{"paper_id":"b3110097-dd91-4e81-bf38-20312a49879f","body_text":"~ 230 ~ \nInternational Journal of Clinical Obstetrics and Gynaecology 2019; 3(1): 230-237 \n \nISSN (P): 2522-6614 \nISSN (E): 2522-6622 \n© Gynaecology Journal \nwww.gynaecologyjournal.com \n2019; 3(1): 230-237 \nReceived: 26-11-2018 \nAccepted: 30-12-2018 \n \nDr. Sujata Rawat \nSenior Resident  \nDepartment of obstetrics and \ngynaecology Dr RML Hospital and \nPGIMER, New Delhi, India \n \nDr. KK Roy \nProfessor, Department of \nObstetrics and Gynaecology \nAIIMS, New Delhi, India \n \nDr. Sunesh Kumar \nProfessor, Department of \nObstetrics and Gynaecology, \nAIIMS, New Delhi, India \n \nDr. JB Sharma \nProfessor, Department of \nObstetrics and Gynaecology, \nAIIMS, New Delhi, India \n \nDr. Neeta Singh \nProfessor, Department of \nObstetrics and Gynaecology, \nAIIMS, New Delhi, India \n \nDr. Kunzang Chodsol \nProfessor, Department of \nBiochemistry, AIIMS,  New Delhi, \nIndia \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \nCorrespondence \nDr. KK Roy \nProfessor, Department of \nObstetrics and Gynaecology \nAIIMS, New Delhi, India \n \n \nA randomised comparative study of ovarian reserve \nfollowing two different techniques of laparoscopic \ncystectomy in ovarian endometrioma \n \nDr. Sujata Rawat,  Dr. KK Roy,  Dr. Sunesh Kumar,  Dr. JB Sharma,  Dr \nNeeta Singh and Dr. Kunzang Chodsol \n \nDOI: https://doi.org/10.33545/gynae.2019.v3.i1d.40  \n \nAbstract \nObjective: To compare ovarian residual volume and ovarian function i.e, the effect on ovarian reserve after \nstripping by two different surgical techniques of cyst removal in endometrioma  & to compare the  \npreoperative anti-mullerian hormone value with the post-operative one in terms of ovarian reserve. \nDesign: Prospective Randomized study.  Prospective randomized clinical study, comparing two different \nsurgical techniques of laparoscopic stripping of ovarian endometrioma. \nPlace of study: Department of Obstetrics and Gynaecology, AIIMS, New Delhi. \nStudy design:  Twenty-one patients who underwent excision of endometrioma.  All patients underwent \nLaparoscopic ovarian cystectomy, by either of the two surgical techniques i.  estripping and coagulation. \nBilateral ovarian volumes, antral follicle counts, and  D2-5 S.AMH, FSH, LH,  Inhibin B Estradiol levels \nwere analysed in 21 patients who had undergone laparoscopic cystectomy for ovarian endometrioma. \nConclusion: The study showed that ovarian cystectomy by stripping causes significant damage to ovarian \nreserve. But, there was no significant difference between the two surgical approaches at hilum. \n \nKeywords: randomised, ovarian reserve, different techniques, endometrioma \n \nIntroduction  \nEndometriosis is one of the most common gynaecologic disorders. It is defined as the presence \nof e ndometrial tissue ( Glands and Stroma) outside the uterus.  The most frequent sites of \nimplantation are the pelvic viscera and the peritoneum  [1]. Endometriosis causes Infertility and \npain. About 30 -40% of woman with endometriosis are infertile, Endometrioma s are \nendometriotic deposits within the ovary. Ovarian endo  metri omasoccurs in 17% to 44% of \npatients with this disease [2, 3, 4]. Ovarian endometriomas account for 35% of benign ovarian \ncysts and are associated with organic type pain such as chronic pelv ic pain and dyspareunia  [5]. \nApproximately 30-40% of women with endometriosis develop endometrioma [1]. \nThe primary indications of treatment of ovarian endometrioma are symptoms of pelvic pain, \ndyspareunia and infertility [5]. \nLaparoscopic excision of ovar ian endometriomas is a favored treatment for the improvement of \nfecundity in infertile women with endometriosis and in recent years, laparoscopy has become \ngold standard for treatment of ovarian endometriomas [6, 7, 8].  \nA growing body of evidence suggest that ovarian reserve is damaged after excision of ovarian \nendometriomas [9, 10, 11]. The damage inflicted by surgery to ovarian reserve may be due to \nremoval of healthy tissue by laparoscopic stripping, the surgery related local inflammation or \nvascular compromise following electrosurgical coagulation [11].  \nPreviously ovarian reserve was assessed by static markers  (Day 2 to day5 estradiol,  follicle-\nstimulating hormone and in  hibin-B, and dynamic markers ( Tests of stimulation with \nclomiphene citrate, gonado tropins and gonadotropin  releasing hormone analogues) and \nultrasonographic markers ( Antral follicle count and ovarian volume). Anti mullerian hormone \n(AMH) is a glycoprotein molecule of  the transforming growth factor beta family. It is produced \nby granulos a cells in the antral ovarian follicles and therefore may be representative of the \nquantity and quality of the ovarian follicle pool. \n \n\n\nInternational Journal of Clinical Obstetrics and Gynaecology \n~ 231 ~ \nThis study will be done with the aim of comparing two different \nsurgical techniques of stripping in ovarian endometriom a and to \ndetermine to what extent different techniques of laparoscopic \nstripping of ovarian endometrioma affect ovarian reserve. Also \nfindings may indicate the importance of measuring preoperative \nand postoperative serum AMH levels as a marker of ovarian \nreserve to evaluate the efficacy of the surgical procedure in \nterms of fertility preservation. \n \nMaterials and Methods \nStudy Design \nProspective randomized clinical study, comparing two different \nsurgical techniques of laparoscopic stripping of ovarian \nendometrioma. \n \nPlace of Study \nDepartment of Obstetrics and Gynaecology, AIIMS, New Delhi. \n \nTotal Number of Patients:  \nA total of 24 patients of endometrioma were recruited for the \nstudy, one patient was lost to follow up and 2 excluded as \nhistopathology of speci men showed Hemorrhagic cyst. \nTherefore, final analysis was done on 21 patients. \nThe randomization was done by computerised generated table:  \n \nGroup 1 - 10 patients for cystectomy done by stripping \n \nGroup 2 - 11 patients for cystectomy done by cutting and \ncoagulation \n \nInclusion Criteria \n1. Women in age group of 21 -35 years with a clinical and \nultrasound diagnosis of endometriosis. \n2. Women with one or more endometrioma (diameter 3 -8 cm) \nwho require laparoscopic cystectomy. \n \nExclusion Criteria: \n1. Patients with non endometriotic ovarian cyst \n2. Patients with malignant ovarian cyst, or dermoid cyst \n3. Patients with adenexal masses e.g.: tuberculosis \n4. Patients with endometriosis of other sites e.g.: bladder, \nbowel, \n5. Patients treated with hormonal supplements, oral \ncontraceptives, GnRH analogues (< 3 months of use). \n \nThis study was conducted from November 2009 to October 2010 \nin the Department of Obstetrics and Gynaecology of AIIMS, \nNew Delhi. The study was approved by Departmental committee \nof All India Institute of Medical scien ces, and informed consent \nwas obtained from all patients. \n \nWorkup of the Patient \nOnce the patients were included in the study, a complete workup \nwas done in all the cases involving complete history and \nexamination, routine investigations as per performa ta king \ninclusion criteria into consideration. Preoperatively Venous \nblood sample was drawn from patient on day 2 to day 5 of \nmenstrual cycle to measure serum FSH, LH, Estradiol and \nInhibin B. About 2ml of same venous sample was centrifuged \nfor AMH. The serum  was taken and stored at -70 degree \ncelceius. Serum anti -mullerian hormone, Follicle stimulating \nhormone and Inhibin B was measured using Beckmann Coulter \n(M/S Immunotech France) ELISA kits and samples were \nanalyzed. In the same sitting 3D Trans vagina lultra souno \ngraphy was performed to measure the summed ovarian volume \nand assess antral follicle count.  The ovarian volume was \ncalculated according to the prolate ellipsoid formula: 4/3p (1/2 \ndiameter) 3 and the endometrioma volumes were calculated by \nthe formula: height _ length _ width _ 0.5233 and expressed in \ncm3. Informed consent explaining the patient the benefits and \nrisk of laparoscopic ovarian cystectomy was taken. \n \nOperative procedure \nTechnique of Laparoscopic Ovarian Cystectomy (Stripping Vs \nCutting and Electrocoagulation):  All Patients underwent \nlaparoscopic surgery under General Anaesthesia, after induction \nof anaesthesia, pneumo  peritoneum was created using CO2 \nmaintained at pressure of 10mm Hg, via verres needle inserted \nsubumblically. A laparoscope was inserted via main subumblical \nentry through a 10 mm port. An atraumatic forceps was inserted \nthrough one of the two ipsilateral lower abdominal 5mm port in \nspinoumblical line under direct vision to grasp utero -ovarian \nligament and to lift the ovar y away from bowel. The \nendometriosis grading was