Strengths and Limitations
There are some limitations of our study. First, ovarian reserve may also be affected by the mechanical nature of performing cystectomy in an endometrioma versus a dermoid cyst or cystadenoma or by whether unilateral or bilateral cystectomy was performed 38. Some RCTs included patients with both unilateral and bilateral ovarian cysts undergoing surgery 2, 4, 16-18, 20, 21, 24, we could not analyze the data separately. However, our results suggest that the detrimental effect of electrocoagulation compared to the nonthermal method remains consistent, regardless of whether cystectomy was performed unilaterally or bilaterally. Furthermore, some patients underwent repeated laparoscopic cystectomy, although the studies did not provide specific data on these cases. It’s also worth noting that the inflammatory factors associated with endometriosis can impact ovarian reserve. Moreover, it’s important to acknowledge that blinding surgeons in these studies is challenging, potentially introducing performance and detection biases. However, it’s noteworthy that in the majority of the included RCTs, surgical procedures were carried out by either a single surgeon or a limited number of surgeons, effectively mitigating performance bias. Ultimately, it’s essential to acknowledge the presence of substantial heterogeneity, potentially stemming from variations in nonthermal hemostatic methods, the sizes and histologic types of ovarian cysts across the studies. We performed a comprehensive, broad, and systematic search for the present report, with hand-searching of some references of included studies and previous systematic reviews. Further studies with double-blinded RCTs and long-term follow-up may be needed to define better the impact of different hemostatic techniques on ovarian reserve.