Surgical excision of endometriomas and ovarian reserve A systematic review on serum antimullerian hormone level modifications

Capsule:
Eleven studies have been published on serum AMH levels after surgical excision of ovarian endometriomas. Most of them documented a significant decrease after surgery, thus supporting surgery-related damage to ovarian reserve.

Authors:
Edgardo Somigliana, M.D., Ph.D., Nicola Berlanda, M.D., Laura Benaglia, M.D., Paola Vigano, D.Sc., Ph.D., Paolo Vercellini, M.D., Luigi Fedele, M.D.

Volume 98, Issue 6, Pages 1531-1538, December 2012

Abstract:

Objective:
To evaluate serum AMH levels modification following surgical excision of ovarian endometriomas.

Design:
Systematic review. MEDLINE search from January 1990 to April 2012 using the combinations of medical subject heading terms endometriosis, endometrioma, endometriotic cyst and AMH or anti-mullerian hormone or MIF or mullerian inhibiting factor. Reference lists of selected studies was checked for additional potential contributions.

Setting:
Published studies evaluating serum AMH level before and after endometrioma stripping.

Patients:
Women with ovarian endometriomas requiring surgery

Interventions:
Serum AMH level assessment.

Main outcome measures:
Serum AMH level modifications.

Results:
Eleven papers satisfied our selection criteria. Data pooling was deemed inopportune owing to the heterogeneity of the study designs and of the reported parameters. Nine out of eleven studies documented a statistically significant reduction of serum AMH level following surgery. The two studies failing to document this decrease were published by the same study group and partly overlapped. The magnitude of the decline was more evident in women operated on for bilateral endometriomas.

Conclusions:
Evidence deriving from the evaluation of serum AMH level modifications following surgical excision of endometriomas supports a surgery-related damage to ovarian reserve.

  • Micah Hill

    Thank you for the very nice systematic review. The conclusions are nearly identical to a meta-analysis in the September JCEM from Raffi et al. Those authors chose to do statistical analysis of the data, although heterogeneity was extremely high, and the authors of this present study chose not to do statistical analysis for this very reason. Either way, it seems clear that current surgical techniques for endometriomas lead to a decrease in ovarian reserve.

    Did you decide against a meta-analysis based purely on the methodologic heterogeneity of the studies or did you evaluate this statistically? Also, do the authors operate on asymptomatic endometriomas in infertility patients and does size play a role in this decision?

  • Juan Garcia-Velasco, MD

    Fantastic review paper by one of the groups leading the way we should treat our infertile patients with endometriomas. How relevant do you think it is to measure AMH right after surgery, when a severe inflammatory process takes place at healing, or should be rather wait 2-3 months to evaluate AMH levels after surgery?

    • Juan

      I have seen short term drops (and bump in fsh) followed by normalization in some cases in less than three months. I always viewed this as neovascularization not inflammation.

      • Juan Garcia-Velasco, MD

        Thanks Steve. Thus, do you recommend not to check FSH/E2 or AMH until 2-3 months post surgery?

        • Juan– it remains unclear how to best use this information. As you know the old approach to wait to try to time cycles based on Day 3 values did not yield better results. What I empirically do is use the testing to adjust the stimulation protocol and if the woman is young enough that a few months delay is not risky then wait until it rises. If the levels are normal enough however she should be able to cycle now at the risk of lower oocyte yield. Unfortunately we do not have any data on what is best for outcomes and if such titration makes a difference.

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