ORIGINAL ARTICLES: ENDOMETRIOSIS
The impact of laparoscopic cystectomy on ovarian reserve in patients with unilateral and bilateral endometriomas Saeed Alborzi, M.D., Pegah Keramati, M.D., Masoomeh Younesi, M.D., Alamtaj Samsami, M.D., and Nasrin Dadras, M.D. Department of Obstetrics and Gynecology, Infertility Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
Objective: To evaluate the effects of laparoscopic cystectomy on ovarian reserve in patients with endometriomas. Design: Prospective study. Setting: Private and university hospitals. Patient(s): A total of 193 patients with endometriomas undergoing laparoscopic cyctectomy. Intervention(s): Serum levels of antim€ ullerian hormone (AMH), FSH, and E2, as well as antral follicle count (AFC) were measured preoperatively and 1 week, 3 and 9 months postoperatively for AMH, and 3 months for other values. Main Outcome Measure(s): Ovarian reserve based on the comparison of AMH alterations. The secondary end points are changes in FSH, E2, and AFC. Result(s): Serum AMH level decreased significantly from the baseline (3.86 3.58 ng/mL) to 1 week (1.66 1.92 ng/mL), 3 months (2.06 2.5 ng/mL), and 9 months (1.77 1.76 ng/mL) postoperatively. Those patients with bilateral endometriomas had significantly lower levels of AMH, 1 week, 3 and 9 months after operation. Also, patients older than 38 years had lower postoperative AMH levels. The FSH levels increased significantly from baseline to 3 months postoperatively. The AFC level increased significantly from baseline to 3 months after operation. Conclusion(s): The AMH level decreased and the FSH level increased after laparoscopic cysUse your smartphone tectomy for endometriomas, especially in older patients and those with bilateral cysts. (Fertil to scan this QR code SterilÒ 2014;101:427–34. Ó2014 by American Society for Reproductive Medicine.) and connect to the Key Words: Laparoscopic cystectomy, endometrioma, ovarian reserve Discuss: You can discuss this article with its authors and with other ASRM members at http:// fertstertforum.com/alborzis-laparoscopic-cystectomy-ovarian-reserve-endometrioma/
E
ndometriosis refers to the presence of endometrial glands and stroma outside of the uterine cavity. It is a common gynecologic condition, often presenting with pelvic pain and infertility. Endometrioma is the formation of ovarian cyst lining by the endometrial glands and stroma, accounting for 17%–44% of patients with endometriosis (1, 2). It is surrounded by a pseudocapsule adjacent to healthy ovarian tissue.
There are two proposed theories— coelomic metaplasia of the ovarian epithelium or the invagination of the inverted ovarian cortex after implantation of the endometriotic foci on the ovarian surface (2, 3). Treatment of endometriosis is still a challenging issue. Because it is encountered most frequently in reproductive aged women, preservation of reproductive function is the main goal. Therefore the least invasive and the least
Received March 2, 2013; revised September 25, 2013; accepted October 9, 2013; published online November 20, 2013. S.A. has nothing to disclose. P.K. has nothing to disclose. M.Y. has nothing to disclose. A.S. has nothing to disclose. N.D. has nothing to disclose. Reprint requests: Saeed Alborzi, M.D., Division of Gynecologic Endoscopy, P.O. Box 71345-1818, Shiraz, Iran (E-mail: [email protected]). Fertility and Sterility® Vol. 101, No. 2, February 2014 0015-0282/$36.00 Copyright ©2014 American Society for Reproductive Medicine, Published by Elsevier Inc. http://dx.doi.org/10.1016/j.fertnstert.2013.10.019 VOL. 101 NO. 2 / FEBRUARY 2014
discussion forum for this article now.*
* Download a free QR code scanner by searching for “QR scanner” in your smartphone’s app store or app marketplace.
expensive approach that will restore normal anatomy, reduce pain, prevent recurrence, and increase pregnancy rate (PR) should be implemented (1, 4). Patients with endometriomas or pelvic adhesion, as well as infertility would not benefit from medical therapy. Based on the current evidence, laparoscopic ovarian cystectomy appears to be the method of choice (5–7). Despite the improvements in technique and management of symptomatic patients with endometriomas, there is growing concern about the negative impact on ovarian reserve due to inadvertent removal or destruction of the healthy ovarian tissue adjacent to the pseudocapsule of the cyst (8–10).
427
ORIGINAL ARTICLE: ENDOMETRIOSIS Ovarian reserve refers to the functional potential of the ovary, reflected as the number and quality of the remaining primordial follicles at any given time. There are various tests and markers of ovarian reserve, none of which has as yet been shown to be ideal. Static tests include age, FSH, LH, E2, FSH:LH ratio, antim€ ullerian hormone (AMH), inhibin B, and sonographic variables such as ovarian volume, antral follicle count (AFC), and stromal blood flow. Dynamic tests include clomiphene citrate (CC) challenge test, exogenous FSH ovarian reserve test, and GnRH agonist stimulation test (11, 12). Recently, AMH has been suggested as the most reliable and reproducible marker, because it is menstrual cycle independent and unaffected by the use of hormonal drugs (13). In the present study, some of the most clinically useful and applicable markers of ovarian reserve, including levels of AMH, FSH, E2, and AFC, were measured before and after laparoscopic cystectomy of endometriomas to determine the ovarian reserve modifications after this operation. We also evaluated effects of age, size of the cyst, bilaterality, multiplicity, and histopathologic grade on the ovarian reserve after laparoscopic excision.
