Fertility-related considerations in endometriosis

The Impact of Endometriosis on Pregnancy

Despite the increased frequency of endometriosis, it remains one of the most enigmatic disorders regarding its effects on pregnancy. Endometriosis adversely affects both natural and assisted conception. Impaired folliculogenesis, which causes follicular dysfunction and low egg quality, as well as luteal phase problems, reduced fertilization, and abnormal embryogenesis, are some of the mechanisms advocated to explain reproductive dysfunction. There is a rising need for a comprehensive study of the potential negative consequences of this condition on pregnancy outcomes, including the postpartum period, as more women with a medical history of endometriosis become pregnant. Obstetrical complications (small for gestational age [SGA], cesarean section [CS], miscarriage, hemorrhage, low placental adhesion, and preterm delivery) are statistically elevated in women with endometriosis. Furthermore, ruptured ovarian endometrioma, appendicitis, intestinal perforation, and hemoperitoneum have been described in pregnancy. Obstetricians are largely unfamiliar with these complications, as they have not been thoroughly investigated. The development and pathogenesis of endometriosis is an important field of study and has not yet been fully elucidated. Finding these mechanisms is crucial for the development of new and more effective strategies to treat this condition. Endometriosis can have an impact on obstetric and neonatal outcomes of pregnancy, in addition to its potential effects on conception. To date, no additional monitoring is recommended for pregnancies with a history of endometriosis. However, more studies are urgently needed to assess the need for the tailored pregnancy monitoring of women with endometriosis.

Patient experiences of being advised by a healthcare professional to get pregnant to manage or treat endometriosis: a cross-sectional study

BACKGROUND

There is a lack of evidence that pregnancy reduces endometriotic lesions or symptoms, however studies indicate that people with endometriosis are commonly advised to get pregnant to manage or treat endometriosis. This study sought to examine the impact of this advice on patients with endometriosis when the advice was provided by healthcare professionals.

METHODS

The Endometriosis Patient Experience Survey was a self-reported, community-based, cross-sectional online survey of people who had been medically diagnosed with endometriosis. Descriptive statistics were used to analyse the quantitative survey data and thematic analysis was undertaken for the qualitative survey data.

RESULTS

1892 participants had received the advice to get pregnant or have a baby to manage or treat their endometriosis, with 89.4% of participants receiving this advice from healthcare professionals. In exploring the qualitative data, seven themes were contextualised relating to the impact of this advice in terms of health literacy, accepting the advice, rejecting the advice, major life decisions, healthcare interactions, mental health and relationships.

CONCLUSIONS

This study demonstrates profound and often negative patient impacts of the advice from healthcare professionals to get pregnant to manage or treat endometriosis. Impacts ranged from planning for pregnancy, hastening the making of major life decisions, eroding trust with healthcare professionals, worsening mental health and straining relationships. Providing evidence-based information on the treatment and management of endometriosis is essential. Pregnancy or having a baby should not be suggested as a treatment for endometriosis and the provision of this advice by healthcare professionals can have negative impacts on those who receive it.

Is the long-acting gonadotropin-releasing hormone agonist long protocol better for patients with endometriosis undergoing IVF?

OBJECTIVE

To investigate the effect of the long-acting gonadotropin-releasing hormone agonist (GnRHa) long protocol on in vitro fertilization (IVF) outcomes of patients with endometriosis (EMs).

METHODS

This retrospective cohort study was carried out from July 1, 2016 to June 30, 2021. In all, 798 patients with EMs who underwent first IVF were enrolled. The patients were classified by the ovarian stimulation protocols. The clinical outcomes of IVF were compared in each group.

RESULTS

Those EMs patients who received the long-acting GnRHa long protocol had significantly higher clinical pregnancy rate (72.00%, 60.70% and 50.90%, respectively; P = 0.047 and 0.010) and implantation rate (51.0%, 44.6%, and 38.7%, respectively; P = 0.006 and <0.001) compared with the short-acting GnRHa long protocol and the GnRH antagonist protocol. Live birth rate was also significantly higher than the GnRH antagonist protocol (60.10% vs. 40.0%, P = 0.032), but not statistically different from the short-acting GnRHa (60.10% vs. 53.80%, P = 0.443). In addition, they also had significantly higher duration of stimulation, total dose of gonadotropin, and number of high-quality embryos transferred compared with other groups (P < 0.001).

CONCLUSIONS

The long-acting GnRHa long protocol could improve IVF outcomes of patients with EMs compared with the short-acting GnRHa long protocol and the GnRH antagonist protocol.

