant difference was found between the \nendometrioma and dermoid cyst groups in terms of AMH \nreduction.\nComparison of preoperative and postoperative FSH levels \nshowed a trend toward increased postoperative FSH values \nacross all three groups; however, this increase did not reach \nstatistical significance (p=0.092) (Figure 2).\nNo significant differences were observed among the three \ngroups regarding postoperative AMH (p=0.14) and FSH \n(p=0.15) levels.\nTable 2. Peri-operative findings\nEndometrioma (n=16) Dermoid cyst (n=16) Serous or mucinous cystadenoma \n(n=11)\np\nMean SD Median\n(Min-Max) Mean SD Median\n(Min-Max) Mean SD Median\n(Min-Max)\nSurgery time (min) 68.13±21.86 61 (45-110) 74.38±28.10 70 (35-130) 77.73±25.53 70 (40-120) 0.56\nBlood loss (mL) 83.75±95.57 52.50 (10-400) 35.00±35.37 22.50 (2-110) 71.09±58.00 50 (10-190) 0.054\nHb change 1.55±0.78 1.45 (0.60-3.10) 1.56±1.03 1.30 (0.50-4.20) 1.42±0.77 1.20 (0.50-2.50) 0.9\nMax cyst diameter \n(mm) 54.65±14.91 51 (34-81) 51.68±16.16 52.75 (23.5-74) 56.09±8.75 55 (40-75.5) 0.70\nSD: Standard deviation, Min: Minimum, Max: Maximum, Hb: Hemoglobin, min: Minutes\nTable 3. Ovarian reserve markers\nEndometrioma (n=16) Dermoid cyst (n=16) Serous or mucinous \ncystadenoma (n=11)\np\nMean SD Median\n(Min-Max) Mean SD Median\n(Min-Max) Mean SD Median\n(Min-Max)\nPreop AMH \n(ng/mL) 4.20±3.27 2.76 (0.67-10.94) 4.40±4.28 2.52 (0.81-16.12) 4.14±3.06 4.09 (0.67-9.42) 0.97\nPostop AMH \n(ng/mL) 2.14±2.24 1.59 (0.15-7.84) 3.16±2.88 2.27 (0.50-11.8) 3.63±3.24 2.49 (0.92-11.81) 0.14\nPreop FSH \n(mlU/mL) 6.56±2.58 7.14 (0.30-10.09) 6.51±2.46 6.56 (1.68-10.77) 7.34±0.98 7.08 (6.31-9.89) 0.22\nPostop FSH \n(mlU/mL) 7.67±3.51 6.78 (2.94-16.66) 7.12±3.43 7.30 (1.45-16.41) 8.33±1.31 8.13 (5.65-10.4) 0.15\nSD: Standard deviation, Min: Minimum, Max: Maximum, AMH: Anti-müllerian hormone, FSH: Follicle-stimulating hormone, Preop: Preoperative, Postop: Postoperative\nFigure 2. xx\nFigure 1. xx\n\n\n Arı et al. Ovarian reserve post-3D cystectomy\nDiscussion\nIn this prospective cohort study, the impact of 3D laparoscopic \novarian cystectomy on OR was evaluated with respect to varying \ntypes of ovarian cysts. The analysis demonstrated no statistically \nsignificant differences in preoperative AMH (p=0.97) or FSH \n(p=0.22) levels among the groups, suggesting that the presence \nof endometriomas, dermoid cysts, or serous/mucinous cysts \ndoes not independently influence baseline OR. However, by the \nend of the study, surgical intervention for endometriomas and \ndermoid cysts was associated with a significant decline in OR, \nwhereas no such impact was observed in patients with serous \nor mucinous cysts.\nEndometrioma is defined as the presence of ectopic endometrial \ntissue within the ovary. Surgical treatment is often indicated to \nalleviate pelvic pain, prevent complications such as cyst rupture \nor ovarian torsion, exclude malignancy, and address infertility. \nAmong its potential complications are ovarian torsion and \nspontaneous rupture. In subfertile patients, surgical removal of \nendometriomas has been associated with improved pregnancy \nrates(8). While surgical treatment of endometriomas has been \nshown to increase spontaneous pregnancy rates, it does not \nappear to significantly influence the outcomes of in vitro \nfertilization(8). Whether endometriomas impair ovarian function \nremains a subject of ongoing debate. In a study evaluating 1,199 \ncycles in 244 women with unilateral endometrioma, ovulation \nwas found to occur at similar rates in both the affected and \nunaffected ovaries(9). In contrast, a meta-analysis encompassing \neight studies demonstrated that endometrioma excision led to \nan average reduction of 38% in serum AMH levels, suggesting \na potentially detrimental effect on OR (10). OR loss is higher \nin recurrent surgeries compared to one definitive surgery (11). \nTherefore, repetitive ovarian endometrioma surgeries should \nbe avoided as much as possible. The recurrence rate of \nendometriomas is up to 25% (12). Postoperative hormonal \nsuppression options should be considered to avoid repetitive \nsurgeries.