MATERIALS AND METHODS Study Population In this prospective study, 193 patients with endometriomas, referred to private and university hospitals of Shiraz University of Medical Sciences, who underwent laparoscopic ovarian cystectomy between June 2010 and July 2012 were studied. Included in the study were 18–43-year-old women with regular menses, unilateral or bilateral, single or multiple endometriomas, presenting with pelvic pain or infertility. Exclusion criteria were: [1] previous adnexal surgery, [2] hormone therapy (HT) or oral contraception (OC) for the past three cycles, [3] other endocrine diseases such as thyroid disease, hyperprolactinemia, diabetes mellitus, or adrenal disorders, [4] suspected or proven ovarian malignancy, and [5] evidence of premature ovarian failure (POF) or premature menopause. The study protocol was approved by the institutional review board and the ethics committee of Shiraz University of Medical Sciences and all the recruited patients provided their informed written consents.
Study Protocol All the patients were examined physically at inclusion into the study and the findings were recorded in the data gathering form. All the patients underwent transvaginal ultrasonography preoperatively to determine the size of the endometrioma as well as its location, multiplicity, and bilaterality. The patients were divided into four groups according to age (% 38 or >38 years of age), size of the cyst (>3 cm, % 3 cm), bilaterality (bilateral or unilateral), and multiplicity (single unilateral, single bilateral, multiple unilateral, multiple bilateral) of endometriomas. The latter three groups were compared after exclusion of patients more than 38 years of age. Before the operation, 10 mL of venous blood was withdrawn to determine the serum levels of ovarian reserve markers including AMH, FSH, and E2. All of the hormonal 428
measurements were performed at the third or fourth day of the menstrual cycle. All the patients underwent laparoscopic cystectomy and were further followed postoperatively to determine the ovarian reserve. Each patient visited the clinic 1 week, 3 and 9 months postoperatively and serum levels of AMH were measured at that time. Serum levels of FSH and E2 were measured preoperatively and 3 months postoperatively. Ultrasonographic examination for evaluation of endometrioma and AFC (the total number of 2- to 10-mm antral follicles in both ovaries) was performed with a transvaginal 7.5-MHz probe (Ultrasonix OP machine) by the same gynecologist preoperatively and 3 months postoperatively on the third or fourth day of the menstrual cycle.
Hormonal Assay All hormonal measurements were performed in the same reference laboratory. Blood samples were obtained by venipuncture and the sera extracted by centrifuge. Serum FSH and E2 levels were measured by enzyme-linked fluorescent assay (VIDAS, BioMerieux SA) according to the manufacturer's instructions. Serum AMH level was measured by DSL active M€ ullerian-inhibiting substance/AMH ELISA kit (Diagnostic Systems Laboratories) and reported as nanograms per milliliter with the detection limit of 0.006 ng/mL. The intraassay and interassay coefficient of variation (CV) was 4.18% and 4.74% for FSH, 4.02% and 4.62% for AMH, and 4.12% and 6.32% for E2, respectively.
Operation Technique All laparoscopic cystectomies were performed under general anesthesia by the same gynecologic surgeon (S.A.) using Storz endoscopic instruments (Karl Storz). Through a subumbilical incision pneumoperitoneum was produced by insertion of Verres needle. A 10-mm trocar and telescope were inserted and then three other trocars were introduced. The pelvic cavity was explored and endometriosis was classified according to the revised American Society for Reproductive Medicine (ASRM) classification (14). Ovarian cystectomy was done after a sharp incision was made on the posterior surface of the cyst and traction and countertraction forces were applied by two atraumatic grasping forceps. Hemostasis was achieved by bipolar coagulation and when necessary by suture to avoid extensive use of bipolar energy, and irrigation was done with Ringer's solution. All adhesions were lysed and excised by sharp dissection and deep infiltrative endometriosis lesions were resected to the extent to restore normal anatomical relations.
Histopathologic Analysis All resected cyst walls and deep infiltrative endometriosis specimens were sent to the pathology laboratory, and endometriosis was confirmed histopathologically. Also, the tissue was evaluated for the presence of adjacent healthy ovarian tissue to determine the extent of inadvertently excised ovarian tissue, and graded on a scale of 0 to 4 (0 ¼ complete absence of follicles; 1 ¼ primordial follicles only; 2 ¼ primordial and primary follicles; 3 ¼ secondary follicles; and VOL. 101 NO. 2 / FEBRUARY 2014
Fertility and Sterility® 4 ¼ pattern of primary and secondary follicles in healthy ovary) (15). Five to 10 sections of each ovary were analyzed by the pathologist.
Statistical Analysis The statistical software package SPSS for Windows, version 16.0 was used for data analysis. Paired sample t-test was used to compare the parametric variables before and after the operation; independent t-test to compare between two groups; one-way analysis of variance (ANOVA) and least significant difference (LSD) as post-hoc test to compare between more than two groups. Nonparametric variables were compared by the c2 test. Spearman's correlation test was applied to evaluate the correlation between ovarian reserve markers and histopathologic grade of the follicular loss, as well as stage of endometriosis. Data are presented as mean SD and proportions as appropriate. A two-sided P value less than .05 was considered statistically significant.
