Impact of ovarian endometrioma on oocytes and pregnancy outcome in in vitro fertilization

Iron availability is increased in individual human ovarian follicles in close proximity to an endometrioma compared with distal ones

STUDY QUESTION

Does the iron content of an endometrioma represent a potential source of toxicity for the adjacent follicles?

SUMMARY ANSWER

The presence of an endometrioma increases iron and H/L ferritin levels, and transferrin receptor (TfR1) mRNA in individual follicles proximal to the endometrioma and is accompanied by reduced oocyte retrieval.

WHAT IS KNOWN ALREADY

Levels of free iron in endometriotic ovarian cysts are much higher than those in normal serum or in non-endometriotic ovarian cysts. The presence of an endometrioma exerts a detrimental effect on the surrounding healthy ovarian tissue as reflected by a reduced number of developing follicles and oocytes retrieved in IVF cycles.

STUDY DESIGN, SIZE, DURATION

This is a research study with prospective collection and evaluation of individual follicles (follicular fluid and luteinized granulosa cells) from the affected and the healthy ovaries of 13 women with unilateral endometrioma.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Individual follicular samples (145) were obtained from 13 women with endometriosis-related infertility undergoing IVF-ICSI procedures from May 2012 to March 2013. All women had unilateral endometrioma not previously treated with surgery; the contralateral ovary was free of endometriomas and previous surgery. The average ± SEM age was 35.36 ± 2.5 years with anti-Mullerian hormone levels of 2.03 ± 0.55 ng/ml. Follicles were classified as: (i) proximal follicles, in physical contact with the endometrioma; (ii) distal follicles, present in the affected ovary but not in close contact with the endometrioma and (iii) contralateral follicles, in the contralateral healthy ovary. Iron content was measured by the FerroZine method. H/L ferritin subunits were evaluated by specific enzyme-linked immunosorbant assays. Expression of H ferritin and TfR1 was examined by semi-quantitative RT-PCR. Oocyte retrieval rates and Day 3 embryo quality were analyzed.

MAIN RESULTS AND THE ROLE OF CHANCE

Total iron levels were higher in endometrioma-proximal follicles compared with endometrioma-distal ones (P = 0.009) and to follicles in the healthy ovary (P = 0.02). L ferritin was higher in proximal versus distal follicles (P = 0.044) or follicles from the healthy ovary (P = 0.027). H ferritin was higher in the proximal and distal follicles compared with follicles in the healthy ovary (P = 0.042 and P = 0.0067, respectively). H ferritin transcript levels in granulosa cells were higher in proximal follicles versus follicles from healthy ovary (P = 0.02). TfR1 transcript levels were higher in proximal versus distal follicles (P = 0.03) and versus follicles from the healthy ovary (P = 0.04). The oocyte retrieval rate was lower in proximal and distal follicles than in follicles from the healthy ovary (P = 0.001 and P = 0.04, respectively).

LIMITATIONS, REASONS FOR CAUTION

This is a study on a relatively small sample size and confirmation in a larger group of patients may be required. The method used to purify luteinized granulosa cells offers the best combination of purity, viability and total number of cells recovered. However, a minor contamination by CD45(+) cells (<5%) cannot be excluded.

WIDER IMPLICATIONS OF THE FINDINGS

This study represents a further in-depth analysis of the toxic influence of the endometrioma content on the surrounding follicles. We demonstrate the presence of iron-related compounds that are potentially toxic to developing ovarian follicles adjacent to the endometrioma during IVF. Our findings provide novel information that suggests that when surgical removal of the endometrioma is not the option, follicle aspiration at sites distant from the endometrioma might increase the probability of retrieving oocytes.

STUDY FUNDING/COMPETING INTEREST(S)

This project was supported by Fondazione Giorgio Pardi, Milan, Italy. The authors have no competing financial interests in relation to the content of this research paper.

TRIAL REGISTRATION NUMBER

NA.

