The Significance of Planned Fertility Preservation for Women With Endometrioma Before an Expected Ovarian Cystectomy

Endometrioma is known to reduce the ovarian reserve and the extent of the decrease is more severe when ovarian surgery is performed. Therefore, to prevent this decline in fertility, patients with endometrioma are considered candidates for preoperative fertility preservation (FP). In this study, we evaluate the efficacy of FP in women with endometrioma before planned ovarian surgery. A total of 95 cycles in 62 patients with endometrioma, undergoing controlled ovarian stimulation (COS) for FP using a gonadotropin-releasing hormone (GnRH) antagonist protocol before an expected ovarian surgery, were enrolled retrospectively. COS outcomes were compared according to endometrioma laterality. Additionally, first COS cycle outcomes in patients with endometrioma were compared with those in infertile patients, or in patients with a benign ovarian cyst using propensity score matching. When multiple COS cycles were performed, the results of cumulative cycles were analyzed. Embryo quality was worse in the bilateral endometrioma group. Compared with the infertile patient group, the patients with endometrioma had significantly lower Anti-Müllerian Hormone (AMH) and fewer numbers of oocytes retrieved (median, 3.3 vs. 1.2, p<0.001; 7.0 vs. 4.0, p=0.009, respectively). Compared with mature oocytes in infertile patients or patients with a benign cyst, mature oocytes were fewer in patients with endometrioma, but this was not statistically significant (median, 4.0 vs. 3.0, p=0.085; 5.5 vs. 3.0, p=0.052, respectively). The median value of the cumulative number of cryopreserved oocytes or embryos was 14.5 up to the fourth cycle compared to 3 up to the first cycle, with cumulative effect. Women with endometrioma should be counseled for FP before planned ovarian cystectomy. The number of cryopreserved oocytes or embryos can be increased by repeated cycles.

The Optimal Time of Ovarian Reserve Recovery After Laparoscopic Unilateral Ovarian Non-Endometriotic Cystectomy

BackgroundLaparoscopic ovarian cystectomy is established as the standard surgical approach for the treatment of benign ovarian cysts. However, previous studies have shown that potential fertility can be directly impaired by laparoscopic ovarian cystectomy, diminished ovarian reserve (DOR), and even premature ovarian failure. Therefore, fertility-preserving interventions are required for benign gynecologic diseases. However, there are still little data on the time period required for recovery of ovarian reserve after the laparoscopic unilateral ovarian cystectomy, which is very important for the individualization of treatment protocols. This study aimed at investigating the time needed for the ovarian reserve to recover after laparoscopic unilateral ovarian non-endometriotic cystectomy.Materials and MethodsSixty-seven patients with unilateral ovarian non-endometriotic cyst from Zhoupu and Punan Hospitals who underwent laparoscopic unilateral ovarian cystectomy were recruited as a postoperative observation group (POG). Also, 69 healthy age-matched women without ovarian cyst who did not undergo surgery were recruited as a referent group (RFG). Ovarian reserve with the serum anti-Müllerian hormone (AMH), follicle-stimulating hormone (FSH), estradiol (E2) levels, ovarian arterial resistance index (OARI), and antral follicle counts (AFCs) were measured on the third to fifth days of the same menstrual cycle. A postoperative 6-month follow-up of cases was performed.ResultsCompared with RFG, AFC of cyst side in the POG group showed no difference in the first, third, and sixth postoperative month (F = 0.03, F = 0.02, F = 0.55, respectively; p = 0.873, p = 0.878, p = 0.460, respectively). The OARI of cyst side in the POG group revealed no differences in the first, third, and sixth postoperative month (F = 0.73, F = 3.57, F = 1.75, respectively; p = 0.395, p = 0.061, p = 0.701, respectively). In the first month, the postoperative AMH levels significantly declined, reaching 1.88 ng/ml [interquartile range (IQR): 1.61–2.16 ng/ml] in POG and 2.57 ng/ml (IQR: 2.32–2.83 ng/ml) in RFG (F = 13.43, p = 0.000). For the data of AMH levels stratified by age, the same trend was observed between less than 25 and more than 26 years old. At this same time interval, the postoperative rate of decline was significantly lower compared to the preoperative one in POG (32.75%). The same trend was observed between the POG and RFG groups (26.67%).ConclusionsThe optimal time for recovery of ovarian reserve after laparoscopic unilateral ovarian cystectomy is estimated to be 6 months.

Preservation of the ovarian reserve and hemostasis during laparoscopic ovarian cystectomy by a hemostatic agent versus suturing for patients with ovarian endometriosis: study protocol for randomized controlled, non-inferiority trial (PRAHA-2 trial)

