Strategies to preserve ovarian function in

endometriosis surgeries

Dr. DEEPAK CHAWLA

M.S.(SURGERY); FMAS, FAIS
DIPLOMA ADVANCED GYNAE LAPAROSCOPY
(GERMANY)
Laparoscopic, Bariatric & Gynae Cancer Surgeon
(M) :9357903001
Strategies to preserve ovarian function
in endometriosis surgeries
Endometriosis

PRESENTATION IN THREE DIFFERENT ENTITIES , WHICH ARE

FREQUENTLY FOUND TOGETHER

1. PERITONEAL LESIONS
2. DEEP ENDOMETRIOSIS
3. OVARIAN ENDOMETRIOTIC CYSTS

ENDOMETRIOMAS….most commonly diagnosed forms

Anatomical considerations

• Endometriomas are frequently stuck densly to the surrounding structures such

as ipsilateral side wall, the fallopian tube, the posterolateral uterus and the bowel

• As a part of pre operative planning , surgeon should consider possibility of

hydroureters and asymptomatic hydronephrosis.

• The ureter enters the pelvis by crossing the iliac vessels, and then courses
anteriorly in the peritoneum of pelvic side walls directly under the ovary.

• Ovaries with endometriotic cysts are usually adherent to the ovarian fossa,
where the ureter may be involved with the disease.( Ureteric obstruction may be
noted at this point)
Anatomical considerations ( cont)

• Ovary…blood supply…2 sources…

• ovarian artery…
• Anastomosis between the ovarian artery and the ascending branch of the uterine
artery/tubal artery in the ovarian ligament

• The larger intra ovarian vessels are found in the anterolateral aspect of the
ovary---the hilum at the insertion of the mesovarium….....surgeon needs to be
aware of this ….to avoid excessive bleeding which might lead to destruction of
healthy ovarian tissue through cauterisation and disruption of ovarian blood
supply
Endometriosis

• Most treatment plans target pain caused by the disease and may overlook the
possibility that the patient may want to conceive.

• Each endometriotic patient should be assessed taking a proactive approach to

increase their chances of pregnancy.
 Endometriosis and Infertility

• Inflammation in pelvic cavity alters sperm-oocyte interactions

impeding chances of natural conception

• Surgeries for endometriotic lesions affects ovarian reserve

and chances of response to ovarian stimulation in ART

• Impaired endometrial receptivity

Preservation of ovarian tissue should be considered in all patients at

serious risk of future fertility impairment

Ziegler DD et al. Assisted reproduction in endometriosis. Best Practice & Research Clinical Endocrinology & Metabolism,
 Introduction on fertility preservation
• In moderate and severe endometriosis, a medico-surgical
approach remains the gold standard

• Excessive surgery may lead to normal ovarian tissue destruction

• Incomplete surgery is associated with a much higher risk of

recurrence

• Frequent reporting of low ovarian reserve after laparoscopic

cystectomy for endometriomas

Ovarian surgery in endometriosis patients should therefore be performed

by experienced surgeons in order to both preserve and improve fertility

Donnez J et al. Fertility preservation in women with ovarian endometriosis. Frontiers in Bioscience. 2012; E4: 1654-62
 Ovarian Endometrioma

• Found in up to 17–44% of women with endometriosis and are

often associated with the severe form of the disease
• Presents a clinical dilemma:
• Uncertainty regarding the decision to operate or to manage
conservatively
• Potential detrimental effect of surgery on the ovarian reserve against
potential benefit that may be gained

Treatment should be guided by factors such as woman’s

symptoms; fertility prognostic factors, including age and ovarian
reserve; previous treatment history with specific reference to
past surgical interventions; nature of the cyst; and the wishes of
the woman

Jayaprakasan K et al. The Effect of Surgery for Endometriomas on Fertility. BJOG 2017; 125:e19–e28.
 Endometrioma “burns out” ovarian
follicles

Focal loss of follicular density may be associated with a vicious ircle of

dysregulated folliculogenesis that eventually results in burnout of the
stockpile of dormant follicles

Donnez J et al. Ovarian endometriosis and fertility preservation: a challenge in 2018. Minerva Ginecologica 2018;70(4):408-14
 Surgery as first line….

