Surgical choices affect ovarian reserve

Laparoscopy is arguably the greatest advance in surgical technique in our lifetime. Surgeries that used to require weeks to months of recovery now require a few days. Gone are the days of long scars across our abdomens. Now we have itsy bitsy half centimeter dots that often all but disappear in a few years. However, with laparoscopy, surgeons have modified their techniques, for instance, using electrocautery more frequently due to its effectiveness and ease of use for controlling bleeding.

One of the most common reasons women require surgery is a benign ovarian cyst. These cysts can cause pain if they are endometriomas, are very bulky, or twist on themselves and cut off blood supply to the ovary (ovarian torsion- a surgical emergency!).  Laparoscopic surgery is the gold standard to remove benign ovarian cysts.

It is an amazing thing to watch a gynecologic surgeon remove an ovarian cyst. First she gently and patiently peels off the cyst wall from the ovary. She then carefully removes the cyst through one of the tiny incisions. Of course, it is important to stop any bleeding from the ovary. Surgeons can either use electrocautery or sutures to stop bleeding. Electrocautery involves using electrical energy to coagulate the blood and stop the bleeding. Unfortunately, prior studies have suggested that surgically removing ovarian cysts can decrease the ovarian reserve, or the ovary's ability to produce egg cells that could be fertilized and result in pregnancy.

The researchers wanted to know if electrocautery is to blame for this decrease in ovarian reserve. They used two metrics to measure ovarian reserve: anti-Mullerian hormone (AMH) and antral follicle count (AFC). AMH is released into the blood by cells in the ovary. The higher the AMH, the better the ovarian reserve. OBGYNs obtain the AFC by doing an ultrasound of the ovaries and counting up the number of follicles they see. Again, a higher AFC means more ovarian reserve.

The researchers hoped to do a meta-analysis and combine the results of all the prior studies on this topic to get one answer. Unfortunately, the prior studies were all too different from each other to allow the authors to do the statistics they had hoped. Instead, they organized the results into a systematic review. They collected 8 studies with a total of 545 women. Five of the studies were randomized clinical trials, 2 were retrospective observational studies, and 1 was a prospective observational study.

Overall, the authors conclude that using electrocoagulation resulted in lower AMH and AFC 3 months after the surgery than using sutures. The AMH and AFC remained lower at 6 and 12 months after the surgery. Did this matter in achieving pregnancy? No. In the four studies that measured it, there was no difference in post-operative pregnancy rates between electrocoagulation and sutures. One study did report that blood loss during the surgery was less in the electrocoagulation group.

The authors support using sutures instead of electrocautery when removing benign ovarian cysts. However, electrocautery does likely lead to less blood loss and shorter operative times, and pregnancy rates were no different between the two methods. It remains to be seen whether surgeons will put down their electrocautery "Bovies" and pick up the needle and thread.