Aboubakr Elnashar

1. OVARIAN
CYSTS
AND
INFERTILITY
Prof
Aboubakr
Elnashar
Benha
university
Hospital,
Egypt
ABOUBAKR
ELNASHAR
CONTENTS
I.
EFFECT
OF
OVARIAN
CYSTS
ON
FERTILITY
II.
MANAGEMENT
OF
OVARIAN
CYST
IN
PREMENOPAUSE
III.
EFFECT
OF
OVARIAN
CYSTECTOMY
ON
FERTILITY
IV.
OVARIAN
CYSTECTOMY
RECOMMENDATIONS
IV
ABOUBAKR
ELNASHAR

2. INTRODUCTION
▪
Ovarian
cystectomy
▪
a
common
procedure
for
the
management
of
benign
ovarian
cysts
in
premenopausal
women.
▪
usually
performed
▪
To
prevent
cyst
complications
such
as
pain,
rupture
or
torsion,
or
▪
When
there
is
concern
of
malignancy,
while
preserving
fertility
in
those
of
reproductive
age.
ABOUBAKR
ELNASHAR
▪
The
effect
of
the
cyst
on
fertility
1.
Nature
2.
Size
3.
Number
4.
Bilaterality
and
5.
Risk
of
recurrence
ABOUBAKR
ELNASHAR

3. I.
EFFECT
OF
OVARIAN
CYSTS
ON
FERTILITY
ABOUBAKR
ELNASHAR
1.
FUNCTIONAL
OVARIAN
CYSTS
▪
Effect
on
fertility
▪
They
almost
always
regress
spontaneously
within
1-3
menstrual
cycles
▪
Should
not
require
any
surgical
or
hormonal
interventions.
▪
With
the
exception
of
luteal
cysts
&
persistent
functional
cysts,
functional
ovarian
cysts
are
simply
by-products
of
ovulation,
so
–
in
theory
–
they
should
not
have
any
effect
on
fertility.
ABOUBAKR
ELNASHAR

4. ▪
Unilocular
▪
Thin-walled
▪
Anechoic
Follicular
cyst
ABOUBAKR
ELNASHAR
▪
The
effect
on
IVF:
▪
Some
studies
suggest
very
poor
outcome
(Biljan
et
al,
2000)
▪
High
cancellation
▪
Decreased
follicular
recruitment
▪
Low
pregnancy
rates
▪
Others
have
failed
to
report
a
difference
in
any
outcome
(Sampaio
et
al,
1991)
ABOUBAKR
ELNASHAR

5. ▪
Treatment
1.
Prolonged
downregulation
with
either
1.
Progesterone-only
pill
or
2.
Combined
contraceptive
pill
2.
Ultrasound
guided
aspiration.
ABOUBAKR
ELNASHAR
▪
Cochrane
SR,
2014:
▪
Insufficient
evidence
to
determine
whether
drainage
of
functional
ovarian
cysts
prior
to
COS
influences
rates
of
LBR,CPR,
number
of
follicles
recruited,
or
number
of
oocytes
collected
▪
The
findings
of
this
review
do
not
provide
supportive
evidence
for
drainage,
particularly
in
view
of
the
requirement
for
anaesthesia,
extra
cost,
psychological
stress
and
risk
of
surgical
complications
ABOUBAKR
ELNASHAR

6. Haemorrhagic
cysts
ABOUBAKR
ELNASHAR
DERMOID
CYSTS
▪
Background:
▪
benign
type
of
germ
cell
tumour
arising
from
totipotent
ovarian
cells.
▪
The
most
common
pathological
cysts
in
premenopausal
women.
▪
bilateral
in
10–20%
of
cases
▪
grow
at
a
rate
of
1.7–1.8
mm
per
year.
▪
The
recurrence
rate
following
cystectomy
is
3–4%
ABOUBAKR
ELNASHAR

