Endometrioma surgery-a systematic review and meta-analysis of the effect on antral follicle count and anti-Müllerian hormone.

OBJECTIVE: Accurate preoperative counseling about whether an endometriotic cystectomy has a detrimental effect on the ovarian reserve has been a considerable challenge, because studies assessing the postoperative antral follicle counts and anti-Müllerian hormone levels have reported conflicting results. Our objective was to explore the impact of endometriotic cystectomy on both the anti-Müllerian hormone levels and antral follicle counts, with focus on prospective studies in which both variables were measured for each woman concurrently (overcoming unmeasured confounding), in the same setting (overcoming surgical technique differences), and at the same 3 postoperative time points, namely early (1-6 weeks), intermediate (2-6 months) and late (9-18 months), to overcome time-sensitive changes. DATA SOURCES: Databases of PubMed, ClinicalTrials.gov, the Cochrane Library, Web of Science, and EBSCO were searched between January 2000 and October 2020. STUDY ELIGIBILITY CRITERIA: Only prospective cohort studies that evaluated the impact of endometriotic stripping cystectomy on anti-Müllerian hormone levels and antral follicle counts in the same women, at matching time points, and in the same setting were eligible. STUDY APPRAISAL AND SYNTHESIS METHODS: Two authors performed the screening and data extraction independently. RESULTS: A total of 14 prospectively designed studies were eligible for the meta-analysis and included 650 women. The included studies had a low risk of bias. The postoperative weighted mean differences in serum anti-Müllerian hormone levels dropped significantly when compared with the preoperative levels by an estimated 1.77 ng/mL (95% confidence interval, 0.77-2.77; P<.001), 1.17 ng/mL (95% confidence interval, 0.66-1.67; P<.001), and 2.13 ng/mL (95% confidence interval, 1.61-2.65; P<.001) at the early (1-6 weeks), intermediate (2-6 months), and late (9-18 months) time points, respectively. This corresponded to a mean reduction in serum anti-Müllerian hormone levels at each of the 3-time points of 44.4%, 35.1%, and 54.2%, respectively. Conversely, the postoperative weighted mean difference in the antral follicle count estimates did not change significantly at any of the 3 time points; the early antral follicle count was 0.70 (95% confidence interval, -2.71 to 3.56; P=.63), the intermediate count was -0.94 (95% confidence interval, -2.53 to 0.65; P=.25), and the late count was 2.58 (95% confidence interval, -0.43 to 5.58; P=.09). Overall, high levels of heterogeneity were encountered (I2 ranging between 92% and 94% for the anti-Müllerian hormone levels and between 94% and 98% for the antral follicle counts at the 3 time points), which were attenuated when similar anti-Müllerian hormone assays were compared, and the meta-regression suggested that age did not contribute to heterogeneity. CONCLUSION: Endometriotic cystectomies are associated with a significant reduction in the serum anti-Müllerian hormone levels but not in the antral follicle counts, with the detrimental effects on the anti-Müllerian hormone levels consistently detectable at the early-, intermediate-, and late-postoperative time points. In women with endometrioma, the anti-Müllerian hormone level may provide a more accurate assessment of the risk for iatrogenic depletion of the ovarian reserve.

Impact of unilateral versus bilateral ovarian endometriotic cystectomy on ovarian reserve: a systematic review and meta-analysis.

