Infertility Unit, Department of Obstetrics and Gynecology, Clinica L. Mangiagalli, University of Milan, Milan, Italy
1 To whom correspondence should be addressed at: Department of Obstetrics and Gynecology, Via Commenda 12, 20122, Milano, Italy. e-mail: dadosomigliana{at}yahoo.it
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Abstract |
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Key words: cyst enucleation/laparoscopy/ovarian cyst/ovarian reserve
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Introduction |
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A body of literature has provided evidence that the pregnancy rate after laparoscopic removal of ovarian cysts is satisfactory (Donnez et al., 1996; Beretta et al., 1998
; Hemmings et al., 1998
). Moreover, results from IVF cycles suggest that, in general, the possibility of achieving pregnancy is not impaired by previous ovarian surgery (Canis et al., 2001
; Donnez et al., 2001
; Geber et al., 2002
; Marconi et al., 2002
). Nevertheless, it is worthwhile noting that the vast majority of operated patients had undergone monolateral excision of an ovarian cyst, leaving the contralateral ovary undamaged. In fact, the intact reserve of the unoperated gonad renders adequate estimation of damage to the operated ovary very difficult. Indeed, in these women, hormonal evaluation and spontaneous and/or assisted reproduction technique-mediated pregnancy rates cannot be considered reliable tools to assess residual ovarian function in the operated ovary. In this regard, results from ovarian stimulation for IVF cycles may represent an appealing possibility to test specifically the functional reserve of a single gonad. Specifically, monitoring ovarian response in the previously operated ovary and using the contralateral gonad of the same patient as a control should be considered an interesting and simple means of assessing residual ovarian function. Surprisingly, this method has been used previously in only four studies, and has produced controversial results (Nargund et al., 1996
; Loh et al., 1999
; Donnez et al., 2001
; Ho et al., 2002
).
The aim of the present study was to evaluate the response to ovarian stimulation in patients who had been referred to the authors infertility unit for IVF techniques and who previously had undergone monolateral excision of endometriotic ovarian cysts. Specifically, ovarian response was compared in the operated and intact ovaries, whilst factors that might influence the severity of the damage were also investigated.
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Materials and methods |
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Investigations
According to the protocol used, all patients who had previously undergone pelvic surgery were requested to provide a copy of the chart referring to their intervention(s). This protocol provided the possibility of obtaining exhaustive information on previous surgical procedure(s). The dimension and histology of the cysts were obtained from surgical and pathological evidence. A detailed ultrasonographic monitoring before and during IVF-ICSI cycles was systematically applied and recorded. In particular, patients routinely underwent transvaginal ultrasound within day 8 of the cycle before ovulation stimulation. The ovarian volume was calculated as 4/3(
diameter)3, where the diameter was taken as the mean of the height, width and depth of the ovary. Moreover, the number and dimension of all follicles on the day of hCG administration were always available. The diameters of the follicles were calculated as the mean of three perpendicular diameters. All data are recorded separately for the two ovaries. hCG was administered when two or more leading follicles had a mean diameter >18 mm. If three or more embryos were available at the time of embryo transfer, the patients was informed about the severe risks associated with multiple gestation and offered the choice of transferring either two or three embryos. Clinical pregnancy was defined as the ultrasonographic demonstration of an intrauterine gestational sac 4 weeks after embryo transfer.
Statistical analysis
Analysis of the data was performed using the Statistics Package for Social Sciences (SPSS, Chicago, IL, USA). Data are expressed as mean ± SD. A paired Students t-test was used to investigate differences between operated and contralateral ovaries. Differences were confirmed using non-parametric Wilcoxon rank test for paired data. A P-value < 0.05 was considered statistically significant.
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Results |
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Discussion |
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The results observed in the present study were in perfect accord with those recently reported by others (Nargund et al., 1996; Ho et al., 2002
), all of whom noted a marked reduction in the number of both dominant follicles and retrieved oocytes in the operated ovary. In contrast, when using a similar retrospective study design, others failed to observe this difference (Loh et al., 1999
; Donnez et al., 2001
). The results from these four studies are summarized in Table IV. There are at least two major reasons that might explain the discrepancies between the present results and those observed in these two recent studies. In the first of these studies (Donnez et al., 2001
), the specific focus was on patients with endometriomas who were operated on using a specific and less frequently employed surgical technique comprising laser vaporization of the internal layer of the cyst wall. It might be speculated that this technique would be less deleterious for the residual normal ovarian cortex. The results from randomized trials comparing laser vaporization and stripping enucleation for the treatment of endometrioma are warranted to draw definitive conclusions on this topic. In the second study (Loh et al., 1999
), the extremely small sample size (12 cycles) used was insufficient to evaluate reliably whether ovarian reserve was impaired in the operated gonad. Of note, in the latter study the response in natural cycles and in stimulation cycles for non-IVF procedures was also analysed. Specifically, these authors reported a statistically significant reduction in terms of number of follicles in the operated ovary among the 11 patients who were monitored during a natural cycle and in 39 clomiphene citrate-stimulated cycles (Loh et al., 1999
). Overall, it may be concluded that the results of the present study, and other currently available data on this topic, support the idea that laparoscopic excision of endometriotic ovarian cysts is associated with a significant reduction in the functional reserve of the operated ovary. This aspect may be of particular relevance for patients who undergo surgery for bilateral ovarian cysts.
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In conclusion, the results from the present study support the following observations: (i) the excision of ovarian endometriotic cysts is associated with a significant reduction in ovarian reserve; and (ii) the damage could not be merely ascribed to the amount of ovarian tissue removed during surgery. Further studies are required to clarify whether the injury is related to the surgical procedure per se or to the previous presence of an endometriotic cyst.
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Acknowledgements |
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References |
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Submitted on May 12, 2003; accepted on July 9, 2003.