Surgical Excision of Endometriomas and Effect on Ovarian Reserve
Abstract & Commentary
By Michael A. Thomas, MD
Professor, Reproductive Endocrinology and Infertility,
Director, Division of Reproductive Endocrinology and
Infertility, University of Cincinnati College of Medicine
Dr. Thomas reports no financial relationships relevant to this field of study.
Synopsis: In a prospective cohort study, women with endometriomas (> 2 cm) were found to have a decrease in ovarian reserve parameters compared to healthy controls 1 and 6 months after the endometriomas were removed.
Source: Uncu G, et al. Prospective assessment of the impact of endometriomas and their removal on ovarian reserve and determinants of the rate of decline in ovarian reserve. Hum Reprod 2013;28:2140-2145.
These authors sought to determine whether surgical excision of endometriomas is associated with short- or long-term effects on ovarian reserve. A cohort of 30 women who underwent surgical removal of endometriomas (> 2 cm) because of pain or subfertility was compared to an age- and gravid-matched control group of 30 otherwise healthy women who did not have a diagnosis of endometriosis. All endometriomas were moved laparoscopically by two experienced surgeons. At the time of surgery, the endometriomas were incised and the cyst wall was stripped away from the ovarian stoma by blunt dissection. Hemostasis was achieved with cautery. The preoperative use of GnRH agonist was not utilized. Of the 30 women with endometriomas, 15 had unilateral cysts and 15 had bilateral cysts. Eighteen women had multiple endometriomas. Ovarian reserve was measured by antimullerian hormone (AMH) and antral follicle count (AFC) at baseline in both groups, and at 1 month and 6 months after surgery in the endometrioma group only.
Mean baseline AMH was 2.81 ng/mL for endometrioma patients and 4.20 ng/mL for controls (P = 0.02). Mean baseline AFC was 9.73 in endometrioma subjects and 14.7 in controls (P > 0.01). Postoperatively, AMH declined to 2.07 ng/mL at 1 month and 1.82 ng/mL at 6 months and AFC did not change (11.0 at 1 month and 10.4 at 6 months). Only the decrease in AMH from baseline to 6 months was statistically significant (P = 0.02). This decline in AMH was not significantly correlated with laterality of endometriomas (unilateral or bilateral), patient age, baseline AFC, diameter of the largest endometrioma, or the number of follicles removed from the ovary at the time of surgeries.
Approximately 0.8-5% of women in the reproductive age range are affected by endometriosis. It is well understood that their fecundity (0.02-0.10) is much lower than that found in women without endometriosis (0.15-0.20).1 Early investigators have noted that 25-50% of infertile women have endometriosis and that 30-50% of women with a diagnosis of endometriosis have infertility issues.2 Women with infertility undergoing laparoscopy have a 48% incidence of endometriosis compared to 5% found in fertile patients undergoing tubal ligation.3
Endometriomas are found in 20-40% of these women who have been diagnosed with endometriosis and can be found inadvertently during an infertility work up.4-6 However, indications for routine surgical removal of endometriomas prior to the start of any treatment for infertility are not clear.7-9
This study demonstrates two things that all practicing gynecologists should consider when treating patients who have endometriomas. The first is that endometriomas are associated with a decrease in ovarian reserve as measured by both AMH and AFC. Clinically, this makes sense because when you see endometriomas on ultrasound, there is usually only a small rim of normal ovarian stroma remaining. It is almost as if the endometrioma is "eating away" at what was once a normal ovary.
The second important finding from this article is that the surgical excision of an endometrioma will cause a decrease in AMH, but no significant change in AFC at 6 months after removal. This decrease in AMH occurred despite the fact that surgical intervention was performed to "save" ovarian integrity. However, the technique of "stripping" the endometrioma cyst wall may decrease recurrence of a future endometrioma, but may adversely affect the number of residual follicles remaining in the ovary.
Though the control group was not assessed after 6 months, AMH and AFC typically remain stable in otherwise healthy women in the late 20s to early 30s. The mean age of the endometrioma group was 29.0 years and the mean age of the control group was 30.1 years. However, a 6-month blood test and ultrasound would have made the study more complete.
In a recent study that also looked at the effects of endometrioma removal on ovarian reserve without a control group, 65 women underwent laparoscopic excision.10 The mean age was 28.4 years. AMH and AFC were obtained at 6 weeks and 6 months after surgery. These investigators noted a significant decrease in AMH from baseline (1.78 ng/mL) to 6 months (0.72 ng/mL) (P < 0.001) and the AFC increased from 4.9 at baseline to 6.4 at 6 months (P = 0.008). This study showed a potential rebound effect on the number of ovarian follicles counted, but this may demonstrate that AFC is probably not the best marker for ovarian reserve in this patient population because its determination is very subjective and likely to vary from sonographer to sonographer.
Because most patients with endometriomas also have concurrent moderate-to-severe adhesive disease, surgical intervention is usually helpful in relieving pelvic pain, constipation, and dyspareunia by decompressing the bulging ovary, lysing adhesions, and subsequently restoring pelvic anatomy. However, routine endometrioma removal should probably not be performed in the asymptomatic patient who wants to preserve her fertility because of the potential to have a detrimental long-term effect on ovarian reserve.
More studies for a longer period of observation should be undertaken on endometrioma excision with age-matched controls that are compared to either an endometrioma group that undergoes surgical excision and a second group that is observed without surgical intervention.
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