Increase in antimullerian hormone in long-term follow-up of patients with endometrioma after laparoscopic surgery

Abstract Background: Endometriosis is a common disease which is characterized by the development of the endometrial tissue outside the uterus. The most common location of endometriosis is the ovary, occurring in 17-44% of affected patients . It is a chronic disease mostly affecting women at reproductive age. Therefore, it is important to predict and protect the patients’ ovarian function. The negative effect of endometrioma on the ovarian reserve is very difficult to assess and quantify. Ovarian endometrioma are often removed to improve women’s fertility or alleviate pelvic pain. Although the most effective treatment for endometrioma is controversial, cystectomy seems to have been the best methods in many investigations, as it is associated with less recurrence of the disease. Some evidence suggests that surgery of ovarian endometrioma may have a detrimental effect on ovarian reserve. Serum antimullerian hormone (AMH) is a reliable marker of evaluating ovarian reserve .To date, there have been several studies of the effect of laparoscopic cystectomy on AMH, which reflects the count of primordial follicles, but controversies still exist. The aim of the study is to investigate the sequential changes of serum AMH level before and after the long-term (more than 1 year) follow up of cystectomy for endometriomas by the method that we performed in this study. Methods: This cross-sectional prospective study conducted to evaluate serum- AMH levels of 58 patients who underwent laparoscopic cystectomy for endometrioma in Nikan hospital between 2017 and 2019, before surgery, 3, 9 and 15 months after surgery.  Every patient was diagnosed as having uni or bilateral endometrioma by two or more transvaginal ultrasound examinations. The inclusion criteria were as follow: women of reproductive age of 18 to 35 year old, presence of sonographic features of uni- or bilateral endometrioma, No history of previous ovarian surgery. Exclusion criteria include: presence of tubo-avarin abscess before or during surgery, ovarian cancer, history of unilateral oophorectomy, history of ovarian surgery. A total of 51.7% of patients undergoing laparoscopic cystectomy had unilateral endometrioma and 48.3% of patients had bilateral endometrioma. Sutures were made for the closure of ovarian parenchyma and control of bleeding. We did not use any hot energy on ovaries such as cauter, monopolar, bipolar cauter and ligasure. After surgery the patients take oral contraceptive pills (OCP) for 3month and then they just take ASA, 2 times weekly.  The follow-up AMH level observation periods were 15 months after surgery. The serum AMH concentration was measured using an enzyme-linked immunosorbent assay (ELISA) kit according to the manufacturer’s instructions. The detection limit of an ELISA can vary widely from 0.01 pg mL−1 to 100 ng mL−1. Serum AMH level were measured preoperatively, 3 months, 9 month and 15 month postoperatively.  Data was extracted from patient’s files and laboratory results and Statistical analyses were performed with SPSS software version 20. Concentration of serum AMH levels were compared between each sampling point (preoperatively and 3, 6, 9 month postoperatively) using paired samples T-test and Fisher exact test. Means were presented with SD, P < 0.001 was considered statistically significant. Ethical approval for this study was obtained from the Health Research Ethics Committee of Nikan hospital. Written consent forms were obtained from all patients. Results: A prospective study enrolled 58 patients aged younger than 35 years (mean age of 30.06±4.97 years (19-35 year old ), who were referred to Nikan hospital in Tehran, Iran, between 2017 and 2019 of whom 48.3% had unilateral endometrioma and 51.7% had bilateral endometriomas to undergo laparoscopic cystectomy for ovarian endometriomas. There is not any recurrence of the disease during the follow- up period of the study. We recorded the sequential changes in the serum AMH levels. Serum AMH level decreased significantly from the preoperative to postoperative level 3 month after laparoscopy then the AMH level was increased significantly in 9 and 15 months follow up. Mean AMH level were 2.98±0.32, 1.07±0.15, 1.47±0.14 and 1.95±0.36 ng/ml, before laparoscopy, 3, 9 and 15 months after laparoscopy respectively. Complete excision of cyst was done. There is no significant differences between AMH level in unilateral and bilateral group. Across the entire study population, post‐operative AMH levels were lower than the baseline. However, in a few patients in our investigation, AMH levels at the end of the treatment was higher than that of before surgery. Conclusion: In conclusion, although there is a reduction in AMH level 3 month after cystectomy in patients with endometrioma, the consequent AMH level 9 and 15 months after surgery increased gradually. Therefore, it can be hoped that the AMH level will improve several months after the operation. This may be due to the surgical method used in this study, which is both in the type of resection andtype of homeostasis to maintain complete ovarian reserve. Sutures were used to close the ovarian parenchyma and control bleeding. We did not use any hot energy in the ovaries.Therefore we can mention here that this method of cystectomy may be effective in the serum AMH level changes after endometrioma laparoscopy.