Impact of Ablation Versus Cystectomy for Endometrioma on Ovarian Reserve, Recurrence, and Pregnancy: An Updated Meta-Analysis

This study aimed to compare the impact of ablation and cystectomy for ovarian endometrioma on ovarian reserve, recurrence rates, and pregnancy rates. Databases were searched for studies reporting ovarian reserve (measurement of anti-müllerian hormone [AMH] only), recurrence rates, and/or pregnancy rates after cystectomy and ablation for ovarian endometrioma. Six randomized clinical trials and five prospective cohort studies were included in this meta-analysis. All included studies had a low risk of bias. After ablation, weighted mean difference (WMD) between post- and pre-operative AMH values was − 0.40 (95% confidence interval [CI]: -0.61 to -0.19, p = 0.0002, I2 = 0%). After cystectomy, the WMD of AMH was − 1.08 (95% CI: -1.34 to -0.82, p < 0.00001, I2 = 48%). The intergroup comparison revealed that pre-operative AMH values were similar between the two groups, but post-operative AMH was significantly higher in the ablation group (WMD: 0.38, 95% CI: 0.13 to 0.63, p = 0.003, I2 = 3%). Subgroup analysis showed that the favorable effects of ablation compared to cystectomy are evident after three months of operation, in a bilateral setting, or with the laser ablation method. Overall recurrence rate (risk ratio [RR]: 1.51, 95% CI: 1.08 to 2.12, p = 0.02, I2 = 0%) and one-year recurrence rate (RR: 2.36, 95% CI: 1.30 to 4.31, p = 0.005, I2 = 0%) were significantly higher in the ablation group than in the cystectomy group. Pregnancy rates were similar between the two groups (odds ratio: 1.18, 95% CI: 0.92 to 1.52, p = 0.20, I2 = 72%). These results demonstrate that ablation could result in a smaller serum AMH decrement than cystectomy, but the recurrence rate could be higher after ablation. Similar content being viewed by others Data Availability Not applicable. Code Availability Not applicable. Change history 03 April 2024 A Correction to this paper has been published: https://doi.org/10.1007/s43032-024-01528-5

