The effect of bipolar electro-coagulation during ovarian cystectomy versus suture on ovarian reserve

INTRODUCTION

A fluid-filled sac that originates inside the ovaries is known as an ovarian cyst. It occurs in nearly all reproductive-age women, as well as 18% of postmenopausal women. Laparoscopy has already been a core component in the therapy of benign masses over the last twenty years, and it is now deemed the "gold standard" for the removal of benign ovarian cysts. Small incisions, decreased pain, reduced wound-infection rates, fast mobility, and short time for recovery all are benefits of laparoscopic ovarian cystectomy versus laparotomy; nonetheless, there are questions regarding ovarian reserve in association to cystectomy surgical and hemostatic procedures. ¹

The inoculation of the cyst wall is accompanied either by bipolar electrocoagulation or simple suturing of the remnant ovarian tissue to achieve appropriate hemostasis in ovarian cystectomy. Previous research has revealed that surgical intervention with ovarian cysts, particularly endometriomas, can reduce ovarian reserve. Although there are few publications on the effect of hemostatic electrocoagulation compared to suturing on ovarian function in child bearing period female with non-malignant ovarian cysts. ²

Because electrocoagulation is a safe and dependable procedure, it is widely employed during laparoscopic surgery. Electrocoagulation for hemostasis following laparoscopic ovarian cystectomy may result in increased loss of normal ovarian tissue. As a result, many medical institutes have utilized alternate ways to limit ovarian tissue hemorrhage after cystectomy, such as hemostatic sealants. ³

Serum levels of FSH, AMH, LH, estradiol, LH/FSH ratio, inhibin B, and sonographic parameters, including average ovarian diameter, ovarian volume, AFC, and PSV of the ovarian artery, have all been suggested as non-invasive indicators to assess ovarian reserve. The most sensitive of these indicators appear to be AMH and AFC. ⁴

It is unknown if the detrimental impact of cyst removal on ovarian reserve is caused by the use of bipolar electrocoagulation, which could possibly harm the ovarian follicles, or if it is caused by the unintentional removal of healthy ovarian tissue after benign cyst removal. ⁵

Endometriomas and non-malignant adnexal lesions are commonly treated with laparoscopic surgery. It is superior because of its small incisions, reduced pain, lower wound rates of infection, faster ambulation, and rapid healing. Nevertheless, there are worries regarding the ovarian reserve following ovarian cystectomy due to the surgical approach used. There has been a decrease in ovarian reserve and a higher incidence of failure of the ovary following the laparoscopic removal of endometriomas in patients with infertility..⁶

Only a few cases have been studied to determine the effect of coagulation vs suturing on ovarian reserve in child-bearing period females with non-malignant ovarian cysts.⁷

The goal of this research was to determine if there was a difference in ovarian reserve following ovarian cystectomy between bipolar electrocoagulation and suture haemostasis.

PATIENTS AND METHODS

An observational randomized prospective study including 50 women with ovarian cysts has been undertaken at the Obstetrics and Gynecology department, Al-Hussein University Hospital, and Damanhour National Medical Institute. Patients were randomly assigned to one of two groups: sutures (25 patients) or bipolar electro-coagulation (25 patients). All patients had an ovarian cystectomy. Prior to participating in our study, we obtained informed consent from the patients.

Inclusion criteria:

Woman who fulfilled to the following criteria were included in the study:

The study involved patients between the ages of 18 and 40 who had been diagnosed with persistent benign ovarian cysts larger than 5 cm and were scheduled to have laparoscopic surgery after other therapies had failed. All of the ladies who were enrolled were in good enough health to undergo the surgery. For all women who have had persistent ovarian cysts for more than three months.

Exclusion criteria:

Patients who had ovarian surgery subsequently were not included in the research. Women having a very low or high BMI, irregular menstrual cycles, endocrine disorders, a prior history of gynecologic surgery, a family history of early ovarian failure, or infertility were also removed from the research.

Ethical consideration:

The ethics committee of AL Azhar University's Faculty of Medicine approved the study protocol. Every patient who participated in the study gave their verbal and written consent.

