Poor response of ovaries with endometrioma previously treated with cystectomy to controlled ovarian hyperstimulation

The progressive simplification of the infertility evaluation

OBJECTIVE

With the advent of evidence-based medicine, much of the complex testing that infertile couples used to undergo is no longer recommended as part of the routine evaluation. Examples of tests no longer implemented include the postcoital test, Rubin test of tubal patency, endometrial biopsy, sperm antibody testing, and the zona-free hamster test. The role of routine diagnostic laparoscopy and hysteroscopy is also reviewed.

CONCLUSIONS

In 2010, the simplicity of the current evaluation of couples presenting with infertility is essential information for patients to know at the initial visit. Ideally, it can help alleviate anxiety and provide patients with a road-map during a visit that is often associated with stress and high emotions.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this educational activity, the obstetrician/gynecologist should be better able to assess the current recommendations for evaluating infertile couples; examine the various ways to assess ovarian reserve, the uterine cavity, and fallopian patency; and appraise the controversy surrounding diagnostic surgery.

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.

Unoperated ovarian endometriomas and responsiveness to hyperstimulation

BACKGROUND

There is a growing consensus that ovarian reserve is reduced after surgical excision of ovarian endometriomas. However, it remains to be fully clarified whether this damage precedes or follows surgery. In order to further elucidate this aspect, we evaluated ovarian responsiveness to hyperstimulation in women selected for IVF with unilateral unoperated endometriomas. The main aim of this study was to compare the number of developing follicles in the affected ovary with that in the contralateral intact gonad as a control.

METHODS

Patients selected for IVF who were diagnosed with one or more monolateral endometriomas (diameter <4 cm) and who did not undergo previous ovarian surgery were retrospectively identified. We compared the number of follicles (diameter ≥ 11 mm) and the number of co-dominant follicles (diameter >15 mm) on the day of hCG administration in the affected and intact ovaries.

RESULTS

Among the 84 women selected, the median interquartile range (IQR) number of follicles ≥ 11 mm in the affected and intact ovaries was 5 (3-7) and 5 (3-8), respectively (P= 0.36). The median (IQR) number of co-dominant follicles in the affected and intact ovaries was 3 (2-4) and 3 (2-5), respectively (P= 0.48). The number of co-dominant follicles was lower in the affected ovary in 36 cases (43%, 95% confidence interval: 32-53%). We also failed to identify any statistically significant difference between the two ovaries when evaluating data according to the number of cysts, their dimension, the dose of gonadotrophins used or the number of oocytes retrieved.

CONCLUSIONS

In women selected for IVF, the presence of an endometrioma does not markedly affect responsiveness to hyperstimulation.

Risk factors for recurrence and re-recurrence of ovarian endometriomas after laparoscopic excision

AIM

Since ovarian endometrioma is frequently diagnosed in women of reproductive age, laparoscopic excision of the endometrioma is performed for most cases. However, endometriomas frequently recurs even after repeated surgical procedures. The aim of our study is to identify risk factors for recurrence and re-recurrence of endometriomas after the first and second laparoscopic excision.

MATERIAL & METHODS

We retrospectively evaluated 173 patients who had a minimum of one year postoperative follow-up after the laparoscopic excision of endometriomas. Ten and eight factors were evaluated to assess their effect on the risk of recurrence and re-recurrence, respectively. Factors were analyzed using univariate and the Cox regression test.

RESULTS

The overall rate of recurrence and re-recurrence were 45.1% and 45.5%, respectively. A high revised American Society for Reproductive Medicine score (1997) was associated with an increased risk of recurrence. Only postoperative pregnancy was associated with a decreased risk of recurrence. Short periods of normal menstruation without pregnancy or gonadotrophin-releasing hormone analogues from first surgery to recurrence were associated with higher rate of re-recurrence.

CONCLUSIONS

A high revised American Society for Reproductive Medicine score was a risk factor, and postoperative pregnancy was protective against recurrence. The patient with short periods of normal menstruation without pregnancy or gonadotrophin-releasing hormone analogues from first surgery to recurrence had a high risk of re-recurrence.