D’Hooghe TM, Debrock S, Hill JA, Meuleman C, editors. Endometriosis and subfertility: is the relationship resolved? Semin Reprod Med. 2003. Barnhart K, Dunsmoor-Su R, Coutifaris C. Effect of endometriosis on in vitro fertilization. Fertil Steril. 2002;77:1148–55. Kitajima M, Defrère S, Dolmans M-M, Colette S, Squifflet J, Van Langendonckt A, et al. Endometriomas as a possible cause of reduced ovarian reserve in women with endometriosis. Fertil Steril. 2011;96:685–91. Kasapoglu I, Ata B, Uyaniklar O, Seyhan A, Orhan A, Oguz SY, et al. Endometrioma-related reduction in ovarian reserve (ERROR): a prospective longitudinal study. Fertil Steril. 2018;110:122–7. Raffi F, Metwally M, Amer S. The impact of excision of ovarian endometrioma on ovarian reserve: a systematic review and meta-analysis. J Clin Endocrinol Metab. 2012;97:3146–54. Younis JS, Shapso N, Ben-Sira Y, Nelson SM, Izhaki I. Endometrioma surgery–a systematic review and meta-analysis of the effect on antral follicle count and anti-Müllerian hormone. Am J Obstet Gynecol. 2022;226:33–51. e7. Younis JS, Shapso N, Fleming R, Ben-Shlomo I, Izhaki I. Impact of unilateral versus bilateral ovarian endometriotic cystectomy on ovarian reserve: a systematic review and meta-analysis. Hum Reprod Update. 2018;25:375–91. Moreno-Sepulveda J, Romeral C, Niño G, Pérez-Benavente A. The effect of laparoscopic endometrioma surgery on anti-Müllerian hormone: a systematic review of the literature and meta-analysis. JBRA Assist Reprod. 2022;26:88. Jee BC. Efficacy of ablation and sclerotherapy for the management of ovarian endometrioma: a narrative review. Clin Exp Reprod Med. 2022;49:76. Hart RJ, Hickey M, Maouris P, Buckett W. Excisional surgery versus ablative surgery for ovarian endometriomata. Cochrane Database Syst Rev. 2008. Dan H, Limin F. Laparoscopic ovarian cystectomy versus fenestration/coagulation or laser vaporization for the treatment of endometriomas: a meta-analysis of randomized controlled trials. Gynecol Obstet Invest. 2013;76:75–82. Zhang Y, Zhang S, Zhao Z, Wang C, Xu S, Wang F. Impact of cystectomy versus ablation for endometrioma on ovarian reserve: a systematic review and meta-analysis. Fertil Steril. 2022. Higgins JP, Altman DG, Gøtzsche PC, Jüni P, Moher D, Oxman AD et al. The Cochrane collaboration’s tool for assessing risk of bias in randomised trials. BMJ. 2011;343. Wells GA, Shea B, O’Connell D, Peterson J, Welch V, Losos M et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. Oxford; 2000. Alborzi S, Momtahan M, Parsanezhad ME, Dehbashi S, Zolghadri J, Alborzi S. A prospective, randomized study comparing laparoscopic ovarian cystectomy versus fenestration and coagulation in patients with endometriomas. Fertil Steril. 2004;82:1633–7. Beretta P, Franchi M, Ghezzi F, Busacca M, Zupi E, Bolis P. Randomized clinical trial of two laparoscopic treatments of endometriomas: cystectomy versus drainage and coagulation. Fertil Steril. 1998;70:1176–80. Candiani M, Ferrari S, Bartiromo L, Schimberni M, Tandoi I, Ottolina J. Fertility outcome after CO2 laser vaporization versus J Minim Invasive Gynecol of minimally invasive gynecology. 2021;28:34–41. Candiani M, Ottolina J, Posadzka E, Ferrari S, Castellano L, Tandoi I, et al. Assessment of ovarian reserve after cystectomy versus ‘one-step’ laser vaporization in the treatment of ovarian endometrioma: a small randomized clinical trial. Hum Reprod. 2018;33:2205–11. Candiani M, Ottolina J, Schimberni M, Tandoi I, Bartiromo L, Ferrari S. Recurrence rate after one-step CO2 Fiber laser vaporization versus cystectomy for ovarian endometrioma: a 3-year follow-up study. J Minim Invasive Gynecol. 2020;27:901–8. Carmona F, Martínez-Zamora MA, Rabanal A, Martinez-Roman S, Balasch J. Ovarian cystectomy versus laser vaporization in the treatment of ovarian endometriomas: a randomized clinical trial with a five-year follow-up. Fertil Steril. 2011;96:251–4. Chen J, Huang D, Zhang J, Shi L, Li J, Zhang S. The effect of laparoscopic excisional and ablative surgery on ovarian reserve in patients with endometriomas: a retrospective study. Medicine. 2021;100. Giampaolino P, Bifulco G, Sardo ADS, Mercorio A, Bruzzese D, Di Carlo C. Endometrioma size is a relevant factor in selection of the most appropriate surgical technique: a prospective randomized preliminary study. Eur J Obstet Gynecol Reprod Biol. 2015;195:88–93. Mircea O, Puscasiu L, Resch B, Lucas J, Collinet P, von Theobald P, et al. Fertility outcomes after ablation using plasma energy versus cystectomy in infertile women with ovarian endometrioma: a multicentric comparative study. J Minim Invasive Gynecol. 2016;23:1138–45. Saito N, Yamashita Y, Okuda K, Kokunai K, Terai Y, Ohmichi M. Comparison of the impact of laparoscopic endometriotic cystectomy and vaporization on postoperative serum anti-mullerian hormone levels. Asian J Endosc Surg. 2018;11:23–9. Shaltout MF, Elsheikhah A, Maged AM, Elsherbini MM, Zaki SS, Dahab S, et al. A randomized controlled trial of a new technique for laparoscopic management of ovarian endometriosis preventing recurrence and keeping ovarian reserve. J Ovarian Res. 2019;12:1–8. Muzii L, Di Tucci C, Di Feliciantonio M, Marchetti C, Perniola G, Panici PB. The effect of surgery for endometrioma on ovarian reserve evaluated by antral follicle count: a systematic review and meta-analysis. Hum Reprod. 2014;29:2190–8. Hachisuga T, Kawarabayashi T. Histopathological analysis of laparoscopically treated ovarian endometriotic cysts with special reference to loss of follicles. Hum Reprod. 2002;17:432–5. Benaglia L, Somigliana E, Vighi V, Ragni G, Vercellini P, Fedele L. Rate of severe ovarian damage following surgery for endometriomas. Hum Reprod. 2010;25:678–82. Hendriks M-L, van der Valk P, Lambalk CB, Broeckaert MA, Homburg R, Hompes PG. Extensive tissue damage of bovine ovaries after bipolar ovarian drilling compared to monopolar electrocoagulation or carbon dioxide laser. Fertil Steril. 2010;93:969–75. Stefanovic S, Sütterlin M, Gaiser T, Scharff C, Neumann M, Berger L et al. Microscopic, Macroscopic and Thermal Impact of Argon Plasma, Diode Laser, and Electrocoagulation on Ovarian Tissue. In vivo. 2023;37:531-8. Donnez J. CO2 laser laparoscopy in infertile women with endometriosis and women with adnexal adhesions. Fertil Steril. 1987;48:390–4. Becker CM, Bokor A, Heikinheimo O, Horne A, Jansen F, Kiesel L, et al. ESHRE guideline: endometriosis. Hum Reprod open. 2022;2022:hoac009. Roman H, Pura I, Tarta O, Mokdad C, Auber M, Bourdel N, et al. Vaporization of ovarian endometrioma using plasma energy: histologic findings of a pilot study. Fertil Steril. 2011;95:1853–6. e4. Nisenblat V, Bossuyt PM, Farquhar C, Johnson N, Hull ML. Imaging modalities for the non-invasive diagnosis of endometriosis. Cochrane Database Syst Rev. 2016.

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