RESULTS In total we included 193 patients with mean age of 28.43 5.35 years among whom 72 (37.3%) had bilateral and 121 (62.7%) had unilateral endometriomas. Deep infiltrative endometriosis was reported in 183 patients (94.8%). The patients' baseline characteristics are summarized in Table 1. The serum levels of AMH decreased significantly 1 week (P< .001), 3 months (P< .001), and 9 months (P< .001) post-
TABLE 1 Baseline characteristics of the 193 patients with endometrioma undergoing laparoscopic cystectomy. Variable Age (y) Age group %38 (%) Age group >38 (%) Location Unilateral (%) Bilateral (%) Cyst size >3 cm (%) %3 cm (%) No. of cysts Single, unilateral (%) Single, bilateral (%) Multiple, unilateral (%) Multiple, bilateral (%) Endometriosis stage III (%) IV (%) Pathologic grade 0 (%) I (%) II (%) III (%) IV (%) Chief complaint Infertility Pain Revised ASRM score
Value (n [ 193) 28.43 5.35 184 (95.3) 9 (4.7) 121 (62.7) 72 (37.3) 175 (90.7) 18 (9.3) 107 (55.4) 49 (25.4) 14 (7.3) 23 (11.9) 69 (35.8) 124 (62.4) 40 (20.7) 35 (18.1) 48 (24.9) 5 (2.6) 65 (33.7) 36 (18.7) 157 (81.3) 60.36 31.84
Note: ASRM ¼ American Society for Reproductive Medicine. Alborzi. Ovarian reserve after endometrioma excision. Fertil Steril 2014.
VOL. 101 NO. 2 / FEBRUARY 2014
operatively. The AMH level increased significantly from 1 week to 3 months after operation (P< .001), but remained approximately unchanged until month 9 (P ¼ .519). The serum levels of FSH increased significantly 3 months (P ¼ .039) after the operation. Although the AFC increased significantly 3 months after the operation (P< .001), the serum level of E2 remained unchanged (P ¼ .318). The changes of ovarian reserve markers after the laparoscopic cystectomy in summarized in Table 2. We compared the role of age, cyst size, bilaterality, and multiplicity on the changes of AMH level after laparoscopic cystectomy. The changes of AMH in these groups are summarized in Table 3. Patients older than 38 years had significantly lower baseline serum level of AMH when compared with those younger than 38 years (1.58 2.53 vs. 3.97 3.59 ng/mL; P ¼ .003). Similar trend of decline in AMH was recorded in those older than 38 and younger than 38 years (Table 3). However, older patients had significantly lower AMH levels 1 week (P< .001), 3 months (P< .001), and 9 months (P< .001) after the operation (Fig. 1A). There was no significant difference between those with large and small cysts (3 cm as a cutoff value) regarding the baseline level of AMH (3.97 3.66 ng/mL vs. 2.84 2.59 ng/mL; P ¼ .152). The trend of decrease in AMH after the operation was similar between these two study groups (Table 3). However, there was no significant difference regarding AMH level between those with large and small cysts 1 week (P ¼ .279), 3 months (P ¼ .386), and 9 months (P ¼ .617) after the operation (Fig. 1B). There were 72 patients (37.3%) with bilateral and 121 patients (62.7%) with unilateral endometriomas. The baseline AMH level was comparable between these two groups (3.29 3.28 ng/mL vs. 4.19 3.71 ng/mL; P ¼ .072). The AMH level decreased significantly 9 months after the operation in those with unilateral (P< .001) and bilateral (P< .001) cysts. The pattern was also comparable between two study groups (Fig. 1C). We found that those with bilateral cysts who underwent laparoscopic cystectomy had significantly lower levels of AMH 1 week (P< .001), 3 months (P< .001), and 9 months (P ¼ .010) after the operation (Table 3). Those with single unilateral cysts had significantly higher baseline levels of AMH when compared with those with single bilateral cysts (P ¼ .006). Also, the baseline serum levels of AMH was higher in those with multiple bilateral cysts compared with those with single bilateral ones (P ¼ .027). The trend of changes of AMH levels after the operation was similar in all groups except for those with multiple unilateral cysts in whom the AMH level did not decreased significantly (P ¼ .144) (Fig. 1D). Patients with single unilateral cysts had significantly lower levels of AMH 1 week (P ¼ .004) and 3 months (P ¼ .004) after the operation. The serum levels of AMH 9 months after the operation was comparable between all groups (P ¼ .132; Table 3).
DISCUSSION At present, laparoscopic ovarian cystectomy for endometriomas has been declared the treatment of choice (5), with the reported benefits of a decrease in the recurrence of sign 429
ORIGINAL ARTICLE: ENDOMETRIOSIS
TABLE 2 The mean levels of ovarian reserve markers before and after laparoscopic ovarian cystectomy in 193 patients with endometriomas.
AMH (ng/mL) FSH (mIU/mL) E2 (pg/mL) AFC
Preoperative
Postoperative 1 week
Postoperative 3 months
Postoperative 9 months
P value
3.86 3.58 6.28 3.79 54.7 49.5 7.81 3.22
1.66 1.92 — — —
2.06 2.5 6.99 3.92 50.7 45.1 10.75 3.68
1.77 1.76 — — —
< .001 .039 .318 < .001
a
a
a
Note: AFC ¼ antral follicle count; AMH ¼ antim€ ullerian hormone. a Significant difference for serum level of AMH when compared with baseline. Alborzi. Ovarian reserve after endometrioma excision. Fertil Steril 2014.