IVF stimulation: protocols for poor responders

One of the most vexing challenges in the practice of reproductive medicine is the management of the "poor responder," specifically the patient manifesting an inadequate follicular response to ovarian stimulation. Poor response predicts a reduction in the number of mature oocytes retrieved, with the consequences of fewer embryos available for selection and transfer, reduced pregnancy rates, and a markedly decreased likelihood of residual embryos for cryopreservation. This chapter reviews the definition and prediction of poor response and discusses strategies that have been developed and incorporated into the reproductive endocrinologist's clinical armamentarium in an effort to optimize outcomes for these women. It should be stated at the outset that no single approach is successful for all patients, and that there is currently no firm clinical consensus regarding the relative efficacy of the different stimulation protocols. This arises in part due to inconsistency regarding the definition of what constitutes a poor response and a paucity of well-designed, randomized controlled trials.

Comparative study on the pregnancy outcomes of in vitro fertilization-embryo transfer between long-acting gonadotropin-releasing hormone agonist combined with transvaginal ultrasound-guided cyst aspiration and long-acting gonadotropin-releasing hormone agonist alone

OBJECTIVE

To retrospectively analyze the effects of long-acting gonadotropin-releasing hormone agonist (GnRH-a) combined with transvaginal ultrasound-guided cyst aspiration on the pregnancy outcomes of in vitro fertilization-embryo transfer (IVF-ET) in the infertile patients with ovarian endometriosis.

METHODS

The 134 patients with ovarian endometriosis who underwent GnRH-a combined with transvaginal ultrasound-guided cyst aspiration and IVF-ET were served as experimental group. The 102 patients with ovarian endometriosis who underwent GnRH-a and IVF-ET were served as control group. After treatment, the cyst size, follicle stimulating hormone (FSH), luteinizing hormone (LH), estradiol (E2), number of ovum pick-up, fertility rate, cleavage rate, high-quality embryo rate, implantation rate, clinical pregnancy rate and abortion rate were compared between the two groups.

RESULTS

In the 134 patients of experimental group, 138 cysts disappeared after GnRH-a combined with three times of transvaginal ultrasound-guided cyst aspiration. In the 102 patients of control group, of the 114 cysts, 34 disappeared after GnRH-a, 67 were decreased and 13 were unchanged. The abortion rate was significantly lower in experimental group than in control group. The level of serum E2 on HCG day, the number of ovarian follicles with 14 mm or more, the number of retrieved oocytes, high-quality embryo rate, implantation rate and clinical pregnancy rate were higher in experimental group than in control group (all P<0.05).

CONCLUSION

GnRH-a combined with transvaginal ultrasound-guided cyst aspiration can obtain better therapeutic effects and pregnancy outcomes in infertile patients with ovarian endometriosis who underwent IVF-ET.

Redefining reproductive surgery

With the availability of and improvements in in vitro fertilization (IVF), the role of reproductive surgery has been questioned. Yet, the scope of reproductive surgery today is much larger than in the past. Hysteroscopic correction of intrauterine disease is an important endoscopic procedure in women with infertility. Evidence suggests that correction of intrauterine disease is often followed by spontaneous pregnancy and improved IVF outcome. Hysteroscopic examination should be considered after 1 failed IVF. Today, it is clear that removal of the hydrosalpinx leads to a higher IVF-related live birth rate. The procedure should be performed thoroughly without compromising the ovarian blood supply. The IVF pregnancy rate is not affected by the presence of ovarian endometriomas, and small endometriomas need not be removed; however, large and symptomatic endometriomas that interfere with oocyte retrieval should be excised. When excision of the cyst wall is difficult, fenestration and ablation should be considered. This might lead to an increased recurrence rate, but is associated with less interference of the ovarian reserve. Although the role of reproductive surgery as primary treatment for tuboperitoneal infertility is limited, it has an important role in enhancing the outcome of IVF treatment and in preservation of fertility. Surgical preservation of fertility consists of ovarian suspension, ovarian excision for cryopreservation, and ovarian tissue transplantation.

In vitro fertilization is a successful treatment in endometriosis-associated infertility

OBJECTIVE

To assess success rates of IVF and intracytoplasmic sperm injection in women with various stages of endometriosis.

DESIGN

Retrospective cohort study.

SETTING

Reproductive medicine unit in a university hospital.

PATIENT(S)

Infertile women (n = 2,245) with various stages of endometriosis or tubal factor infertility.

INTERVENTION(S)

IVF or intracytoplasmic sperm injection.

MAIN OUTCOME MEASURE(S)

Dose of FSH, number of oocytes retrieved, fertilization rate, implantation rate, pregnancy rate (PR), live birth/ongoing PR.

