The effect of laparoscopic ovarian cystectomy versus coagulation in bilateral endometriomas

Literature Review Article

The effect of laparoscopic ovarian cystectomy versus coagulation in bilateral endometriomas on ovarian reserve as determined by antral follicle count and ovarian volume: a prospective randomized study. Turgut, V., Batioglu, S., Tonguc, E., Kahyaoglu, I. Fertility & Sterility. 2011 June; 95(7): 2247-50.

Review
Dr. John Preston Parry, M.D., M.P.H.

The question asked by this study is which surgical approach to endometrioma, cystectomy or coagulation, is less detrimental to ovarian reserve. Forty eight patients with bilateral endometriomas each measuring 4 to 6 cm had one of two ovaries randomly assigned to cystectomy with atraumatic forceps and focal bipolar coagulation (15 watt). The contralateral ovary served as the control with fenestration and cyst wall coagulation (30 watt). Neither ovary was sutured or closed, and all procedures were performed by the same surgeon. Postcystectomy antral follicle count (AFC) was 3.7 ± 1.3 and postcoagulation AFC was 4.8 ± 0.6. Postcystectomy ovarian volume was 6.3 ± 2 and postcoagulation ovarian volume was 9.9 ± 2. Both differences were statistically significant. Of the 48 patients, 11 subsequently became spontaneously pregnant and 37 underwent IVF. Among those undergoing IVF, the postcystectomy ovary averaged 3.1 ± 0.8 follicles retrieved and the postcoagulation ovary averaged 3.9 ± 0.9 follicles retrieved, which was statistically significant. The conclusion of the study is that coagulation of an endometrioma can be less detrimental to ovarian reserve than cystectomy, as reflected by changes in the AFC, ovarian volume, and number of follicles retrieved for IVF.

Comments
Dr. Meike Uhler, M.D.


This is a well-designed RCT which addressed the question of whether cystectomy or coagulation has a more detrimental effect on short term ovarian reserve (up to 6 months). Because there is a wide range in age of 20 to 35, it would have been interesting to know if age affected the balance of risk and benefit when selecting a technique. Other markers of ovarian reserve, such as FSH and AMH, would have been useful supplemental information relative to AFC, ovarian volume, and the number oocytes retrieved with IVF. Certainly, this paper challenges the dogma of cystectomy as the standard by which we treat endometriomas. After accounting for patient goals, reproductive surgeons need to honestly consider whether they will change practice on the basis of one well-designed study that will be difficult to duplicate. 

The above review and commentary on this article were written by SRS members. Publication of these summaries does not reflect endorsement of any particular procedure or treatment.  Views expressed in these summaries do not necessarily reflect the views of SRS or ASRM.

 

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