Evaluation of ovarian reserve after different surgical techniques in management of endometrioma

Background: Endometriosis could be present among women without any symptoms, accounting for as many as fifty percent of women seeking infertility treatment . Antral follicle count (AFC) as well as serum anti-Mullerian hormone (AMH) levels are often utilized as accurate quantitative ovarian reserve indicators. This work was aimed at assessing different endometrioma surgical treatment modalities’ impact on ovarian reserve.

Our prospective comparative study involved 40 cases whose ages fall between 20 and 35 years, female patients who are married, nullipara with unilateral endometrioma > 4 cm. Subject underwent a random equal allocation into two equal groups according to patient's condition intra -operative, hence decision of the operator: Group A (n=20): treated by laparoscopic excision of endometrioma and Group B (n=20): treated laparoscopically by evacuation of the cyst then by cyst wall’s cauterization utilizing Bipolar Diathermy.

A significantly variance among AMH levels was documented within group A as well as between AFC in group A and B and AMH in group B during various follow -up periods ( p<0.05). AMH within group A during various follow -up periods was significantly different between base line and after 6 months (P2 < 0.05). There was a significantly difference between base line with after 6 months, between base line with after 3 months and between 3 months with 6 months (P1, P2, P3 < 0.05) regarding of AFC within group A as well as AMH within group B during various follow -up periods. Pregnancy rate exhibited significant variances among both groups (p<0.05).

Both techniques, complete laparoscopic cystectomy and partial cystectomy with bipolar coagulation of the cyst wall have adverse effect as regards ovarian reserve determined with serum AMH level. However, AFC increased after both techniques. No significant variance was documented among both groups as regards the ovarian reserve’s degree of reduction.

Ovarian reserve, laparoscopic excision, endometrioma, antral follicle count, anti -mullerian hormone

