Involvement of mesosalpinx in endometrioma is a possible risk factor for decrease of ovarian reserve after cystectomy: a retrospective cohort study

Diminished Ovarian Reserve in Endometriosis: Insights from In Vitro, In Vivo, and Human Studies-A Systematic Review

Endometriosis, a prevalent disorder in women of reproductive age, is often associated with undesired infertility. Ovarian reserve, an essential measure of ovarian function that is crucial for maintaining fecundity, is frequently diminished in women with endometriosis. Though the causative relationship between endometriosis and reduced ovarian reserve is not fully understood due to the lack of standardized and precise measurements of ovarian reserve, there is ongoing discussion regarding the impact of interventions for endometriosis on ovarian reserve. Therefore, in this review, we investigate articles that have related keywords and which were also published in recent years. Thereafter, we provide a comprehensive summary of evidence from in vitro, in vivo, and human studies, thereby shedding light on the decreased ovarian reserve in endometriosis. This research consolidates evidence from in vitro, in vivo, and human studies on the diminished ovarian reserve associated with endometriosis, as well as enhances our understanding of whether and how endometriosis, as well as its interventions, contribute to reductions in ovarian reserve. Furthermore, we explore potential strategies to modify existing therapy options that could help prevent diminished ovarian reserve in patients with endometriosis.

Anti-Müllerian hormone beyond an ovarian reserve marker: the relationship with the physiology and pathology in the life-long follicle development

Anti-Müllerian hormone (AMH), an indirect indicator of the number of remaining follicles, is clinically used as a test for ovarian reserve. Typically, a decline suggests a decrease in the number of remaining follicles in relation to ovarian toxicity caused by interventions, which may implicate fertility. In contrast, serum AMH levels are elevated in patients with polycystic ovary syndrome. AMH is produced primarily in the granulosa cells of the preantral and small antral follicles. Thus it varies in association with folliculogenesis and the establishment and shrinking of the follicle cohort. Ovarian activity during the female half-life, from the embryonic period to menopause, is based on folliculogenesis and maintenance of the follicle cohort, which is influenced by developmental processes, life events, and interventions. AMH trends over a woman's lifetime are associated with in vivo follicular cohort transitions that cannot be observed directly.

Follicle development and its prediction in patients with primary ovarian insufficiency: Possible treatments and markers to maximize the ability to conceive with residual follicles

Background

Primary ovarian insufficiency (POI) is characterized by the development of hypergonadotropic hypogonadism before 40 years of age and leads to intractable infertility. Although in vitro fertilization and embryo transfer with donated eggs enables pregnancy, not a few patients desire pregnancy using their oocytes. However, follicular development is rare and unpredictable in patients with POI. Thus, there is a need for treatments that promote the development of residual follicles and methods to accurately predict infrequent ovulation.

Methods

This review discusses the effects of various treatments for obtaining eggs from POI patients. Furthermore, this study focused a potential marker for predicting follicular growth in patients with POI.

Main Findings

Different treatments such as hormone-replacement therapy, dehydroepiandrosterone supplementation, platelet-rich plasma injection, and in vitro activation have shown varying degrees of effectiveness in retrieving oocytes from patients with POI. To predict follicle development in the cycle, elevated serum estradiol and reduced follicle-stimulating hormone (FSH) levels are important. However, these markers are not always reliable under continuous estradiol-replacement therapy. As a novel marker for predicting follicle growth, serum anti-Müllerian hormone (AMH) levels, measured using the picoAMH enzyme-linked immunosorbent assay, were found to predict follicle growth in patients and the cycle.

Conclusion

This review highlights the challenges and available interventions for achieving pregnancy using a patient's oocytes in cases of POI. We believe that a combination of currently available treatments and prediction methods is the best strategy to enable patients with POI to conceive using their own eggs. Although AMH levels may predict follicle growth, further research is necessary to improve the chances of successful follicular development and conception in patients with POI.

Effect of salpingectomy on ovarian reserve: A systematic review and meta-analysis

AIM

To determine the effect of salpingectomy on ovarian reserve.

METHODS

PubMed, EMBASE, Web of Science, Dynamed plus, and Cochrane Controlled Trials Register databases were searched from their inception to December 2020 to identify relevant studies, including cross-sectional studies, retrospective studies, and randomized controlled trials. Studies that compared anti-Müllerian hormone (AMH) levels and/or antral follicle count (AFC) between the control and salpingectomy groups or before and after surgery were included.