The effectiveness of reproductive surgery in the treatment of female infertility: facts, views and vision

BACKGROUND

The role of reproductive surgery is declining due to the widespread availability of assisted reproductive technology, but an evidence-based fundament for this decline is lacking. We therefore performed a systematic review of the literature.

METHODS

We searched MEDLINE, EMBASE and the Cochrane Library for randomised trials evaluating laparoscopic or hysteroscopic interventions in subfertile women, studying pregnancy or live birth rates. We present an overview of the results and quality of the detected studies.

RESULTS

The methodological quality of the 63 detected studies was mediocre. The laparoscopic treatment of minimal/ mild endometriosis might increase the pregnancy rate but the two major studies report conflicting results. Excision of the endometriotic cyst wall increases the spontaneous conception rate (RR 2.8, 95% CI 1.4-5.5). Laparoscopic ovarian drilling results at least in equal pregnancy rates as gonadotropin treatment (RR 1.0, 95% CI 0.83-1.2) but decreases the multiple pregnancy rate (RR 0.16, 95% CI 0.04-0.58). Laparoscopic tubal surgery for hydrosalpinx prior to IVF increases the pregnancy rate (RR 1.9, 95% CI 1.4-2.7). Removal of polyps prior to IUI increases the pregnancy rate (RR 2.2, 95% CI 1.6-3.1). Myomectomy for submucosal fibroids results in higher pregnancy rates (RR 2.2, 95% CI 1.6-2.9). The removal of intramural/ subserosal fibroids shows a beneficial trend, albeit not statistically significant (RR 1.2, 95% CI 0.75-1.9). Hysteroscopy in patients with recurrent IVF failure increases the pregnancy rates even in the absence of pathology (RR 1.6, 95% CI 1.3-1.9).

CONCLUSIONS

Although the limited evidence indicates a positive role for some surgical reproductive interventions, we should be very cautious in providing guidelines for clinical practice in reproductive surgery since more research is needed.

Ethanol sclerotherapy: a treatment option for ovarian endometriomas before ovarian stimulation

Several surgical treatment modalities have been described in cases of isolated or multiple ovarian endometriotic cysts. The aim of this preliminary study was to investigate and test the efficacy of ethanol sclerotherapy (EST) for recurrent endometriotic cysts, before ovarian stimulation in infertile patients with an adequate ovarian status. In the setting of a prospective comparative study, EST was proposed to 31 infertile patients with recurrence of ovarian endometriomas before inclusion in assisted reproduction cycles. Reproductive outcome was compared with that of patients who had previous laparoscopic cystectomy for recurrent endometriomas. The mean size of endometriomas treated with sclerotherapy was 38.6 +/- 11.2 mm in diameter. Ovarian cysts recurred in 12.9% of cases; at a mean time of 10 months after EST. Ovarian reserve and ovarian response to stimulation were better in the EST group than in the control group. Consequently, clinical and cumulative pregnancy rates of the study group were higher than those of the control group (48.3% versus 19.2%, P = 0.04; and 55.2% versus 26.9%, P = 0.03, respectively). Ethanol sclerotherapy may be a good alternative to surgical management of recurrent endometriotic cysts before assisted reproductive treatment. It could be advised for selected infertile patients.

Laparoscopic management of endometriosis: comprehensive review of best evidence

STUDY OBJECTIVE

To provide a comprehensive review of the best evidence available in the laparoscopic management of endometriosis for pain and/or fertility and to provide practical recommendations based on this information.

DESIGN

Review article of randomized controlled trials.

PATIENTS

Women with endometriosis.

METHODS

A systematic search was performed of the Cochrane Library and MEDLINE database for randomized controlled trials relating only to laparoscopic management of endometriosis. The information from 7 Cochrane review articles and 35 original randomized trials is presented in a clinically relevant question-and-answer format.