Endometriosis represents a chronic inflammatory condition linked to persistent pelvic pain, affecting six to ten percent of females within their reproductive age. The endometriosis diagnosis remains definitive only while confirming endometrial like tissue lesions outside the uterus following the surgical procedure. Endometriosis could be present among women without any symptoms, accounting for as many as fifty percent of women seeking infertility treatment. The predominant endometriosis symptoms involve discomfort, gastrointestinal as well as urinary issues, along with exhaustion and sadness resulting from the persistent pain . There could be a delay while diagnosis such a condition since symptoms, involving pelvic discomfort and/or infertility, may or may not be oberverd among all individuals. Additionally, they could also be linked to other medical disorders [1]. The current therapies for this condition involve the surgical lesions' excision along with administering medicines, inhibiting the ovarian hormones synthesis. More than fifty percent of individuals going through surgery will need an additional surgical operation withi n five years. Additionally, several medical therapies have adverse side effects. Surveys conducted on cases regularly emphasize the symptoms alleviation along with enhancing medical treatments that do not have any negative impact on fertility [2]. Ovarian reserve refers to the reproductive capacity determined by the quantity and quality of resting primordial follicles that have the ability to mature into primary, antral, as well International Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com ~ 61 ~ as ovulatory follicles. Antral follicle count (AFC) as well as serum anti -Mullerian hormone (AMH) levels are often utilized as accurate quantitative ovarian reserve indicators. Publications in the literature present comparative analysis studies between different surgical techniques used in the treatment of endometrioma [3]. AMH exhibits a crucial role as regards the physiology of ovaries. It is produced by the granulosa cells of developing follicles, starting from the early stages of follicle growth until cyclic selection. AMH has a detrimental effect on the recruitment of primor dial follicles [4]. The AMH level is a dependable and valuable indicator of ovarian reserve, since it consistently decreases as a person ages and becomes undetectable during the perimenopause stage. It is widely agreed that cases developing endometrioma ha ve a more rapid fall in serum AMH levels as opposed to healthy women. Endometrioma may mechanically impact ovarian reserve via compressing the adjacent ovarian cortex, which hinders vascular circulation, resulting in follicles loss [5]. Endometriotic cyste ctomies lead to a significant decrease in serum AMH levels, but do not affect the AFC. The negative impact on AMH levels could be reliably seen at several time points, involving early, intermediate, as well as late postoperative periods. Among women having endometrioma, the AMH level could be a more precise marker, assessing the risk for the ovarian reserve’s iatrogenic depletion [6]. This work was aimed at assessing different endometrioma surgical treatment modalities’ impact on ovarian reserve. Patients and Methods Our prospective comparative study involved 40 cases whose ages fall between 20 and 35 years, female patients who are married, nullipara with unilateral endometrioma > 4 cm. The research commenced following the Ethical Committee’s approval at Ta nta University Hospitals, Tanta, Egypt. All subjects were allowed to sign an informed consent. We excluded polycystic ovarian syndrome based on the Rotterdam criteria, prior ovarian surgical procedures, any ovarian mass either benign or malignant, known en docrinal disorders or other chronic conditions along with consuming oral contraceptives or gonadotropin releasing hormone (GnRH) agonist or antagonist or any other medicines affecting ovarian function within a minimum of three months prior to the research. Subject underwent a random equal allocation into two equal groups according to patient's condition intra -operative, hence decision of the operator: Group A (n=20): treated by laparoscopic excision of endometrioma and Group B (n=20): treated laparoscopical ly by evacuation of the cyst then by cyst wall’s cauterization utilizing Bipolar Diathermy. All subjects underwent a comprehensive medical history taking, general assessment and ovarian reserve evaluation prior to surgical procedure and at three, six month s postoperatively by: [serum AMH and AFC by transvaginal ultrasonography (TV/US). Evaluation of ovarian reserve prior to the surgical procedure, at three, and six months postoperatively by Serum Anti- Mullerian Hormone (AMH) During the time frame of 8 t o 9 AM, blood samples were obtained via venipuncture then underwent storage within tubes containing heparin. They were then placed on ice till being centrifuged. The plasma obtained following centrifugation (With a force of 1200 times the acceleration due to gravity for a duration of 10 minutes) was separated into smaller portions and kept at a temperature of -20 °C until it was examined for AMH levels. The plasma concentrations of AMH were measured utilizing a commercially available ELISA kit (MOFA Global AMH ELISA, Verona, WI) based on the instructions provided by the manufacturer. This analysis was specifically to quantify AMH levels within serum and plasma samples. The absorbance at 450 and 630 nm was measured employing a microplate spectrophotometer (BioTek Powerwave HT, Winooski, VT). Antral Follicular Count (AFC) by TV/US Transvaginal sonography was employed on cycle day 1, 2, 3, or 4 to examine the ovaries. The same observer conducted sonography measures, G.S., utilizing a 7.5 MHz transvaginal probe on a Toshiba Capasee SSA -220A. The ovary's examination was conducted via scanning from the outside to inner edge. Every follicle with a size falling between two and ten mm was measured then counted within both ovaries. The total of both numbers equated to the AFC. The follicle size was determined by taking two or three perpendicular measures, according to the follicle's diameter (6 mm). Each follicle's volume was determined utilizing the equation for the volume of an ellipsoid, which is L3W3D3p/6. The tota l follicular volume was calculated via summing the all follicles volumes measuring up to 10 mm in size within both ovaries. The mean follicular volume was determined through dividing the total follicular volume by the follicles' number counted. Ovarian vol ume was determined via measuring the ovarian contour's diameter in three perpendicular directions, employing the formula for the volume of an ellipsoid (D13D23D33p/6). The total ovarian volume was calculated through adding together the left as well as right ovary's volumes. Prior research have shown intra - as well as inter-observer variability while evaluatng AFC as well as ovarian volume. The primary outcome was assessed by measurement of serum AMH and AFC by TV/US before surgery and after surgery by 3 m and 6 m and secondary outcome: was assessed by occurrence of pregnancy. Statistical analysis Data underwent a statistical analysis utilizing SPSS v26 (IBM Inc., Chicago, IL, USA). Quantitative variables were exhibited as mean and SD then a comparison amon g both groups was employed with unpaired Student's t - test. Qualitative variables were exhibited as frequency and percentage (%) then underwent analysis with the Chi -square test or Fisher's exact test when appropriate. A two tailed P value of below 0.05 de emed to exhibit a statistically significance.

