Comparative effect of different surgical treatments for ovarian endometrioma on anti-Müllerian hormone levels: a systematic review and network meta-analysis.

study questionWhich surgical technique for endometrioma has the least detrimental effect on ovarian reserves? SUMMARY ANSWER: Drainage with hemostatic sealants and cystectomy with ovarian suturing were associated with relatively smaller anti-Müllerian hormone (AMH) declines 3-6 months postoperatively; however, further research assessing fertility and long-term outcomes is needed to clarify the safety and efficacy of these techniques. WHAT IS KNOWN ALREADY: Ovarian endometriomas are common in women of reproductive age and can affect their ability to have a pregnancy. Surgical removal of the endometrioma is one of the strategies to favor pregnancy, with different possible surgical techniques. However, damage to the ovary can result in lower ovarian reserve. To date, it is uncertain what surgical technique provides the best balance between efficacy and safety. STUDY DESIGN SIZE DURATION: We conducted a systematic review and network meta-analysis (NMA), searching PubMed, Embase, and Cochrane Register of Trials for randomized controlled trials (RCTs) that compared the impact of different surgical techniques for endometrioma on ovarian reserves (measured with the AMH level or antral follicle count (AFC)) from inception to June 2024. All relevant peer-reviewed studies were included. PARTICIPANTS/MATERIALS SETTING

methodsThe primary outcome was ovarian reserve, measured by the change in AMH levels (ng/ml) at 3-6 months after the treatment. Secondary outcome was the change in AFC at 3-6 months after the surgery. We assessed the quality of included studies with the Cochrane risk of bias tool 2 and performed an NMA, comparing the head-to-head effect of different surgical strategies, calculating mean differences (MDs) and 95% CIs. MAIN RESULTS AND THE ROLE OF CHANCE: 21 RCTs with 1519 participants, comparing 8 different surgical techniques (cystectomy with ovarian suturing, cystectomy with hemostatic sealants, cystectomy with tranexamic acid, cystectomy alone, drainage with hemostatic sealants, drainage alone, laser ablation, and transvaginal sclerotherapy) were included in the systematic review and 17 studies in the NMA. Regarding AMH at 3-6 months after surgery, drainage with hemostatic sealants (MD: 0.96; 95% CI: 0.60-1.33; high level of certainty), cystectomy with ovarian suturing (MD: 0.69; 95% CI: 0.39-0.98; moderate certainty), and cystectomy with hemostatic sealants (MD: 0.37; 95% CI: 0.12-0.61; low certainty) resulted in higher values of AMH compared with cystectomy alone. Regarding AFC at 3-6 months after surgery, laser ablation showed higher values of AFC (MD: 2.30; 95% CI: 0.20-4.40) compared with cystectomy alone at 3-6 months after surgery, followed by cystectomy with ovarian suturing (MD: 1.88; 95% CI: 0.98-2.79). The overall risk of bias of the included studies was low. The Confidence in Network Meta-Analysis (CINeMA) assessment showed that the only comparison with high certainty of evidence is the comparison between cystectomy and drainage with hemostatic sealants, followed by moderate certainty for the comparison between cystectomy and cystectomy with ovarian suturing and between cystectomy and laser, while the remaining comparisons had a low certainty of evidence. LIMITATIONS REASONS FOR CAUTION: The heterogeneity among the included studies, due to differences in the timing of AMH measurement, the localization and size of endometriomas, and the varying surgical techniques and expertise, is the main limitation of this study. In addition, further reasons for caution are the short follow-up period, the lack of data regarding pregnancy rates, and specific interventions such as sclerotherapy. WIDER IMPLICATIONS OF THE

findingsConsidering the estimated effect sizes and certainty of evidence for both AMH and AFC, cystectomy with ovarian suturing and drainage with hemostatic sealants were associated with the least negative impact on ovarian reserve markers. Drainage with hemostatic sealants showed associations with higher short-term AMH preservation; however, this is based on limited data, primarily from a single RCT, and more evidence from different centers is needed to assess effectiveness, recurrence risk, and potential adverse effects such as inflammation or fibrosis from allogenic materials. Given the large number of patients operated on for endometriomas globally, we urgently call for well-powered, multicentric RCTs to compare reproductive outcomes across surgical techniques, including those associated with relatively higher AMH in our analysis. STUDY FUNDING/COMPETING INTERESTS: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The authors report no relevant conflict of interest. TRIAL REGISTRATION NUMBER: CRD42021238909.