CONCLUSIONS

Awareness of endometriosis as a disease with substantial morbidity is vitally important. Laparoscopic treatment of endometriosis is beneficial for reducing pain and improving fertility. Laparoscopic presacral neurectomy, but not laparoscopic uterosacral nerve ablation, is a useful adjunct to conservative surgery for endometriosis in patients with a midline component of pain. Preoperative hormonal suppression with gonadotropin-receptor hormone analogue may be helpful in decreasing endometriosis disease scores. Postoperative hormonal suppression with either a gonadotropin-receptor hormone analogue or progestin (including the levonorgestrel intrauterine system) may be helpful in reducing pain and increasing time to recurrence of symptoms. Excisional cystectomy is the preferred method to treat endometrial cysts for both pain and fertility and may be aided by the use of mesna and initial circular excision. An absorbable adhesion barrier (Interceed), 4% icodextrin solution (Adept), and a viscoelastic gel (Oxiplex/AP, FzioMed, Inc., San Luis Obispd, CA; not available in the United States) are safe and effective products to help prevent adhesions in laparoscopic surgery to treat endometriosis.

Laparoscopic management of endometriomas using a combined technique of excisional (cystectomy) and ablative surgery

OBJECTIVE

To describe and evaluate a new technique of laparoscopic treatment of endometriomas that combines excisional and ablative surgery.

DESIGN

Descriptive and prospective study.

SETTING

Gynecology research unit in a university hospital.

PATIENT(S)

Fifty-two women under 35 years of age presenting for infertility and/or pelvic pain with endometriomas larger than 3 cm were included in the study. None had undergone any surgery for endometriosis.

INTERVENTION(S)

A large part of the endometrioma wall was first excised according to the cystectomy technique. After this first step, CO(2) laser was used to vaporize the remaining 10%-20% of the endometrioma wall close to the hilus.

MAIN OUTCOME MEASURE(S)

The feasibility of this new technique was assessed. Ovarian volume and antral follicle count (AFC) were compared between operated ovaries and nonoperated ovaries of patients with endometriosis and controls (women with male factor infertility).

RESULT(S)

The combined technique was possible in all cases. The volume of the ovary after the combined technique was similar to that of the contralateral normal ovary, as well as to that observed in infertile women without endometriosis presenting for male factor infertility. The AFC on day 2-5 showed the same number of antral follicles in all subgroups. Histopathology of the excised part of the endometrioma revealed the presence of follicles in only one case (2%). The pregnancy rate was 41% at a mean follow-up of 8.3 months. Recurrence of a small endometrioma was observed in only one case (2%).

CONCLUSION(S)

The combined technique (stripping and ablation) has proved not to be deleterious to the ovary.

The frequency of ovulation from the affected ovary decreases following laparoscopic cystectomy in infertile women with unilateral endometrioma during a natural cycle

PURPOSE

To evaluate the cystectomy-induced damage on the follicular growth and ovulation of an affected ovary during natural cycles.

METHODS

Twenty-eight infertile patients with unilateral ovarian endometriomas who underwent laparoscopic cystectomy were retrospectively evaluated. The ovulation rate of an affected ovary during natural cycles was compared before and after cystectomy in each patient, and it was also determined if ovulation from the affected ovaries resulted in pregnancy.

RESULTS

After surgery, the ovulation rate was significantly lower than that before cystectomy (16.9 +/- 4.5% vs. 34.4 +/- 6.6%, P = 0.013). After surgery, 14 pregnancies were achieved without IVF treatment, and only 2 of them (14.3%) were achieved from an operated-side ovary. However, the pregnancy rate per ovulatory cycle of the operated-side ovary was not different from that of the intact ovary (8.8% vs. 5.8%, P = 0.750).

CONCLUSIONS

Laparoscopic cystectomy is an invasive treatment in that it reduces the frequency of ovulation; however the pregnancy rate per ovulation did not deteriorate.

Infertility surgery is dead: only the obituary remains?

Despite the multiple advantages of assisted reproductive technology compared with surgery, there remain several diagnoses for which surgery is still widely performed: distal tubal occlusion, regret of permanent sterilization, and endometriosis. Assisted reproductive technology is superior to surgery and should be offered as first-line treatment.

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.

