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Skorupskaite K, Hardy M, Bhandari H, Yasmin E, Saab W, Seshadri S. Evidence based management of patients with endometriosis undergoing assisted conception: British fertility society policy and practice recommendations. HUM FERTIL 2024; 27:2288634. [PMID: 38226584 DOI: 10.1080/14647273.2023.2288634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 09/27/2023] [Indexed: 01/17/2024]
Abstract
Endometriosis is a chronic inflammatory condition in women of reproductive age, which can lead to infertility and pelvic pain. Endometriosis associated infertility is multifactorial in nature adversely affecting each step of the natural reproductive physiology and thereby processes and outcomes of Assisted Reproductive Technology (ART) cycles. These outcomes are further complicated by the subtype of endometriosis, being peritoneal, deep infiltrating and ovarian, which bear negative effects on ovarian reserve, response to stimulation, accessibility for oocyte retrieval, intraoperative safety and endometrial receptivity. There is still a lack of clear guidance about the role of surgery for ovarian endometriosis/endometriomas. This guideline evaluates the evidence of the impact of pelvic endometriosis and endometriomas on the outcome of ART and provides recommendations for management options before and during ART including intra-uterine insemination. Recommendations are made based on the current evidence for the management of patients with endometriosis across each step of ART with the primary aim of improving ART outcomes.
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Affiliation(s)
- Karolina Skorupskaite
- Edinburgh Fertility & Reproductive Endocrine Centre, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Madeleine Hardy
- Leeds Centre for Reproductive Medicine at Leeds Teaching Hospitals NHS Trust, Seacroft Hospital, Leeds, UK
| | - Harish Bhandari
- Leeds Centre for Reproductive Medicine at Leeds Teaching Hospitals NHS Trust, Seacroft Hospital, Leeds, UK
| | - Ephia Yasmin
- Reproductive Medicine Unit, University College London Hospital NHS Foundation Trust, London, UK
| | - Wael Saab
- The Centre for Reproductive & Genetic Health, London, UK
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2
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Ferrero S, Gazzo I, Crosa M, Rosato FP, Barra F, Leone Roberti Maggiore U. Impact of surgery for endometriosis on the outcomes of in vitro fertilization. Best Pract Res Clin Obstet Gynaecol 2024; 95:102496. [PMID: 38631927 DOI: 10.1016/j.bpobgyn.2024.102496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 03/23/2024] [Accepted: 03/26/2024] [Indexed: 04/19/2024]
Abstract
This narrative review aims to summarize available evidence on the IVF-associated outcomes after surgery for endometriosis. Only one retrospective study investigated if surgical treatment of superficial/peritoneal endometriosis may modify the outcomes of IVF; therefore, more data are needed to confirm the benefit of surgery for this type of disease for improving ART outcomes, and to be able to support it in routine practice. Solid evidence from several meta-analyses demonstrates that surgical treatment of endometriomas does not enhance the outcomes of IVF. In contrast, surgical treatment of ovarian endometriosis may lead to a reduction in ovarian reserve, especially in cases involving bilateral endometriomas or repeated surgical procedures. Some non-randomized studies have examined if surgical treatment on deep endometriosis may influence IVF outcomes. A systematic review with meta-analysis revealed that patients who underwent surgery before IVF exhibited significantly higher pregnancy rates per patient, pregnancy rates per cycle, and live birth rates per patient compared to those without prior surgery. However, the available data are insufficient to recommend surgical excision of deep endometriosis as the first-line treatment for asymptomatic patients to enhance IVF outcomes.
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Affiliation(s)
- Simone Ferrero
- DINOGMI, University of Genova, Genova, Italy; Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genova, Italy.
