Risk Factors for Anti Mullerian Hormone Decline after Laparoscopic Excision of Endometrioma: A Prospective Study

Document Type : Original Article


1 IumsShahid Akbarabadi Hospital, Iran University of Medical Sciences, Tehran, Iran

2 Yas Hospital, Tehran University of Medical Sciences, Tehran, Iran

3 Arash Hospital, Tehran University of Medical Sciences, Tehran, Iran

4 Shahid Akbarabadi Hospital, Iran University of Medical Sciences, Tehran, Iran

5 Vali-E-Asr Reproductive Health Research Center, Family Health Research Institute, Tehran University of Medical Sciences, Tehran, Iran


Background: Laparoscopic excision of ovarian endometrioma is believed to decrease the ovarian reserve, but the risk factors of declining ovarian reserve are not well studied. This study aimed to determine the risk factors of anti mullerian hormone (AMH) decline after laparoscopic surgery of endometrioma.
Materials and Methods: This prospective study was recruited in Yas and Arash Hospitals affiliated to Tehran University of Medical Sciences from 2020 to 2021. Women between 18-45 years with ovarian endometriomas with a diameter greater than 3 centimeters who were candidates for laparoscopy were included. AMH, luteinizing hormone (LH),
and follicular stimulating hormone (FSH) as well as cancer antigen 125 (CA125) and cancer antigen 19-9 (CA19-9) were obtained and compared pre and postoperatively. Indeed, the relation of AMH decline rate and the demographic, symptoms and endometrioma characteristics were investigated either.
Results: In this study, 100 women were recruited. The mean ± SD age of the participants was 29.08 ± 4.6. AMH (P<0.000) and LH (P=0.013) declined significantly postoperatively. Whereas, no significant difference was observed between pre and postoperative FSH (P=0.520). AMH decline rate was 30.07 ± 2.30% and didn’t have significant relation with the demographic characteristics, preoperative AMH, and the amount of CA125. Otherwise in the multivariate analysys, CA125 (P=0.160) and the grade of endometriosis (P=0.05) had significant correlation with AMH decline rate.
Conclusion: Ovarian reserve decline after laparoscopic excision of endometrioma. Otherwise, there may no specific risk factor to predict the degree of ovarian reserve decline. Therefore, the selection of patients for laparoscopic excision of endometrioma should be taken more cautiously as the ovarian reserve diminishes even in the patients with the lowest risks.