• Highly symptomatic women with an intact ovarian reserve

• Unilateral and large cysts

• Cysts with suspicious radiological and clinical features

There are no data to suggest that surgery for an endometrioma will

prevent adhesion reformation and facilitate oocyte retrieval effectively

Jayaprakasan K et al. The Effect of Surgery for Endometriomas on Fertility. BJOG 2017; 125:e19–e28.
cystectomy

Make an incision to reveal the clevage plane

To aid dissection and identification of the cyst wall….slaine or diluted vasopressin

may be injected under the cyst capsule

Use traction and countertraction

Avoid blind or excessive diathermy

Ensure final hemostasis after removal of cyst capsule…bipolar

coagulation,suturing, or intra ovarian hemostatic sealents
Specimen retrival…through port or bag or posterior colpotomy
 Surgical Treatment Prior to IVF

• Similar live birth rates and clinical pregnancy rates following IVF
treatment in women with surgically-treated endometriomas compared
to those with intact endometriomas

• Comparable oocyte retrievals and cancellation rates

• Lower antral follicle count and higher doses o gonadotrophins for

ovarian stimulation in women with surgically treated endometriomas

Lack of evidence of the clear benefit of surgical treatment for the

management of an endometrioma on pregnancy rates,

Jayaprakasan K et al. The Effect of Surgery for Endometriomas on Fertility. BJOG 2017; 125:e19–e28.
 Issues with conservative management

• Interference with ovarian responsiveness to controlled stimulation and

oocyte competence

• Risk and technical difficulties during oocyte retrieval

• Associated risks to injury to adjacent organs due to altered pelvic

anatomy with the presence of adhesions, infection and abscess
formation
• Follicular fluid contamination with endometrioma content

• Progression of endometriosis, further growth and rupture of the

endometrioma

Jayaprakasan K et al. The Effect of Surgery for Endometriomas on Fertility. BJOG 2017; 125:e19–e28.
 Surgical decisions for ovarian
endometrioma prior to ART treatment

Unlu C et al. Ovarian cystectomy in endometriomas: Combined approach. J Turk Ger Gynecol Assoc 2014; 15: 177-89
 ESHRE recommendations on surgery
prior to ART in ovarian endometrioma
• In infertile women with endometrioma larger than 3 cm there is no
evidence that cystectomy prior to treatment with assisted reproductive
technologies improves pregnancy rates: A

• In women with endometrioma larger than 3 cm, the GDG recommends

clinicians only to consider cystectomy prior to assisted reproductive
technologies to improve endometriosis-associated pain or the
accessibility of follicles: GPP

• It is recommended that clinicians counsel women with endometrioma

regarding the risks of reduced ovarian function after surgery and the
possible loss of the ovary. The decision to proceed with surgery should
be considered carefully if the woman has had previous
ovarian surgery : GPP
Management of women with Endometriosis Guideline of the European Society of Human Reproduction and Embryology. ESHRE Endometriosis
Guideline Development Group September 2013. Available from: URL: https://www.eshre.eu/guidelines-and-legal/guidelines/endometriosis-
guideline.aspx
 Cystectomy and Ovarian Reserve

• Women with ovarian endometriomas >4 cm can benefit from surgery

(laparoscopic cystectomy):
• Cystectomy specimens help in correct diagnosis
• Cystectomy helps in establishing a good pelvic anatomy so that IVF egg retrieval
is facilitated.

