| Objective: Ovarian endometriotic cyst is the formation of ovarian cyst lined with ectopic endometrial glands and stroma,also called ovarian chocolate cyst,and in which the internal chocolate colored fluid is generally thought to be the non-resorbed blood derived from repeated hemorrhages of the endometriotic cells in the cyst during menstrual cycles,accounting for17%-44% of patients with endometriosis.Ovarian endometrioma are usually associated with the symptoms of dysmenorrhea,chronic pelvis pain,dyspareunia,and infertility.Treatment of endometrioma is still a challenging issue clinically,especially for infertility patients with endometrioma.It is difficult to choose which one is better,surgery or assisted reproductive technology(ART)directly.Based on the current evidence,laparoscopic ovarian cystectomy appears to be the method of choice.Besides the usual risks of anesthesia and surgery in general,another major concern associated with surgical management of endometrioma in subfertile women is the potential detrimental impact of surgical excision on ovarian reserve,which can be already diminished in these women.Antimüllerian hormone(AMH)is produced by the granulosa cells of primary,preantral,and antral follicles 2-6mm in diameter.Because early follicles secrete antimüllerian hormone in a gonadotropin-independent state and is not affected by the use of hormones,the antimüllerian hormone concentration is fairly stable within and between menstrual cycles.Serum antimüllerian hormone is a relatively new and better marker of ovarian reserve and is increasingly applied to the clinic especially for ART.Most studies suggest that serum antimüllerian hormone concentration is significantly lower in women with endometrioma and surgical excision of endometrioma led to a further loss.However,another study found that there is no significant difference between endometrioma patient and normal women.Now,there is not any study about whether the endometrioma-related decline in ovarian reserve per se is progressive in nature and whether it exceeds the surgery-related decline.The present study was conducted prospectively to determine(i)whether women with endometrioma had a lower ovarian reserve than women without endometrioma,(ii)whether the endometrioma-related decline in ovarian reserve per se is progressive in nature.Methods:1 Clinical data collection: The case group: 37 women of reproductive age who had an ultrasonographic diagnosis of endometrioma and visited or had a follow up in the Second Hospital of Hebei Medical University between July2015 and February 2016 were offered participation.Inclusion criteria consisted of 18-to 45-year-old women with regular menstrual cycles(5-7/25-35days)and no evidence of any other endocrine disorders such as diabetes mellitus,thyroid dysfunction,hyperprolactinemia or adrenal diseases.Exclusion criteria were as follows:(i)postmenopausal status at the time of follow-up,(ii)polycystic ovarian syndrome according to the Rotterdam criteria,(iii)previous history of adnexal surgery,(iv)any suspicious findings of malignant ovarian diseases and(v)taking any medication such as oral pill and hormonal drugs within 3 months before the enrollment.The control group comprised 20 women of reproductive age who did not have ovarian cysts.The same inclusion and exclusion criteria were applied to the controls.The subjects were asked to visit the hospital on 1 month、3 months and 6 months after the first visit.2 Blood samples collection,preservation and measurement: All the participants of the study were phlebotomized peripheral blood after obtaining the informed consent.The blood samples were put in serum tube,the subjects’ sera were obtained from blood samples by centrifuge at 3000r/min for 10 minutes,the serum was transferred to cryogenic tube and stored at-20℃ until assayed.Serum AMH levels were measured by enzyme-linked immunosorbent assay.Recording AMH concentration by AMH0,AMH1,AMH3,AMH6 respectively.3 Statistical analyses: Measurement data was expressed by mean ±standard deviation and was compared by using Student’s t test if the distributions of data satisfy the normal distribution,the non-normal distribution measurement data was expressed by median and was compared by using Mann-Whitney U test.Correlations between the change of serum AMH levels at each age,disease course,and size of endometrioma were analyzed by bivariate correlation analysis,and expressed as Spearman correlation coefficients or Pearson correlation coefficients.Repeated measures data was analyzed using repeated measures analysis of variance.The statistical software package SPSS version 13.0 was used,and the results were considered statistically significant at P-value﹤0.05.Results:1 Thirty-seven patients of the case group finished the first visit,17 patients were lost during follow-up,thus,20 patients could completely finish experiment;2 The mean(SD)age was 32.70(5.78)and 32.65(4.03)years in case and control groups,respectively(P=0.968),the mean(SD)body mass index(BMI)was 22.24(2.49)and 22.58(2.91)Kg/m2 in case and control groups,respectively(P=0.650),the percentage of nullipara was32.43% and 15% in case and control groups,respectively(P=0.154).They all had no statistical significance;3 In case group,the median of disease course was 10 months,the maximum was 7 years and the minimum was 1 month.Twenty-four patients had dysmenorrheal and chronic pelvis pain,4 patients associated with infertility.Nineteen women(51.35%)in the endometrioma group had unilateral cyst,14 patients had cyst in the left ovarian and 5 in the right side.and 18(48.65%)had bilateral cysts.The diameter of endometrioma was between 0.94cm-5.26 cm,the mean(SD)diameter of left and right endometriomas was 2.76(0.90)cm and 3.67(0.90)cm respectively;4 In case and control group,serum AMH0 levels both found to have been decreased significantly with age(r=-0.401,P=0.014;r=-0.601,P=0.005,respectively)and disease course of endometrioma(r=-0.514,P=0.001).Serum AMH0 levels found to have been decreased with BMI(r=-0.195,P=0.249)and increased with the diameter of endometrioma(r= 0.211,P=0.387),but theywere not significant;5 The patient with unilateral cyst had a lower AMH0 concentration than bilateral cysts,(1.868±1.700)ng/mL and(2.545±2.161)ng/mL,respectively(P=0.295 ﹥ 0.05),the patients associated with dysmenorrheal and chronic pelvis pain had a lower AMH0 concentration than who had not,(1.893±1.956)ng/mL and(2.758±1.856)ng/mL,respectively(P=0.200 ﹥ 0.05),but they were not significant;6 The variation tendency of AMH between case and control groups within 6 months was analyzed by using repeated measures analysis of variance;6.1 Mauchly’s test of Sphericity:it satisfied the condition of covariance matrix spherical symmetry(P=0.529﹥0.05);6.2 Tests of within-subjects effects: there were a significant difference within every time points about AMH concentration in case group(F=4.870,P=0.03 ﹤ 0.05),there was no interactive effect between groups and time points(F=0.521,P=0.669﹥0.05);6.3 Tests of between-subjects effects: There was no significant difference between case and control groups about AMH concentration within every time points(F=1.724,P=0.197 ﹥ 0.05);6.4Multivarite tests: there was a similar variation tendency of AMH between case and control groups(F=0.602,P=0.618﹥0.05),it can be judged roughly by the profile chart.Conclusions:1 Women with endometrioma had a lower ovarian reserve than women without endometrioma,but it was not significant.It was negatively correlated with age and disease course of endometrioma,but not correlated with BMI,the diameter and side of endometrioma.2 There was a similar variation tendency of AMH between case and control groups within 6 months.It suggests that the endometrioma-related decline in ovarian reserve per se is not progressive in nature within 6 months. |
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