and symptoms and reoperation risk, increase in responsiveness to ovarian stimulation, and cumulative PR in randomized controlled trials (5, 6). Because of different patients' complaints and the risk of decrease in ovarian reserve after laparoscopic cystectomy, the researchers are investigating new techniques to reach the individual's treatment goals with the least adverse effect on the healthy ovarian tissue (16–18). This study has been conducted on patients with endometriomas undergoing laparoscopic cystectomy to assess the effects of the surgery on ovarian reserve markers. We found a significant decline in serum AMH level from baseline to 1 week, and 3 and 9 months postoperatively. This is consistent with other studies with follow-up periods of 1 month (19, 20), 3 months (19, 21– 23), and 9 months (24) despite the heterogeneity in their age, patients' clinical characteristics, and small population of subjects included in their study. Two studies failed to show a statistically significant decline in serum AMH level 3 months after the surgery (20, 25). With 1 month surgical follow-up, a significant decline in AMH level was detected by Hirokawa et al. (26) and Iwase et al. (27) but not by Ercan et al. (28) and Litta et al. (29). Sugita et al. (24) demonstrated that serum level of AMH decreases 1 month and 1 year after laparoscopic cystectomy. However, some patients showed higher AMH levels 1 year after surgery than 1 month after surgery. These findings suggest that the decrease in the
serum AMH levels caused by cystectomy can recover (24). Our results along with other reports (19–24) suggest that removal of the ovarian cortex might be involved in the decrease of the ovarian reserve just after surgery, and that a continuous decrease of the ovarian reserve after cystectomy might be attributed to other mechanisms. A lower serum AMH level 1 week postoperatively would be expected due to inflammation, edema, vascular injury, and ischemia. In our study, the significant increase in serum AMH level 3 months after surgery could be explained by a good healing process and reperfusion of the operated ovaries. But we detected no significant increase in level from 3–9 months after the operation, which could be explained by the removal of antral follicles that may not be recovered in 9 months. In addition the increasing age, as the independent risk factor for decreasing the ovarian reserve, could be responsible for decreased levels of AMH 9 months after the operation. Jadoul and co-workers (30) performed a review to determine the role of different surgical techniques for endometriosis on ovarian reserve. They reported that repeated surgeries are associated with a severe decrease in ovarian reserve. It was also demonstrated that considerable surgical expertise is required to maintain the ovarian reserve in endometrioma surgery. However, the lack of comparative studies yields no conclusions on the best surgical technique (30).
TABLE 3 €llerian hormone before and after laparoscopic ovarian cystectomy in 193 patients with endometriomas in different The serum level of antimu groups.
Age %38 y >38 y Cyst size >3 cm %3 cm Bilaterality Unilateral Bilateral No. of cysts Single, unilateral Single, bilateral Multiple, unilateral Multiple, bilateral a
Preoperative
Postoperative 1 week
Postoperative 3 months
Postoperative 9 months
P value
3.97 3.59 1.58 2.53
1.74 3.59a 0.23 0.16a
2.15 2.53a 0.37 0.33a
1.80 1.76a 0.06 0.13a
< .001 < .001
3.97 3.66 2.84 2.59
1.72 1.99a 1.03 0.82a
2.14 2.59a 1.34 1.02a
1.80 1.78a 1.45 1.02a
.018 .022
4.19 3.71 3.29 3.28
1.99 2.08a 1.03 1.40a
2.53 2.82a 1.24 1.48a
2.18 1.87a 1.19 1.43a
< .001 < .001
4.31 3.82 2.60 1.98 3.38 2.57 4.60 4.79
1.99 2.17a 0.73 0.62a 2.03 1.15 1.66 2.20a
2.53 2.92a 1.07 0.97a 2.74 1.86 1.48 2.15a
2.25 1.89a 1.13 1.44a 1.77 1.68 1.18 1.41a
.016 .004 .144 .028
P< .005 for antim€ ullerian hormone when compared with the baseline.
Alborzi. Ovarian reserve after endometrioma excision. Fertil Steril 2014.
430
VOL. 101 NO. 2 / FEBRUARY 2014
Fertility and Sterility®
FIGURE 1
Changes in serum antimullerian hormone (AMH) levels in different age (A), size (B), bilatrality (C), and number (D) groups. Asterisks denote statistically significant changes; values are reported in the text. (D) One-way analysis of variance (ANOVA) with post hoc least significant difference (LSD) test was used to compare the groups. A significant decrease in AMH levels was observed at the third postoperative (postop) month in multiple bilateral endometriomas compared with single unilateral and multiple unilateral cysts. Preop ¼ preoperative. Alborzi. Ovarian reserve after endometrioma excision. Fertil Steril 2014.
