Reproductive Medicine Unit, Department of Obstetrics and Gynecology, The Baruch-Padeh Medical Center, Poriya, Israel; The Azrieili Faculty of Medicine, Bar-Ilan University, Safed, Israel.
Reproductive Medicine Unit, Department of Obstetrics and Gynecology, The Baruch-Padeh Medical Center, Poriya, Israel.
Am J Obstet Gynecol. 2022 Jan;226(1):33-51.e7. doi: 10.1016/j.ajog.2021.06.102. Epub 2021 Jul 13.
Accurate preoperative counseling about whether an endometriotic cystectomy has a detrimental effect on the ovarian reserve has been a considerable challenge, because studies assessing the postoperative antral follicle counts and anti-Müllerian hormone levels have reported conflicting results. Our objective was to explore the impact of endometriotic cystectomy on both the anti-Müllerian hormone levels and antral follicle counts, with focus on prospective studies in which both variables were measured for each woman concurrently (overcoming unmeasured confounding), in the same setting (overcoming surgical technique differences), and at the same 3 postoperative time points, namely early (1-6 weeks), intermediate (2-6 months) and late (9-18 months), to overcome time-sensitive changes.
Databases of PubMed, ClinicalTrials.gov, the Cochrane Library, Web of Science, and EBSCO were searched between January 2000 and October 2020.
Only prospective cohort studies that evaluated the impact of endometriotic stripping cystectomy on anti-Müllerian hormone levels and antral follicle counts in the same women, at matching time points, and in the same setting were eligible.
Two authors performed the screening and data extraction independently.
A total of 14 prospectively designed studies were eligible for the meta-analysis and included 650 women. The included studies had a low risk of bias. The postoperative weighted mean differences in serum anti-Müllerian hormone levels dropped significantly when compared with the preoperative levels by an estimated 1.77 ng/mL (95% confidence interval, 0.77-2.77; P<.001), 1.17 ng/mL (95% confidence interval, 0.66-1.67; P<.001), and 2.13 ng/mL (95% confidence interval, 1.61-2.65; P<.001) at the early (1-6 weeks), intermediate (2-6 months), and late (9-18 months) time points, respectively. This corresponded to a mean reduction in serum anti-Müllerian hormone levels at each of the 3-time points of 44.4%, 35.1%, and 54.2%, respectively. Conversely, the postoperative weighted mean difference in the antral follicle count estimates did not change significantly at any of the 3 time points; the early antral follicle count was 0.70 (95% confidence interval, -2.71 to 3.56; P=.63), the intermediate count was -0.94 (95% confidence interval, -2.53 to 0.65; P=.25), and the late count was 2.58 (95% confidence interval, -0.43 to 5.58; P=.09). Overall, high levels of heterogeneity were encountered (I ranging between 92% and 94% for the anti-Müllerian hormone levels and between 94% and 98% for the antral follicle counts at the 3 time points), which were attenuated when similar anti-Müllerian hormone assays were compared, and the meta-regression suggested that age did not contribute to heterogeneity.
Endometriotic cystectomies are associated with a significant reduction in the serum anti-Müllerian hormone levels but not in the antral follicle counts, with the detrimental effects on the anti-Müllerian hormone levels consistently detectable at the early-, intermediate-, and late-postoperative time points. In women with endometrioma, the anti-Müllerian hormone level may provide a more accurate assessment of the risk for iatrogenic depletion of the ovarian reserve.
准确地向患者术前告知卵巢储备功能是否会因子宫内膜异位囊肿切除术而受损一直是一个挑战，因为评估术后窦卵泡计数和抗苗勒管激素水平的研究结果存在冲突。我们的目的是探讨子宫内膜异位囊肿切除术对抗苗勒管激素水平和窦卵泡计数的影响，重点关注前瞻性研究，这些研究同时测量了每位女性的这两个变量（克服未测量的混杂因素），在相同的设置中（克服手术技术差异），并在术后的 3 个时间点（即早期[1-6 周]、中期[2-6 个月]和晚期[9-18 个月]）进行测量，以克服时间敏感的变化。
检索了 2000 年 1 月至 2020 年 10 月期间 PubMed、ClinicalTrials.gov、Cochrane 图书馆、Web of Science 和 EBSCO 数据库。
只有前瞻性队列研究评估了子宫内膜异位症剥除术对同一位女性在相同时间点和相同环境下的抗苗勒管激素水平和窦卵泡计数的影响才符合入选标准。
两位作者独立进行了筛选和数据提取。
共有 14 项前瞻性设计的研究符合荟萃分析的纳入标准，共纳入 650 名女性。纳入的研究存在低偏倚风险。与术前水平相比，术后早期（1-6 周）、中期（2-6 个月）和晚期（9-18 个月）时血清抗苗勒管激素水平的术后加权平均差异分别显著下降 1.77ng/ml（95%置信区间，0.77-2.77；P<.001）、1.17ng/ml（95%置信区间，0.66-1.67；P<.001）和 2.13ng/ml（95%置信区间，1.61-2.65；P<.001）。这相当于在 3 个时间点中，血清抗苗勒管激素水平的平均降低分别为 44.4%、35.1%和 54.2%。相反，在任何 3 个时间点中，窦卵泡计数的术后加权平均差异均无显著变化；早期窦卵泡计数为 0.70（95%置信区间，-2.71 至 3.56；P=.63），中期为-0.94（95%置信区间，-2.53 至 0.65；P=.25），晚期为 2.58（95%置信区间，-0.43 至 5.58；P=.09）。总的来说，存在高异质性（抗苗勒管激素水平的 I 值在 92%-94%之间，窦卵泡计数的 I 值在 94%-98%之间），当比较类似的抗苗勒管激素检测时，异质性会减弱，Meta 回归表明年龄不会导致异质性。
子宫内膜异位囊肿切除术与血清抗苗勒管激素水平显著降低相关，但与窦卵泡计数无关，在术后早期、中期和晚期时间点，抗苗勒管激素水平的不良影响均持续存在。在患有子宫内膜异位症囊肿的女性中，抗苗勒管激素水平可能更能准确评估卵巢储备功能因医源性耗竭而受损的风险。