done, and feasibility of laparoscopic \nprocedure was assessed. Complete adhesiolysis and mobilisation \nof ovaries was done if necessary. The uterus, bilateral tubes, \novaries and POD was inspected to get an ove rview of pelvis. \nBilateral chromotubation was done in infertile patients, by \ninjecting methylene blue dye via Foleys catheter in cervix to \ncheck free spill of dye from both tubes. Uterine elevator was \ninserted inside the uterus to manipulate uterus. The ov ary with \nthe endometrioma was mobilised from its adhesion to ovarian \nfossa, cyst was ruptured and contents rinsed. Rupture site was \ncompletely exposed. The wall of the cysts was stripped from the \nhealthy surrounding normal ovarian tissue with the use of tw o \natraumatic 5mm grasping forceps by traction and counter -\ntraction after identification of the cleavage plane. Dissection in \nthe cleavage plane was continued till the area of ovarian hilum is \nreached. \nAfter approaching ovarian hilum randomization was done,  into \ntwo groups for two different techniques of cystectomy \nGroup1: Stripping of the ovarian hilus: Completion of stripping \nprocedure  upto complete removal of the cyst wall \nGroup 2: Coagulation and cutting at the ovarian hilus: Bipolar \ncoagulation of fina l cyst wall pedicle and subsequent cutting \nwith scissors. \nEach ovary was cooled by irrigating with normal saline solution \nbefore releasing the ligament. At the end of procedure 500ml of \nnormal saline was left in pelvis to create artificial ascites to \nprevent future adhesions. The ports were withdrawn and the skin \nincision was closed by 3 -0 nylon sutures. Patient was extubated \nand shifted to observation room. Patients were discharged on the \nsame day, or the next day. After surgery all endometriomas were \nconfirmed by histological examination. In all the cases surgery \nwas performed by same surgeon experienced in laparoscopic \nsurgery. \n \nFollow Up Monitoring  \nThe patients were followed up 1 month after laparoscopic \nsurgery, During followup visit followings were done:- \nSerum FSH, LH, estradiol, inhibin B, and anti -mullerian \nhormone were measured between day 2 and day 5 of menstrual \ncycle. The sample for AMH was separated from whole blood by \ncentrifugation, transferred to sterile polypropylene tubes and \nstored at -700C until assayed. The serum AMH concentrations \nwere measured by the same enzyme immunoassay kit according \nto the manufacturer’s instructions (EIA AMH/MIS, \n\nInternational Journal of Clinical Obstetrics and Gynaecology \n~ 232 ~ \nIMMUNOTECH, and Marseille , France). All assays were \nassessed in duplicates.  Post-operatively, ovarian volume was \nmeasured by 3D transvaginal ultrasonography between day 2 to \nday 5 of menstrual cycle. Antral follicle count was done by 3D \ntransvaginal ultrasonography between day 2 and day 5 of \nmenstrual cycle. All the observations were made by a single \nobserver to avoid inter observer variation. \nOvarian reserve was assessed as follows: \n the difference between ovarian volume and  antralfollicule \ncount before and after cystectomy, \n Hormonal levels (Day2 to Day5 FSH, LH, Estradiol, inhibin \nB and anti -mullerian hor mone) measured before and after \ncystectomy. \nAll these patients were followed up subsequently to see their \novulation and conception for 1 yr after surgery. \n \nStatistical analysis \nData were analyzed using the Sigma Plot 11 software program. \nSimple linear regr ession analyses and the Pearson correlation \nwere applied where appropriate. Multiple linear regression \nanalysis were applied using the significant factors in the simple \nlinear regression analyses. Student’s t -test and the Fisher exact \ntest were used for co mparing the patient characteristics and \nvariables between unilateral and bilateral groups. The Wilcoxon \nsigned-rank test for comparing the serum AMH levels before \nand after surgery. The Mann –Whitney U -test was applied \ninstead of the Student’s t-test when the variables did not pass the \nnormality test.  p-value of <0.05 was considered to be \nstatistically significant. \n \nObservations and Results \nA total of 22 patients with suspected ovarian endometrioma \ndiagnosed on the basis of clinical examination and ultrasoun d, \nand confirmed by laparoscopy were recruited in the study \ncarried out at AIIMS, from November 2009 to october 2010. All \npatients