\nOvarian germ cell tumors arise from ovarian primordial germ \ncells and constitute 20-25% of ovarian neoplasms. Malignancies \nare detected in only 5% of these neoplasms (13). These tumors \nusually affect females between the ages of 10 to 30. Benign \ncystic mature teratomas, also known as dermoid cysts, are the \nmost frequently encountered ovarian germ cell tumors. Almost \nall are benign (14). Surgery is recommended for confirmation \nof diagnosis, exclusion of malignancy, preservation of OR, \nprevention of complications such as torsion and rupture, and \nrelieving symptoms, if any. The abdomen should be washed \nwith plenty of water to avoid chemical peritonitis at the end of \nthe surgery.\nSerous and mucinous cystadenomas are the most common \nbenign ovarian neoplasms. These cysts may be thin-walled, \nunilocular, or multilocular, and typically range in size from 5 to \n20 cm. Mucinous cysts are less common than serous cysts and \nare more frequently multilocular. Histologically, the inner lining \nof serous cysts resembles tubal epithelium, whereas mucinous \ncysts are usually lined with endocervical or gastrointestinal-\ntype epithelium. Most serous and mucinous cystadenomas \nare asymptomatic and are often detected incidentally during \nultrasound examinations.\nAccording to current literature, surgical excision of \nendometriomas is generally associated with a more substantial \ndecline in OR compared to other cyst types. The impact of \ndermoid cyst removal on OR remains controversial. One study \ninvestigating the early postoperative effects of laparoscopic \nunilateral ovarian cystectomy reported comparable reductions \nin AMH levels in both the endometrioma and dermoid cyst \ngroups, with significantly smaller decreases observed in the \nsimple cyst group (15). Although our study focuses on longer-\nterm outcomes, these findings align with our observations.\nCyst size also plays a role in OR outcomes. Henes et al. (16) \ndemonstrated a significant AMH decrease post-surgery only in \nwomen with cysts ≥5 cm. Conversely, Lind et al. (1) reported \nthat factors such as cyst size, patient age, timing of surgery, \nand intraoperative blood loss did not significantly influence \nOR. In their study, which included 75 women undergoing \novarian surgery, AMH levels were measured preoperatively and \nat six months postoperatively. A significant reduction in AMH \nlevels was observed in patients with endometriomas when \ncompared to those with dermoid cysts. While a postoperative \ndecrease in AMH was also noted in the functional cyst group, \nit did not reach statistical significance. Interestingly, the study \nrevealed that patients with elevated baseline AMH levels (AMH \n>4 ng/mL) experienced a more substantial decrease in AMH \nsix months after surgery compared to those with normal or \nlow baseline AMH levels (1). Our findings are consistent with \nprevious research, demonstrating a greater decline in OR in \nthe endometrioma group compared to the dermoid cyst group. \nHowever, this difference did not reach statistical significance.\nIn another prospective observational study involving 71 \nwomen undergoing their first unilateral ovarian cystectomy via \nlaparoscopy, investigators assessed antral follicle count, ovarian \nvolume, resistance index, and OR at six months postoperatively. \nThe aim was to evaluate the impact of different cyst types on OR \nby comparing the operated ovary with the contralateral one. The \nstudy concluded that surgical intervention led to a reduction in \nOR, regardless of cyst type (17). This study is inconsistent with \nmany studies in the literature and our study.