Ercan et al. (25) found normal Doppler indices of the operated ovaries at the third postoperative month as a marker of good revascularization with no change in ovarian volume. However, another study (31) reported adverse changes after laparoscopic stripping of endometriomas on vascular supply of the operated ovaries. Candiani et al. (32) demonstrated no significant changes in stromal blood flow despite the significant reduction in the ovarian volume and they support a role for local inflammation. Chang et al. (20) reported a steady increase in serum AMH level from 1 week to 9 months after operation, up to a 65% recovery of the preoperation level, although their study was conducted on a very small number of patients. Although the hypothesis of the damaging effect of the laparoscopic cystectomy on ovarian reserve emerges from histopathologic studies that showed the presence of healthy ovarian tissue adjacent to the pseudocapsule of the cyst (8, 33), other studies and ours found no correlation VOL. 101 NO. 2 / FEBRUARY 2014
between the histopathologic grade of follicular loss and decrease in ovarian reserve (26, 34), except for one study by Kitajima et al. (21). No data exist on longer term follow-up periods to establish whether this increase in AMH level would continue or reach a steady state. Biacchiardi et al. (23) reported a significant decrease in serum AMH level 9 months after operation, but a nearly steady state from 3–9 months after surgery. Celik et al. (34) documented a significant progressive decline from the baseline and 6 weeks postoperatively up to 6 months. Also, another study (18) showed a significant decline in AMH level 6 months after surgery. This decline in the serum AMH level did not reach a clinically significant level (
The impact of laparoscopic cystectomy on ovarian reserve in patients with unilateral and bilateral endometriomas Saeed Alborzi, M.D., Pegah Keramati, M.D., Masoomeh Younesi, M.D., Alamtaj Samsami, M.D., and Nasrin Dadras, M.D. Department of Obstetrics and Gynecology, Infertility Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
Objective: To evaluate the effects of laparoscopic cystectomy on ovarian reserve in patients with endometriomas. Design: Prospective study. Setting: Private and university hospitals. Patient(s): A total of 193 patients with endometriomas undergoing laparoscopic cyctectomy. Intervention(s): Serum levels of antim€ ullerian hormone (AMH), FSH, and E2, as well as antral follicle count (AFC) were measured preoperatively and 1 week, 3 and 9 months postoperatively for AMH, and 3 months for other values. Main Outcome Measure(s): Ovarian reserve based on the comparison of AMH alterations. The secondary end points are changes in FSH, E2, and AFC. Result(s): Serum AMH level decreased significantly from the baseline (3.86 3.58 ng/mL) to 1 week (1.66 1.92 ng/mL), 3 months (2.06 2.5 ng/mL), and 9 months (1.77 1.76 ng/mL) postoperatively. Those patients with bilateral endometriomas had significantly lower levels of AMH, 1 week, 3 and 9 months after operation. Also, patients older than 38 years had lower postoperative AMH levels. The FSH levels increased significantly from baseline to 3 months postoperatively. The AFC level increased significantly from baseline to 3 months after operation. Conclusion(s): The AMH level decreased and the FSH level increased after laparoscopic cysUse your smartphone tectomy for endometriomas, especially in older patients and those with bilateral cysts. (Fertil to scan this QR code SterilÒ 2014;101:427–34. Ó2014 by American Society for Reproductive Medicine.) and connect to the Key Words: Laparoscopic cystectomy, endometrioma, ovarian reserve Discuss: You can discuss this article with its authors and with other ASRM members at http:// fertstertforum.com/alborzis-laparoscopic-cystectomy-ovarian-reserve-endometrioma/
E
ndometriosis refers to the presence of endometrial glands and stroma outside of the uterine cavity. It is a common gynecologic condition, often presenting with pelvic pain and infertility. Endometrioma is the formation of ovarian cyst lining by the endometrial glands and stroma, accounting for 17%–44% of patients with endometriosis (1, 2). It is surrounded by a pseudocapsule adjacent to healthy ovarian tissue.
There are two proposed theories— coelomic metaplasia of the ovarian epithelium or the invagination of the inverted ovarian cortex after implantation of the endometriotic foci on the ovarian surface (2, 3). Treatment of endometriosis is still a challenging issue. Because it is encountered most frequently in reproductive aged women, preservation of reproductive function is the main goal. Therefore the least invasive and the least
Received March 2, 2013; revised September 25, 2013; accepted October 9, 2013; published online November 20, 2013. S.A. has nothing to disclose. P.K. has nothing to disclose. M.Y. has nothing to disclose. A.S. has nothing to disclose. N.D. has nothing to disclose. Reprint requests: Saeed Alborzi, M.D., Division of Gynecologic Endoscopy, P.O. Box 71345-1818, Shiraz, Iran (E-mail: [email protected]). Fertility and Sterility® Vol. 101, No. 2, February 2014 0015-0282/$36.00 Copyright ©2014 American Society for Reproductive Medicine, Published by Elsevier Inc. http://dx.doi.org/10.1016/j.fertnstert.2013.10.019 VOL. 101 NO. 2 / FEBRUARY 2014
discussion forum for this article now.*
* Download a free QR code scanner by searching for “QR scanner” in your smartphone’s app store or app marketplace.
expensive approach that will restore normal anatomy, reduce pain, prevent recurrence, and increase pregnancy rate (PR) should be implemented (1, 4). Patients with endometriomas or pelvic adhesion, as well as infertility would not benefit from medical therapy. Based on the current evidence, laparoscopic ovarian cystectomy appears to be the method of choice (5–7). Despite the improvements in technique and management of symptomatic patients with endometriomas, there is growing concern about the negative impact on ovarian reserve due to inadvertent removal or destruction of the healthy ovarian tissue adjacent to the pseudocapsule of the cyst (8–10).
427
ORIGINAL ARTICLE: ENDOMETRIOSIS Ovarian reserve refers to the functional potential of the ovary, reflected as the number and quality of the remaining primordial follicles at any given time. There are various tests and markers of ovarian reserve, none of which has as yet been shown to be ideal. Static tests include age, FSH, LH, E2, FSH:LH ratio, antim€ ullerian hormone (AMH), inhibin B, and sonographic variables such as ovarian volume, antral follicle count (AFC), and stromal blood flow. Dynamic tests include clomiphene citrate (CC) challenge test, exogenous FSH ovarian reserve test, and GnRH agonist stimulation test (11, 12). Recently, AMH has been suggested as the most reliable and reproducible marker, because it is menstrual cycle independent and unaffected by the use of hormonal drugs (13). In the present study, some of the most clinically useful and applicable markers of ovarian reserve, including levels of AMH, FSH, E2, and AFC, were measured before and after laparoscopic cystectomy of endometriomas to determine the ovarian reserve modifications after this operation. We also evaluated effects of age, size of the cyst, bilaterality, multiplicity, and histopathologic grade on the ovarian reserve after laparoscopic excision.