underwent Laparoscopic ovarian cystectomy, by either \nof the two surgical techniquesi.e stripping (picture1) and \ncoagulation. (Picture 2) One patient was lost to follow up after \nsurgery. Therefore final analysis was done in 21 patients of \nendometriosis. \n \n \n \n  \n \nPicture 1: Stripping   Picture 2: coagulation. \n \nAge distribution \nThe mean age of patients studied was 25.3 years, in th e range \nfrom 17-32 years. There were 3 patients in age group of 15 - 20 \nyrs age. Seven patients were in age group of 21 -25 years, 8 \npatients were between 26-30 years and 3 patients between 31 -35 \nyears. No significant difference was found regarding the mean \nages of patients between the two groups. i,e both the groups \nwere comparable on the basis of age distribution as shown in \ntable 1 \nTable 1: Age distribution comparison in two groups \n \nVariable Group 1 n=10 Group 2 N=11 p value \nMean ± SD 23.5± 4.47 26.18± 4.02 0.174 (NS) \n*NS – not significant \n \nSerum FSH value \nAll patients had normal FSH values pro -operatively. There was \nno significant difference in the mean s.FSH of patients between \nthe two groups. The range of baseline s.FSH in group 1 was 2.1 -\n3.6 IU/L and in group 2 it was ranging from 2.1-4.2 IU/L \nIn both the groups (Stripping or coagulation), a statistically \nsignificant difference of the mean FSH value was seen post -\noperatively. (p=0.02 in group 1, p= 0.021 in group 2).  Shown in \ntable 2. \n \nTable 2: preoperative and postoperative s.FSH in both groups \n \nVariable Study group Pre-operative \n(mean±SD) \nPost-operative \n(mean±SD) p value \ns. FSH \nGroup 1 \n(stripping at hilum) 2.7± 0.49 3.6±0.87 0.020 (S) \nGroup 2 \n(Coagulation at hilum) \n3.2± 0.67 \n 3.9± 1 0.022 (S) \n*S- significant \n \nSince both surgical procedures causes significant rise in \npostoperative s.FSH levels, so it is important to know which of \nthe two causes more rise. This was calculated as follows: \nPercentage rise in FSH in Group 1 = mean  of ( post-operative \nFSH- preoperative FSH)/ preoperative FSH \ni,e % Rise in FSH in Group 1 = 100 × 0.9/2.7 = 33.3% \nSimilarly, % Rise in FSH in group 2 = 100 × 0.7/3.9 = 17.9% \nTherefore, postoperatively there is more rise in s.FSH in group 1 \nthan in group 2. (as shown in figure 1) \n \n\nInternational Journal of Clinical Obstetrics and Gynaecology \n~ 233 ~ \n \n \nFig 1: percentage rise of s. FSH in two groups \n \nSerum AMH  \nThere was no statistically significant difference in baseline \npreoperative AMH levels between two groups.  Postoperatively, \nthe serum AMH levels in both groups was significantly lower \nthan the preoperative values, as shown in table 3.  \n \nTable 3: Preoperative and postoperative s. AMH levels in two groups \n \nVariables  Pre-operative Post-operative p value \ns. AMH Group 1 (10) 4.7 ±0.94 4.27±1.02 0.002 (s*) \nGroup 2 (11) 4.4±0.72 4.2±0.76 0.004 (s*) \n*s- significant \n \nSince both groups have statistically significant difference \nbetween their preoperative and postoperative values, we need to \nknow which of the group has more fall relative to other. To \nknow this, we have calculated the rate of decline o f serum AMH \nlevels:  \n \nRate of decline (%) = 100 × [preoperative AMH level – post-\noperative AMH level]/preoperative AMH level.  \nPercentage fall in s.AMH in group 1 = 100× mean of ( post-\noperative AMH – preoperative AMH) / preoperative AMH  \ni,e 100 ×0.43/4.7 = 9.1% \nSimilarly% fall in s. AMH in group 2 = 100 ×0.2/4.4 = 4.5% \nThus the postoperative fall in s. AMH concentration after \nsurgery is more in group1compared to that in group 2(9.1% Vs \n4.5%). Therefore coagulation and cutting at hilum may be \npreferred surg ical approach in terms of compromising ovarian \nreserve. \n \n \n \nFig 2: Postoperative Fall in s. AMH levels in both groups \n \n \nInhibin B, Estradiol& S.LH \nThe baseline values were comparable between the two groups. \nThere was no statistically significant difference  between \npreoperative and Postoperative values.  \n \nAntral follicle count \nThe baseline antral follicle counts were comparable between the \ntwo groups. When postoperative antral follicle counts were \ncompared with the preoperative values, statistically signific ant \ndifference was seen in both the groups. As shown in table 4. \n \nTable 4: Comparison of preoperative and postoperative AFC in both \ngroups \n \nVariables  Pre-operative Post-operative P value \nAntral follicle count Group 1 8.3± 1.16 6.6 ± 2.06 0.001 (S) \nGroup 2 8 ±1.14 6.5 ± 1.17 0.001 (S) \n*S- significant \n \nOvarian Volume \nThe baseline sonographic findings were comparable between the \ntwo groups. The mean size of endometriomas was 84.7 mm 3 in \nGroup 1 and 102.95 mm3in Group 2.  \n \nPregnancy outcome \nOne patient in group 1 and one patient in group 2 concieved \nspontaneously. There is no difference in pregnancy outcome \namong two groups. As shown in table 5, \n \nTable 5: Pregnancy outcome in patients \n \nVariable Pregnancy outcome P value \nGroup 1 1(10%) 0.916 \nGroup 2 1(9%) NS \n*NS- not significant \n \nDiscussion \nLaparoscopic excision of all forms of endometriosis is effective \nand today can be considered as the gold standard surgical \ntechnique for women with endometriosis related to pelvic pain \nor infertility  [7]. The ideal cons ervative laparoscopic approach \nfor management of endometriomas is still controversial  [12, 13, 14, \n15, 16]. Various techniques of endometrioma excision have been \ndescribed, but the two most common laparoscopic techniques, \nexcision and coagulation, have bee n compared t o each other in \nvarious studies [13, 17, 18, 19] but it remains a matter of controversy \nthat which surgical technique is favoured approach for \nendometrioma.  \n \n\nInternational Journal of Clinical Obstetrics and Gynaecology \n~ 234 ~ \nDuring cystectomy, it is sometimes difficult to identify and \nseparate the cleavage pl ane between the cyst wall and adjacent \novarian cortex tissue due to endometriosis induced fibrosis. Also \nserious bleeding at the ovarian hilus requiring extensive \napplication of bipolar electrocoagulation and causes, adverse \nchanges in ovarian blood supply  [20, 21] as well as a functional \nloss in the ovarian reserve  [22, 23, 24]. Thus technically how \ndissection is carried out at hilum area determines the subsequent \novarian function and determines efficacy of surgical approach. \nBeretta et al  [17]. conducted a randomized trial in which these \ntwo different approaches (stripping and coagulation) have been \ncompared, showed statistically no significant difference in the \nrate of disease recurrence between the two groups (6.2% vs \n18.8%), but a higher pregnancy rate at 24 -month follow -up in \nthe group treated with complete cyst excision.  Another study by \nbrosen et al . [25]. retrospectively compared these two different \nsurgical techniques and concluded that laparoscopic excision of \novarian endometriomas at 42 - month fol low-up is associated \nwith a lower reoperation rate than that of fenestration and \nablation (23.6% vs 57.8%). \nMuzii et al [26] in 2005 conducted another study on 48 patients \nwith ovarian endo  metrioma. Two different techniques were \nanalysed at the ovarian hi lus (stripping versus coagulation and \ncutting). Operative time and technical difficulties were \nprospectively evaluated. At the initial part of the stripping \nprocedure, the technique of circular excision and subsequent \nstripping appeared to be more easily p erformed than the \ntechnique of direct stripping (P < 0.01), although operative times \nwere comparable between the two techniques. At the hilus, the \ntwo techniques utilized appeared to be comparable both for \neasiness of procedure and operating times. Thus, t hey concluded \nthat different techniques used during the stripping procedure \nappeared to be comparable in terms of operative times and \ncomplications.  \nFew prospective randomized trials have established laparoscopic \nexcision with stripping as the optimal met hod of treatment of \nendo metriomas from the aspects of recurrence, reoperation rate, \npain relief and postoperative conception rate  [17, 27] . Cochrane \n2011 includes 2 trials and concluded that excisional surgery for \nendo metrioma provides a more favourable outcome than \ndrainage and ablation with regard to the recurrence of the endo  \nmetrioma, recurrence of pain symptoms, and subsequent \nspontaneous pregnancy in women who were previously \nsubfertile. \nIn the present study, we found that technically coagulation an d \ncutting at hilum is more easier to perform as it causes less \nbleeding, whereas stripping at hilum was associated with more \nbleeding, possibly because of tearing of vessels at hilum. \nThere are significant concerns about the potential deleterious \neffects of surgical treatment of endometrioma on ovarian reserve \n& future fertility  [7, 28, 29, 30, 31, 32] . Certain degree of inadvertent \nloss of ovarian tissue is related to removing of the \npseudocapsule of endometriomas that is actually the ovarian \ntissue [26, 28]. This inadvertent loss of ovarian tissue  [28, 33] \nsurrounding the cyst wall results in compromise to ovarian \nreserve. Also serious bleeding at the ovarian hilus requiring \nextensive application of bipolar electrocoagulation and hence, \nadverse changes in ovarian blood supply [20, 21] as well as a \nfunctional loss in the ovarian reserve [23, 24, 33].  \nTsolakidis D et al (2010) [34] conducted a study comparing \ncystectomy with ablation procedure, used s.FSH, s. AMH, s. \nInhibin B, s. Estradiol , AFC, Ovarian vol ume to determine \novarian reserve preoperatively and postoperatively.  Ovarian \nreserve as determined by AMH was less diminished after the \nablation procedure compared with cystectomy of \nendometriomas. They also found a nonsignificant rise in s. FSH. \nThe results were similar to our present study. \nBiacchiardi35et al 2011conducted a study to estimate the impact \nof laparoscopic stripping of endometriomas on the ovarian \nfollicular reserve, on 43 normo -ovulatory women using \nendocrine (anti-Müllerian hormone (AMH), FSH, LH, inhibin B, \noestradiol) and ultrasonographic (antral follicle count (AFC)) \nmethods before surgery, and 3 and 9months after surgery. Serum \nAMH concentrations significantly decreased after the operation \nwhereas basal FSH, LH, oestradiol and inhibin B concentrations \nremained unchanged.The volume of the operated ovary \nsignificantly diminished after surgery (P<0.0001), whereas the \nAFC was not significantly altered. \n In our study stripping at hilus or coagulation and cutting at hilus \nboth causes decrease i n ovarian reserve as assessed 1 month \npostoperatively. However, out of the two approaches, \ncoagulation of the endometrioma stump near hilum and cutting \ncauses less ovarian reserve damage. This can be explained by \nthe following: As dissection generally beco mes difficult close to \novarian hilus  (due to endometriosis induced fibrosis), an \ninadequate stripping technique may tear ovarian vessels and \ninduce significant bleeding, which was controlled by \nelectrocautery. Use of bipolar electro -coagulation was done \nclose to hilum which might have caused irreversible damage to \nhilar vessels leading to decrease in ovarian reserve. Also \nstripping at hilum cause inadvertent removal of healthy ovarian \ntissue even by experienced laparoscopist, due to endometriosis \ninduced fi brosis and consequent absence of cleavage plane. \nStripping also might lead to tear of ovarian vessels and damage \nto ovarian reserve. This shud be avoided by using careful \ntechnique. If dissection near hilum appears too difficult then it’s \nbetter to stop pr ocedure. The surgeon should avoid coagulation \nof the remaining ovarian stroma and the ovarian hilus [36]. \n Preservation of the vascular blood supply to the ovary is of \nimportance as it is vital for the preservation of ovarian function. \nSo, gentle and caref ul bipolar coagulation of the bleeders after \nstripping the pseudocapsule is important. \nMany studies have been done using only s.  FSH to assess \novarian [37]. The clinical value of testing for basal FSH value is \nlimited in view of its intercycle and intracycle variability [37]. \n. It is well known fact that plasma AMH measurements are a far \nmore sensitive marker of diminished ovarian reserve than \ntraditional markers such as early follicular phase FSH  [38, 39, 40] . \nUltrasonographic markers, such as antral folli cle count and \novarian volume, can be used as indicators of ovarian reserve. \nHowever, it is difficult to assess the exact number of antral \nfollicles and ovarian volume of the  cystic ovary before \ncystectomy [41]. As it is difficult to determine AFC of \nendometriotic ovary, particularly if size of cyst is large.  \nPreviously various studies have evaluated the ovarian reserve \ndamage using serum AMH levels in women undergoing \nendometrioma cystectomy [42, 43]. Tsolakidis et al. reported that \nthe mean serum AMH leve l was significantly reduced 6 months \nafter surgery.34However a study conducted by ercan CM [44] et al \nshowed results different from above mentioned authors. They \nconducted a prospective controlled trial in 47 women with \nendometrioma. They showed a decrease  in mean level of post -\noperative serum AMH but this reduction was no t statistically \nsignificant. (P > 0.05).  