RESULTS

Twenty-one articles were included in the systematic review. Meta-analyses were performed on 16 studies in which data were presented as mean ± SD values. A meta-analysis comparing AMH levels before and after surgery in the same patients showed no significant decrease in all cases, irrespective of whether it was unilateral or bilateral salpingectomy. There was no significant decrease in the AFC in the meta-analysis comparing levels before and after bilateral salpingectomy, either. In contrast, in the case-controlled study the salpingectomy group had significantly lower levels of AMH in all meta-analyses of unilateral and bilateral surgery (mean difference: -0.31, 95% confidence interval [CI]: -0.55, -0.07), only unilateral cases (mean difference: -0.28, 95% CI: -0.50, -0.06), and only bilateral cases (mean difference: -0.71, 95% CI: -1.19, -0.23). The salpingectomy group that included unilateral and bilateral cases had significantly lower AFC compared with no-surgery controls (mean difference: -1.31, 95% CI: -2.13, -0.48).

CONCLUSION

Although not conclusive, it does appear that patients who underwent salpingectomy (either unilateral or bilateral) have a decreased ovarian reserve.

Coexistence of endometriomas with extraovarian endometriosis and adhesions

OBJECTIVE

The aim of the study is to show the coexistence of the endometriomas with peritoneal and deep infiltrating endometriosis, as well as with the adhesions. Study design It's a randomized retrospective study. Patients treated for endometrioma at Academic Hospital Cologne Weyertal from January 2014 to October 2019 were included. In total there were 1054 patients. 310 medical records were chosen at random without a special selection and the data were analysed.

RESULTS

In our study, endometriomas were alone, which means without extraovarian endometriosis and/or adhesions, in only 2.3% of the cases. In the total population, 80.6% (250) of the patients had peritoneal endometriosis, 43.2% (134) of the patients had deep infiltrating endometriosis and 38% (118) of the patients had peritoneal and deep infiltrating endometriosis. In our analysis we found that in unilateral endometriomas there is no relationship between endometrioma size and adnexal adhesions. The risk of Douglas obliteration increases with the size of the endometriomas in unilateral endometriomas. In bilateral endometriomas, the risk of a complex adhesions is independent of the size of the endometriomas and relevantly higher than in unilateral endometriomas (Douglas obliteration 31.5% vs 16%, bilateral adnexal adhesions 45.2% vs 21.1%). Unilateral adnexal adhesions occurred in bilateral endometriomas only in 13.7%.

CONCLUSION

Endometriomas are the relevant problem in gynaecological practice. It must be taken into account here that endometriomas usually occur with peritoneal endometriosis and that surgical therapy may be useful. However, adhesions and DIE are to be expected with surgical treatment, which could make the operation more difficult. Especially in large and bilateral endometriomas, a high coexistence with extraovarian endometriomas and adhesions is observed. Therefore, surgery should be performed by an experienced surgeon.

Very Low Levels of Serum Anti-Müllerian Hormone as a Possible Marker for Follicle Growth in Patients with Primary Ovarian Insufficiency Under Hormone Replacement Therapy

Patients with primary ovarian insufficiency (POI) occasionally present with follicle growth; however, accurately predicting cycles accompanied by follicle growth is challenging. Early-stage follicles produce serum anti-Müllerian hormone (AMH), a useful marker of ovarian reserve. Therefore, serum AMH levels indicate growth of small follicles (which are difficult to detect ultrasonographically) and may predict follicle growth in patients with POI. Using an ultrasensitive enzyme-linked immunosorbent assay (ELISA) kit, we observed very low serum AMH levels in patients with POI. We further evaluated follicle growth in each patient during each cycle to determine the usefulness of measuring serum AMH levels as a predictor of follicle growth in patients with POI who receive hormone replacement therapy (HRT). We investigated 19 patients with POI in whom we analyzed 91 cycles; 14 cycles showed positive and 77 cycles showed negative results on serum AMH testing. The rate of cycles showing follicle growth in AMH-positive cycles was higher than that in AMH-negative cycles (64.3% vs. 6.5%, p = 0.0001). The median serum AMH level (7.7 pg/mL [25th and 75th percentiles 4.6 pg/mL and 22.3 pg/mL, respectively]) in AMH-positive cycles was lower than the lower limit of detection of conventional AMH ELISA kits. The positive predictive value of positive serum AMH levels for follicle growth was higher than that of follicle-stimulating hormone (< 10 mIU/mL). These results indicate that a very low level of serum AMH detected using picoAMH assays is a useful predictor of follicle growth in patients with POI receiving HRT.

Ovarian function after the use of various hemostatic techniques during treatment for endometrioma: protocol for a randomized clinical trial

Background

Laparoscopic cystectomy is currently considered the gold standard for the treatment of ovarian endometrioma, resulting in an improvement in symptoms, a lower recurrence rate, and a higher pregnancy rate among infertile patients. However, this treatment is not free from risk, since it is associated with a reduction in ovarian reserve. There is still controversy in the literature regarding whether the cause of the reduction in ovarian reserve is due to damage caused by the coagulation energy during hemostasis or whether the procedure itself is the cause of the damage irrespective of the hemostatic method used. The aim of this study is to compare the effects of different hemostatic methods on the ovarian function of women subjected to laparoscopic surgery for ovarian endometrioma.