RESULT(S)

Women with endometriosis had similar pregnancy and live birth/ongoing PR as did women with tubal factor infertility, but the American Society for Reproductive Medicine (ASRM) stage I and II endometriosis patients had a lower fertilization rate, and stage III and IV patients required more FSH and had fewer oocytes retrieved. Splitting the stage III and IV groups into patients with and without endometriomas showed that the endometrioma group required more FSH and had a significantly lower pregnancy and live birth/ongoing PR.

CONCLUSION(S)

With the exception of patients with endometrioma, infertile women with various stages of endometriosis have the same success rates with IVF and intracytoplasmic sperm injection as patients with tubal factor. This contrasts with the systematic review on which the European Society of Human Reproduction and Embryology bases its recommendations.

Aspiration and ethanol sclerotherapy to treat recurrent ovarian endometriomas prior to in vitro fertilization – a pilot study

ABSTRACT Objective: To describe the evolution of controlled ovarian hyperstimulation in women with recurrent ovarian endometriomas treated with sclerotherapy. Methods: Twenty-one patients with a laparoscopic diagnosis of stage III or IV endometriosis who had an endometrioma larger than 3 cm before ovarian hyperstimulation for in vitro fertilization were included in the study. After using a GnRH agonist analog for at least 20 days, the cysts were punctured using ultrasound guidance and subsequent ethanol sclerotherapy was performed. Then, the patients were stimulated with 100 or 200 U/day of recombinant follicle stimulating hormone, varying the dose according to the patient's age or history of a previous unilateral oophorectomy. Results: The ovarian cysts had an average diameter of 4.7 ± 1.4 cm and did not recur after aspiration during the ovulation induction. Oocyte extraction occurred after 11 days of hyperstimulation, with 3.95 ± 3.30 oocytes obtained per cycle, on average. Embryo transfer occurred in 71.4% (15/21) of patients, and the pregnancy rate after transfer was 20% (3/15). Conclusion: Aspiration followed by ethanol sclerotherapy prior to in vitro fertilization can be an option for patients who desire a pregnancy and have recurrent endometriomas.

Ovarian endometriomas and IVF: a retrospective case-control study

We performed this retrospective case-control study analyzing 428 first-attempt in vitro fertilization (IVF) cycles, among which 254 involved women with a previous or present diagnosis of ovarian endometriosis. First, the results of these 254 cycles were compared with 174 cycles involving patients with proven non-endometriotic tubal infertility having similar age and body mass index. Women with ovarian endometriosis had a significantly higher cancellation rate, but similar pregnancy, implantation and delivery rates as patients with tubal infertility. Second, among the women with ovarian endometriosis, the women with a history of laparoscopic surgery for ovarian endometriomas prior to IVF and no visual endometriosis at ovum pick-up (n = 112) were compared with the non-operated women and visual endometriomas at ovum pick-up (n = 142). Patients who underwent ovarian surgery before IVF had significantly shorter period, lower antral follicle count and required higher gonadotropin doses than patients with non-operated endometriomas. The two groups of women with a previous or present ovarian endometriosis did, however, have similar pregnancy, implantation and live birth rates. In conclusion, ovarian endometriosis does not reduce IVF outcome compared with tubal factor. Furthermore, laparoscopic removal of endometriomas does not improve IVF results, but may cause a decrease of ovarian responsiveness to gonadotropins.

The impact of endometrioma and laparoscopic cystectomy on serum anti-Müllerian hormone levels

BACKGROUND

Serum anti-Müllerian hormone (AMH) had been proposed as a marker of ovarian reserve. The aim of this study was to evaluate the impact of endometrioma and laparoscopic cystectomy on ovarian reserve as measured by serum AMH levels.

METHODS

A total of 1,642 patients were recruited in this retrospective analysis. Control group (group 1) included 1,323 infertility patients without endometrioma. Endometrioma group (group 2) included 141 patients with ovarian endometrioma. Previous cystectomy group (group 3) included 147 patients who underwent unilateral or bilateral laparoscopic cystectomy due to ovarian endometrioma more than 6 months before enrollment. Current cystectomy group (group 4) included 31 patients who underwent cystectomy during study period. Serum anti-müllerian hormone (AMH) levels were measured upon enrollment with all patients. For patients in group 4, AMH levels were measured before and 3 months after cystectomy.

