The effect of laparoscopic ovarian cystectomy of endometrioma versus cyst deroofing on ovarian reserve as determined by Anti-mullerian hormone and antral follicle count: a prospective randomized study

Abstract

Endometriomas usually present as a pelvic mass arising from growth of ectopic endometrial tissue within the ovary. They typically contain thick brown tar-like fluid (hence the name "chocolate cyst") and are often densely adherent to surrounding structures, such as the peritoneum, fallopian tubes, and bowel. An endometrioma may be associated with symptoms of endometriosis (e.g., pelvic pain, dysmenorrhea, and dyspareunia) or identified at the time of evaluation for a pelvic mass or infertility. A woman with a ruptured endometrioma may initially present with peritoneal signs and symptoms, elevated white blood cell count, and low grade fever, similar to patients with acute pelvic inflammatory cystic manifestation of ovarian endometriosis.Endometrioma is found to be in 17%–44% of patients with endometriosis, represents 35% of benign ovarian cysts requiring surgery. Objectives This study aimed to evaluate the impact of laparoscopic ovarian cystectomy versus laparoscopic cyst deroofing on ovarian reserve measured by serum levels of anti mullerianhormone,antral follicle count and ovarian volume in patients with endometriomas.

Setting: Ain Shams University Maternity Hospital (ASUMH). Recruitment: Recruitment took place between March 2013 and November 2014. Patients: 122 patients aged between 18 and 35 years that have been diagnosed with endometrioma (unilateral or bilateral) by Transvaginal ultrasound and they are candidates for laparoscopic surgery. They were selected according to inclusion and exclusion criteria which was regular menstrual cycles, endometrioma with diameter ≥3 cm, no evidence of any previous ovarian surgeries, no evidence of polycystic ovarian syndrome, premature ovarian failure or endocrinal diseases, not receiving hormonal medications last 3 months before surgery, no evidence of ovarian malignancy or contra indication for surgery.

Study design: Prospective randomized clinical trial.

Study procedure: Total 122 patients were randomized into 2 groups (61 per group) according to generated computer list and were subjected to basic investigations required for general anesthesia; venous blood samples were drawn from all patients for measurement of Anti-mullerian hormone levels and stored at -80C until being essayed using commercially availableELISA kits.On the third day of the menstruation before the surgery transvaginal ultrasound examination was performed in order to calculate the antral follicle count and ovarian volume.One study group underwent laparoscopic ovarian cystectomy; the other study group underwent laparoscopic cyst deroofing. Follow up: 1 month post-operative. PrimaryOutcomes: Comparisonbetween the impacts of laparoscopic ovarian cystectomy and laparoscopic cyst deroofing on ovarian reserve as determined by alteration of AMH level in endometrioma patients. Secondaryoutcomes Detection the changes in AFC and ovarian volume. Results: AMH values shows significant decrease p< 0.001 from preoperative values Mean ± SD (4.25 ± 0.87)ng/ml in cystectomy group, and Mean ± SD (4.28 ± 1.96)ng/ml in cyst deroofing group to be during the follow up after one month post-operative with Mean± SD (1.66± 1.02)ng/ml in cystectomy group, and Mean ± SD (2.15±1.48)ng/ml in cyst deroofing group. In the cystectomized ovary the pre-operative AFC was 8.9 ± 2.6 decreased significantly p< 0.001 to 3.2 ± 1.3 after 1month in cyst deroofing group 7.3± 2.7 decreased significantly p<0.001 to 5.8±2.6 one month post-operative. In the cystectomy group, the preoperative ovarian volume was with mean ± SD= 8.3 ± 2.0 cm3, which decreased significantly p<0.001 to 3.1 ± 1.6 cm3 after 1month post operatively, in cyst deroofing group, ovarian volume was with mean ± SD = 7.30 ± 2.6 cm3 decreased significantly p < 0.001 to 5.8 ± 2.6 cm3after 1month post operative. There was significant difference between groups as regard changes in AMH (p< 0.05), TAFC (p< 0.001) and ovarian volume (p<0.001).