BACKGROUND: Ovarian endometrioma is a frequent manifestation of endometriosis in women of reproductive age. Several issues related to its space occupying effects, local reactions and surgical removal continue to be actively debated today. The impact of ovarian endometrioma per se on ovarian reserve is still controversial and the effect of ovarian surgery is still actively discussed. Furthermore, the optimal biomarker of ovarian reserve estimation in women with ovarian endometrioma is still under examination. Additionally, there is no consistent agreement on the effect of endometrioma bilaterality on ovarian reserve. OBJECTIVE AND RATIONALE: The objective of this systematic review and meta-analysis was to study the impact of unilateral versus bilateral ovarian endometrioma on ovarian reserve biomarkers before and after endometrioma cystectomy. SEARCH METHODS: We performed an extensive electronic database search employing PubMed, EBSCO, Web of Science, ClinicalTrials.gov and the Cochrane Library, to identify published research articles published between January 2000 and October 2018. Search terms included endometriotic cyst OR endometrioma OR endometriomata, cystectomy OR resection OR stripping OR removal OR excision and infertility OR subfertility. Only prospective controlled studies that compared the impact of unilateral versus bilateral ovarian endometriotic cystectomy on ovarian reserve tests in the same setting were included. Studies which included cases with PCOS, ovarian failure, early menopause, oral contraception treatment, or prior chemotherapy and/or radiotherapy or ovarian surgery, were excluded from evaluation. We used the Newcastle-Ottawa Scale for assessing the quality of studies found eligible for meta-analysis. We registered the systematic review on PROSPERO and its number is CRD42018117170. OUTCOMES: Twelve studies were eligible for meta-analysis including collectively 783 women: 489 and 294 in the unilateral and bilateral groups, respectively. The included studies had a low risk of bias. The pre-operative weighted mean difference (WMD) showed that serum AMH levels did not differ significantly between the groups. Conversely, AMH levels were significantly (P < 0.05) lower in bilateral groups than in unilateral groups at the early, intermediate and late post-operative periods, corresponding WMDs of 0.78 ng/ml (95% CI: 0.41-1.15), 0.59 ng/ml (95% CI: 0.14-1.04) and 1.08 ng/ml (95% CI: 0.63 to 1.52), respectively. Heterogeneity among eligible studies reporting on before the operation and at the early and intermediate post-operative periods was high. Pre-operative and post-operative AFC values were not significantly different between the groups. The heterogeneity among the studies reporting on AFC was high. Analysis of each of the unilateral and bilateral groups separately showed a significant and sustained serum AMH drop by 39.5% and 57.0%, respectively from baseline to after the operation. WIDER IMPLICATIONS: Our results challenge the concept that endometrioma per se adversely affects ovarian reserve, whereas endometrioma cystectomy, especially as bilateral operation, has a deleterious and sustained effect on ovarian reserve. AMH seems to be a more appropriate biomarker of ovarian reserve than AFC in cases with endometrioma. Since low AMH implies a shorter reproductive lifespan, excision of endometrioma should be cautiously considered, especially in bilateral cases.

A comparison of enriched culture and Xpert polymerase chain reaction assay of Group B streptococcus carrier status at 35-37-week gestation to labor onset: a prospective controlled study.

OBJECTIVES: (1) To compare the accuracy of vagino-rectal enriched culture (EC) and a rapid polymerase chain reaction (PCR) test for the detection of Group B streptococcus (GBS) carrier status at 35-37-week gestation and at onset of labor. (2) To assess the conversion rate of GBS carrier status between 35-37 weeks to the onset of labor according to the EC/PCR tests. A prospective study was performed at a women's health clinic, referred to give birth at one medical center. STUDY POPULATION: Low risk pregnant women at 35-37-week gestation who did not know their GBS carrier status. METHODS: Participants were evaluated for GBS status both at 35-37 weeks and at labor onset. Correlation between tests was calculated by Spearman correlation. RESULTS: One hundred and ten specimens were analyzed. Correlations: EC-PCR: 35-37 weeks - very high (r = 0.8), at labor - high (r = 0.5). EC-EC: 35-37 weeks and at labor - high (r = 0.39); PCR-PCR: 35-37 weeks and at labor- high (r = 0.7). CONCLUSIONS: Both the EC and Xpert PCR tests are accurate for detecting GBS carrier, both at 35-37 weeks and at labor onset. We did not detect a significant conversion of the GBS status from negative at 35-37 weeks to positive at onset of labor.