Methods

An open-label randomized clinical trial to be conducted at the Lauro Wanderley University Hospital between December 2017 and August 2020. Eighty-four patients will be randomly allocated to three groups according to the hemostatic technique used during laparoscopic surgery for ovarian endometrioma: bipolar coagulation; laparoscopic suture; and hemostatic matrix. Ovarian function will be assessed by serum anti-Müllerian hormone measurement and by performing an antral follicle count using ultrasound before surgery and one, three, and six months after surgery. The internal review board of the Medical Sciences Center, Federal University of Paraíba approved the study protocol under reference CAAE 71621717.9.0000.8069.

Discussion

Bearing in mind the need for more randomized clinical trials to clarify this issue, we hope to contribute with data that will determine whether there is any difference between hemostatic methods despite the rational use of bipolar energy or whether the procedure itself explains the ovarian damage irrespective of the hemostatic technique used.

Trial registration

ClinicalTrials.gov, NTC03430609. Registered on XX.10/31/2017.

ISRCTN Registry, ISRCTN11469394. Registered on XX.17/12/2017.

Unique Protocol ID: U1111–1203-2508.

Analysis of key candidate genes and pathways of endometriosis pathophysiology by a genomics-bioinformatics approach

Endometriosis is a common disease in women, but the signaling pathways and driven genes involved remain unclear. This study integrated four datasets to elucidate potential key candidate genes and pathways in endometriosis. Four expression profile datasets including 29 endometriosis lesions and 37 normal tissues were integrated and analyzed. Differentially expressed genes (DEGs) were sorted, and the gene ontology, pathway enrichment, and protein-protein interaction network of candidate genes were then analyzed. A total of 94 shared DEGs were identified from the four datasets. The DEGs were clustered based on functions and signaling pathways through the analysis of significant enrichment. Among the DEG protein-protein interaction network complex, 87 nodes/DEGs were identified. Furthermore, 18 central node genes were identified, and most of the corresponding genes were involved in the angiotensin system, smooth muscle contraction, cell junction organization, and lipoxin pathways. Through integrated bioinformatic analysis, we identified candidate genes and pathways in endometriosis, which could improve our understanding of endometriosis.

The role of antimullerian hormone in assessing ovarian damage from chemotherapy, radiotherapy and surgery

PURPOSE OF REVIEW

Iatrogenic ovarian damage can occur after chemotherapy, radiotherapy and surgery for cancer as well as for non-malignant conditions. This review describes the effects of such treatment on antimullerian hormone (AMH) and the implications of the fall in AMH in relation to ovarian function and fertility, especially in the era of improved fertility preservation strategies.

RECENT FINDINGS

The risk of gonadotoxicity differs between chemotherapy regimens. There is growing evidence that pretreatment AMH has prognostic significance for the degree of fall in AMH after treatment, the reversibility of ovarian damage and risk of premature ovarian insufficiency. The accuracy of prediction increases when age is coupled with AMH. The adverse effect of removal of endometriomas is increasingly clear, and AMH pre and post surgery useful is assessing the degree of damage to the ovary. The implications of low AMH after such treatment on natural fertility and reproductive lifespan are less clear. Apart from treatment effects, there are other coexisting conditions that can affect AMH which needs to be taken into consideration during interpretation of AMH before and after treatment.

SUMMARY

A fall in AMH in women after gonadotoxic treatment has been consistently described, with variable recovery, the accurate interpretation and clinical application of post-treatment AMH level on reproductive lifespan and fertility prediction needs to be studied in future larger prospective studies with longer follow-up.

Clinical application of serum anti-Müllerian hormone as an ovarian reserve marker: A review of recent studies

It has been more than 15 years since the measurement of serum anti-Müllerian hormone (AMH) first allowed the quantitative assessment of ovarian reserve. Meanwhile, the clinical implication of serum AMH has been expanding. The measurement of serum AMH has been applied in various clinical fields, including assisted reproduction, menopause, reproductive disorders and assessment of ovarian damage/toxicity. Well-known findings about the usefulness of serum AMH revealed by numerous studies executed in the early era include decline with aging, a good correlation with oocyte yield in assisted reproduction, upregulation in polycystic ovarian syndrome and a decrease on ovarian surgery and toxic treatment. More intensive research, including a meta-analysis, cutting-edge clinical trial and advances in AMH assays, has yielded newer findings and firmer clinical interpretations in serum AMH in the past few years. Variations in the AMH decline trajectory in the general population do not support the accurate prediction of menopause. The ability to predict pregnancy in infertility treatment and natural conception is poor, while a nomogram integrating serum AMH as a stimulation protocol is useful for avoiding poor and/or hyper-responses. On the other hand, improvements in measuring very low concentrations of serum AMH may be capable of distinguishing women with poor ovarian function. Age-independent standardization of AMH values may be helpful for comparing ovarian reserves among women at different ages.