There was insignificantly variance among both groups as regards demographic data as well as size of endometrioma (p>0.05). Table 1: Comparison among both groups as regards demographic data as well as size of endometrioma Group A (n=20) Group B (n=20) P Age (Years) 26.3±4.52 28±5.29 0.141 BMI (kg/m2) 26.235±3.51 26.435±3.65 0.430 Size of endometrioma 5.02±0.62 4.925±0.59 0.311 Data are exhibited as mean ± SD. BMI: Body mass index. A significa ntly variance between levels of AMH was documented within group A within various follow -up periods (p<0.05). There was a significantly difference between base line and after 6 months (P2 < 0.05) while there was insignificant International Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com ~ 62 ~ difference between base line w ith after 3 months and between 3 months with 6 months (P1, P3 > 0.05) regarding levels of AMH in group A within various follow -up periods. There was a significantly different between AFC within group A as well as B and AMH within group B during various fol low-up periods (p<0.05). There was a significantly different between base line with after 6 months, between base line with after 3 months and between 3 months with 6 months (P1, P2, P3 < 0.05) regarding of AFC within group A as well as AMH within group B during different periods of follow up. Table 2 Table 2: Comparison between levels of AMH and AFC in group A and B within various follow-up periods At base line After 3 months After 6 months P Group A AMH 3.5±1.2 3±1 2.5±0.8 0.005* P1=0.069, P2=0.002*, P3=0.061 AFC 4.8±0.7 7.1±1.1 10.5±1.4 0.001* P1=0.006*, P2=0.001*, P3=0.042* Group B AMH 3.79±1.32 3.28±1.13 2.85±1.01 0.036* P1=0.089, P2=0.002*, P3=0.061 AFC 4.68±0.62 6.83±1.18, 9.38±2.14 0.001* P1=0.021*, P2=0.001*, P3=0.003* Data are exhibited as mean ± SD. *significant p value < 0.05, P1 comparison among base line as well as following three months, P2 comparison among base line and following six months, P3 comparison among three as well as six months, AMH: Anti -Mullerian hormone, AFC: Antral follicle count. There was insignificant variance among both groups as regards AMH within various follow -up periods ( p>0.05) and AFC at base line and after 3 months ( p>0.05) while a significantly variance was documented after six months (p<0.5). Table 3 Table 3: Comparison among both groups regarding AMH and AFC within various follow-up periods Group A (n=20) Group B (n=20) P AMH At base line 3.5±1.2 3.79±1.32 0.328 After 3 months 3.0±1.0 3.28±1.13 0.310 After 6 months 2.5±0.8 2.85±1.01 0.098 AFC At base line 4.8±0.7 4.68±0.62 0.328 After 3 months 7.1±1.1 6.83±1.18 0.209 After 6 months 10.5±1.4 9.38±2.14 0.046* Data are exhibited as mean ± SD. *significant p value < 0.05, AMH: Anti-Mullerian hormone, AFC: Antral follicle count. Patients who had pregnancy rate in group A were 14(70%) and in group B were 7(35%) while patients who had not pregnancy rate were 6(30%) and 13(65%) in both groups respectively. There was a significantly variance among both groups as regards pregnancy rate (p<0.05). Table 4 Table 4: Comparison among both groups as regards pregnancy rate Group A (n=20) Group B (n=20) P Pregnancy rate No 6(30.0%) 13(650%) 0.026* Yes 14(70.0%) 7(35.0%) Data are exhibited as frequency (%). *Significant p value < 0.05.

