Impact of the hemostatic approach after laparoscopic endometrioma excision on ovarian reserve: Systematic review and network meta-analysis of randomized controlled trials

Background: Laparoscopic excision of endometrioma and subsequent hemostasis have detrimental effects on ovarian reserve. Objectives: To evaluate which hemostatic approach after stripping cystectomy shows less damage on ovarian reserve. Search strategy: Embase, MEDLINE, Scopus, Scielo.br, LILACS, Cochrane Library at the CENTRAL Register of Controlled Trials, Clinicaltrials.gov, CINAHL, conference abstracts, and International Clinical Trials Registry Platform were searched from inception until April 2022. Selection criteria: Randomized controlled trials of women undergoing laparoscopic endometrioma excision that compared at least two hemostatic approaches. Data collection and analysis: Relevant data were extracted and tabulated. Network meta-analysis based on random-effects model for mixed multiple treatment to rank hemostatic strategies using the surface under the cumulative ranking curve area (SUCRA) was performed. Quality assessment was performed using Cochrane criteria. The primary outcome was serum antimullerian hormone levels 3 months after surgery. Main results: Ten studies, including 748 women, were selected. Suturing the ovary with barbed suture (SUCRA, 82.80%) seem the most effective strategy to avoid antimullerian hormone reduction. Similarly, for ultrasonographic antral follicular count, barbed (SUCRA, 30.70%) and simple suture (SUCRA, 30.70%) were ranked the best choices. Ovarian suturing with simple suture demonstrated lower follicle-stimulating hormone levels (SUCRA, 88.70%). Conclusions: Suturing the ovary, with simple or barbed suture, seems the most effective approach to keep ovarian reserve higher.