Ovarian reserve and IVF/ICSI outcomes after various laparoscopic approaches in infertility patients with endometriomas and suspected compromised ovarian reserve: A retrospective study

OBJECTIVE: To assess the ovarian reserve and in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) outcomes after various laparoscopic approaches in infertile patients with endometriomas and suspected compromised ovarian reserve, and the operated and non-operated/healthy ovaries were also compared, aiming to determine the most appropriate laparoscopic approach for each patient. METHODS: A total of 132 infertile patients with endometriomas and suspected compromised ovarian reserve (anti-Müllerian hormone [AMH] <2.0 ng/mL or antral follicle count [AFC] <8) were treated by various laparoscopic approaches at the Sir Run Run Shaw Hospital from January 2021 to December 2023, followed by IVF/ICSI. Patients were divided into three groups-group A (n = 33) received anhydrous alcohol instillation, group B (n = 65) underwent fenestration/coagulation, and group C (n = 34) underwent ovarian cystectomy. The clinical characteristics, ovarian reserve, and IVF/ICSI outcomes were evaluated among the three groups. The operated side and non-operated/healthy side in patients undergoing initial surgery were also compared. RESULTS: The proportion of bilateral endometriomas was higher in group A (63.6%, 21/33) than in group B (40.0%, 26/65) and group C (32.4%, 11/34) (P = 0.023). There was no statistically significant difference in serum AMH in group A before and after surgery (median 1.32 [0.84-1.86 ng/mL] vs. 1.13 [0.59-1.86 ng/mL], P = 0.098). However, significant postoperative decreases were observed in groups B (median 1.30 [0.97-1.76 ng/mL] vs. 0.91 [0.50-1.23 ng/mL], P = 0.009) and C (median 1.52 [1.02-1.81 ng/mL] vs. 1.15 [0.76-1.67 ng/mL], P = 0.006). In group C, the follicle-stimulating hormone/luteinizing hormone ratio also increased postoperatively (median 1.75 [1.33-2.50] vs. 2.29 [1.84-3.61], P = 0.005), while no significant differences were seen in groups A (median 1.72 [1.56-2.80] vs. 2.89 [1.89-3.54], P = 0.096) and B (median 2.14 [1.67-2.82] vs. 2.37 [1.83-3.03], P = 0.189). The clinical pregnancy rate was significantly higher in group A than in group C (60.6%, 20/33 vs. 36.4%, 12/33; P = 0.042), but not significantly different between groups A and B (60.6%, 20/33 vs. 46.9%, 30/64; P = 0.143) or groups B and C (P = 0.220). Compared with the control group, there was a statistically significant difference in preoperative AFC in the group anhydrous ethanol instillation side (median 4.0 [2.0-5.0] vs. 2.0 [0.75-3.25], P < 0.001), the group fenestration/coagulation side (median 2.0 [0-3.0] vs. 2.0 [0.75-3.25], P < 0.001), and the group ovarian cystectomy side (median 2.0 [0-4.0] vs. 2.0 [0.75-3.25], P = 0.003), with no significant differences among the three groups themselves. Compared with the control group, significant differences were also observed between the group fenestration/coagulation side (median 2.0 [1.0-3.75] vs. 2.0 [1.0-3.0], P = 0.014) and the group ovarian cystectomy side (median 2.0 [1.0-4.0] vs. 2.0 [1.0-3.0], P = 0.040), in the 15-20 mm follicles, while no significant differences were found in the group anhydrous ethanol instillation side (median 3.0 [2.0-5.0] vs. 2.0 [1.0-3.0], P = 0.108). CONCLUSION: This study suggests that laparoscopic anhydrous ethanol treatment prior to IVF/ICSI in infertile patients with ovarian endometrioma and suspected compromised ovarian reserve may be superior to fenestration/coagulation and ovarian cystectomy.