7. 3.
Haemorrhagic
cyst
▪
Result
from
bleeding
into
a
follicular
or
corpus
luteum
cyst.
▪
Like
functional
cysts,
most
will
resolve
spontaneously,
but
occasionally
they
can
become
trapped
by
pelvic
adhesions.
▪
On
US
and
at
laparoscopy,
persistent
haemorrhagic
cysts
can
be
mistaken
for
endometriomas,
and
diagnosis
can
only
be
confirmed
by
histology.
▪
Like
functional
cysts,
haemorrhagic
cysts
are
unlikely
to
have
any
effect
on
fertility,
thus
cystectomy
for
a
haemorrhagic
cyst
is
more
likely
to
have
an
adverse
effect.
ABOUBAKR
ELNASHAR
▪
Effects
on
ovarian
function
and
fertility
1.
Very
little
or
no
effect
on
fertility
2.
No
significant
differences
in
mean
AMH
levels
between
women
with
dermoid
cysts
&
a
control
group
after
adjustment
for
age
and
body
mass
index.
The
average
size
of
dermoid
cysts
in
that
series
was
6.3
cm
(Kim
et
al15)
3.
IVF
outcomes
in
dermoid
cysts
with
a
mean
size
of
2.4
cm
showed
no
difference
in
the
number
of
eggs
collected.
ABOUBAKR
ELNASHAR

8. ▪
Why?
1.
The
follicular
density
is
higher
in
dermoid
cysts
than
in
endometriotic
&
serous
cysts.
2.
A
clear
limit
between
the
dermoid
cyst
&
the
ovarian
cortex:
ovarian
cortex
is
stretched
but
not
damaged
by
the
dermoid
cyst
(Schubert
et
al,2005
)
3.
The
cortical
tissue
surrounding
dermoid
cysts
showed
normal
morphological
patterns
&
a
regular
vascular
network
similar
to
that
of
the
normal
ovarian
cortex
(Maneschi
et
al,
1993)
ABOUBAKR
ELNASHAR
▪
Management
(Balachandren
et
al,
2021)
▪
Operating
early,
while
the
cyst
is
still
small,
may
prevent
the
need
for
a
large
cystectomy
and
thus
lower
the
effect
on
the
ovarian
reserve.
Why?
1.
Dermoid
cysts
frequently
occur
bilaterally&
have
a
relatively
high
recurrence
rate
2.
Ability
to
grow
to
relatively
large
sizes:
repeated
surgery,
bilateral
procedures
and
relatively
large
cystectomies;
all
of
which
can
have
an
adverse
effect
on
fertility.
3.
One
study
showed
a
statistically
significant
reduction
in
AMH
following
surgery
for
cysts
over
5
cm
in
diameter.
ABOUBAKR
ELNASHAR

9. Endometriomas
Background:
▪
reported
in
17–44%
of
women
with
endometriosis
▪
are
a
marker
of
more
severe,
deeper
disease.
▪
28%
of
endometriomas
are
bilateral.
▪
The
risk
of
recurrence
in
the
same
ovary
or
contralateral
ovary
following
surgery
is
high,
with
cumulative
rates
of
12–
30%
after
2–5
years
of
follow-up.
▪
81%
had
recurrence
in
the
treated
ovary,
▪
11%
on
the
contralateral
untreated
ovary
▪
8%
in
both
the
treated
and
untreated
ovaries
(Exacoustos
et
al,
2006)
ABOUBAKR
ELNASHAR
Endometrioma.
Sagittal
TVS
an
ovarian
mass
with
multiple
fine
internal
echoes
(arrows)
and
several
hyperechoic
mural
foci.
ABOUBAKR
ELNASHAR

10. 1.
On
Histology
(Schubert
et
al.2005)
▪
Endometriotic
cysts
had
▪
lower
follicular
density
than
dermoid
&serous
cysts.
▪
Invasion
of
the
surrounding
cortex:
▪
Fibrosis
▪
Abnormal
morphological
patterns
and
irregular
vascular
networks.
ABOUBAKR
ELNASHAR
2
.
On
ovarian
reserve
▪
Lower
AMH
levels
&
AFC
in
women
with
endometriomas
compared
with
age-matched
controls
(Chen
et
al,
2014)
▪
Preoperative
AFC
for
the
ovary
with
the
endometrioma
was
lower
than
that
for
the
contralateral
one,
but
statistical
significance
was
not
reached
(Muzii
et
al,
2014)
ABOUBAKR
ELNASHAR

