Does laparoscopic hysterectomy + bilateral salpingectomy decrease ovarian reserve more than total abdominal hysterectomy? A cohort study measuring anti-Müllerian hormone before and after surgery | BMC Women’s Health

Study design

In this prospective cohort study, approved by the ethics committee of Shiraz University of Medical Sciences (code: 930-01-01-7579), patients who were referred to Hazrat-Zeinab and Ghadir hospitals, affiliated at the University of Medical Sciences in Shiraz for a hysterectomy for a year were recruited. Serum AMH levels were compared before hysterectomy and 4 months after hysterectomy between groups that underwent TAH + bilateral salpingectomy and TLH + bilateral salpingectomy.

The sample size was calculated to be 31, based on previous studies and taking into account an error of 5%, a power of 80% and an effect size of 50%, using the following formula:

$$ n = frac {{2 (z_ {1 – alpha / 2} + z_ {1 – beta})} delta ^ {2}} {{( mu_ {2} – mu_ {1} ) ^ {2}}} + 1 $$

Therefore, 33 patients were considered in each group, considering 5% of cases lost to follow-up.

After explaining the objectives and steps of the study to all patients (of similar race), written informed consent was obtained from the participants and those who met the inclusion criteria entered the study by a method of convenient sampling. The inclusion criteria were women who were referred to Shiraz University of Medical Sciences hospitals with abnormal uterine bleeding (UAS) without anatomical (according to PALM-COIN classification) or hormonal (except FIGO 7 leiomyoma) reasons. with a uterine size less than 12 weeks. , weight less than 600 g [23, 24], and unresponsive to medical treatment had to undergo abdominal or laparoscopic hysterectomy and had not taken any hormonal medication for at least two months prior to surgery.

The patients included should not have had menopause, no history of endometriosis or previous ovarian surgery. The exclusion criteria included the following: all medical comorbidities that resulted in decreased ovarian reserve before and after the operation, including: all women who received gonadotoxic therapy before and after surgery, postmenopausal women , polycystic ovarian disease, patients with a history of endometriosis or a history of ovarian surgery, patient with an autoimmune disease, such as: systemic lupus erythematosus, rheumatoid arthritis, thyroid disease, as well as patients with insulin-dependent diabetes mellitus or cardiovascular disease.

If the ovaries were (completely or partially) removed during the hysterectomy (or had any other adnexal surgery) for any reason, the patient was excluded from the study. Included patients were matched for age, parity, uterine size and weight, as well as AMH levels. All participants were divided into two groups of abdominal and laparoscopic hysterectomy, depending on the patient’s condition and preference, as well as surgical principles.

Total abdominal hysterectomy + bilateral salpingectomy was performed by an expert gynecologist according to the standard protocol which included ligation and cutting of the round and uretero-ovarian ligaments, separation of the bladder and cutting of the uterine artery and ligament. cardinal, cutting and suturing the vaginal cuff without resorting to electrosurgical techniques. .

Laparoscopic total hysterectomy + bilateral salpingectomy was also performed by the same gynecologist. In this process, the round and uretero-ovarian ligaments were sealed and cut by ligature 10 (Covedian 1037 with a blunt tip as a bipolar vessel sealer, used with a force test generator to provide permanent fusion for vessels up to 7 mm in diameter and heat the spread depends on the tip and duration of activation), then the uterine artery was sealed (cut humor, power 40 W) and cut by bipolar cauterization ( Bipolar powergrip from Günter Bissinger Medizintechnik), and the bladder was separated by clean dissection. Finally, the vaginal cuff was cut by monopolar cauterization and sutured. During both procedures, the adhesion of the intestine and omentum to the anterior wall of the abdomen, if present, was released.

For each patient, the demographic characteristics of the patient, including age and weight, as well as obstetric and gynecological characteristics, including severity, parity and surgical details, including uterine weight and blood loss during surgery, in addition to serum AMH levels before and after surgery were recorded and compared between the two groups.

A venous blood sample was taken from all patients from their left ulnar vein while seated. Serum from the samples was then separated, stored at -20 ° C and sent to the laboratory, where AMH levels were measured by the Backmann kit.

statistical analyzes

For statistical analysis, the collected data was entered into SPSS 15.0 Statistics for Windows (SPSS Inc., Chicago, IL) and the results were analyzed by descriptive analysis, including frequency, mean and deviation. type (SD) or median (IQR), analytical analysis, including Wilcoxon’s test to compare pre and post-surgical values ​​and Mann-Whitney to compare the two groups. Since the test of the normal distribution of data by the Kolmogorov-Smirnov test was statistically significant, non-parametric statistical tests were used. In this study, a significant level of 0.05 was taken into account for the data analysis.

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