Inonu University, Turgut Ozal Medical Centre

1. The long-term effect of endometrioma surgery on ovarian reserve: A prospective case-control study Ilgın Türkçüoğlu Rauf Melekoglu Ayşe Gülçin Baştemur Inonu University, Turgut Ozal Medical Centre

2. Effect of endometrioma on ovarian reserve • Endometriosis is a chronic disease effecting the 2 to 10% of general population and 30 to 50% of infertile women and/or women with pelvic pain. • A rising trend has been found in the endometriosis and endometriosis associated infertility over years. • Endometrioma is present in 30 to 40% of cases with endometriosis. • The recommended treatment option is surgery due to the ineffectiveness of medical treatment in case of endometrioma.

3. Effect of endometrioma on ovarian reserve • The cumulative spontaneous pregnancy rate has been found around 50% after excision of the endometrioma. • Guidelines have recommended surgery in case of pelvic pain, to improve access to follicles during oocyte retrieval if the endometrioma is larger than 3 cm or 4 cm in diameter, to reduce risk of infection during oocyte retrieval and possibly improve ovarian response. • However patients should be councelled about the possible decrease in ovarian reserve after endometrioma excision.

4. Effect of endometrioma on ovarian reserve • The findings of studies evaluating the effect of endometrioma excision on the ovarian reserve are heterogeneous. • Although some found a decrease in the ovarian reserve evaluated by the AMH level short after the surgery, the others found no change in the ovarian reserve. • Moreover the long term consequence of endometrioma excision on ovarian reserve, is unknown

5. Effect of endometrioma on ovarian reserve Objective To evaluate the long term effect of endometrioma excision on the ovarian reserve. 21 endometrioma surgery Material and Methods All the participants were called on the D3 and evaluated by TVUSG. Blood samples were obtained on the same day . Patients who underwent laparoscopic excisional ovarian endometrioma surgery with the diagnosis of unilateral or bilateral endometrioma between the years 2007-2015 21 age-matched cases with unilateral or bilateral endometrioma 21 age-matched fertile women with no pathological findings

6. Effect of endometrioma on ovarian reserve • Inclusion criteria • Women aged between 18 to 39 years; • Having no other ovarian surgery accept one course of endometrioma surgery for the ES group; • The presence of a standard operation technique applied by one surgeon for the ES group; • Presence of at least 12 months of duration after surgery, for the ES group. • Exclusion criteria • Presence of previous ovarian surgery (other than one course of endometrioma surgery for the ES group); • A history of early menopause or premature ovarian failure; • A history of autoimmune or genetic disease; • Using oral contraceptive pills or hormone preparations within three months before enrollment;

7. Effect of endometrioma on ovarian reserve • Operation Technique • All endometrioma operations were performed by the one operator experienced in endometrioma surgery (I.T.). • The cystectomy procedure stripping technique including a sharp dissection of the ovarian-surface to reveal the cleavage plane of the cyst pseudocapsule and removal of the pseudocapsule by blunt dissection and traction from the ovary, with two atraumatic grasper. • Hemostasis was achieved with bipolar cautery, and cauterization was avoided as much as possible to reduce ovarian damage. • In the cases, the ovarian cortex was left open without suturization. • Excised cysts were undergone histopathologic examination, and the diagnosis was confirmed by pathology.

8. Effect of endometrioma on ovarian reserve

9. Effect of endometrioma on ovarian reserve

10. Effect of endometrioma on ovarian reserve Independent Predictors of Low AMH In Endometrioma Cases P Age 0.029 Surgery 0.001 Bilaterality 0.629 Endometrioma 0.109 size Smoking 0.622 The effect of Age and Surgery on the AMH level R square B P Age 0.076 -0.059 0.029 Surgery 0.181 -1.170 0.001 Age and Surgery 0.244 - <0.001

11. Effect of endometrioma on ovarian reserve • Conclusion • The results of this study demonstrated the deleterious effect of excisional endometrioma surgery on ovarian reserve in the long-term period. • Besides, this study showed that increasing age and presence of endometrioma surgery are significantly associated with diminished ovarian reserve. • Therefore, the decision of surgery should be done carefully especially in elderly patients with ovarian endometrioma by considering these long-term detrimental effects. Thank you