Impact of laparoscopic cystectomy on fecundity of infertility patients with ovarian endometrioma

AIM

To clarify the effect of laparoscopic cystectomy for ovarian endometrioma in infertility patients, the pregnancy outcome was evaluated.

METHODS

This was a retrospective study. From August 2002 to February 2006, 33 infertility patients with ovarian endometrioma underwent laparoscopic cystectomy at our center. According to the laparoscopic findings 33 were divided into two groups; 10 were evaluated as the patients who need assisted reproductive technologies (ART) treatment (IVF subgroup) and 23 were evaluated as the patients who do not need ART treatment but conventional infertility treatment (non-IVF subgroup). During the same period, 70 patients who were age-matched and received ART treatment without laparoscopy were defined as control (control group). Following up to 12 months after laparoscopy, the cumulative pregnancy rate in the non-IVF subgroup was calculated.

RESULTS

The patients age, duration of infertility and size of endometrioma were equal in the IVF and the non-IVF subgroups. The revised-American Society of Reproductive Medicine (r-ASRM) score in the IVF subgroup was significantly higher than that in the non-IVF group (P < 0.05). The pregnancy rates after laparoscopic cystectomy in IVF and non-IVF subgroups were 50.0% and 60.9%, respectively. These rates in the IVF and the non-IVF groups were slightly higher than that in control group (41.4%), but these differences were not significant. The cumulative pregnancy rate in the non-IVF group reached 52.2%, 12 months after laparoscopic surgery.

CONCLUSIONS

Laparoscopic surgery should be performed prior to ART treatment not only for making a decision about the treatment course but also for establishing a good pelvic condition to induce a pregnancy during ART treatment in infertility treatment with ovarian endometrioma.

Long-term use of gonadotropin-releasing hormone analogues before IVF in women with endometriosis

PURPOSE OF REVIEW

To discuss the relationship between endometriosis and infertility, the impact of endometriosis on assisted reproductive techniques and also the benefits of prolonged use of gonadotropin-releasing hormone analogue before IVF in women with endometriosis.

RECENT FINDINGS

The available evidence suggests that endometriosis is strongly associated with infertility. Many studies indicate lower pregnancy and implantation rates even in assisted reproductive cycles in women with endometriosis. It is well known that medical suppression of endometriosis does not appear to be warranted for endometriosis-associated infertility. Prolonged pretreatment with gonadotropin-releasing hormone analogue before IVF has been reported to improve clinical pregnancy rates in infertile women with endometriosis.

SUMMARY

Based on the recently published data, infertile women with endometriosis may benefit from long-term pretreatment of gonadotropin-releasing hormone analogue prior to IVF.

Women with advanced-stage endometriosis and previous surgery respond less well to gonadotropin stimulation, but have similar IVF implantation and delivery rates compared with women with tubal factor infertility

OBJECTIVE

To investigate the response to controlled ovarian hyperstimulation and ART outcomes in women with advanced-stage endometriosis and previous surgeries at the Yale IVF program between 1996 and 2002.

DESIGN

Retrospective case control study.

SETTING

Academic medical center.

PATIENT(S)

The study group consisted of 68 women who previously undergone laparoscopic surgery for advanced-stage endometriosis. The control group included 106 women with tubal-factor infertility. The women with endometriosis underwent 133 IVF-ET cycles and the control group 208 cycles.

INTERVENTION(S)

Controlled ovarian hyperstimulation and IVF-ET.

MAIN OUTCOME MEASURE(S)

Response to gonadotropins, fertilization, cleavage, implantation, pregnancy, miscarriage, and live birth rates.

RESULT(S)

Lower peak E(2) levels, higher total gonadotropin requirements, lower oocyte yield, and higher cancellation rates were found in women with endometriosis compared with tubal-factor control subjects. However, no differences were found in fertilization, cleavage, implantation, pregnancy, miscarriage, and delivery rates between the endometriosis and tubal-factor groups.

