Impact of haemostasis methods during ovarian cystectomy on ovarian reserve: a pairwise and network meta-analysis

Figures & data

Figure 1. PRISMA flow diagram for identification and selection of studies.

Table 1. Characteristics of randomised controlled trials included in the quantitative analysis.

Study	Year	Inclusion criteria	Exclusion criteria	Cases/control	Outcomes
					AMH-1 month	AMH-3 months	AMH-6 months	AMH-12 months
Sahin et al. (2017)	2016	(1) Patient age between 18 and 40 years; (2) unilateral ovarian cyst; (3) regular menstrual period (history of menstrual cycle between 21 and 35 days); (4) appropriate medical condition for laparoscopic surgery	(1) History of endocrinopathy; (2) postmenopausal status; (3) pregnancy and lactation; (4) suspicious findings for malignancy; (5) AMH levels <0.5 ng/mL; (6) history of previous ovarian surgery or premature ovarian failure in family	30 women were included in the electrocoagulation group; 29 women were included in the suture group.	Yes	Yes		Yes
Mohamed et al. (2011)	2011	(1) Age 18–40 years; (2) no evidence of endocrinologic disorders; (3) no clinical signs or ultrasound evidence suspicious of ovarian malignancy; (4) presence of a unilateral ovarian cyst; (5) regular menstrual cycles	(1) Previous history of adnexal surgery; (2) history of oral contraceptive pill use or intake of other hormonal agents within 3 months before enrolment; (3) endometrioma diagnosed at laparotomy or laparoscopy; (4) cigarette smoking within a short period before the examination; (5) asthma and use of asthma medications; (6) hypertension; and use of any other medication (over-the-counter or prescribed)	55 women were included in the electrocoagulation group; 55 women were included in the suture group.	Yes	Yes	Yes
Zhang et al. (2016)	2016	(1) aged from 18 years to 45 years; (2) primarily diagnosed with unilateral or bilateral ovarian endometrioma by ultrasonography and clinical examination; (3) regular menstrual cycles with 25–35 days in the first 6 months of operation; (4) informed consent	(1) Previous intake of contraceptive pills or hormone medicines; (2) history of ovarian surgery; (3) confirmed diagnosis of endocrine system disease or polycystic ovary syndrome; (4) excision of hysterectomy and adnexa; (5) ovarian malignant cancer; (6) conditions incompatible with the ideas of the investigators	69 women were included in the electrocoagulation group; 69 women were included in the suture group.	Yes	Yes	Yes	Yes
Tanprasertkul et al. (2014)	2014	(1) Ages of 18–45, (2) understand the process of this study with written informed consent, (3) having regular menstrual cycles, (4) never taking any medication such as oral pill and hormonal drugs during the 3 months before the enrolment, (5) no previous history of adnexal surgery, (6) no evidence of any other endocrine disordersand (7) pathological diagnosis of excised ovarian tissue confirmed as endometriotic cyst	(1) Diagnosis of polycystic ovarian syndrome according to the Rotterdam criteria (2) Pathological diagnosis of excised ovarian tissue was confirmed as non-endometriotic cyst and converted to laparotomy.	25 women were included in the electrocoagulation group; 25 women were included in the suture group.	Yes	Yes	Yes
Xiao et al. (2019)	2019	(1) 21–36 years old; (2) menstrual cycle 28–35 days; (3) diagnosed with bilateral ovarian cysts by B-ultrasound; (4) 5–8 cm in cyst diameter; (5) no history of gynaecological surgery in the past one year; (6) no endocrine disorders; (7) no hormone use history in the past 6 months.		40 women were included in the electrocoagulation group; 40 women were included in the suture group.	Yes		Yes
Owczarek et al. (2018)	2018	(1) At the age of 20–35 years; (2) cystic lesions of 40–70 mm in diameter	With history of cyst enucleation	33 women were included in the electrocoagulation group; 33 women were included in the suture group.		Yes
Chung et al. (2019)	2019	(1) Subjects aged between 18 and 40 years, (2) unilateral or bilateral ovarian endometrioma measuring 3–8 cm in size in greatest diameter diagnosed by ultrasound examination, (3) no history of any previous ovarian surgeryand (4) no history of hormonal therapy (gonadotrophin releasing hormones (GnRH) or combined oral contraceptive pills (COC)) in the 6-month period before surgery.	(1) Polycystic ovarian syndrome according to the Rotterdam criteria, (2) pregnancy, (3) active pelvic inflammatory disease, (4) genital or extra-genital malignancy, (5) intraoperative diagnosis of another type of cyst (other than endometrioma) and (6) patient refusal	47 women were included in the electrocoagulation group; 47 women were included in the haemostatic sealant group.	Yes	Yes
Chung et al. (2021)	2021	(1) Subjects aged between 18 and 40 years, (2) unilateral or bilateral ovarian endometrioma measuring 3–8 cm in size in greatest diameter diagnosed by ultrasound examination, (3) no history of any previous ovarian surgery and (4) no history of hormonal therapy (gonadotrophin releasing hormones (GnRH) or combined oral contraceptive pills (COC)) in the 6-month period before surgery.	(1) Polycystic ovarian syndrome according to the Rotterdam criteria, (2) pregnancy, (3) active pelvic inflammatory disease, (4) genital or extra-genital malignancy, (5) intraoperative diagnosis of another type of cyst (other than endometrioma) and (6) patient refusal	36 women were included in the electrocoagulation group; 39 women were included in the haemostatic sealant group.		Yes	Yes	Yes
Park et al. (2021)	2021	(1) age ≥18 and ≤45 years; (2) unilateral benign ovarian cysts confirmed by pelvic ultrasonography; (3) a regular menstrual period between 21 and 45 days; (4) preoperative serum AMH levels of ≥0.50 ng/mL; (5) planned LESS ovarian cystectomy; (6) American Society of Anaesthesiologists (ASA) physical status classification 1–2; (7) written informed consent	(1) Suspicious ovarian malignancy shown by imaging studies; (2) planned multi-port laparoscopic ovarian cystectomy; (3) pregnancy or breastfeeding; (4) comorbid endocrine disease, such as thyroid function abnormality, hyperprolactinaemia or Cushing’s disease; (5) history of hormonal therapy within 3 months.	26 women were included in the electrocoagulation group; 26 women were included in the haemostatic sealant group.		Yes
da Cunha Araujo et al. (2022)	2022	(1) Aged 18 years or above with regular menstrual cycles (21–35 days), (2) ultrasound diagnosis of a unilateral cyst suggestive of an endometrioma and (3) with an indication for laparoscopic surgery to remove the cyst because of pelvic pain, infertility or persistence of the cyst	(1) Previous ovarian surgery; endocrine dysfunction (diabetes, thyroid disorders, hyper-prolactinaemia, adrenal disease and polycystic ovary syndrome); (2) use of hormones in the preceding 3 months; (3) suspected malignant ovarian tumour requiring oophorectomy; (4) previous chemotherapy or radiotherapy; (5) coagulation disorders; (6) pregnancy; (7) autoimmune disease.	27 women were included in the electrocoagulation group; 26 women were included in the suture group; 24 women were included in the haemostatic sealant group.	Yes		Yes

