Grand Rounds

Does Vasopressin Injection Reduce Risk of Reduced Ovarian Reserve During Surgery for Bilateral Endometriomas?

BACKGROUND AND PURPOSE:

Cystectomy is a recognized treatment for endometriomas, but previous literature suggests that especially with bilateral endometriomas, there may be decreased post-op ovarian reserve
Qiong-zhen et al. (JMIG, 2018) sought to determine if vasopressin injection during laparoscopic cystectomy for bilateral endometriomas can protect ovarian reserve

Prospective randomized controlled trial (RCT)
Participants
- Women with bilateral endometriomas
- Mean diameter of 4.0 to 6.0 cm (based on ultrasound)
- Age 30 to 38 years
- Normal menses: 28 to 30 days in the 6 months before surgery
- No previous surgical treatment for endometriosis
- No previous medical treatment for endometriosis in previous 9 months
- No intention to become pregnant in the next 1 to 2 years
Patients randomized to 3 groups
- Laparoscopic cystectomy by stripping with vasopressin injection technique (VIT group)
  - 20 to 30 mL diluted vasopressin (vasopressin concentration 0.06 U/mL) injected between the cyst wall and the normal ovarian cortex using 22-gauge suction needles
  - 1 puncture for each ovary
  - Total of 2.4 to 3.6 U vasopressin was injected in each cyst
- Laparoscopic cystectomy by stripping with injection of saline solution (saline)
- Laparoscopic cystectomy by stripping without injection (control)
Primary outcome
- Removed ovarian tissue thickness
- Coagulation events
Secondary outcomes
- Basal FSH level before surgery and at 3-, 6-, and 12-month follow-up
Statistics
- P value of <0.05 used for statistical significance

86 women were included
- 29 VIT group | 29 control group | 28 saline group
- Baseline characteristics (e.g. age, size of endometrioma) were the similar in all groups
No complications in any of the groups
- Transient BP elevation in some patients (10-15 mmHg) in VIT group
Cyst stripping was easier in the VIT and saline groups because fluid improved separation of surgical planes between normal ovary and cyst
- VIT group had less oozing and made finding bleeding points easier to identify
Compared to controls both VIT and saline group had (p<0.01)
- Less ovarian tissue in the cyst wall
  - Control group: 0.55 mm
  - Saline group: 0.31 mm
  - VIT group: 0.30 mm
- Less mean (SD) coagulation events p<0.01)
  - Control group: 17.8 (4.2)
  - Saline group: 10.8 (2.4)
  - VIT group: 4.4 (1.2)
- Compared to the saline group, the VIT group had
  - Fewer coagulation events (p < 0.01)
  - Lower preoperative FSH levels (p < 0.01) detected than in the saline group
  - There was no significant difference in the thickness of ovarian tissues removed in the 2 groups (p > 0.05)
- Basal FSH levels were significantly different (slightly) before and after surgery in the control and saline groups (p < 0.01) but not in the VIT group (p > .05)
- 12-month follow up FSH levels were similar in the 3 groups (p > 0.05)
- Premature Ovarian Failure
  - Control: 3 patients
  - Saline: 1 patient
  - VIT: 0 patients

Vasopressin injection appears to limit to ovarian reserve in the setting of bilateral endometriomas
Further studies needed to confirm long-term benefits related to cyst recurrence and fertility

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