CONCLUSION(S)

Women with advanced-stage endometriosis who have undergone previous surgery respond less well to gonadotropins than women with tubal-factor infertility. However, implantation, pregnancy, and delivery rates are similar, suggesting that embryo quality and uterine receptivity remains unaffected despite diminished ovarian reserve in women with endometriosis.

Role of gonadotropin-releasing hormone antagonists in poor responders

OBJECTIVE

To evaluate the role of GnRH antagonists in poor-responder protocols.

DESIGN

Literature review.

CONCLUSION(S)

The optimum stimulation protocol for poor responders is unknown. Although many IVF programs currently use GnRH antagonists for poor responders, there have been only four prospective, randomized trials comparing GnRH antagonists to alternate protocols. None of these studies had sufficient power to evaluate a difference in pregnancy rates (PRs), and in all four cases, IVF outcomes were comparable. Nevertheless, interest in the use of GnRH antagonists in poor responders has continued. GnRH antagonists may be associated with simpler stimulation protocols, lower gonadotropin requirements, reduced patient costs, and shorter downtimes between consecutive cycles. However, the greatest advantage of GnRH antagonists may lie in the ability to assess ovarian reserves immediately prior to deciding whether or not to initiate gonadotropin stimulation. The ability to respond to cycle-to-cycle variation in antral follicle counts may allow the optimization of oocyte yield and reduce cycle cancellation rates. It remains to be seen if this approach (initiating gonadotropins only in cycles where an adequate antral follicle count is present) also translates into higher clinical PRs for poor responders.

Management of ovarian endometrioma

The optimal conservative treatment for endometriotic cysts is unclear, particularly when treated laparoscopically. We performed a systematic analysis of the published literature on ovarian endometrioma especially focused on comparing laparoscopic cystectomy with laparoscopic drainage and coagulation of the cyst with regard to evaluating advantage and disadvantage of each method. We observed that cystectomy was superior in terms of risk of recurrent symptoms, cyst, reoperation, pregnancy: this was true in both prospective and retrospective studies previously published. Given the evidence available, excision of cyst wall in endometrioma is strongly recommended especially in infertile patients.

Endométriomes ovariens : effet de la kystectomie laparoscopique sur la réponse ovarienne en fécondation in vitro

OBJECTIVE

To investigate the follicular response to controlled ovarian hyperstimulation (COH) in IVF-ET cycles after laparoscopic ovarian cystectomy for large endometriomas.

PATIENTS AND METHODS

In the set of a retrospective controlled study, the medical records of 113 infertile women who underwent IVF-ET cycles after laparoscopic surgery were reviewed. The study group (A) consisted of 63 patients with severe pelvic endometriosis and endometrioma excision. The control group (B) consisted of 50 infertile patients with mild or minimal endometriosis. Interventions were laparoscopic ovarian cystectomy in the study group, and COH in both groups.

RESULTS

Groups A and B were not different in terms of epidemiologic data. The total numbers of recruited follicles (9.1+/-3.3 vs 10.6+/-4.2; P = 0.001), mature follicles (> or =16 mm) (4.2+/-1.7 vs 4.8+/-2.2; P = 0.04), mature oocytes retrieved (5.8+/-3.8 vs 7.4+/-4.6; P = 0.02), and fertilization rate (48.9+/-34.9 vs 61.8+/-32.1%; P = 0.02) observed in group A were lower than those observed in group B, respectively. While the mean number of rFSH ampoules (75 IU) was increased in group A (38.1+/-20.4) compared to group B (29.3+/-16.4; P = 0.004), cumulative pregnancy rates were similar in both groups (27.5+/-8.8% vs 37.2+/-10.6%; P = 0.37).

DISCUSSION AND CONCLUSIONS

Ovarian response was reduced during IVF-ET cycles in patients with history of severe endometriosis and laparoscopic excision of endometriomas compared to women with mild or minimal endometriosis without ovarian surgery.

Recurrence of endometriomas after laparoscopic removal: sonographic and clinical follow-up and indication for second surgery

STUDY OBJECTIVE

This study involved patients who, after laparoscopic surgery, had recurrence of endometriomas detected by sonography. The aim of this study was to evaluate the role of transvaginal sonography (TVS) in the management of recurrent endometriomas and to establish ultrasonographic criteria that would direct the therapy toward additional surgery versus medical or expectant management.

