Laparoscopic stripping of endometriomas negatively affects ovarian follicular reserve even if performed by experienced surgeons

摘要

In order to estimate the impact of laparoscopic stripping of endometriomas on the ovarian follicular reserve, 43 normo-ovulatory women were studied by endocrine (anti-Müllerian hormone (AMH), FSH, LH, inhibin B, oestradiol) and ultrasonographic (antral follicle count (AFC)) methods before surgery, and 3 and 9 months after surgery. The operation was performed by experienced laparoscopists, particularly aware of the need to avoid damaging the healthy part of the ovary. Serum AMH concentrations significantly decreased after the operation (1.4 ± 0.2 ng/ml after 3 months and 1.3 ± 0.3 ng/ml after 9 months versus 3.0 ± 0.4 ng/ml before surgery; P < 0.0001), whereas basal FSH, LH, oestradiol and inhibin B concentrations remained unchanged. The volume of the operated ovary significantly diminished after surgery (P < 0.0001), whereas the AFC was not significantly altered. Overall, the data show that laparoscopic stripping of endometriomas reduces ovarian reserve. The significant decrease of AMH after surgery confirms that part of the healthy ovarian pericapsular tissue, containing primordial and preantral follicles, is removed or damaged despite all the surgical efforts to be atraumatic. This must be carefully considered when laparoscopic cystectomy surgery is scheduled for patients with no relevant symptoms besides infertility or with already small ovarian reserve. Ovarian endometriomas are removed to relieve symptoms or to improve either spontaneous fertility or the outcome of subsequent pro-fertility treatments. The surgical treatment of ovarian endometriosis by laparoscopic 'stripping', probably the most widespread technique, may improve symptoms, but was repeatedly reported to worsen the ovarian responsiveness to ovulation induction in patients later submitted to IVF. This study aims to estimate the impact of laparoscopic stripping of endometriomas on the ovarian follicular reserve. We studied 43 normo-ovulatory women by endocrine (anti-Müllerian hormone (AMH), FSH, LH, inhibin B, oestradiol) and ultrasonographic (antral follicle count (AFC)) methods before and some months after laparoscopic cystectomy. The operation was performed by experienced laparoscopists who were aware of the need to avoid damaging the healthy part of the ovary. Serum AMH concentrations significantly decreased after the operation (P < 0.0001) and basal FSH concentrations slightly increased (non significantly); LH, oestradiol and inhibin B remained unchanged. The volume of the operated ovary significantly diminished after surgery (P < 0.0001), whereas the AFC was not significantly altered. Overall, our data show that, even when performed by experienced surgeons, the laparoscopic stripping of endometriomas reduces ovarian reserve. Part of the healthy ovarian pericapsular tissue is removed or damaged despite all the surgical efforts to be atraumatic. This must be carefully considered when laparoscopic cystectomy surgery is scheduled for patients with no relevant symptoms besides infertility or with already small ovarian reserve (e.g. those aged over 38 years).