• Preoperative and postoperative ovulation rates may not change

significantly after cystectomy in women with ovarian endometriomas
>4 cm.
• Notably, in women with ovarian endometriomas <4 cm, ovulation rates
may decline significantly, postoperatively.
• Preoperative ovulation rates have been reported to be lower than
normal on the side of endometrioma (34.4% vs 50.0%).
• However, pregnancy rate per ovulation cycle in the operated ovary
was comparable with that of the intact ovary
Nakagawa K et al. Laparoscopy should be strongly considered for women with unexplained infertility. J Obstet Gynaecol Res. 2007;33(5):665-70.
 Cystectomy vs Fenestration
Coagulation and Ovarian Reserve
• Infertile women with unilateral disease underwent either cystectomy or
fenestration coagulation
• Women with bilateral disease underwent cystectomy on one ovary and
fenestration coagulation on the other
• The number of dominant follicles obtained postoperatively by either
surgical technique was comparable to women who had unilateral
endometriomas
• Ovulation rate in the operated ovary was also comparable to that of
the healthy ovary
• Furthermore, the number of follicles obtained from either ovary
postoperatively in women with bilateral disease was comparable

Nakagawa K et al. Laparoscopy should be strongly considered for women with unexplained infertility. J Obstet Gynaecol Res. 2007;33(5):665-70.
 Cystectomy vs 3-stage Procedure and
Ovarian Reserve
• The 3-stage procedure consists of laparoscopic cyst drainage,
followed by medical treatment with GnRH agonists for 3 months, and
then laser vaporization using a CO2 laser to eliminate any remaining
endometriotic tissue

• Antral follicle count in the patients undergoing the 3-stage procedure

was significantly higher than that in the patients who underwent
cystectomy

• This indicates that the 3-stage procedure was more effective at

preserving ovarian reserve

Nakagawa K et al. Laparoscopy should be strongly considered for women with unexplained infertility. J Obstet Gynaecol Res. 2007;33(5):665-70.
 Combined technique of excisional and
ablative surgery for fertility preservation
• Stripping technique allows
removal of 80-90% of the
cyst

• CO2 used to vaporize the

remaining 10-20% of the
endometrioma close to the
hilus

• Care must be taken to

vaporize all the residual cyst
wall in order to avoid
recurrence

Donnez J et al. Fertility preservation in women with ovarian endometriosis. Frontiers in Bioscience. 2012; E4: 1654-62
 Clinical efficacy of combined
technique

Ovarian volume and antral follicle count (AFC) six months after surgery

• The volume of the ovary after the combined technique was similar to
that of the contralateral normal ovary and to normal women without
endometriosis

• Histopathology of the excised part of the endometrioma revealed the

presence of follicles in only one case

Donnez J et al. Fertility preservation in women with ovarian endometriosis. Frontiers in Bioscience. 2012; E4: 1654-62
 Modified Combined technique for
removal of ovarian endometrioma

Unlu C et al. Ovarian cystectomy in endometriomas: Combined approach. J Turk Ger Gynecol Assoc 2014; 15: 177-89
 Evidence highlights Surgical
techniques and impact on AMH
• Significantly lower AMH levels in the electrosurgical bipolar
coagulation group as compared with the hemostatic matrix group
at first postoperative month

• The risk of endometrioma re-recurrence was higher after laser

vaporization as compared to cystectomy

• The cumulative pregnancy rates were 59.4% in the cystectomy

group and 23.3% in the fenestration and coagulation group
Even though some studies suggest electrocoagulation after fenestration,
cystectomy seems more effective in terms of preserving fertility and
preventing recurrences

Sonmezer M et al. Fertility preservation in women with ovarian endometriosiss. Womens Health. 2015; 11(5), 625–631
Key Surgical Pearls for fertility
preservation in ovarian endometrioma
surgeries
• Inefficient coagulation may create a great risk of recurrence

• Minimize or avoid spillage of endometrioma contents during

surgical resection and thereby avoid the need for irrigation and
suction

• Aspiration of the endometrioma fluid before rupture, and a sterile

bag collection device to avoid spillage of the endometrioma fluid

• Stripping procedure used in laparoscopy for ovarian cyst

excision appears to be an organ-preserving procedure

Unlu C et al. Ovarian cystectomy in endometriomas: Combined approach. J Turk Ger Gynecol Assoc 2014; 15: 177-89
 Key Pearls for Surgeons!!!