DESIGN

Retrospective analysis of 62 reproductive-age women who showed recurrence of endometriomas on TVS after laparoscopic removal of an ovarian endometrioma by the stripping technique (Canadian Task Force classification II-1).

SETTING

Obstetrics and Gynecology Department, University of Rome Tor Vergata.

PATIENTS

Sixty-two patients with recurrent endometriomas after first-line treatment with laparoscopy.

INTERVENTIONS

Ultrasonographic follow-up and/or second surgery.

MEASUREMENTS AND MAIN RESULTS

Recurrence of an ovarian endometrioma was defined as the presence of ovarian cysts with the typical sonographic criteria of endometriomas and a diameter of more than 10 mm. The clinical and sonographic postoperative follow-up period lasted from 6 to 97 months (median 24.6) after the first procedure. Of 62 patients with recurrent endometriomas, 50 had recurrence on the treated ovary, 7 on the contralateral untreated ovary, and 5 on both the treated and untreated ovaries. Recurrence of endometriomas was associated with symptoms (pain or infertility) in 47 patients (76%), while the remaining 15 (24%) were asymptomatic. Of the 47 symptomatic patients with recurrence detected by TVS, a second procedure was performed in 15. Second surgery in these patients was indicated by the larger size of the recurrent cysts, a poor response to medical treatment, the presence on TVS of pelvic adhesions and nodules of deep endometriosis, and overall progression of the disease. Symptomatic patients who did not undergo a second procedure (32) had smaller recurrent endometriomas. However of the 31 symptomatic patients with large recurrent endometriomas (>3 cm), only 45% had repeat surgery.

CONCLUSION

Recurrent endometriomas, as detected by TVS, can remain asymptomatic and do not necessarily progress in size with or without medical treatment. The decision to reoperate depends less on the endometrioma's size than on symptoms, in particular severe pain, and failure of medical treatment. However such patients are also more likely to have signs of deep nodules and adnexal/bowel adhesions and larger endometriomas on TVS scan, thus predisposing them to require a second procedure.

Postsurgical ovarian failure after laparoscopic excision of bilateral endometriomas

OBJECTIVE

This study was undertaken to determine the frequency of postsurgical ovarian failure in patients undergoing laparoscopic excision of bilateral endometriomas.

STUDY DESIGN

Patients who had been operated on for bilateral ovarian endometriosis between January 1995 and December 2003 and who were younger than 40 years at the time of surgery were contacted by telephone and interviewed.

RESULTS

A total of 126 patients were recruited. Mean +/- SD age of patients at the time of surgery was 30.4 +/- 4.3 years. Postsurgical ovarian failure was documented in 3 cases, corresponding to a rate of 2.4% (95% CI 0.5%-6.8%). In all cases, this complication occurred immediately after surgery.

CONCLUSION

Patients who had been operated on for bilateral endometriomas have a low but definite risk of premature ovarian failure occurring immediately after surgery.

The presence of ovarian endometriomas is associated with a reduced responsiveness to gonadotropins

OBJECTIVE

To clarify whether the presence of ovarian endometriomas is associated with a reduced responsiveness to ovarian hyperstimulation.

DESIGN

Observational study.

SETTING

University teaching hospital.

PATIENT(S)

Women selected for in vitro fertilization-intracytoplasmic sperm injection (IVF-ICSI) cycles who were found to have unilateral ovarian endometriomas and who did not undergo previous ovarian surgery.

INTERVENTION(S)

Ovarian hyperstimulation using gonadotropins.

MAIN OUTCOME MEASURE(S)

Number of codominant follicles (mean diameter >15 mm) in the affected and in the contralateral intact gonads.