11. 3.
On
ovulation
▪
lower
ovulation
rates
in
ovaries
containing
endometriomas
greater
than
10
mm
in
diameter
compared
with
the
healthy
contralateral
ovary
(Benaglia
et
al,
2009
)
▪
244
women,
with
a
unilateral
endometrioma
greater
than
20
mm
in
diameter:
No
difference
in
the
ovulation
rates
between
the
affected
ovary
and
healthy
ovary
(50.3%
vs
49.7%)
(Maggiore
et
al,
2017)
ABOUBAKR
ELNASHAR
4.
On
oocyte
and
embryo
quality
▪
Inconclusive
▪
Oocytes
retrieved
from
women
affected
by
endometriosis
are
more
likely
to
fail
in
vitro
maturation
and
showed
altered
morphology
and
a
lower
cytoplasmic
mitochondrial
content
than
in
women
with
other
causes
of
infertility
(Sanchez
et
al,
27
SR,
2017)
ABOUBAKR
ELNASHAR

12. 5.
On
fertility
has
a
detrimental
effect.
Due
to
1.
Chronic
inflammation
affecting
quality
of
oocytes
2.
Impaired
ovarian
function:
defective
folliculogenesis
and
fertilisation
3.
Poor
embryo
quality
secondary
to
an
altered
follicular
environment:
embryos
with
reduced
implantation
capacity
4.
Poor
ovarian
reserve
with
a
significant
reduction
in
the
primordial
follicle
cohort
secondary
to
fibrosis
from
increased
tissue
oxidative
stress
5.
Anatomical
distortion
and
tubal
damage
or
occlusion
secondary
to
pelvic
adhesions.
ABOUBAKR
ELNASHAR
6.
On
IVF
outcome:
1.
Lower
mean
number
of
eggs
retrieved
2.
Higher
cancellation
rates
in
women
with
endometriomas
compared
with
no
endometriomas
(Hamdan
et
al,
2015)
3.
CPR
was
significantly
lower
for
endometriosis
patients
4.
LBR
were
not
statistically
different,
although
women
with
endometriosis
had
lower
CPR
(MA,
Harb
et
al,
2013)
▪
Similar
LBR
and
CPR
(Hamdan
et
al,
2015)
5.
Higher
rates
of
miscarriage
in
patients
with
endometriosis/endometriomas
than
in
healthy
controls
following
spontaneous
conception.
ABOUBAKR
ELNASHAR

13. Ovarian
cystadenomas
▪
Background:
▪
common
benign
epithelial
neoplasms,
of
which
serous
and
mucinous
are
two
of
the
most
common
types
seen.36,37
▪
Serous
cystadenomas
are
more
prevalent
in
menopausal
women,
while
the
mucinous
type
mainly
occurs
during
the
third
to
sixth
decade.38
▪
Mucinous
cystadenomas
are
usually
unilateral,
but
they
can
grow
large
in
size
–
on
average
between
15
and
30
cm
▪
Effect
on
fertility
▪
Nothing
in
literature
▪
{relatively
large
sizes
of
these
cysts},
there
is
a
greater
chance
of
oophorectomy
▪
Surgical
spill
of
mucinous
material:
pelvic
adhesions
and
subsequent
infertility.
ABOUBAKR
ELNASHAR
Ovarian
torsion
&
its
effect
on
fertility
▪
Rare
gynaecological
emergency
▪
3%
of
all
emergency
gynaecological
surgeries
▪
usually
involves
the
ovary
&
fallopian
tube
▪
More
commonly
seen
with
benign
cysts
greater
than
5
cm
▪
Effect
of
torsion:
haemorrhage,
congestion
and
apoptosis
secondary
to
ischaemia,
which
can
affect
the
ovarian
reserve
▪
Laparoscopic
de
torsion:
treatment
of
choice
in
prepubescent
girls
and
women
of
reproductive
age,
regardless
of
the
colour
of
the
ovary
at
the
time
of
surgery
ABOUBAKR
ELNASHAR