MATERIALS AND METHODS Study Population In this prospective study, 193 patients with endometriomas, referred to private and university hospitals of Shiraz University of Medical Sciences, who underwent laparoscopic ovarian cystectomy between June 2010 and July 2012 were studied. Included in the study were 18–43-year-old women with regular menses, unilateral or bilateral, single or multiple endometriomas, presenting with pelvic pain or infertility. Exclusion criteria were: [1] previous adnexal surgery, [2] hormone therapy (HT) or oral contraception (OC) for the past three cycles, [3] other endocrine diseases such as thyroid disease, hyperprolactinemia, diabetes mellitus, or adrenal disorders, [4] suspected or proven ovarian malignancy, and [5] evidence of premature ovarian failure (POF) or premature menopause. The study protocol was approved by the institutional review board and the ethics committee of Shiraz University of Medical Sciences and all the recruited patients provided their informed written consents.
Study Protocol All the patients were examined physically at inclusion into the study and the findings were recorded in the data gathering form. All the patients underwent transvaginal ultrasonography preoperatively to determine the size of the endometrioma as well as its location, multiplicity, and bilaterality. The patients were divided into four groups according to age (% 38 or >38 years of age), size of the cyst (>3 cm, % 3 cm), bilaterality (bilateral or unilateral), and multiplicity (single unilateral, single bilateral, multiple unilateral, multiple bilateral) of endometriomas. The latter three groups were compared after exclusion of patients more than 38 years of age. Before the operation, 10 mL of venous blood was withdrawn to determine the serum levels of ovarian reserve markers including AMH, FSH, and E2. All of the hormonal 428
measurements were performed at the third or fourth day of the menstrual cycle. All the patients underwent laparoscopic cystectomy and were further followed postoperatively to determine the ovarian reserve. Each patient visited the clinic 1 week, 3 and 9 months postoperatively and serum levels of AMH were measured at that time. Serum levels of FSH and E2 were measured preoperatively and 3 months postoperatively. Ultrasonographic examination for evaluation of endometrioma and AFC (the total number of 2- to 10-mm antral follicles in both ovaries) was performed with a transvaginal 7.5-MHz probe (Ultrasonix OP machine) by the same gynecologist preoperatively and 3 months postoperatively on the third or fourth day of the menstrual cycle.
Hormonal Assay All hormonal measurements were performed in the same reference laboratory. Blood samples were obtained by venipuncture and the sera extracted by centrifuge. Serum FSH and E2 levels were measured by enzyme-linked fluorescent assay (VIDAS, BioMerieux SA) according to the manufacturer's instructions. Serum AMH level was measured by DSL active M€ ullerian-inhibiting substance/AMH ELISA kit (Diagnostic Systems Laboratories) and reported as nanograms per milliliter with the detection limit of 0.006 ng/mL. The intraassay and interassay coefficient of variation (CV) was 4.18% and 4.74% for FSH, 4.02% and 4.62% for AMH, and 4.12% and 6.32% for E2, respectively.
Operation Technique All laparoscopic cystectomies were performed under general anesthesia by the same gynecologic surgeon (S.A.) using Storz endoscopic instruments (Karl Storz). Through a subumbilical incision pneumoperitoneum was produced by insertion of Verres needle. A 10-mm trocar and telescope were inserted and then three other trocars were introduced. The pelvic cavity was explored and endometriosis was classified according to the revised American Society for Reproductive Medicine (ASRM) classification (14). Ovarian cystectomy was done after a sharp incision was made on the posterior surface of the cyst and traction and countertraction forces were applied by two atraumatic grasping forceps. Hemostasis was achieved by bipolar coagulation and when necessary by suture to avoid extensive use of bipolar energy, and irrigation was done with Ringer's solution. All adhesions were lysed and excised by sharp dissection and deep infiltrative endometriosis lesions were resected to the extent to restore normal anatomical relations.
Histopathologic Analysis All resected cyst walls and deep infiltrative endometriosis specimens were sent to the pathology laboratory, and endometriosis was confirmed histopathologically. Also, the tissue was evaluated for the presence of adjacent healthy ovarian tissue to determine the extent of inadvertently excised ovarian tissue, and graded on a scale of 0 to 4 (0 ¼ complete absence of follicles; 1 ¼ primordial follicles only; 2 ¼ primordial and primary follicles; 3 ¼ secondary follicles; and VOL. 101 NO. 2 / FEBRUARY 2014
Fertility and Sterility® 4 ¼ pattern of primary and secondary follicles in healthy ovary) (15). Five to 10 sections of each ovary were analyzed by the pathologist.
Statistical Analysis The statistical software package SPSS for Windows, version 16.0 was used for data analysis. Paired sample t-test was used to compare the parametric variables before and after the operation; independent t-test to compare between two groups; one-way analysis of variance (ANOVA) and least significant difference (LSD) as post-hoc test to compare between more than two groups. Nonparametric variables were compared by the c2 test. Spearman's correlation test was applied to evaluate the correlation between ovarian reserve markers and histopathologic grade of the follicular loss, as well as stage of endometriosis. Data are presented as mean SD and proportions as appropriate. A two-sided P value less than .05 was considered statistically significant.