RESULT(S)

Thirty-six patients were enrolled. They underwent 56 IVF-ICSI cycles. The number of codominant follicles in the intact and affected ovaries were 4.0 +/- 2.2 and 3.0 +/- 1.7, respectively (P=.01). This difference corresponded to a mean reduction (95% confidence interval [CI]) of 25% (6%-44%). This deleterious effect was more evident in women with larger cysts, in those with more than one cyst, and in those who were more responsive to ovarian hyperstimulation.

CONCLUSION(S)

The presence of ovarian endometriomas is associated with a reduced responsiveness to gonadotropins.

Outcome of in vitro fertilization/intracytoplasmic sperm injection after laparoscopic cystectomy for endometriomas

OBJECTIVE

To assess the impact of prior unilateral or bilateral endometrioma cystectomy on controlled ovarian hyperstimulation (COH) and intracytoplasmic sperm injection (ICSI) outcome.

DESIGN

Retrospective case-control study.

SETTING

Department of Obstetrics and Gynecology, School of Medicine, Hacettepe University, Ankara, Turkey.

PATIENT(S)

Fifty-seven consecutive infertile patients were enrolled who had previously undergone unilateral (n = 34) or bilateral (n = 23) laparoscopic cystectomy for endometriomas more than 3 cm in diameter and underwent ICSI. The control group consisted of 99 patients with tubal factor infertility.

INTERVENTION(S)

Controlled ovarian hyperstimulation and ICSI.

MAIN OUTCOME MEASURE(S)

Cycle cancellation rate, number of oocytes, fertilization rate, embryo quality, clinical pregnancy rate (PR), and implantation rate.

RESULT(S)

The mean number of oocytes, metaphase II oocytes, and two-pronucleated oocytes were significantly lower in the bilateral cystectomy group compared to the unilateral cystectomy and control groups. However, all other parameters, including fertilization rate, the mean number of embryos transferred, the mean number of grade 1 embryos transferred, the clinical PR per embryo transfer, and implantation rate, were comparable among the three groups. Within the unilateral cystectomy group, the mean number of oocyte retrieved from the operated site was significantly less than in the contralateral nonoperated site.

CONCLUSION(S)

Laparoscopic endometrioma cystectomy does reduce the ovarian reserve. However, diminished ovarian reserve does not translate into impaired pregnancy outcome.

Laparoscopic excision of recurrent endometriomas: long-term outcome and comparison with primary surgery

OBJECTIVE

To compare the laparoscopic excision of primary versus recurrent ovarian endometriomas.

DESIGN

Descriptive study.

SETTING

Tertiary referral center for the treatment of endometriosis.

PATIENT(S)

Between 1993 and 2002, 359 consecutive patients: 305 primary surgeries (group A) and 54 reoperations for a recurrent endometrioma in the same ovary of the primary cyst (group B).

INTERVENTION(S)

Laparoscopic stripping of the cyst wall. Follow-up evaluations every 6 months, including clinical and ultrasonographic evaluations and a questionnaire for pain symptoms (mean follow-up time, +/- standard deviation: 35.4 +/- 27.6 months).

MAIN OUTCOME MEASURE(S)

Recurrence of pain symptoms, sonographic recurrence of endometriomas, need for a new medical or surgical treatment, and reproductive outcome.

RESULT(S)

In groups A and B, respectively, the 5-year cumulative rates were not statistically significantly different: pain recurrence 20.5% versus 17.4%; ultrasonographic recurrence 18.9% versus 15.1%; retreatment requirement 19.4% versus 17.3%; and pregnancy 40.8% versus 32.4%. Although the difference was not statistically significant, compared with patients of group A, the women of group B underwent assisted reproduction techniques more frequently (50% vs. 32.2%) and had more irregular menstrual cycles associated with follicle-stimulating hormone levels > or = 14 IU/mL in the early follicular phase (5.5% vs. 1.3%).

CONCLUSION(S)

After laparoscopic excision of recurrent ovarian endometriomas, the recurrence of pain and the reproductive outcome are comparable with those found after primary surgery.

Excision of endometriotic cyst wall may cause loss of functional ovarian tissue

Management of ovarian cysts is still controversial especially when dealing with endometriomas. Cyst excision was accepted surgical method by many centers; however, relationship between the excision and the loss of functional ovarian tissue is still uncertain.