14. TVS:
Adnexal
torsion.
1.
An
enlarged
ovary
(maximal
diameter,
>5
cm)
2.
Congestion:
▪
prominent
peripheral
nonovulatory
follicles
▪
small
amount
of
free
fluid
(arrow)
around
the
inferior
margin.
ABOUBAKR
ELNASHAR
▪
Effects
of
Detorsion
of
the
ischaemic
ovary
▪
Preserved
ovarian
function
in
91.3%
of
patients
▪
No
difference
in
the
AFC
between
the
affected&
contralateral
ovary
3
months
after
detorsion
▪
No
difference
in
the
AMH
level
taken
preoperatively
on
the
day
of
detorsion
and
at
1
and
3
months
postoperatively.
▪
Follicular
development
and
successful
fertilisation
of
oocytes
retrieved
from
the
ischaemic
ovary
following
COS
▪
In
cases
where
torsion
has
occurred
in
the
presence
of
an
ovarian
cyst,
an
elective
cystectomy
2–3
weeks
later
is
advised
to
allow
time
for
the
congestion
and
oedema
to
resolve
ABOUBAKR
ELNASHAR

15. II.
MANAGEMENT
OF
OVARIAN
CYST
IN
PREMENOPAUSE
ABOUBAKR
ELNASHAR
▪
RMI
=
U
x
M
x
CA-125
▪
The
ultrasound
score
is
calculated
by
awarding
1
point
for
each
of
the
following
characteristics:
Multilocular
cyst
Evidence
of
solid
areas
Evidence
of
metastases
Presence
of
ascites
Bilateral
lesions
U
=
0,
if
none
of
the
above
listed
features
is
found
U
=
1,
for
ultrasound
score
of
1
U
=
3,
for
ultrasound
score
≥
2
▪
Menopausal
status
(M
=
1
if
premenopausal
and
M
=
3
if
postmenopausal)
ABOUBAKR
ELNASHAR

16. NHS
Guidelines2020
ABOUBAKR
ELNASHAR
III.
EFFECT
OF
OVARIAN
CYSTECTOMY
ON
FERTILITY
ABOUBAKR
ELNASHAR

17. 1.
Effect
of
ovarian
cystectomy
on
ovarian
reserve
▪
There
are
several
ways
to
perform
ovarian
cystectomy,
but,
in
principle
▪
Incising
the
ovarian
cortex
to
identify
the
cyst
capsule
▪
Removing
the
cyst
wall
▪
±with
or
without
draining
▪
Haemostatic
measures.
▪
Factors
determine
effect
of
cystectomy
on
the
ovarian
reserve.
I.
Cyst:
size,
nature,
bilaterality
and/or
recurrent
II.
Surgery:
Method
of
cystectomy,
method
of
haemostasis
III.
Surgeon:
Skill
and
experience
ABOUBAKR
ELNASHAR
I.
Surgery:
1.
Stripping
&removing
the
cyst
wall
and
the
thermal
damage:
coagulation:
loss
of
healthy
ovarian
tissue:
reduction
in
the
follicle
density.
2.
Laparoscopic
excision
using
the
stripping
technique:
1.
54%
of
ovarian
tissue
is
inadvertently
excised
along
with
the
cyst
wall
in
those
with
endometriotic
cysts
2.
6%
in
those
with
non-endometriotic
cysts
(Muzii
et
al.
2002)
ABOUBAKR
ELNASHAR

18. II.
Cyst:
1.
Nature:
▪
3
months
after
surgery:
recovery
of
AMH
levels
to
65%
of
the
preoperative
level
in
both
endometriotic
and
non-endometriotic
cysts
(Amooee
et
al,
2015)
▪
Cystectomy
for
endometriomas:
▪
30%
decrease
in
AMH
▪
AFC,
did
not
change
significantly
(Muzii
et
al.2014
)
{AFC
is
likely
to
be
less
reliable
in
the
presence
of
endometriomas
and
that
the
preoperative
AFC
underestimates
the
value:
obscure
the
postoperative
reduction
in
AFC.(Ata
et
al,
2014}
▪
Reduced
ovarian
reserve
following
cystectomy
for
non-endometriotic
cysts,
primarily
dermoid
cysts.
ABOUBAKR
ELNASHAR
2.
The
size
of
the
cyst
1.
Endometrioma
cystectomy:
An
average
loss
of
200
µm
of
ovarian
tissue
per
centimetre
increase
in
endometrioma
diameter
(Roman
et
al.2010)
▪
More
significant
decline
in
ovarian
reserve
following
removal
of
endometriomas
greater
than
5–
7
cm.
2.
To
surgery
when
the
cyst
is
small:
why?
▪
Especially
in
those
with
mucinous
cystadenomas,
which
have
a
propensity
to
grow
into
large
cysts
▪
Higher
risk
of
oophorectomy
when
performing
large
cystectomies
▪
Significant
risk
of
ovarian
torsion
with
large
cyst
ABOUBAKR
ELNASHAR