RESULTS

Mean AMH level of patients in control group was significantly higher than that of endometrioma group or previous cystectomy group in each age subgroup, while the mean serum AMH level of the endometrioma group was also significantly higher than that of the previous cystectomy group in each age subgroup. The mean AMH level was significantly lower in patients with previous bilateral cystectomy compared to that of patients with unilateral cystectomy. The mean serum AMH level was also significantly lower in patients with bilateral endometrioma compared to that of patients with unilateral endometrioma. In group 4, mean AMH level significantly decreased from 3.95 +/- 0.42 preoperation to 2.01 +/- 0.21 ng/ml at 3-month postoperation.

CONCLUSIONS

Both ovarian endometrioma and cystectomy are associated with a significant reduction on ovarian reserve. Bilateral endometrioma exerts a more profound negative impact on ovarian reserve than unilateral endometrioma, regardless of either conservative or surgical intervention.

[Assisted reproductive technologies place]

There are three kinds of infertility treatment: medical treatment, surgical treatment and assisted reproductive technology (ART). ART includes intra uterine insemination (IUI), in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI). ART technologies made a lot of progress last years and their field of applications extended. Through literature reviews, IUI is recommended for unexplained infertility and discussed for male or cervical infertility. IVF is recommended for tubal and unexplained infertility. Limits between IVF and ICSI in case of male infertility remains unclear. In non mal infertility ICSI is not recommended.

Poor pregnancy outcome following assisted reproductive technology among women operated on for bilateral endometriomas

Purpose

To determine the first line of infertility treatment for managing patients with unilateral or bilateral ovarian endometriomas.

Methods

We evaluated pregnancy outcome in patients who had received ovarian surgery for unilateral (Group U, n = 47) or bilateral endometriomas (Group B, n = 38) and aspiration with or without alcohol fixation for unilateral (Group u, n = 37) or bilateral endometriomas (Group b, n = 22). Subsequently, 64 of these women, excluding 29 dropouts, underwent assisted reproductive technology. We compared the clinical pregnancy rates of the four groups.

Results

The cumulative pregnancy rate after operation of Group B (18%) was significantly lower than that of a cyst-free control group (n = 143; 44%) and Group U (43%). Group B had fewer oocytes fertilized during ART than did Group b (P < 0.005) and fewer blastocysts available for transfer (P < 0.005). The cumulative pregnancy rate of Group B was also lower than in Group b (P = 0.052).

Conclusions

Pregnancy outcomes of Group B were not better than for Group b. Therefore, encouraging such women to move directly to ART might help avoid ovarian damage and improve their ability to achieve a pregnancy.

In vitro fertilization in normoresponder patients with endometriomas: comparison with basal simple ovarian cysts

OBJECTIVE

To investigate whether the space-occupying effect of an endometrioma, rather than endometriosis itself, affects results in in vitro fertilization (IVF) using women with simple ovarian cysts as the control group.

METHODS

85 normoresponder patients with endometriomas of 10-50 mm who underwent IVF treatment directly without initial removal were compared with 83 normoresponder patients with simple ovarian cysts of 10-35 mm detected at the beginning of stimulation and initiated treatment without aspiration.

RESULTS

Gonadotropin consumption was higher in the endometrioma group (3,013 vs. 2,451 IU; p = 0.001), although significantly fewer numbers of oocytes were retrieved (13.9 vs. 16.4; p = 0.03). However, oocyte maturation rates were similar. The transferred grade I embryos ratio was evaluated and found to be better in the cyst group (79.7 vs. 70.7%; p = 0.03). Consequently, the implantation rate was found to be significantly higher in the cyst group (28 vs. 19%; p = 0.02), although pregnancy and ongoing pregnancy rates were similar.

CONCLUSION

The presence of an endometriotic cyst during the IVF cycle was demonstrated to be associated with a lower embryo quality and implantation rate, although pregnancy success was unaffected. This adverse effect is suggested to be the result of the disease itself, not the presence of a cystic mass.

