Management algorithm for reproductive-aged patients with ovarian endometriomas with a view to preserving ovarian reserve

Abstract

Objective. To conduct a comparative analysis of the effects of different organ-preserving surgical techniques for ovarian endometriomas on ovarian reserve (OR) in reproductive-aged patients. Patients and methods. This randomized cohort study included 112 patients aged 20 to 44 years (mean age: 28.2 ± 3.4 years) with bilateral ovarian endometriomas who underwent organ-preserving surgical treatment. Depending on the surgical approach, all patients were divided into three groups: group 1 (n = 34) consisted of women who underwent cystectomy; group 2 (n = 32) – laparoscopic ablation of the endometrioma capsule using bipolar and/or plasma energy (PlasmaJet); group 3 (n = 46) – ethanol sclerotherapy for endometriomas. The preoperative (baseline) and postoperative state of ovarian reserve (at 3, 6, and 12 months) was assessed using laboratory markers (serum anti-Müllerian hormone and follicle-stimulating hormone levels) and ultrasound parameters (volume of unaffected ovarian tissue and antral follicle count). Results. At baseline, all patients demonstrated a non-significant reduction in OR parameters, supporting the hypothesis of the toxic effect of ovarian endometriomas. The most significant postoperative decline in OR parameters was observed in patients after cystectomy (p < 0.05). After laparoscopic ablation, a similar decrease was also noted, but it was not statistically significant (p > 0.05). Following ethanol sclerotherapy, all OR parameters remained unchanged compared to baseline values. Conclusion. In patients of optimal reproductive age with no history of prior pregnancies, as well as in those undergoing assisted reproductive technologies, ethanol sclerotherapy for ovarian endometriomas has no alternative as a technique with no detrimental effect to OR. Sclerotherapy should also be considered the only feasible treatment option for recurrent endometriomas after cystectomy, particularly in cases of bilateral cystectomy or in patients with a single remaining ovary. Laparoscopic stripping cystectomy is recommended for reproductive-aged women with completed childbearing (≥40 years of age) and unilateral ovarian involvement. As postoperative (anti-recurrence) hormonal therapy, it is advisable to use a combined oral contraceptive containing 2 mg dienogest and 0.03 mg ethinyl estradiol according to the original regimen. Key words: ovarian endometriomas, cystectomy, ablation, sclerotherapy, ovarian reserve, recurrence prevention, dienogest