  1. La Marca A, Broekmans FJ, Volpe A, Fauser BC, Macklon NS, et al. Anti-Mullerian hormone (AMH): what do we still need to know? Hum Reprod. 2009; 24(9): 2264-2275.
  2. Ceyhan T, Atay V, Gungor S, Karateke A, Oral O, Baser I. Efficacy of laparoscopically-assisted extracorporeal cystectomy in patients with ovarian endometrioma. J Minim Invasive Gynecol. 2006; 13(2): 145-149.
  3. Galczynski K, Jóźwik M, Lewkowicz D, Semczuk-Sikora A, Semczuk A. Ovarian endometrioma - a possible finding in adolescent girls and young women: a mini-review. J Ovarian Res. 2019; 12: 104.
  4. Parasar P, Ozcan P, Terry KL. Endometriosis: epidemiology, diagnosis and clinical management. Curr Obstet Gynecol Rep. 2017; 6(1): 34-41.
  5. Moini, A, Malekzadeh F, Amirchaghmaghi E, Kashfi F, Akhoond MR, Saei M, et al. Risk factors associated with endometriosis among infertile Iranian women. Arch Med Sci. 2013. 9(3): 506-514.
  6. Chapron C, Vercellini P, Barakat H, Vieira M, Dubuisson JB. Management of ovarian endometriomas. Hum Reprod Update. 2002; 8(6): 591-597.
  7. Kitajima M. Defrère S, Dolmans MM, Colette S, Squifflet J, Van Langendonckt A, et al. Endometriomas as a possible cause of reduced ovarian reserve in women with endometriosis. Fertil Steril. 2011; 96(3): 685-591.
  8. Raffi F, Metwally M, Amer S. The impact of excision of ovarian endometrioma on ovarian reserve: a systematic review and metaanalysis. J Clin Endocrinol Metab. 2012; 97(9): 3146-3154.
  9. Hanege BY, Çekıç SG, Ata B. Endometrioma and ovarian reserve: effects of endometriomata per se and its surgical treatment on the ovarian reserve. Facts Views Vis Obgyn. 2019; 11(2): 151-157.
  10. La Marca A, Sighinolfi G, Radi D, Argento C, Baraldi E, Artenisio AC, et al. Anti-Mullerian hormone (AMH) as a predictive marker in assisted reproductive technology (ART). Hum Reprod Update. 2010; 16(2): 113-130.
  11. Somigliana E, Berlanda N, Benaglia L, Viganò P, Vercellini P, Fedele L. Surgical excision of endometriomas and ovarian reserve: a systematic review on serum antimullerian hormone level modifications. Fertil Steril. 2012; 98(6): 1531-1538.
  12. Moolhuijsen LME, Visser JA. Anti-mullerian hormone and ovarian Reserve: update on assessing ovarian function. J Clin Endocrinol Metab. 2020; 105(11): 3361-3373.
  13. La Marca A, Stabile G, Artenisio AC, Volpe A. Serum anti-Mullerian hormone throughout the human menstrual cycle. Hum Reprod. 2006; 21(12): 3103-3107.
  14. Gracia CR, Shin SS, Prewitt M, Chamberlin JS, Lofaro LR, Jones KL, et al. Multi-center clinical evaluation of the access AMH assay to determine AMH levels in reproductive age women during normal menstrual cycles. J Assist Reprod Genet. 2018; 35(5): 777-783.
  15. Hehenkamp WJ, Looman CW, Themmen AP, de Jong FH, Te Velde ER, Broekmans FJ. Anti-Mullerian hormone levels in the spontaneous menstrual cycle do not show substantial fluctuation. J Clin Endocrinol Metab. 2006; 91(10): 4057-4063.
  16. Ragni G, Somigliana E, Benedetti F, Paffoni A, Vegetti W, Restelli L, et al. Damage to ovarian reserve associated with laparoscopic excision of endometriomas: a quantitative rather than a qualitative injury. Am J Obstet Gynecol. 2005; 193(6): 1908-1914.
  17. Ruiz-Flores FJ, Garcia-Velasco JA. Is there a benefit for surgery in endometrioma-associated infertility? Curr Opin Obstet Gynecol. 2012; 24(3): 136-140.
  18. Tang Y, Chen SL, Chen X, He YX, Ye DS, Guo W, et al. Ovarian damage after laparoscopic endometrioma excision might be related to the size of cyst. Fertil Steril. 2013; 100(2): 464-469.
  19. Turkcuoglu I, Melekoglu R. The long-term effects of endometrioma surgery on ovarian reserve: a prospective case-control study. Gynecol Endocrinol. 2018; 34(7): 612-615.
  20. Wang Y, Ruan X, Lu D, Sheng J, Mueck AO. Effect of laparoscopic endometrioma cystectomy on anti-Mullerian hormone (AMH) levels. Gynecol Endocrinol. 2019; 35(6): 494-497.
  21. Vignali M, Mabrouk M, Ciocca E, Alabiso G, Barbasetti di Prun A, Gentilini D, et al. Surgical excision of ovarian endometriomas: Does it truly impair ovarian reserve? Long term anti-Mullerian hormone (AMH) changes after surgery. J Obstet Gynaecol Res. 2015; 41(11): 1773-1778.
  22. Sugita A, Iwase A, Goto M, Nakahara T, Nakamura T, Kondo M, et al. One-year follow-up of serum antimullerian hormone levels in patients with cystectomy: are different sequential changes due to different mechanisms causing damage to the ovarian reserve? Fertil Steril. 2013; 100(2): 516-522 e3.
  23. Goodman LR, Goldberg JM, Flyckt RL, Gupta M, Harwalker J, Falcone T. Effect of surgery on ovarian reserve in women with endometriomas, endometriosis and controls. Am J Obstet Gynecol. 2016; 215(5): 589 e1-589 e6.
  24. Chen Y, Pei H, Chang Y, Chen M, Wang H, Xie H, et al. The impact of endometrioma and laparoscopic cystectomy on ovarian reserve and the exploration of related factors assessed by serum anti- Mullerian hormone: a prospective cohort study. J Ovarian Res. 2014; 7(1): 108.
  25. Uncu G, Kasapoglu I, Ozerkan K, Seyhan A, Oral Yilmaztepe A, Ata B. Prospective assessment of the impact of endometriomas and their removal on ovarian reserve and determinants of the rate of decline in ovarian reserve. Hum Reprod. 2013; 28(8): 2140- 2145.
  26. Celik HG, Dogan E, Okyay E, Ulukus C, Saatli B, Uysal S, et al. Effect of laparoscopic excision of endometriomas on ovarian reserve: serial changes in the serum antimullerian hormone levels. Fertil Steril. 2012; 97(6): 1472-1478.
  27. Muzii L, Di Tucci C, Di Feliciantonio M, Galati G, Di Donato V, Musella A, et al. Antimullerian hormone is reduced in the presence of ovarian endometriomas: a systematic review and meta-analysis. Fertil Steril. 2018; 110(5): 932-940 e1.
  28. Suardi D, Permadi W, Djuwantono T, Hidayat YM, Bayuaji H, Gautama GP. Correlation of serum anti-mullerian hormone (AMH) level on ovarian volume in women with endometrioma. Int J Gen Med. 2021; 14: 1-8.