La stérilité par endométriose

From the literature, the crucial knowledge were drawn among endometriosis related infertility. Endometriosis is an important factor of infertility in minimal or light stages and a major one in mild or moderate stages. Thus, a laparoscopy must be performed to confirm endometriosis when suggestive clinical or biological signs exist. In absence of them, laparoscopy can be delayed after intra-uterine inseminations (IUI). The first line treatment is laparoscopic surgery. Its efficacy is proven. It is useless to prescribe a post-operative medical treatment (GnRH analogues). Surgery leads to 25 to 40% of deliveries. It is dependant on age, infertility duration, tubo-ovarian adhesion and tubes involvement. But, surgery can be avoided and the patient is directly referred to In Vitro Fertilization (IVF) when the lesions extension is so important that surgery exposes to complications or when there is a permanent other indication for IVF (severe male infertility). When infertility persists 6 to 12 months after surgery and without patent recurrence, ovulation stimulations and IUI are performed as the second line treatment. After IUI failure, or in case of recurrence, IVF must be applied. A second surgery is not recommended. The IVF results are not impaired by the presence of endometriosis and even of endometriomas. Thus, it is useless to operate again endometriosis before IVF. In opposition, in severe stages or in cases of recurrence, a pre-IVF medical treatment (GnRH analogues) improves the results. IVF do not increased the risk of endometriosis acute growth. In case of infertility and pain, infertility is considered as the first target. But medical treatment can be prescribed between the IVF attempts.

Leukaemia inhibitory factor and interleukin 11 levels in uterine flushings of infertile patients with endometriosis

BACKGROUND

Exact aetiology of infertility in stage I/II endometriosis patients is not known. Interleukin 11 (IL-11) and leukaemia-inhibitory factor (LIF) are factors associated with implantation window in human eutopic endometrium. We decided to test whether there is an altered secretion of these factors, which could explain receptivity defect in patients with minimal endometriosis.

METHODS

Uterine flushing and endometrial samples were collected 7-9 days after ovulation (implantation window) from infertile patients with stage I/II endometriosis (n = 14) and fertile, endometriosis-free controls (n = 21). IL-11 and LIF were assessed in uterine flushings in eutopic endometria in all patients by enzyme-linked immunosorbent assay (ELISA). In eutopic endometrium, semiquantitative RT-PCR was performed for LIF and IL-11 mRNA expressions.

RESULTS

No statistically significant differences were found in uterine flushing in women with and without endometriosis with regard to IL-11 levels (0.0 pg/ml versus 0.0 pg/ml) and LIF (25.53 pg/ml versus 36.26 pg/ml). These results were confirmed by the results of RT-PCR, where there were also no differences between studied groups.

CONCLUSIONS

There is no receptivity defect with regard to LIF and IL-11 secretions by eutopic endometrium in infertile women with endometriosis.

IgG-antiphospholipid antibodies in follicular fluid of IVF-ET patients are related to low fertilization rate of their oocytes

PROBLEM

Patients undergoing in vitro fertilization and embryo transfer (IVF-ET) failures show an increased incidence of antiphospholipid antibodies (aPL) in their blood. The physiological manifestations of aPL in this patient group are nonetheless controversial. Pathological effects of aPL on embryos in vitro have been documented. We questioned whether aPL if found in follicular fluids (FFs) could result in embryonic damage.

METHOD OF STUDY

Blood from 44 patients with three or more IVF-ET failures were tested by enzyme-linked immunosorbent assays (ELISA) for the presence of immunoglobulin (Ig)G, IgM and IgA aPL. Both the 29 aPL-positive and 15 aPL-negative patients gave permission for FF collection during their next IVF-ET attempt for additional aPL determinations.

RESULTS

Patients with no aPL in their blood, had no aPL in their FFs. Patients with IgG and/or IgM aPL in their blood had IgG but not IgM in their respective FFs.

CONCLUSIONS

The presence of IgG aPL in FFs and increased infertility length were significantly related to lower fertilization rates, independently. Follicular fluid IgG aPL appears as a risk factor in association with successful IVF-ET outcomes.

Long-term pituitary down-regulation before in vitro fertilization (IVF) for women with endometriosis

BACKGROUND

Women with endometriosis who are treated with in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) have a lower pregnancy rate compared to women with tubal factor infertility. It has been suggested that the administration of gonadotrophin releasing hormone (GnRH) agonists for a few months prior to IVF or ICSI increases the pregnancy rate.

OBJECTIVES

To determine the effectiveness of administering GnRH agonists for three to six months prior to IVF or ICSI in women with endometriosis.

