Ovarian endometriomas and anti-Mullerian hormone : review

Background : Endometriosis is common, affecting up to 10% of females in their reproductive years. The vast majority of sufferers present with pain and infertility. The etiology of endometriosis is thought to be due to retrograde menstruation and implantation of endometrial tissue onto visceral peritoneum outside the uterus. Anti-Mullerian hormone is produced by granulose cells within the primordial follicles, and represents the ovarian reserve. AMH levels decline with age; however there are multiple factors which may affect the level at any given point. Many women presenting to infertility clinics have ovarian endometriomas. Diagnosis : The gold standard diagnostic modality for endometriosis is laparoscopic inspection of the pelvis. A positive histological result of biopsied tissue will confirm endometriosis; however a negative histological result does not exclude the diagnosis. In the case of ovarian endometriomas, one may palpate a pelvic mass or see a mass originating from the adnexa on ultrasound examination. Excised endometriomas should be sent for histological examination to exclude rare forms of ovarian carcinoma. The positive predictive value of sonar in identifying ovarian endometriomas can be as high as 97% in the hands of an experienced sonographer. Treatment of ovarian endometriomas : Laparoscopic excision is considered the treatment of choice. Excision has many advantages compared to drainage alone. Medical therapy alone has a limited role in the treatment of endometriosis; however certain modalities do offer acceptable symptomatic relief but their cost and side effect profile can limit their long term use. It is evident that even in the hands of an experienced surgeon there is often accidental damage to normal ovarian tissue during laparoscopic excision of ovarian endometriomas. There are various techniques that can be used during laparoscopy to excise ovarian endometriomas, with the combined technique and the three-step management technique being superior. Surgery and AMH levels : The evidence of how surgery affects AMH levels is conflicting. Assessing the evidence has remained a challenge. Study methodology varies tremendously and study heterogenicity remains a problem. This makes meta-analysis and systematic review very difficult to interpret. There seems to be a reduction in the AMH level following surgery however there are studies that have found no significant reduction in AMH levels following surgery. Conclusion : Ovarian endometriomas are commonly seen in women with endometriosis. Laparoscopic surgery remains the treatment of choice, however new evidence suggests that such surgery negatively affects the ovarian reserve. Unfortunately there are serious flaws in surgical technique which can bias the results of these studies. We propose that using only experienced surgeons, performing the appropriate surgical technique, without using bipolar electrocoagulation, one can preserve AMH levels in women undergoing laparoscopic excision of ovarian endometriomas.