Investigation of biomarkers in Endometriosis-associated infertility: Systematic Review

The relationship between endometriosis and infertility is still unknown, but it is possible that genetic polymorphisms influence these two variables. This study aims to identify, in the literature, which polymorphisms are related to infertility in women with endometriosis. A search was performed in databases using the descriptors: polymorphisms genetics and infertility and endometriosis. 386 articles were identified, and after applying the inclusion and exclusion criteria, 33 case-control studies were included. Genes and their respective polymorphisms, which exhibited statistically significant values, were classified into three categories: related to metabolic/cellular processes, steroidogenesis and sex hormone receptors, inflammation and immune response. In summary, the results of these studies suggest that the polymorphisms rs882605 of MUC4 gene, rs16826658 of WNT4 gene, rs10953316 of MUC17 gene, rs10928050 of KAZN gene, rs1799889 of PAI-1 gene, (TA)n repeats of ESR1 gene, (CA)n repeats of ESR2 gene, rs605059 of HSD17B1 gene, rs743572 of CYP17A1 gene, insLQ of LHR gene, p.Ile49Ser of AMH gene, rs12700667 of NPVF/NFE2L3 gene, G1502A of LHβ gene, G + 1730A of ERβ gene, rs7528684 of FCRL3 gene, rs3761549 of FOXP3 gene and rs28362491 of NFKβ1 gene are implicated in the etiology of infertility in women with endometriosis.

Effectiveness of gonadotrophin-releasing hormone agonist therapy to improve the outcomes of intrauterine insemination in patients suffering from stage I-II endometriosis

OBJECTIVE

To explore the role of postoperative gonadotrophin releasing hormone agonist (GnRH-a) therapy before treatment with intrauterine insemination (IUI) for infertile females with stage I-II endometriosis.

MATERIAL AND METHODS

Ninety-seven patients diagnosed with stage I-II endometriosis before IUI were enrolled in this study. The clinical pregnancy rate, cumulative pregnancy rate, live birth rate and newborn conditions were compared between the two groups with and without GnRH-a therapy.

RESULTS

The clinical pregnancy rate of IUI in the GnRH-a group was higher than that in the control group (15.29% vs. 11.82%, p = .035). By logistic regression analysis, patients treated with GnRH-a had a higher clinical pregnancy rate than those without (adjusted odds ratio (AOR) 23.190, 95% confidence interval (CI) 1.238-434.312). The live birth rate per IUI cycle in the GnRH-a group was also higher than in the controls (12.94% vs. 10%). However, the difference was not statistically significant (p = .311, AOR 4.844, 95% CI 0.229-102.320). The patients with GnRH-a therapy had a similar incidence of multiple pregnancy rate (0% vs. 0%), miscarriage rate (2.35% vs. 0.91%) and ectopic pregnancy rate (0% vs. 0.91%) as compared to the control group. The cumulative pregnancy rates were all higher in patients administered with GnRH-a than those without GnRH-a treatment in different cycles (one cycle: 17.07% vs 12.50%; two cycles: 29.27% vs 19.64%; three cycles: 31.71% vs 23.21%; ≥four cycles: 31.71% vs 23.21%), but the difference was not statistically significant. Notably, there was no more pregnancy after the third IUI cycle. The gestation weeks of delivery in the two groups were 39.09 ± 1.04 and 38.60 ± 1.17, respectively (p = .323). Nor was there difference in birth weight between the two groups (3236 ± 537 g vs 3435 ± 418 g, p = .360).

CONCLUSIONS

The administration of GnRH-a in patients with stage I-II endometriosis could be beneficial to the outcomes of IUI. It is recommended that IUI should be discontinued after three failed attempts. KEY MESSAGESEndometriosis is a common cause of infertility, but the exact mechanism remains unclear.The administration of GnRH-a before IUI treatment is beneficial for patients suffering from stage I-II endometriosis.After three failed attempts, IUI should be stopped in patients with stage I-II endometriosis.

Effect of early inflammatory reaction on ovarian reserve after laparoscopic cystectomy for ovarian endometriomas

This study aimed to investigate the effect of early inflammatory reaction on ovarian reserve of patients with ovarian endometriomas after laparoscopic cystectomy. Our retrospective case series included 112 patients with ovarian endometriomas that underwent the laparoendoscopic single-site cystectomy. Interleukin-6 (IL-6), hs-CRP, tumour necrosis factor-α (TNF-α), interleukin-17A (IL-17A) and AMH level were detected during perioperative and postoperative period. In our study, ovarian endometriomas with low AMH group were found having higher level of IL-6 than the normal AMH group in the preoperative status. On the 3rd day after operation, the change of AMH level was inversely proportional to the IL-6 level. During the follow-up within one year, it was found that the bilateral nature of the cyst and the postoperative IL-6 increased level were the risk factors for AMH not returning to baseline level. Our results suggested that inflammatory reaction is indeed involved in the damage of ovarian reserve during laparoscopic cystectomy. Hence, the negative impact of inflammatory injury should be fully considered before operation, especially young women with bilateral ovarian endometriomas.Impact StatementWhat is already known on this subject? Ovarian reserve in women always was reduced after the laparoscopic cystectomy. It is reported that it may be related to the use of energy instruments, haemostatic methods or the size of cysts in minimally invasive surgery.What do the results of this study add? Inflammatory reaction is indeed involved in the damage of ovarian reserve during LESS cystectomy. Interleukin-6 (IL-6) may act as the most main inflammatory factor aggravating damage of the ovarian reserve. Moreover, increased IL-6 level after surgery and bilateral cyst burden are the two risk factors for AMH not returning to baseline level within one year after surgery.What are the implications of these findings for clinical practice and/or further research? In clinic, the negative impact of inflammatory injury on ovarian reserve should be fully considered before operation, especially young women with bilateral ovarian endometriomas. Moreover, this is also the clinical basis for further study on the mechanism of inflammatory ovarian injury or the method of blocking the inflammatory response to reduce the damage of ovarian reserve after surgery.

