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

Abstract

OBJECTIVE\nAccurate pre-operative counseling regarding whether endometriotic cystectomy has a detrimental effect on the ovarian reserve has been a considerable challenge, as studies assessing antral follicle counts (AFC) and anti-Müllerian hormone (AMH) levels have reported conflicting results. Our objective was to explore the impact of endometriotic cystectomy on both AMH and AFC measurements, but focusing on prospective studies where both were measured for each woman concurrently (overcoming unmeasured confounding), in the same setting (overcoming surgical technique differences) and at the same three postoperative time points; early (one to six weeks), intermediate (two to six months) and late (nine to eighteen months), to overcome time-sensitive changes.\n\n\nDATA SOURCES\nDatabases of PubMed, ClinicalTrials.gov, the Cochrane Library, Web of Science, and EBSCO were searched between January 2000 and October 2020.\n\n\nSTUDY ELIGIBILITY CRITERIA\nOnly prospective cohort studies that targeted the impact of endometriotic stripping cystectomy on AMH and AFC in the same women, at matching time points and in the same setting were eligible.\n\n\nSTUDY APPRAISAL AND SYNTHESIS METHODS\nTwo authors performed the screening and data extraction independently.\n\n\nRESULTS\nFourteen prospectively designed studies were eligible for meta-analysis, including 650 women. The included studies had a low risk of bias. Postoperative weighted mean difference of serum AMH levels dropped significantly as compared to the preoperative levels by estimates of 1.77 ng/mL (95% CI: 0.77 to 2.77, P < 0.001), 1.17 ng/mL (95% CI: 0.66 to 1.67, P < 0.001) and 2.13 ng/mL (95% CI: 1.61 to 2.65, P < 0.001), in the early (one to six weeks), intermediate (two to six months) and late (nine to eighteen months) time points, respectively. Corresponding to a mean reduction in serum AMH levels at each of the three-time points of 44.4%, 35.1%, and 54.2%, respectively. Conversely, postoperative weighted mean difference of AFC estimates did not change significantly at any of the three-time points; early 0.70 antral follicles (95% CI: -2.71 to 3.56, P = 0.63), intermediate -0.94 antral follicles (95% CI: -2.53 to 0.65, P = 0.25) and late 2.58 antral follicles (95% CI: -0.43 to 5.58, P = 0.09). Overall high levels of heterogeneity were encountered (I2 ranging between 92-94% for AMH and 94-98% for AFC, at the three-time points), which were attenuated when similar AMH assays were compared, while meta-regression suggested that age did not contribute to heterogeneity.\n\n\nCONCLUSIONS\nEndometriotic cystectomy is associated with a significant reduction in serum AMH but not AFC, with detrimental effects consistently detectable for AMH at the early, intermediate, and late postoperative time-points. In women with endometrioma AMH may be of greater utility in the assessment of the risk of iatrogenic depletion of the ovarian reserve.