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.

Damage to ovarian reserve associated with laparoscopic excision of endometriomas: a quantitative rather than a qualitative injury

OBJECTIVE

Retrospective studies suggest that laparoscopic excision of endometriomas is associated with a reduced responsiveness to ovarian hyperstimulation. In this study, we prospectively evaluated ovarian response to hyperstimulation in women selected for in vitro fertilization and intracytoplasmic sperm injection cycles who previously underwent laparoscopic enucleation of a monolateral endometrioma.

STUDY DESIGN

Operated and contralateral intact ovaries of the same patient were compared in terms of number of follicles, number of oocytes retrieved, fertilization rate, and rate of high-quality embryos.

RESULTS

Thirty-eight subjects were included. A reduced number of dominant follicles, oocytes, embryos, and high-quality embryos was observed in the operated gonad. The mean percentage of reduction was 60% (95% confidence interval 38-81%), 53% (95% confidence interval 30-75%), 55% (95% confidence interval 28-81%), and 52% (95% confidence interval 17-87%), respectively. Fertilization rate and rate of good-quality embryos were similar.

CONCLUSION

Laparoscopic excision of endometriomas is associated with a quantitative but not a qualitative damage to ovarian reserve.

Ovarian recovery after laparoscopic enucleation of ovarian cysts: Insights from echographic short-term postsurgical follow-up

STUDY OBJECTIVE

To evaluate damage to ovarian reserve following laparoscopic cystectomy of benign ovarian cysts.

DESIGN

Prospective study (Canadian Task Force classification II-3).

SETTING

Tertiary gynecologic endoscopic unit at a university-affiliated hospital.

PATIENTS

Thirty-one patients who underwent excision of monolateral (n=25) or bilateral (n=6) benign ovarian cysts.

INTERVENTIONS

Serial transvaginal ultrasound examinations during the first and third postsurgical menstrual cycles. The following ovarian echographic variables were evaluated: antral follicle count, ovarian volume, stromal blood flow, and side of ovulation. Two types of statistical analysis were performed: a paired analysis comparing operated and intact ovaries of the same patient and a prospective analysis comparing ecographic characteristics of the operated gonad at first and second evaluation.

MEASUREMENTS AND MAIN RESULTS

Antral follicle count and stromal blood flow were not significantly affected by surgery. While ovarian volume was similar in the operated and in the contralateral intact gonad at the first ultrasound evaluation, the volume of the operated ovary was significantly reduced at the second assessment. The median (interquartile range) of the percentage of this reduction was 33% (18%-81%). This progressive reduction was confirmed by prospectively analyzing the operated ovaries. An increased probability of ovulation in the intact gonad was observed at both assessments.

CONCLUSION

Laparoscopic excision of ovarian cysts is associated with damage to ovarian reserve, at least immediately after surgery. This effect does not appear to be consequent to an injury to ovarian vascularization.

Endometrioma undergoing laparoscopic ovarian cystectomy: its influence on the outcome of in vitro fertilization and embryo transfer (IVF–ET)

PURPOSE

To evaluate the effect of laparoscopic ovarian cystectomy for endometrioma on the clinical outcome of IVF treatment.

METHODS

Patients who received IVF treatment were retrospectively classified into two groups. Group 1 included 95 patients who received IVF due to tubal occlusion. Group 2 included 127 patients who had received laparoscopic ovarian cystectomy for endometrioma(s) followed by IVF treatment. Clinical outcomes of IVF treatment were compared between two groups.

RESULTS

More oocytes were harvested per retrieval in Group 1 than Group 2 (p < 0.05). The fertilization rate was higher in Group 1 than Group 2 (p < 0.05). Although the implantation rate was higher in Group 2 (p < 0.05), the clinical pregnancy rate revealed no statistically significant difference between the two groups.

CONCLUSIONS

Women who received ovarian cystectomy for endometriomas have fewer oocytes harvested during IVF treatment. However, their chance of pregnancy was comparable to patients with tubal problems who underwent IVF treatment.