Endometriosis is through to be a factor in infertility due to increased the disease incidence among sub -fertile women (Reaching fifty percent) as opposed to other women having a history of proven fertility (Five to ten percent) [7]. Recently, a marked rise as regards the infertile patients’ number developing endometriosis have been documented. It is uncertain if this indicates a rise in numbers or just signifies the higher frequency of laparoscopy use. The dysmenorrhea prevalence among women is e stimated to fall between forty and sixty percent, whereas the subfertility prevalence is estimated to fall between twenty and thirty percent among women [8]. Endoscopic surgery adheres to the essential microsurgical principles of delicate tissue manipulat ion, continuous irrigation, cautious bleeding control, as well as accurate tissue dissection. The choice of operative procedures for endometriosis depends on the lesions type as well as extent. Several technologies could be utilized, with hydrodissection a s well as CO2 laser being the most effective methods [9]. In our study the results showed that the hormonal assay in this study showed no significant variance among both groups as regards AMH. In group A and B, a significant decrease within AMH level was documented following 6 as opposed to base line level. Our findings supported a meta -analysis by Raffi et al . [10] suggesting a negative effect linked to endometriomas’ excision on ovarian reserve, involving a marked decline as regards circulating AMH post operatively, which could occur as a result of comparable mean age group as well as sample size. Biacchiardi et al . [11] documented no significant variance between AMH level among both laparoscopic excision group as well as bipolar diathermy. In the result s of our study the AFC shows insignificant difference among both groups at base line and following three months, while after six months the AFC was significantly greater within group A as opposed to group B. Within group A and B, a significant rise as rega rds AFC was documented after three months and following 6 months compared to base line value. Celik et al. [12] addressed significant drop of serum AMH at the sixth month (61%) post operatively after laparoscopic endometrioma stripping. The AMH level exhib ited a significant reduction among cases having the cyst below 5 cm as well as among those having bilateral endometrioma. Raffi et al . [10] reported a statistically significant decline (thirty percent) as regards serum AMH post operatively in patients with unilateral endometrioma. This indicates a significant ovarian reserve damage following ovarian cystectomy for endometrioma. The ovarian endometrioma’s laparoscopic treatment has been linked to worsening ovarian reserve in several different ways. These in clude surgical -related local inflammation, heat injury from adhering cyst wall or bleeding arteries, and unintentional healthy ovarian cortex removal [13]. Our research addressed that pregnancy rate in group A were 14 (70%) and in group B were 7 (35%). A statistically significant rise as regards pregnancy rate was documented among patients treated by laparoscopic excision of endometrioma more than the patients treated laparoscopically by evacuation of the cyst then by cauterization of the cyst wall by Bipo lar Diathermy. Supporting our research, Pais et al . [14] investigated the pregnancy chances following endometriomas’ laparoscopic excision fell between 30% and 67%, addressing an overall weighted mean around fifty oercent. Zhou et al. [15] performed a prospective study involving 124 cases aligned with such findings, addressing a total spontaneous pregnancy rate reaching 50.49% at twenty -four months following excisional surgical procedure. The procedure utilized for hemostasis following cysts' excision is one of the factors, probably inducing harm to ovarian reserve. Common methods for achieving hemostasis involve utilizing sutures, haemostatic gel, or bipolar cauterization (BC). International Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com ~ 63 ~ The drawbacks of suturing involve the need for specialized skills as well as ischemia possibilities induced by elevated intraovarian pressure during suture tightening. Hemostatic gels are costly along with potentially causing severe complications such as bowel obstruction or thrombosis. BC, or cryotherapy, represents a cost -effective, uncomplicated, as well as efficient method. However, caution must be implemented for minimizing thermal damage risks [16].

involve a single -senter study with a relatively modest sample size. Therefore, more research should be implemented for calrifying issues associated with ovarian reserve with the ovarian endometrioma’s conservative treatment, specifically in terms of medical or expectant care. Research on the effect of surgery for endometrioma on ovarian reserve should continue to be prior itized in the field of reproductive medicine.

Both techniques, complete laparoscopic cystectomy and partial cystectomy with bipolar coagulation of the cyst wall have adverse effect as regards ovarian reserve determined with serum AMH level. Ho wever, AFC increased after both techniques. No significant variance was documented among both groups as regards the ovarian reserve’s degree of reduction. Financial support and sponsorship: Nil Conflict of Interest: Nil

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