RESULTS In total we included 193 patients with mean age of 28.43 5.35 years among whom 72 (37.3%) had bilateral and 121 (62.7%) had unilateral endometriomas. Deep infiltrative endometriosis was reported in 183 patients (94.8%). The patients' baseline characteristics are summarized in Table 1. The serum levels of AMH decreased significantly 1 week (P< .001), 3 months (P< .001), and 9 months (P< .001) post-
TABLE 1 Baseline characteristics of the 193 patients with endometrioma undergoing laparoscopic cystectomy. Variable Age (y) Age group %38 (%) Age group >38 (%) Location Unilateral (%) Bilateral (%) Cyst size >3 cm (%) %3 cm (%) No. of cysts Single, unilateral (%) Single, bilateral (%) Multiple, unilateral (%) Multiple, bilateral (%) Endometriosis stage III (%) IV (%) Pathologic grade 0 (%) I (%) II (%) III (%) IV (%) Chief complaint Infertility Pain Revised ASRM score
Value (n [ 193) 28.43 5.35 184 (95.3) 9 (4.7) 121 (62.7) 72 (37.3) 175 (90.7) 18 (9.3) 107 (55.4) 49 (25.4) 14 (7.3) 23 (11.9) 69 (35.8) 124 (62.4) 40 (20.7) 35 (18.1) 48 (24.9) 5 (2.6) 65 (33.7) 36 (18.7) 157 (81.3) 60.36 31.84
Note: ASRM ¼ American Society for Reproductive Medicine. Alborzi. Ovarian reserve after endometrioma excision. Fertil Steril 2014.
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operatively. The AMH level increased significantly from 1 week to 3 months after operation (P< .001), but remained approximately unchanged until month 9 (P ¼ .519). The serum levels of FSH increased significantly 3 months (P ¼ .039) after the operation. Although the AFC increased significantly 3 months after the operation (P< .001), the serum level of E2 remained unchanged (P ¼ .318). The changes of ovarian reserve markers after the laparoscopic cystectomy in summarized in Table 2. We compared the role of age, cyst size, bilaterality, and multiplicity on the changes of AMH level after laparoscopic cystectomy. The changes of AMH in these groups are summarized in Table 3. Patients older than 38 years had significantly lower baseline serum level of AMH when compared with those younger than 38 years (1.58 2.53 vs. 3.97 3.59 ng/mL; P ¼ .003). Similar trend of decline in AMH was recorded in those older than 38 and younger than 38 years (Table 3). However, older patients had significantly lower AMH levels 1 week (P< .001), 3 months (P< .001), and 9 months (P< .001) after the operation (Fig. 1A). There was no significant difference between those with large and small cysts (3 cm as a cutoff value) regarding the baseline level of AMH (3.97 3.66 ng/mL vs. 2.84 2.59 ng/mL; P ¼ .152). The trend of decrease in AMH after the operation was similar between these two study groups (Table 3). However, there was no significant difference regarding AMH level between those with large and small cysts 1 week (P ¼ .279), 3 months (P ¼ .386), and 9 months (P ¼ .617) after the operation (Fig. 1B). There were 72 patients (37.3%) with bilateral and 121 patients (62.7%) with unilateral endometriomas. The baseline AMH level was comparable between these two groups (3.29 3.28 ng/mL vs. 4.19 3.71 ng/mL; P ¼ .072). The AMH level decreased significantly 9 months after the operation in those with unilateral (P< .001) and bilateral (P< .001) cysts. The pattern was also comparable between two study groups (Fig. 1C). We found that those with bilateral cysts who underwent laparoscopic cystectomy had significantly lower levels of AMH 1 week (P< .001), 3 months (P< .001), and 9 months (P ¼ .010) after the operation (Table 3). Those with single unilateral cysts had significantly higher baseline levels of AMH when compared with those with single bilateral cysts (P ¼ .006). Also, the baseline serum levels of AMH was higher in those with multiple bilateral cysts compared with those with single bilateral ones (P ¼ .027). The trend of changes of AMH levels after the operation was similar in all groups except for those with multiple unilateral cysts in whom the AMH level did not decreased significantly (P ¼ .144) (Fig. 1D). Patients with single unilateral cysts had significantly lower levels of AMH 1 week (P ¼ .004) and 3 months (P ¼ .004) after the operation. The serum levels of AMH 9 months after the operation was comparable between all groups (P ¼ .132; Table 3).
DISCUSSION At present, laparoscopic ovarian cystectomy for endometriomas has been declared the treatment of choice (5), with the reported benefits of a decrease in the recurrence of sign 429
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TABLE 2 The mean levels of ovarian reserve markers before and after laparoscopic ovarian cystectomy in 193 patients with endometriomas.
AMH (ng/mL) FSH (mIU/mL) E2 (pg/mL) AFC
Preoperative
Postoperative 1 week
Postoperative 3 months
Postoperative 9 months
P value
3.86 3.58 6.28 3.79 54.7 49.5 7.81 3.22
1.66 1.92 — — —
2.06 2.5 6.99 3.92 50.7 45.1 10.75 3.68
1.77 1.76 — — —
< .001 .039 .318 < .001
a
a
a
Note: AFC ¼ antral follicle count; AMH ¼ antim€ ullerian hormone. a Significant difference for serum level of AMH when compared with baseline. Alborzi. Ovarian reserve after endometrioma excision. Fertil Steril 2014.