19. 2.
Bilateral
cystectomy
▪
greater
decline
in
the
ovarian
reserve
than
with
unilateral
surgery
▪
Surgery
for
bilateral
endometriomas:
an
increased
risk
of
POI
ABOUBAKR
ELNASHAR
2.
Effect
of
Ovarian
cystectomy
on
IVF
outcomes
▪
Cystectomy
for
endometriomas
prior
to
IVF
treatment
▪
Not
routinely
recommended
{not
improve
IVF
outcomes
(Benschop
et
al,
SR,
2010)
▪
Cochrane
review:
no
evidence
of
benefit
for
CPR.68,69
▪
Decreased
ovarian
response
to
GnT
following
cystectomy
for
endometriomas
(Demirol
et
al,
2006)
▪
Surgery
should
be
considered
under
some
clinical
circumstances.
ABOUBAKR
ELNASHAR

20. ▪
Garcia-Velasco
and
Somigliana,
2009
ABOUBAKR
ELNASHAR
3.
Effect
of
surgical
technique
on
fertility
outcomes
▪
Techniques:
1.
Excision
2.
Drainage
&
bipolar
coagulation
or
ablation
using
plasma
or
laser
energy.
▪
Cystectomy
is
superior
to
drainage
&
bipolar
coagulation
in
terms
of
▪
Spontaneous
PR
▪
Lower
risk
of
recurrence
▪
Pain
symptoms
among
subfertile
patients
with
endometriomas
greater
than
3
cm
ABOUBAKR
ELNASHAR

21. ▪
Laser
ablation
or
plasma
energy
Vs
cystectomy
▪
better
preservation
of
ovarian
reserve
▪
recurrence
rates
at
1
year
higher
(Carmona
et
al,
2011)
▪
Laparoscopic
suturing
was
superior
to
bipolar
coagulation
when
comparing
AMH
and
AFC
–
even
12
months
after
surgery
(Baracat
et
al,
2019)
▪
Bipolar
vs.
haemostatic
sealants,
the
results
favoured
the
use
of
haemostatic
agents.
ABOUBAKR
ELNASHAR
IV.
RECOMMENDATIONS
FOR
OVARIAN
CYSTECTOMY
ABOUBAKR
ELNASHAR

22. 1.
Preoperative
Recommendations
1.
Ovarian
reserve
assessments
▪
For
women
who
have
not
completed
their
family,
in
1.
Repeat
surgery
on
the
same
or
contralateral
ovary
2.
Severe
endometriosis
and
bilateral
endometriomas
3.
coexistent
aetiologies
for
subfertility,
including
low
sperm
parameters
in
the
male
partner
4.
Advanced
reproductive
age
5.
Coexistent
risk
factors
for
POI.
ABOUBAKR
ELNASHAR
▪
Ovarian
cystectomy
can
reduce
ovarian
reserve,
which
can
hinder
the
chance
of
success
with
IVF
▪
Significance
of
Ovarian
reserve
assessments
▪
An
indirect
measure
of
oocyte
quantity
but
are
poor
predictors
of
oocyte
quality
▪
Should
not
be
used
to
predict
spontaneous
conception.
▪
AFC
and
AMH
have
been
shown
to
be
▪
Lower
in
the
presence
of
endometriomas
▪
Not
affected
by
the
presence
of
other
types
of
cysts.
ABOUBAKR
ELNASHAR