Figure 2. Forest plot for the estimates of postoperative changes of AMH level between bipolar coagulation and suture.

Figure 3. Forest plot of subgroup analysis with ovarian endometrioma for the estimates of postoperative changes of AMH level between bipolar coagulation and suture.

Table 2. League table of results from a network meta-analysis for the preservation of ovarian reserve indicated by the postoperative changes of AMH level.

Outcomes/haemostasis	Suture	Sealant
Postoperative changes of AMH-1m
Sealant	−0.54 (–1.58, 0.55)
Coagulation	−0.46 (–1.08, 0.16)	0.07 (–0.91, 1.00)
Postoperative changes of AMH-3m
Sealant	−0.29 (–1.33, 0.86)
Coagulation	−0.60 (–1.23, 0.22)	−0.32 (–1.12, 0.56)
Postoperative changes of AMH-6m
Sealant	−0.31 (–1.07, 0.34)
Coagulation	−0.68 (–1.11, −0.22)	−0.39 (–0.91, 0.35)
Postoperative changes of AMH-12m
Sealant	−0.37 (–2.18, 1.82)
Coagulation	−0.95 (–2.10, 0.51)	−0.60 (–2.10, 0.90)

Postoperative changes of AMH = the AMH value of 1 month, 3 months, 6 months, or 12 months after the ovariocystectomy – the baseline AMH value. The horizontal variable of coagulation and sealant serve as the reference group for comparison. If the WMD < 0, it indicated that the decrease of AMH value after ovarian operation in the reference treatment was less and was better for ovarian reserve preservation.

Table 3. Probabilities of the ranking of three haemostasis for ovarian preservation.

Outcomes/haemostasis	Rank 1	Rank 2	Rank 3
AMH-1m
Coagulation	0.04	0.54	0.42
Sealant	0.14	0.30	0.55
Sutures	0.81	0.16	0.03
AMH-3m
Coagulation	0.02	0.22	0.77
Sealant	0.27	0.55	0.18
Suture	0.72	0.23	0.05
AMH-6m
Coagulation	0.00	0.10	0.89
Sealant	0.12	0.78	0.10
Suture	0.87	0.12	0.00
AMH-12m
Coagulation	0.02	0.20	0.78
Sealant	0.31	0.54	0.15
Suture	0.67	0.26	0.07

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Data availability statement

The authors confirm that the data supporting the findings of this study are available within the article [and/or] its supplementary materials.