Background Endometriosis (EMS) can be implanted everywhere, especially in pelvic organs. EMS can be asymptomatic, but it can result in pelvic pain and infertility by inducing local inflammation and pelvic adhesion. The prevalence of EMS is about 10% in reproductive-age women and higher in women with pelvic pain or infertility. For young patients with ovarian EMS, laparoscopic ovarian cystectomy is effective in relieving pelvic pain and preventing local recurrence. However, there is a concern that the ovarian reserve would decrease after the operation because of the removal of a part of the normal ovarian tissue and thermal damage during hemostasis, which depends on the types of hemostasis such as bipolar electrocoagulation, suturing, and the use of a hemostatic agent. In this study, we aim to evaluate the protective effect for the ovarian reserve and hemostasis between a hemostatic agent and suturing during laparoscopic ovarian cystectomy for patients with ovarian EMS. Methods This study is a randomized controlled, non-inferiority trial, where a total of 90 patients with ovarian EMS will be randomly assigned to the experimental (hemostatic agent) and control (suturing) groups. In the control group, a barbed suture will be applied for hemostasis, whereas a hemostatic agent will be applied in the experimental group. If two methods are insufficient, bipolar electrocoagulation will be applied for complete hemostasis. As the primary endpoint, the reduction rate of serum anti- Müllerian hormone (AMH) levels reflecting the ovarian reserve will be compared between the two groups 12 weeks after surgery. As secondary endpoints, we will compare the reduction rate of AMH level 48 weeks after surgery, the time required to complete hemostasis, the success rate of hemostasis within 10 min, and adverse events associated with operation. Discussion We expect that the protective effect for the ovarian reserve and hemostasis may be comparable between the two methods, suggesting that a hemostatic agent may be preferred considering that it is easy to use during laparoscopic ovarian cystectomy. Trial registration ClinicalTrials.govNCT04643106. Registered on 22 November 2020

The ideal approach of ovarian dermoid cyst excision; the predicament of laparoscopy versus laparotomy

Purpose: The aim of the current retrospective study for reviewing the cases of dermoid cyst managed at our hospital during the study period, to find out the best and safest management approach after taking in consideration the related factors. Setting: This analysis took place at the department of Gynecology and Obstetrics at Jordan University Hospital. Material and methods: The retrospective records were reviewed for over 6 years (from January 2015 to January 2021). The sample of study included a total number of 87 patients operated with ovarian dermoid. Thirty-five patients (40.22%) presented with abdominal mass, 16 patients (18.39%) were accidently found to have this kind of ovarian cysts, 12 patients (13.79%) presented with pressure symptoms, 11 patients (12.64%) presented with dyspareunia and dysmenorrhea, 8 patients (09.19%) with abdominal pain, and 5 patients (05.74%) with recurrent attacks of nausea. Thirty-nine patients (44.83%) treated by laparotomy, another 39 patients (44.83%), the management procedure completed laparoscopically, and 9 patients (10.34%), the procedure started laparoscopically, then converted to laparotomy. Sixty-one patients (70.11%) were found to have right sided ovarian dermoid, while 19 patients (21.84%) were found to have bilateral, and 7 patients (08.05%) were found to have left sided one. The size of the cyst was more than 11 cm in 40 patients (45.98%), while less than 5 cm in 5 patients (5.75%). Results: ovarian cystectomy performed in 70 patients (80.46%), and salpingo-oophorectomy on 17 patients (19.54%) on both reproductive and postmenopausal group. The average blood loss and operative time were more on the laparoscopic group; 298.7 ml, 98.8 minutes respectively. Conclusion: Laparotomy and ovarian cystectomy seems to be superior to other methods of management for ovarian dermoid, particularly when the size of the cyst is more than 5 cm, and predominantly the cysts presentation bilaterally.

Preservation of the ovarian reserve and hemostasis during laparoscopic ovarian cystectomy by a hemostatic agent versus suturing for patients with ovarian endometriosis: study protocol for randomized controlled, non-inferiority trial (PRAHA-2 trial)

Background: Endometriosis (EMS) can be implanted everywhere, especially in pelvic organs. EMS can be asymptomatic, but it can result in pelvic pain and infertility by inducing local inflammation and pelvic adhesion. The prevalence of EMS is about 10% in reproductive-age women and higher in women with pelvic pain or infertility. For young patients with ovarian EMS, laparoscopic ovarian cystectomy is effective in relieving pelvic pain and preventing local recurrence. However, there is a concern that the ovarian reserve would decrease after the operation because of removal of a part of the normal ovarian tissue and thermal damage during hemostasis, which depends on types of hemostasis such as bipolar electrocoagulation, suturing, and the use of a hemostatic agent. In this study, we aim to evaluate the protective effect for the ovarian reserve and hemostasis between a hemostatic agent and suturing during laparoscopic ovarian cystectomy for patients with ovarian EMS.Methods: This study is a randomized controlled, non-inferiority trial, where a total of 90 patients with ovarian EMS will be randomly assigned to the experimental (hemostatic agent) and control (suturing) groups. In the control group, a barbed suture will be applied for hemostasis, whereas a hemostatic agent will be applied in the experimental group. If two methods are insufficient, bipolar electrocoagulation will be applied for complete hemostasis. As the primary endpoint, the reduction rate of serum anti- Müllerian hormone (AMH) levels reflecting the ovarian reserve will be compared between the two groups 12 weeks after surgery. As secondary endpoints, we will compare the reduction rate of AMH level 48 weeks after surgery, the time required to complete hemostasis, the success rate of hemostasis within 10 minutes, and adverse events associated with operation. Discussion: We expect that the protective effect for the ovarian reserve and hemostasis may be comparable between the two methods, suggesting that a hemostatic agent may be preferred considering that it is easy to use during laparoscopic ovarian cystectomy. Trial registration: ClinicalTrials.gov: NCT04643106. Registered on 22 November 2020.