Ovarian Reserve Following Triple-Step Procedure on Bilateral Large Endometrioma: A Retrospective Study from Bali, Indonesia

Introduction: The triple-step method, which comprises transvaginal ultrasound-guided aspiration (TUGA) of cyst fluid, three cycles of a gonadotropin-releasing hormone (GnRH) agonist, and laparoscopic cystectomy, has been proposed for managing large endometriomas. The impact of this procedure on ovarian reserve can be measured using antral follicle count (AFC) and serum anti-Mullerian hormone (AMH) levels. We aimed to comprehensively evaluate the triple-step procedure for endometrioma and its effect on ovarian reserve in patients with large endometriomas at Bali Royal Hospital (BROS), Denpasar. Methods: This study used a retrospective design and secondary data. The study population included all patients diagnosed with bilateral large endometriomas on transvaginal ultrasonography during a 3-year study period. A large endometrioma is an endometrial cyst measuring >4 cm in diameter. AMH and AFC are measured before aspiration and three months after cystectomy. The collected data were processed using SPSS v.23. Results: Most patients were aged <35 years (n = 14; 73.7%). Based on infertility status, almost all patients had primary infertility (17 patients; 89.5%) with a duration of <5 years (11 patients; 57.9%). Regarding preoperative AFC parameters, the minimum and maximum AFC values were 3.00 and 9.00, respectively, with a mean of 5.57 (1.952). After surgery, the minimum and maximum AFC values were 5.00 and 14.00, respectively, with a mean of 8.47 (2.412). The mean AMH levels before surgery were 2.95 ng/mL (2.027) and 2.83 ng/mL (1.611) after surgery, respectively. A significant difference was found in the AFC values between pre-surgery and post-surgery groups (p<0.001). However, no significant difference in AMH values was found between the groups. Conclusion: The triple-step procedure may conserve ovarian reserve in large bilateral endometriomas.