Pregnancy outcomes in women with endometriosis and/or ART use: a population-based cohort study

STUDY QUESTION

What is the association between endometriosis and adverse pregnancy outcomes with ART use and non-use?

SUMMARY ANSWER

Endometriosis and ART use are both associated with increased risk of preterm birth, antepartum haemorrhage, placenta praevia and planned birth (caesarean delivery or induction of labour).

WHAT IS KNOWN ALREADY

There are contradictory findings on the association between endometriosis and adverse pregnancy outcomes, and many large studies have not considered the effect of ART use.

STUDY DESIGN, SIZE, DURATION

Population-based cohort study of 578 221 eligible pregnancies during 2006-2015, comparing pregnancy outcomes across four groups (No endo/no ART, No endo/ART, Endo/no ART and Endo/ART).

PARTICIPANTS/MATERIALS, SETTING, METHODS

All female residents of New South Wales, Australia aged 15-45 years and their index singleton pregnancy of at least 20 weeks gestation or 400 g birthweight. Linked hospital, pregnancy/birth and mortality data were used. Modified Poisson regression with robust error variances was used to estimate adjusted risk ratios (aRRs) and 99% CIs, adjusting for sociodemographic and pregnancy factors.

MAIN RESULTS AND THE ROLE OF CHANCE

Compared to women without endometriosis who had pregnancies without ART use, there was increased risk of preterm birth (<37 weeks) in all groups [No endo/ART (aRR 1.85, 99% CI 1.46-2.34), Endo/no ART (aRR 1.24, 99% CI 1.06-1.44), Endo/ART (aRR 1.93, 99% CI 1.11-3.35)] and antepartum haemorrhage [No endo/ART (aRR 1.99, 99% CI 1.39-2.85), Endo/no ART (aRR 1.31, 99% CI 1.03-1.67), Endo/ART (aRR 2.69, 99% CI 1.30-5.56)] among pregnancies affected by endometriosis or ART use, separately and together. There was increased risk of placenta praevia [No endo/ART (aRR 2.26, 99% CI 1.42-3.60), Endo/no ART (aRR 1.66, 99% CI 1.18-2.33)] and planned birth [No endo/ART (aRR 1.08, 99% CI 1.03-1.14), Endo/no ART (aRR 1.11, 99% CI 1.07-1.14)] among pregnancies with endometriosis or ART use, separately. There was increased risk of placental abruption [No endo/ART (aRR 2.36, 99% CI 1.12-4.98)], maternal morbidity [No endo/ART (aRR 1.67, 99% CI 1.07-2.62)] and low birthweight (<2500 g) [No endo/ART (aRR 1.45, 99% CI 1.09-1.93)] among pregnancies with ART use without endometriosis. There was decreased risk of having a large-for-gestational age infant [Endo/no ART (aRR 0.83, 99% CI 0.73-0.94)] among pregnancies with endometriosis without ART use.

LIMITATIONS, REASONS FOR CAUTION

Endometriosis is often under-diagnosed and women with a history of hospital diagnosis of endometriosis may represent those with more symptomatic or severe disease. If the effects of endometriosis on pregnancy are greater for those with more severe disease, our results may over-estimate the effect of endometriosis on adverse pregnancy outcomes at a population level. We were unable to assess the effect of endometriosis stage or typology on the study outcomes.

WIDER IMPLICATIONS OF THE FINDINGS

These results suggest that women with endometriosis including those who used ART to achieve pregnancy are a higher-risk obstetric group requiring appropriate surveillance and management during their pregnancy.

STUDY FUNDING/COMPETING INTEREST(S)

This study was supported by the Prevention Research Support Program, funded by the New South Wales Ministry of Health. The funder had no role in the design, data collection and analysis, interpretation of results, manuscript preparation or the decision to submit the manuscript for publication. The authors have no conflicts of interest.

TRIAL REGISTRATION NUMBER

N/A.