and symptoms and reoperation risk, increase in responsiveness to ovarian stimulation, and cumulative PR in randomized controlled trials (5, 6). Because of different patients' complaints and the risk of decrease in ovarian reserve after laparoscopic cystectomy, the researchers are investigating new techniques to reach the individual's treatment goals with the least adverse effect on the healthy ovarian tissue (16–18). This study has been conducted on patients with endometriomas undergoing laparoscopic cystectomy to assess the effects of the surgery on ovarian reserve markers. We found a significant decline in serum AMH level from baseline to 1 week, and 3 and 9 months postoperatively. This is consistent with other studies with follow-up periods of 1 month (19, 20), 3 months (19, 21– 23), and 9 months (24) despite the heterogeneity in their age, patients' clinical characteristics, and small population of subjects included in their study. Two studies failed to show a statistically significant decline in serum AMH level 3 months after the surgery (20, 25). With 1 month surgical follow-up, a significant decline in AMH level was detected by Hirokawa et al. (26) and Iwase et al. (27) but not by Ercan et al. (28) and Litta et al. (29). Sugita et al. (24) demonstrated that serum level of AMH decreases 1 month and 1 year after laparoscopic cystectomy. However, some patients showed higher AMH levels 1 year after surgery than 1 month after surgery. These findings suggest that the decrease in the
serum AMH levels caused by cystectomy can recover (24). Our results along with other reports (19–24) suggest that removal of the ovarian cortex might be involved in the decrease of the ovarian reserve just after surgery, and that a continuous decrease of the ovarian reserve after cystectomy might be attributed to other mechanisms. A lower serum AMH level 1 week postoperatively would be expected due to inflammation, edema, vascular injury, and ischemia. In our study, the significant increase in serum AMH level 3 months after surgery could be explained by a good healing process and reperfusion of the operated ovaries. But we detected no significant increase in level from 3–9 months after the operation, which could be explained by the removal of antral follicles that may not be recovered in 9 months. In addition the increasing age, as the independent risk factor for decreasing the ovarian reserve, could be responsible for decreased levels of AMH 9 months after the operation. Jadoul and co-workers (30) performed a review to determine the role of different surgical techniques for endometriosis on ovarian reserve. They reported that repeated surgeries are associated with a severe decrease in ovarian reserve. It was also demonstrated that considerable surgical expertise is required to maintain the ovarian reserve in endometrioma surgery. However, the lack of comparative studies yields no conclusions on the best surgical technique (30).
TABLE 3 €llerian hormone before and after laparoscopic ovarian cystectomy in 193 patients with endometriomas in different The serum level of antimu groups.
Age %38 y >38 y Cyst size >3 cm %3 cm Bilaterality Unilateral Bilateral No. of cysts Single, unilateral Single, bilateral Multiple, unilateral Multiple, bilateral a
Preoperative
Postoperative 1 week
Postoperative 3 months
Postoperative 9 months
P value
3.97 3.59 1.58 2.53
1.74 3.59a 0.23 0.16a
2.15 2.53a 0.37 0.33a
1.80 1.76a 0.06 0.13a
< .001 < .001
3.97 3.66 2.84 2.59
1.72 1.99a 1.03 0.82a
2.14 2.59a 1.34 1.02a
1.80 1.78a 1.45 1.02a
.018 .022
4.19 3.71 3.29 3.28
1.99 2.08a 1.03 1.40a
2.53 2.82a 1.24 1.48a
2.18 1.87a 1.19 1.43a
< .001 < .001
4.31 3.82 2.60 1.98 3.38 2.57 4.60 4.79
1.99 2.17a 0.73 0.62a 2.03 1.15 1.66 2.20a
2.53 2.92a 1.07 0.97a 2.74 1.86 1.48 2.15a
2.25 1.89a 1.13 1.44a 1.77 1.68 1.18 1.41a
.016 .004 .144 .028
P< .005 for antim€ ullerian hormone when compared with the baseline.
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FIGURE 1
Changes in serum antimullerian hormone (AMH) levels in different age (A), size (B), bilatrality (C), and number (D) groups. Asterisks denote statistically significant changes; values are reported in the text. (D) One-way analysis of variance (ANOVA) with post hoc least significant difference (LSD) test was used to compare the groups. A significant decrease in AMH levels was observed at the third postoperative (postop) month in multiple bilateral endometriomas compared with single unilateral and multiple unilateral cysts. Preop ¼ preoperative. Alborzi. Ovarian reserve after endometrioma excision. Fertil Steril 2014.
Ercan et al. (25) found normal Doppler indices of the operated ovaries at the third postoperative month as a marker of good revascularization with no change in ovarian volume. However, another study (31) reported adverse changes after laparoscopic stripping of endometriomas on vascular supply of the operated ovaries. Candiani et al. (32) demonstrated no significant changes in stromal blood flow despite the significant reduction in the ovarian volume and they support a role for local inflammation. Chang et al. (20) reported a steady increase in serum AMH level from 1 week to 9 months after operation, up to a 65% recovery of the preoperation level, although their study was conducted on a very small number of patients. Although the hypothesis of the damaging effect of the laparoscopic cystectomy on ovarian reserve emerges from histopathologic studies that showed the presence of healthy ovarian tissue adjacent to the pseudocapsule of the cyst (8, 33), other studies and ours found no correlation VOL. 101 NO. 2 / FEBRUARY 2014
between the histopathologic grade of follicular loss and decrease in ovarian reserve (26, 34), except for one study by Kitajima et al. (21). No data exist on longer term follow-up periods to establish whether this increase in AMH level would continue or reach a steady state. Biacchiardi et al. (23) reported a significant decrease in serum AMH level 9 months after operation, but a nearly steady state from 3–9 months after surgery. Celik et al. (34) documented a significant progressive decline from the baseline and 6 weeks postoperatively up to 6 months. Also, another study (18) showed a significant decline in AMH level 6 months after surgery. This decline in the serum AMH level did not reach a clinically significant level (
