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• W2896073865 abstract "In this issue of Fertility and Sterility, Muzii et al. (1Muzii L. Di Tucci C. Di Feliciantonio M. Galati G. Di Donato V. Musella A. et al.Anti-mullerian hormone is reduced in the presence of ovarian endometriomas: a systematic review and meta-analysis.Fertil Steril. 2018; 110: 932-940Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar) present results of a meta-analysis on the peripheral levels of antimüllerian hormone (AMH) in women carrying ovarian endometriomas. They show that these levels are lower compared to controls thus indirectly suggesting that the reported damage to the ovarian reserve observed after surgery for endometriomas may, at least in part, precedes the intervention (2Hamdan M. Dunselman G. Li T.C. Cheong Y. The impact of endometrioma on IVF/ICSI outcomes: a systematic review and meta-analysis.Hum Reprod Update. 2015; 21: 809-825Crossref PubMed Scopus (190) Google Scholar). These results are of great interest and solve a long-standing controversy, but they must be interpreted cautiously and within a more comprehensive vision of the argument. Most relevant is the need to keep these findings within the boundaries of research without inferring undue and simplistic clinical recommendations. This study shows that serum AMH is lower in women with endometriomas. It does not demonstrate that ovarian reserve is injured in women with ovarian endometriomas. Indeed, one may speculate that the presence of these cysts may not be directly detrimental to the ovarian reserve but, conversely, may only perturb the physiology of the ovary causing a transient derangement of the complex and unknown mechanisms regulating AMH production. Moreover, one should also consider the important effects on local vascularization caused by the presence of large endometriomas. AMH could be normally produced in affected ovaries but may encounter more difficulties to reach the peripheral circulation. To note, AMH is a paracrine factor and not a hormone (to date there is no convincing evidence of a systemic role of AMH): an impairment of the processes leading to AMH secretion into the peripheral circulation is not compensated by feedback mechanisms. In other words, to date, we do not have sufficient evidence to speculate that the reduced serum AMH in women with endometriomas reflects a real and definitive damage to the ovarian reserve rather than only a transient and potentially reversible interference with ovarian physiology. In this context, it would be also of utmost interest obtaining data on the role of time, i.e. on the role of the age of the endometriomas on serum AMH. From a clinical perspective, the demonstration of a time-related effect would support causality and may be an important information for clinicians. Unfortunately, this information is not reported in the studies included in the meta-analysis and Muzii et al. (1Muzii L. Di Tucci C. Di Feliciantonio M. Galati G. Di Donato V. Musella A. et al.Anti-mullerian hormone is reduced in the presence of ovarian endometriomas: a systematic review and meta-analysis.Fertil Steril. 2018; 110: 932-940Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar) could not obviously overcome this limitation. Surprisingly, to date, the possible role of time on endometrioma-related damage has received scanty attention in the literature and the few available data is contrasting (3Benaglia L. Castiglioni M. Paffoni A. Sarais V. Vercellini P. Somigliana E. Is endometrioma-associated damage to ovarian reserve progressive? Insights from IVF cycles.Eur J Obstet Gynecol Reprod Biol. 2017; 217: 101-105Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar, 4Kasapoglu I. Ata B. Uyaniklar O. Seyhan A. Orhan A. Yildiz Oguz S. et al.Endometrioma-related reduction in ovarian reserve (ERROR): a prospective longitudinal study.Fertil Steril. 2018; 110: 122-127Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar). A further issue deserving to be commented is the dimension of the endometriomas. The mean diameter reported in the studies included in the meta-analysis is considerable (it exceeds 5 cm in the clear majority). As properly pointed out by Muzii et al. (1Muzii L. Di Tucci C. Di Feliciantonio M. Galati G. Di Donato V. Musella A. et al.Anti-mullerian hormone is reduced in the presence of ovarian endometriomas: a systematic review and meta-analysis.Fertil Steril. 2018; 110: 932-940Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar), this point has received scanty attention in the past but may play a crucial role. Noteworthy, for geometrical reasons, the volume of endometriomas of 6 cm is 27-fold superior compared to the volume of an endometrioma of 2 cm (about 113 ml and 4 ml, respectively). Moreover, one has also to consider that these lesions develop within an organ (the ovary) whose basal volume is of only about 4 ml. This observation may explain the differences between the meta-analysis of Muzii et al. (1Muzii L. Di Tucci C. Di Feliciantonio M. Galati G. Di Donato V. Musella A. et al.Anti-mullerian hormone is reduced in the presence of ovarian endometriomas: a systematic review and meta-analysis.Fertil Steril. 2018; 110: 932-940Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar) and previous evidence obtained in in vitro fertilization contexts that generally failed to show a significant impact of ovarian endometriomas (2Hamdan M. Dunselman G. Li T.C. Cheong Y. The impact of endometrioma on IVF/ICSI outcomes: a systematic review and meta-analysis.Hum Reprod Update. 2015; 21: 809-825Crossref PubMed Scopus (190) Google Scholar). Indeed, in in vitro fertilization studies, the mean diameter of the studied endometriomas rarely exceeds 2 cm. Note, this unique study exclusively focusing on ovarian endometriomas larger than 5 cm showed a reduced responsiveness in affected ovaries (5Ferrero S. Scala C. Tafi E. Racca A. Venturini P.L. Leone Roberti Maggiore U. Impact of large ovarian endometriomas on the response to superovulation for in vitro fertilization: a retrospective study.Eur J Obstet Gynecol Reprod Biol. 2017; 213: 17-21Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar). Finally, even if the meta-analysis clearly concluded for a reduction in serum AMH in women carrying ovarian endometriomas, some methodological pitfalls impair the reliability of the estimation of the magnitude of this reduction. The high heterogeneity of the meta-analyses, the use of parametric statistics (while serum AMH is commonly positively skewed) and the unilaterality of the lesions in most cases do not actually consent to draw a reliable estimation of the pure effect of ovarian endometriomas. This information would be important to comment on the clinical relevance of this reduction and to disentangle the relative impacts of endometrioma per sé and surgery on ovarian reserve impairment. In conclusion, the study of Muzii et al. (1Muzii L. Di Tucci C. Di Feliciantonio M. Galati G. Di Donato V. Musella A. et al.Anti-mullerian hormone is reduced in the presence of ovarian endometriomas: a systematic review and meta-analysis.Fertil Steril. 2018; 110: 932-940Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar) represents a step forward but should not be used to deny the possible detrimental effect of surgery. It is a plea to continue our efforts to disentangle the intricate relations between ovarian endometriomas, ovarian reserve and the impact of surgery. Future studies should aim to reveal whether this partial impairment of ovarian function is definitive or transient and, if definitive, whether it progresses over time or not. Moreover, there is the need to better understand the mechanisms causing the arm to ovarian reserve (either endometrioma or surgery-related) to develop effective preventive measures and/or ameliorate the surgical techniques. Antimüllerian hormone is reduced in the presence of ovarian endometriomas: a systematic review and meta-analysisFertility and SterilityVol. 110Issue 5PreviewTo evaluate if the presence of endometriomas impacts on the ovarian reserve as evaluated with antimüllerian hormone (AMH). Full-Text PDF" @default.
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• W2896073865 date "2018-10-01" @default.
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• W2896073865 title "Ovarian reserve, endometriomas, and surgery: research must go on" @default.
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