They concluded that Laparoscopic  \nendometrial striping surgery do not appear to cause a damage in \nthe AMH secreting healthy ovarian tissue. Also, th e results of \nour study are in contrast to those by Alper et al . [45], who \nsuggested that laparoscopic removal of an ovarian cyst did not \n\nInternational Journal of Clinical Obstetrics and Gynaecology \n~ 235 ~ \naffect the AMH or AFC levels. These authors attributed their \nfinding to the relatively small number of patients in their study.  \nIn the present study, significant decreases in serum AMH levels \nwas detected after surgery in both groups.  This could be \nexplained by possible thermal damage to ovarian stromal blood \nvessels at hilum after bipolar electrocoagulation during \nlaparoscopy. Another factor could be the increase in the amount \nof ovarian tissue removed during laparoscopic stripping of an \novarian cyst, with resultant decreases in AFC and AMH levels. \nStripping causes inadvertent loss of ovarian stroma adjoining \ncyst wall, w hich results in removal of primordial follicles along \nwith. There by resulting in decreased ovarian reserve after \ncystectomy. Even by experienced laparoscopist, stripping at \nhilum can be difficult (due to endometriosis induced fibrosis). 63 \nand such difficulties may provoke severe bleeding and excessive \nuse of bipolar coagulation, so inducing irreversible severe \ndamage of ovarian reserve.  \nThe real amount of surgery -mediated ovarian reserve damage \ncannot be measured directly. In the previous reports, ovarian  \nresponsiveness to gonadotropin hyperstimulation, ovarian \nvolume, and antral follicle count (AFC) have been used as the \nmarker for assessing ovarian reserve damage  [7, 36] . AFC is \nthought to be the most reliable indicator factor of primordial \nfollicle pool  46. Sonographic assessment of the AFC has been \nused as a reliable sonographic indicator of ovarian reserve  [46, 47] \nand spontaneous pregnancy. 48Similar result was seen by Ercan \nCM et al. [44]. Ercan CM et al conducted a study on 36 patients  \nwhere they fou nd that mean antral follicle counts (AFC) of the \noperated side ovaries were significantly lower on the second \npostoperative day and in the third month. \nAFC showed its better predictive power than pulsatility and \nresistance indexes in comparison with two la paroscopic \nmanagement of endometriomas in the study of Pados et al. [43]. \nPados et al  2010 conducted a study on 20 patients with \nendometrioma to evaluate the impact of two different \nlaparoscopic methods (cystectomy Vs ablation) on sonographic \nindicators of  ovarian reserve in the treated ovary. All patients \nunderwent ultrasound examination preoperatively and 6 months \nand 12 months after laparoscopy. They investigated the \nalterations in the residual ovarian volume, ovarian vascular \nsupply and antral follicle count (AFC) on the ovary with the \nendometriotic cyst by transvaginalcolor Doppler \nultrasonography. The residual ovarian volume and the lowest \npulsatility and resistance indexes were found to be similar \nbetween the two groups before and 6 months after lapar oscopic \nintervention. The AFC of the operated ovary was increased \nsignificantly (P = 0.002) in Group 2 compared with Group 1 \nafter 6 months.  \nOur study also showed significant decrease of AFC, confirms \nthat part of the healthy ovarian pericapsular tissue, containing \nprimordial and preantral follicles, is removed or damaged \ndespite all the surgical efforts to be atraumatic. \nOvarian volume has also been reported as a reliable indicator of \novarian reserve [56, 213, 218] which can be used as a surrogate \nmeasurement of the remaining primordial follicle pool  [41, 42]. It \nhas been reported that diminished ovarian volume results in poor \nresponse to ovulation induction, low clinical pregnancy rate 48 \nand early menopause. Some authors have suggested that ovarian \nstripping of endometriomas was associated with significant \ndecrease in residual ovarian volume [42]. \nExacoustos et al. [42]. (2004) have found that ovarian stripping of \nendometriomas is associated with a significant decrease in \nresidual ovarian volume. In our s