23. ▪
AFC
assessment
in
endometrioma:
▪
The
reduced
AFC
associated
with
endometriomas
could
be
associated
with
an
inability
to
visualise
the
antral
follicles
on
US
in
the
presence
of
an
endometrioma.
▪
Although
the
AFC
was
reduced
in
the
ovaries
with
an
endometrioma,
the
median
number
of
oocytes
retrieved
was
similar
between
ovaries
with
an
endometrioma
and
the
contralateral
ovaries
(Candiani
et
al,
2018)
ABOUBAKR
ELNASHAR
2.
Discuss
fertility
preservation
options
▪
Indication
▪
ovarian
reserve
is
already
compromised
▪
considerable
risk
of
POI
▪
For
postpubertal
females:
egg
or
embryo
storage
following
ovarian
stimulation
▪
The
disadvantages
of
fertility
preservation
before
cystectomy
▪
Delay
in
surgery
▪
Visceral
injury
during
egg
collection,
▪
Pelvic
infection
from
accidental
puncture
of
the
cyst
▪
theoretical
increase
in
the
risk
of
torsion
of
the
hyperstimulated
ovary.
ABOUBAKR
ELNASHAR

24. 3.
Pelvic
US
&
a
bimanual
examination
▪
US:
Assess
the
type,
size,
number
and
location
(unilateral
or
bilateral)
of
the
ovarian
cysts
before
surgery
▪
Bimanual
examination:
identify
deep
endometriotic
nodules
in
the
Pouch
of
Douglas,
which
can
be
difficult
to
visualise
on
US.
4.
Consent
possible
risks
associated
with
the
surgical
procedure,
including
reduction
in
ovarian
reserve
and
risk
of
oophorectomy.
5.
Refer
the
woman
to
a
centre
of
expertise
If
the
surgery
cannot
be
performed
or
completed
safely,
the
patient
should
be
referred
to
a
centre
of
expertise.
ABOUBAKR
ELNASHAR
6.
Blood
supply
of
the
ovary
1.
Ovarian
artery
approaches
the
ovary
through
the
infundibulopelvic
ligament
2.
An
anastomosis
between
the
ovarian
artery
&
ascending
branch
of
the
uterine
artery/tubal
artery,
found
within
the
ovarian
ligament.
These
intra-ovarian
vessels
are
found
in
the
anterolateral
aspect
of
the
ovary,
at
the
insertion
of
the
mesovarium.
ABOUBAKR
ELNASHAR

25. ABOUBAKR
ELNASHAR
ABOUBAKR
ELNASHAR

26. ABOUBAKR
ELNASHAR
2.
Operative
recommendation
▪
Non-endometriotic
cysts
1.
An
incision
on
the
anti-mesenteric
surface
of
ovarian
cortex
2.
Identify
the
plane
between
the
cyst
wall
&the
ovarian
cortex;
develop
this
plane
further
3.
Enucleate
the
cyst
or
cyst
wall
(if
the
contents
are
spilled
or
aspirated)
by
▪
Combination
of
blunt
&
sharp
dissection,
▪
Traction
&
countertraction.
4.
Haemostasis
by
▪
targeted
coagulation
of
blood
vessels
or
▪
suturing
▪
Avoid
indiscriminate
use
of
diathermy
▪
consider
using
haemostatic
sealants
instead
of
excessive
diathermy.
5.
Reconstruct
ovary
ABOUBAKR
ELNASHAR

27. Ovarian
cystectomy.
(a)
Reveal
cleavage
plane.
(b)
Dissect
the
cyst
wall
from
the
ovarian
parenchyma.
(c,d)
Achieve
haemostasis
by
targeted
coagulation
and/or
suturing
and
then
reconstruct
the
ovary.
ABOUBAKR
ELNASHAR
▪
Endometriotic
cysts
World
Endometriosis
Society
(WES)
recommends
the
following
approaches:
1.
Mobilise
the
ovary
and
drain
the
cyst
2.
Incision
to
reveal
the
cleavage
plane,
either
1.
On
the
edge
of
the
cyst
opening
or
2.
Central
incision,
which
divides
the
cyst
into
two
halves.
▪
Incision
should
be
away
from
the
blood
vessels
in
the
hilum/mesovarium.
▪
Use
of
cold
cut
at
the
edge
of
the
cyst
opening
may
assist
in
identifying
the
cleavage
plane.
ABOUBAKR
ELNASHAR