Courses, books and Appropriate

literature instrumentation

Briefing of
Go through learning
anesthesiologist and
curve of laparoscopy
operation theater team

The level of expertise in endometriosis

surgery is inversely correlated with
inadvertent removal of healthy ovarian tissue
along with the endometrioma capsule

Unlu C et al. Ovarian cystectomy in endometriomas: Combined approach. J Turk Ger Gynecol Assoc 2014; 15: 177-89
Assumptions used for the evaluations on
the potential relevance of egg banking in
women with endometriosis

Somigliana E et al. Fertility preservation in women with endometriosis: for all, for some, for none? Human Reproduction. 2015; 30(6): 1280-86
 Validity of fertility preservation in
different clinical scenarios

Somigliana E et al. Fertility preservation in women with endometriosis: for all, for some, for none? Human Reproduction. 2015; 30(6): 1280-86
 Orthotopic transplantation of fresh
ovarian cortex

Donnez J et al. Fertility preservation in women with ovarian endometriosis. Frontiers in Bioscience. 2012; E4: 1654-62
 Options for ovarian tissue
cryopreservation and reimplantation

Donnez J et al. Fertility preservation in women with ovarian endometriosis. Frontiers in Bioscience. 2012; E4: 1654-62
Oocyte cryopreservation: Anti-Müllerian
hormone is a reliable Marker of the
Ovarian Follicle Density
Retrospective analysis of serum AMH levels and prospective
investigation of ovarian follicle number during clinical pro-gram of
cortical ovarian cryopreservation in endometriosis patients

• 202 women with endometriosis and 400 controls

• AMH levels were significantly lower in endometriosis compared to
controls only in patients over 36 years old
• Primordial follicle number decreased with the reduction of AMH levels
in both cases and controls

AMH is a reliable marker of ovarian reserve in endometriosis patients, and

it can predict follicular density in women undergoing ovarian tissue
cryopreservation

Garavagila E et a. Fertility Preservation in endometriosis Patients: anti-Müllerian hormone is a reliable Marker of the Ovarian Follicle Density. Frontiers
in Surgery. 2017; 4(40): 1-6
 FPSI: Opinion on Fertility Preservation
in Endometriosis
• Laparoscopic cyst drainage with CO2laser vaporization followed by
medical treatment with GnRH agonists for 3 months had a higher
antral follicle count (AFC) compared to those who underwent
cystectomy with bipolar coagulation

• Avoiding unnecessary surgery and individualization of each patient

with careful surgery performed by experienced surgeon limits damage
to ovarian reserve

• Pre-operative ovarian reserve assessment to plan best approach

If ovarian reserve is not reduced, patients with stage III or IV

endometriosis subjected to GnRH therapy 6 months before their IVF–ET
cycle show a 30% increase in pregnancy rates per cycle compared with
patients who undergo a standard controlled ovarian hyperstimulation

Patil M. Fertilty Preservation in Endometriosis. Fertility Preservation Society India. FPSI e-news. Available from: URL:
Summary of few surgical reviews

Carvalho L et al. Seven ways to preserve female fertility in patients with endometriosis. Expert Review of Obstetrics & Gynecology, 2014 ; 7(3): 227-240
Snapshot of preserving fertility in
endometriosis

Carvalho L et al. Seven ways to preserve female fertility in patients with endometriosis. Expert Review of Obstetrics & Gynecology, 2014 ; 7(3): 227-240
 Conclusions

• Surgery for ovarian endometrioma should be both effective to

decrease the risk of recurrence and protective avoid normal
ovarian tissue destruction)

• Combined surgical techniques with different components have

been proposed as effective to address both above objectives

• Ovarian cortex cryopreservation should be offered to all women

at high risk of severe recurrent ovarian endometriomas

• Adequate counseling of patients on the pros and cons of

different approaches is needed
THANK YOU