The consent contained:

The study's objective should be explained in a simple way that is understandable to the general public.

No harmful manoeuvre’s will be performed or used.

All data will be kept confidential and will not be shared outside of the study without permission.

At any time, the researcher's phone number and all possible communication methods were identified for explanation.

All participants were announced by the result of study.

Participants had the right to quit the research at any moment for any reason, and were subsequently excluded from it.

Personal history, obstetric history, menstrual history, current history (urinary symptoms and gynecological symptoms), previous history, and the abdomen and pelvis examination were all taken.

Obstetric history included gravidity, parity, time, type and site of previous delivery, number of children, abortion (regarding gestational age, possible cause, treatment received, method of termination, any complication happened in the post abortive period and time of last abortion).

Investigations was done to all patient includes routine investigations (complete blood count, coagulation profile, virology screening, blood group, Rh. group) and ultrasounds scan to assess the ovarian cyst.

On the third day of menstruation, blood specimens were taken from every subject for analysis of serum FSH and AMH. Ovarian antral follicle counts on day three of menstruation, three and six months following surgery for the affected ovary. For the US examination, a 5–6 MHz transvaginal transducer was employed.

Two surgeons conducted laparoscopic ovarian cystectomy on all subjects. All of the participants have been operated on in a supine posture with their legs extended and their arms tucked alongside their bodies in a 25° Trendelenburg position. A Veress needle was used to establish pneumoperitoneum, and a 10-mm optic trocar was introduced through the abdomen. The intraabdominal CO2 pressure has been adjusted between 13 and 15 mmHg. Two ancillary trocars have been placed in the lower abdomen quadrants on the left and right. The ovaries have been exposed after the abdomen and pelvis have been explored. With traction and counter-traction by atraumatic graspers, the cyst wall has been unroofed and the cyst has been enucleated intact. Micro scissors have been employed when necessary. Hemostasis has been acquired by bipolar coagulation in 25 cases by using 35–40 W current bipolar coagulation with every site's exposure time limited to 1 second and by intra-corporeal sutures (2/0 Polyglactin) in 25 cases by knot tying. Endobag has been used to retrieve cysts.

Data has been obtained, coded, revised, and entered into IBM SPSS version 20 (Statistical Package for Social Science). The qualitative data has been represented as numbers and percentages, whereas the quantitative data has been represented as mean, standard deviations, and ranges, with a parametric distribution. P < 0.05: Significant (S)

RESULTS

Table 1: Comparison of the Suture and the Bipolar Electro-coagulation groups concerning age. There has been no statistically significant difference between the Suture and bipolar electro-coagulation groups regarding age.

Table 2: Comparison of Suture and bipolar electro-coagulation groups concerning FSH and AMH, FSH and AMH and the count of antral follicles on the third day of the monthly period. There has been no statistically significant difference between Suture and bipolar electro-coagulation groups regarding FSH and AMH, FSH and AMH, and the count of antral follicles on the third day of the monthly period.

Table 3: Comparison of suture and bipolar electro-coagulation groups concerning FSH, AMH, and count of antral follicles at 3 months following the surgery. At 3 months following the surgery, there was no statistically significant difference between the Suture and bipolar electro-coagulation groups regarding FSH, AMH, and the count of antral follicles.

Table 4: Comparison between Suture and bipolar electro-coagulation groups regarding FSH, AMH, and count of antral follicles at 6 months following the surgery. The mean value of FSH at 6 months following the surgery was statistically lower in the suture group compared to the bipolar electro-coagulation group (5.68; 6.77), P=0.002. There have been no statistically significant differences between the suture group and the bipolar electro-coagulation group regarding AMH and the count of antral follicles at 6 months following the surgery.

