Frequency
of post surgical ovarian failure after laparoscopic
excision of bilateral endometriomas
Research shows that removal
of bilateral endometriomas is associated with a small,
but real, risk of premature ovarian failure (POF), in
addition to the benefits of improved fertility and pain
Since the introduction of ovarian stripping more than
25 years ago years [1], there has been concern regarding
ovarian compromise. This study was undertaken to determine
the frequency of postsurgical ovarian failure in patients
undergoing this procedure. While laparoscopic excision
is still generally considered the first-line treatment
for ovarian endometriomas, its effect on ovarian reserve
has recently been questioned, especially in women with
bilateral endometriotic cysts [2].
Mauro Busacca and his team from Ospedale Macedonio
Melloni in Milano, Italy, contacted 126 patients who
had been operated on for bilateral ovarian endometriosis
between January 1995 and December 2003 and who were
younger than 40 years at the time.
From these interviews they were able to determine a
frequency of 2.6 percent of women (3 out of 126), who
had experienced POF, with all cases occurring immediately
after surgery. Surgery also brought advantages, however.
Dysmenorrhea and dyspareunia each improved in more than
80 percent of patients, while nine (50 percent) of the
18 women who were infertile before surgery later conceived.
This has lead the researchers to conclude that patients
who are operated on for bilateral endometriomas should
be informed that they have a low but definite risk of
POF occurring immediately after surgery. However, says
Busacca and team: "Taking into consideration the
significant benefits in terms of both pain relief and
improvement of fertility associated with laparoscopic
treatment, this risk should not currently lead to banning
surgery in these patients."
Harry Reich, president of the International Society
for Gynecologic Endoscopy, and Mauricio Abrao of the
University of Sao Paulo, Brazil, welcome this paper
becauses it raises the issue of possible consequences
of a well-debated topic: surgery for the management
of ovarian endometrioma [3].
In their paper they stress that the ESHRE Guidelines
for the diagnosis and management of endometriosis mentions
that laparoscopic cystectomy for ovarian endometriomas
>4cm improves fertility when compared to drainage
and coagulation [4]. Coagulation or laser vaporisation
of ovarian endometriomas without preseudocapsule excision
is associated with a significantly increased risk of
cyst recurrence.
Reich and Abrao call for studies to examine better
how ovarian failure occurs. They emphasise the need
for surgeons to video their cases and prospectively
identify those patients most likely to have ovarian
compromise.
A larger clinical study may provide new data, including
evalutation of the best form of the surgical treatment
of endometrioma depending on whether the woman is suffering
pain or infertility, and thus may aid in determining
what is the best treatment to ensure optiminal quality
of life including optimal pregnancy rates in women with
endometrioma.
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