tudy, post -surgical ovarian \nvolume was influenced to the same degree irrelevant of the \ntechnique used. Ovarian volume has been reported to be a \nreliable indicator of ovarian reserve by several authors  [32]. \nContrary to above views, this study does not show  significant \nchange in ovarian volume. It might be attributed to short follow  \nup period. It might be a result of the gentle surgical technique, \nmeticulous haemostasis using excessive bipolar forceps electro \ncoagulation. Also the surgery being done by skill ed surgeon and \nfinding the right cleavage plane may also protect the ovary from \nsevere damage and may have a positive effect on its future \nvolume. \nThis study has several strengths, it is a prospective randomised \ncontrolled trial, and two  different surgical  techniques were \nattempted, by the same surgeon (without inter  observer \nvariability). This study has used biochemical markers like s. \nAMH, s.FSH, and ultrasound markers like antral follicle count, \nwhich are very accurate measure of ovarian reserve. In this  \nprospective study of ours, the ovarian reserve was evaluated in \nan unselected population with endometriomas suffering mainly \nfrom pelvic pain and less from infertility, without using any type \nof ovarian hyperstimulation. The advantage of this study is tha t \nthe ovarian reserve was assessed in our unselected population \nwithout postoperative stimulation of ovaries for determination of \nfollicular response. In the majority of studies [129, 176] the ovarian \nreserve was assessed by measuring the early follicular phase \nserum AMH level, the follicular response of ovaries, and the \nnumber of retrieved oocytes, after controlled ovarian \nhyperstimulation (COH) with clomiphene (CC) or \ngonadotropins. These studies have many biases and definite \nconclusions cannot be drawn. \nThe present study has several limitations: The relative small size \nof the sample, short postoperative follow-up (only 1 month), the \nabsence of pathological confirmation of normal functioning \novarian tissue in our cyst specimens and non-use of Doppler \nstudies. Another disadvantage was the inability to determine the \nthermaldamage of ovarian reserve by histological examination \nand correlateit to any sonographic marker. Also in the study, a \nsingle sample of FSH was obtained preoperatively, so we cannot \ndemonstrate that FSH levels were uniform and unchanging \nbefore the surgery. FSH per say has high biological variability. \nThus, one could argue that the change of FSH merely represents \nvariability in FSH values in these women secondary to some \ntype of ovarian dysfu nction or is because of surgery mediated \ninjury. \nIn conclusion, the results of our study show that laparoscopic \nstripping of ovarian endometrioma is associated with a \nstatistically significant reduction in ovarian reserve as seen after \none month postoperative follow up. The postoperative values of \ns. FSH, s.AMH changed significantly from their respective \npreoperative values. But the change was well with in normal \nrange. The damage cannot be ascribed merely to the amount of \novarian tissue removed during surgery; but there may be damage \nto the ovarian vascular system by electrocoagulation as depicted \nby significant differences in s.AMH in both groups. Thus use of \nelectro-coagulation for hemostasis causes additional adverse \neffect on ovarian reserve. This adverse effect could be less if the \nhemostasis is achieved by suturing rest of the ovarian tissue. 13 or \nvaporisation [49, 50] or manage endometrioma by 3 stage \ntechnique [7, 51]. However, further studies in a larger number of \npatients are required to make certa in judgments whether the \ninjury is related to other factors and to ascertain which is the less \nharmful alternative therapeutic approach. \n \nConclusion \nIn present study of 21 cases of endometrioma, the effect on \n\nInternational Journal of Clinical Obstetrics and Gynaecology \n~ 236 ~ \novarian reserve after stripping by two differen t surgical \ntechniques of cyst removal was compared, using biochemical (s.  \nAMH, s.FSH, s.  LH, s.  Estradiol, s.  Inhibin) and ultrasono  \ngraphic markers (AFC and Ovarian volume) of ovarian reserve.  \nThe result of the study showed that ovarian cystectomy by \nstripping causes significant damage to ovarian reserve. 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