\nA retrospective evaluation of 97 patients revealed that \npostoperative AMH levels declined more markedly in \nindividuals with endometrioma than in those with other types \nof benign ovarian cysts. Furthermore, an inverse correlation \nwas identified between cyst size and preoperative AMH \nconcentrations(18).\nThe reduction in OR following endometrioma excision is \nprimarily attributed to the unintentional removal of healthy \n\n Arı et al. Ovarian reserve post-3D cystectomy\novarian tissue, which may occur due to the invaginating nature \nof the cyst into the ovarian cortex (19). While the reduction in \nOR following endometrioma excision can be explained by \nthe mechanisms described above; the decline associated with \ndermoid cyst removal is thought to result from the cyst’s firm \nadhesion to the ovarian tissue and the hemostatic techniques \nemployed during surgery (1). Conversely, the reduction in \nOR during dermoid cyst removal is often attributed to cyst \nadherence and the hemostatic methods employed.\n3D laparoscopy has been reported to provide significant benefits \nin complex surgical procedures, including improved image \nquality, reduced operative time, and decreased intraoperative \nblood loss. Despite these advancements, particularly enhanced \ndepth perception and greater surgical precision, our study \ndemonstrated that the use of 3D laparoscopy in ovarian surgery \ndid not prevent the decline in OR associated with different cyst \ntypes(20,21). While we observed significant postoperative AMH \nreductions in the endometrioma and dermoid cyst groups, FSH \nlevels did not show a similar pattern, possibly due to differing \nkinetics during the menstrual cycle compared to AMH. The \nfindings of our study are further substantiated by the recent \nsystematic reviews and meta-analyses conducted by Moreno-\nSepulveda et al. (22) and Samartzis et al. (23), both of which \nemphasize the limited efficacy of current surgical techniques in \npreserving OR during endometrioma surgery. Their conclusions \nresonate with our observations, reinforcing the notion that \ndespite advancements in surgical approaches, the preservation \nof ovarian function remains a significant clinical challenge.\nStudy Limitations\nOur study’s strengths include its prospective design, robust \nsample size across various cyst types, and standardized surgical \nprotocols by experienced minimally invasive surgeons at \na tertiary university hospital. Future studies could explore \nadditional factors influencing OR outcomes post-ovarian \ncystectomy, including long-term hormonal assessments and \nfertility outcomes.\nConclusion\nThis study demonstrates that 3D laparoscopic cystectomy for \nendometriomas and dermoid cysts is associated with a significant \nreduction in OR, whereas cystectomy for serous and mucinous \ncysts does not appear to have a significant impact. Preoperative \nassessment of OR and appropriate patient counseling regarding \npotential fertility implications are particularly important for \nreproductive-aged women undergoing ovarian cyst surgery.\nEthics\nEthics Committee Approval: The study protocol was approved \nby the Ethics Committee of Ege University Faculty of Medicine \non April 29, 2016 (approval number: 16-4T/56).\nInformed Consent:  Written informed consent was obtained \nprior to enrollment.\nFootnotes\nAuthorship Contributions\nSurgical and Medical Practices: A.Ö.Y., T.Ç., Concept: S.A.A., \nA.M.E., M.C.T., İ.M.İ., Design: S.A.A., A.M.E., M.C.T., İ.M.İ., \nData Collection or Processing: Ç.Ş., Analysis or Interpretation: \nÇ.Ş., A.A., Literature Search: S.A.A., T.Ç., Writing: S.A.A., \nM.C.T., İ.M.İ.\nConflict of Interest:  No conflict of interest was declared by \nthe authors.\nFinancial Disclosure:  This work was supported by the Ege \nUniversity Scientific Research Projects (grant number: 17-TIP-\n056).\nReferences \n1. 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