Table 5: shows the relationship between FSH on day 3 of the menstrual cycle and FSH 3 and 6 months after surgery, as well as FSH 3 months postsurgical and FSH 6 months postsurgical in the Suture group. The mean value of FSH at day 3 of the monthly cycle was statistically lower than FSH at 3 months after the surgery among the Suture group (5.31; 5.66) P=0.000. Mean value of FSH at day 3 of menstrual cycle was statistically lower than FSH at 6 months after the surgery among Suture group (5.31; 5.68) P=0.000. Mean value of FSH at 3 months was statistically lower than FSH at 6 months after the surgery among Suture group (5.66; 5.68) P=0.001.

Table 6: shows the relationship between AMH on day 3 of the menstrual cycle and (AMH 3 months postsurgical, AMH 6 months postsurgical, and AMH 6 months postsurgical) in the Suture group. Mean value of AMH at day 3 of menstrual cycle was statistically higher than AMH at 3 months after the surgery among Suture group (2.95; 2.72) P=0.000. Mean value of AMH at day 3 of menstrual cycle was statistically higher than AMH at 6 months after the surgery among Suture group (2.95; 2.71) P=0.000. Between 3 and 6 months postsurgical, there had been a statistically significant difference in AMH in the Suture group.

Table 7: shows the relationship between antral follicle count on day 3 of the monthly cycle and (antral follicle count at 3 months and antral follicle count at 6 months postsurgical) and antral follicle count at 3 months postsurgical and antral follicle count at 6 months after the surgery in the Suture group. In the suture group, the mean value of the count of antral follicles on day 3 of the monthly cycle was statistically lower than the mean value of the count of antral follicles at 3 months postsurgical (4.84; 5.80) P=0.000. In the suture group, the mean value of the count of antral follicles on day 3 of the monthly cycle was statistically lower than the mean value of the count of antral follicles at 6 months postsurgical (4.84; 6.48) P=0.000. In the suture group, the mean value of the count of antral follicles at 3 months was statistically lower than the mean value of the count of antral follicles at 6 months postoperative (5.80; 6.48) P=0.001.

Table 8: shows the relationship between FSH on day 3 of the menstrual cycle and (FSH at 3 months, 6 months postsurgical) and FSH at 3 months postsurgical and FSH at 6 months postsurgical in bipolar electro-coagulation group. The mean value of FSH at day 3 of the monthly cycle was statistically lower than FSH at 3 months after the surgery among the Suture group (4.88; 5.55) P=0.000. Mean value of FSH at day 3 of menstrual cycle was statistically lower than FSH at 6 months after the surgery among Suture group (4.88; 6.77) P=0.000.  Mean value of FSH at 3 months after the surgery was statistically lower than FSH at 6 months after the surgery among Suture group (5.55; 6.77) P=0.000.

Table 9: shows the relationship between AMH on day 3 of the menstrual cycle and (AMH at 3 months and 6 months postsurgical) and AMH at 3 months and 6 months postsurgical in the bipolar electro-coagulation group. Mean value of AMH at day 3 of menstrual cycle was statistically higher than AMH at 3 months after the surgery among Bipolar electro-coagulation group (3.08; 2.63) P=0.000. Mean value of AMH at day 3 of menstrual cycle was statistically higher than AMH at 6 months after the surgery among Bipolar electro-coagulation group (3.08; 2.60) P=0.000. In the bipolar electro-coagulation group, there was no statistically significant difference in AMH at 3 months and AMH at 6 months postsurgical.

Table 10: shows the relationship between antral follicle count on day 3 of the monthly cycle and (antral follicle count 3 months and 6 months after surgery) and antral follicle count 6 months after surgery in bipolar electro-coagulation group.  The mean value of AFC at day 3 of the menstrual cycle was statistically lower than the AFC at 3 months after the surgery among the bipolar electro-coagulation group (4.84; 5.60) P=0.001. The mean value of the antral follicle count on day 3 of the menstrual cycle was statistically lower than the AFC at 6 months after the surgery among the bipolar electro-coagulation group (4.84; 6.48), P = 0.000. The mean value of AFC at 3 months after the surgery was statistically lower than the AFC at 6 months after the surgery among the bipolar electro-coagulation group (5.60; 6.48) P=0.000.