SEARCH STRATEGY

We used computer searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, the National Research Register (NRR) and the MDSG Specialised Register of controlled trials. We handsearched proceedings of annual meetings of the American Society for Reproductive Medicine (ASRM) and the European Society for Human Reproduction and Embryology (ESHRE). We reviewed lists of references in original research and review articles. We contacted experts in various countries to identify unpublished trials.

SELECTION CRITERIA

We included randomised controlled trials using any GnRH agonist prior to IVF or ICSI to treat women with any degree of endometriosis diagnosed by laparoscopy or laparotomy

DATA COLLECTION AND ANALYSIS

Two independent review authors abstracted data (HNS and JGV). We sent e-mails to investigators to seek additional information. We assessed the validity of each study using the methods suggested in the Cochrane Handbook. The data were checked by the third review author (SD) and any disagreement was resolved by arbitration with the fourth review author (AA). We generated 2 x 2 tables for principal outcome measures. The Peto-modified Mantel-Haenszel technique was used to calculate odds ratios (OR) and assess statistical heterogeneity between studies.

MAIN RESULTS

Three randomised controlled trials (with 165 women) were included. The live birth rate per woman was significantly higher in women receiving the GnRH agonist compared to the control group (OR 9.19, 95% CI 1.08 to 78.22). However, this was based on one trial reporting "viable pregnancy" only. The clinical pregnancy rate per woman was also significantly higher (three studies: OR 4.28, 95% CI 2.00 to 9.15). The information on miscarriage rates came from two trials with high heterogeneity and, therefore, results of the meta-analysis were doubtful. The included studies provided insufficient data to investigate the effects of administration of GnRH agonists on multiple or ectopic pregnancies, fetal abnormalities or other complications.

AUTHORS' CONCLUSIONS

The administration of GnRH agonists for a period of three to six months prior to IVF or ICSI in women with endometriosis increases the odds of clinical pregnancy by fourfold. Data regarding adverse effects of this therapy on the mother or fetus are not available at present.

Impact of ovarian endometrioma on assisted reproduction outcomes

The effects of ovarian endometrioma on fertility outcomes with IVF and embryo transfer have been causally related to poor outcomes. The objective of this meta-analysis was to evaluate the ovarian reserve and ovarian responsiveness to ovarian stimulation and assisted reproduction outcomes in patients with ovarian endometrioma. The odds for clinical pregnancy were not affected significantly in patients with ovarian endometrioma compared with controls, with an overall odds ratio of 1.07 from three studies [95% CI: (0.63, 1.81), P = 0.79]. The overall pregnancy rate was similar with an estimated odds ratio of 1.17 [95% CI: (0.85, 1.60), P = 0.34]. Decreased ovarian responsiveness to ovarian stimulation in patients with ovarian endometrioma may be due to a reduced number of follicles in these patients compared with controls (P = 0.002). Prospective randomized controlled trials are needed to assess whether surgical treatment versus no surgical treatment improves pregnancy outcomes in patients with ovarian endometrioma undergoing assisted reproduction cycles.

Effect of endometrioma cystectomy on IVF outcome: a prospective randomized study

The study was conducted to investigate the effect of conservative surgery of ovarian endometriomas before an ICSI cycle. Ninety-nine patients with endometriomas who were referred to an intracytoplasmic sperm injection (ICSI) cycle were enrolled in the study. The patients were prospectively randomized into two groups; group I (49 patients) underwent conservative ovarian surgery before the ICSI cycle and group II (50 patients) underwent the ICSI cycle directly. The stimulation was started 3 months after the operation in group I and directly in group II. In the ovarian surgery group, stimulation was significantly longer (14.0 days in group I and 10.8 days in group II; P = 0.001), total recombinant FSH dose was significantly higher (4575 IU in group I and 3675 IU in group II; P = 0.001), and mean number of mature oocytes was significantly lower (7.8 in group I and 8.6 in group II; P = 0.032). There was no difference in terms of fertilization (86% in group I and 88% in group II), implantation (16.5% in group I and 18.5% in group II) and pregnancy rates (34% in group I and 38% in group II). Ovarian surgery resulted in longer stimulation, higher FSH requirement and lower oocyte number, but fertilization, pregnancy and implantation rates did not differ between the groups.