28. Ovarian
cystectomy
of
an
endometrioma.
(a)Right
ovarian
endometrioma
and
adherent
right
ovary.
(b)
Drainage
of
endometrioma
after
mobilising
the
ovary.
(c)
Exposure
of
the
plan
between
the
cyst
wall
and
ovarian
cortex.
(d)
Vasopressin
injection
under
the
cyst
capsule.
(e)Dissect
cyst
capsule
from
the
ovarian
parenchyma.
(f)
Cyst
capsule
after
complete
removal.
(g)
Precise
spot
bipolar
diathermy
to
achieve
haemostasis.ABOUBAKR
ELNASHAR
3.
Saline
or
diluted
synthetic
vasopressin
may
be
injected
under
the
cyst
capsule
▪
aid
dissection&
identification
of
the
cyst
wall,
(0.1–1
unit/ml)
▪
reducing
bleeding
during
cyst
removal.
4.
Traction
and
countertraction
to
dissect
the
cyst
capsule
from
the
ovarian
parenchyma
▪
Avoid
excessive
force
to
separate
a
highly
adherent
cyst
from
the
ovary.
This
is
likely
to
tear
the
ovarian
tissue:
excessive
bleeding
and
the
need
for
coagulation
or
diathermy,
which
will
further
damage
normal
ovarian
tissue.
ABOUBAKR
ELNASHAR

29. 5.
Haemostasis
▪
Precise
spot
bipolar
coagulation
will
prevent
unnecessary
damage
to
healthy
tissue&
avoids
blind
or
excessive
diathermy
▪
Suturing
or
intraovarian
haemostatic
sealant
agents
▪
It
is
important
to
avoid
damaging
the
major
blood
supply
at
the
hilum
coming
in
from
the
ovarian&infundibulopelvic
lig
6.
Reconstruct
the
ovary
▪
with
monofilament
sutures,
placed
inside
the
ovary,
as
the
exposed
suture
may
be
prone
to
adhesion
formation.
▪
For
small
cysts:
suturing
is
often
not
required
because
the
ovarian
opening
usually
approximates
spontaneously.
ABOUBAKR
ELNASHAR
Two-step
approach
for
large
endometriomas
▪
Opening
and
draining
the
endometrioma
as
described
previously,
the
cyst
wall
is
inspected
and
a
biopsy
taken.
▪
GnRHa
therapy
is
then
given
for
3
months
to
reduce
the
thickness
of
the
cyst
wall
through
atrophy
and
reduction
in
stromal
vascularization
▪
Second
laparoscopy
in
the
form
of
cystectomy,
CO2
vaporisation,
bipolar
diathermy
or
plasma
ablation
of
the
cyst
wall
lining.
▪
Disadvantages:
women
have
to
undergo
two
invasive
procedures
▪
Benefit:
▪
Facilitate
the
management
of
larger
ovarian
endometriomas,
▪
Reduce
recurrence
rates
▪
Limit
the
damage
to
the
ovarian
reserve.20
ABOUBAKR
ELNASHAR

30. CONCLUSION
▪
The
impact
of
benign
ovarian
cysts
on
fertility
depend
on
nature,
size,
number,
bilaterality
&
risk
of
recurrence
▪
Laparoscopic
detorsion
has
the
potential
to
preserve
ovarian
reserve
and
should
remain
the
optimal
treatment
for
ovarian
torsion
in
girls
and
premenopausal
women.
▪
Surgery
for
bilateral
endometriomas
has
been
shown
to
increase
the
risk
of
developing
POI.
▪
Ovarian
reserve
assessments
before
any
ovarian
surgery
in
women
who
have
not
completed
their
family.
▪
Considerable
pain
related
to
the
cyst
and
who
are
unsuitable
for
hormonal
therapy
will
often
require
surgery.
ABOUBAKR
ELNASHAR
▪
Before
an
ovarian
cystectomy
▪
age
of
the
patient,
the
nature
of
the
cyst,
rate
of
growth,
risk
of
recurrence,
surgical
history
and
future
fertility
plans
▪
Assess
other
causes
of
subfertility
that
would
increase
the
likelihood
of
ART
in
the
future,
including
male
factor
▪
Regardless
of
whether
or
not
a
cystectomy
is
performed,
it
is
imperative
that
the
risk
to
fertility
and
ovarian
function
is
discussed
with
all
patients.
▪
Discussing
fertility
preservation
options
when
there
is
a
significant
risk
of
injury
to
a
woman’s
reproductive
potential
ABOUBAKR
ELNASHAR