| | - Irene Gazzo
- DINOGMI, University of Genova, Genova, Italy; Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Marco Crosa
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Francesco Paolo Rosato
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Fabio Barra
- Unit of Obstetrics and Gynecology, P.O. "Ospedale del Tigullio"-ASL4, Chiavari, Genoa, Italy; Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
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3
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Leone Roberti Maggiore U, Chiappa V, Ceccaroni M, Roviglione G, Savelli L, Ferrero S, Raspagliesi F, Spanò Bascio L. Epidemiology of infertility in women with endometriosis. Best Pract Res Clin Obstet Gynaecol 2024; 92:102454. [PMID: 38183767 DOI: 10.1016/j.bpobgyn.2023.102454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 12/21/2023] [Indexed: 01/08/2024]
Abstract
Endometriosis is a benign, chronic, inflammatory condition affecting up to 10 % of women and characterised by the presence of glands and stroma tissue outside the uterus. Epidemiological and clinical studies demonstrate a consistent association between endometriosis and infertility. However, this relationship is far to be clearly understood and several mechanisms are involved. Available data show that patients with endometriosis have an increased estimated risk of infertility between two and four times compared with the general population. On the other hand, the probability of patients with infertility to have endometriosis is reported up to about 50 % of the cases. Future studies should aim to better elucidate the mechanisms behind endometriosis-associated infertility in order to offer the more appropriate and tailored management for the patients.
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Affiliation(s)
| | - Valentina Chiappa
- Gynecologic Oncology Unit, Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy
| | - Marcello Ceccaroni
- Department of Obstetrics and Gynecology, Gynecologic Oncology and Minimally Invasive Pelvic Surgery, International School of Surgical Anatomy, IRCCS "Sacro Cuore - Don Calabria" Hospital, Negrar di Valpolicella, Verona, Italy
| | - Giovanni Roviglione
- Department of Obstetrics and Gynecology, Gynecologic Oncology and Minimally Invasive Pelvic Surgery, International School of Surgical Anatomy, IRCCS "Sacro Cuore - Don Calabria" Hospital, Negrar di Valpolicella, Verona, Italy
| | - Luca Savelli
- Obstetrics and Gynecology Unit, Morgagni-Pierantoni Hospital, Forlì, Italy
| | - Simone Ferrero
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genoa, Italy; Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Francesco Raspagliesi
- Gynecologic Oncology Unit, Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy
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4
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Bartolacci A, dell'Aquila M, Coticchio G, Intra G, Parodi F, Patria G, Zacà C, Borini A. Endometriosis affects the number of retrieved oocytes but not early embryonic development and live birth: a retrospective analysis of 716 IVF cycles. HUM FERTIL 2023; 26:1469-1476. [PMID: 37139851 DOI: 10.1080/14647273.2023.2200979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Accepted: 01/27/2023] [Indexed: 05/05/2023]
Abstract
To investigate the potential effect of endometriosis on embryo development and clinical outcomes, a retrospective analysis of 716 women undergoing their first standard in vitro fertilization (sIVF) cycles (205 endometriosis and 511 with tubal factor infertility) was performed. The endometriosis group included women with an ultrasonographic or surgical diagnosis. Control subjects were women diagnosed with tubal factor infertility by laparoscopy or hysterosalpingogram. The primary outcome of the study was live birth. Cumulative live birth was also assessed in a subgroups analysis. After adjusting for confounders we found no significant difference in fertilization rate, blastulation, top-quality blastocyst, live birth, cumulative live birth (subgroups analysis) and miscarriage rate. In the endometriosis group, the number of retrieved oocytes was smaller (6.94 ± 4.06 Vs 7.50 ± 4.6, adjusted p < 0.05). We observed a statistically significant difference in the percentage of day-3 embryos with ≥8 blastomeres (33.12 ± 22.72 endometriosis vs, 40.77 ± 27.62 tubal factor, adjusted p < 0.01) and a negative correlation between the presence of endometriomas and a number of retrieved oocytes [B coefficient =-1.41, 95%CI (-2.31-0.51), adjusted p = 0.002]. Our results suggest that endometriosis affects the number of retrieved oocytes but not embryo development and live birth.
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5
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Somigliana E, Piani LL, Paffoni A, Salmeri N, Orsi M, Benaglia L, Vercellini P, Vigano' P. Endometriosis and IVF treatment outcomes: unpacking the process. Reprod Biol Endocrinol 2023; 21:107. [PMID: 37936154 PMCID: PMC10629090 DOI: 10.1186/s12958-023-01157-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 10/26/2023] [Indexed: 11/09/2023] Open
Abstract
Advanced endometriosis is associated with a reduction of IVF success. Surgical damage to the ovarian reserve following the excision of endometriomas has been claimed as a critical factor in the explanation of this detrimental effect. However, it is generally inferred that other mechanisms might also hamper IVF success in affected women. They include diminished responsiveness to ovarian stimulation, altered steroidogenesis, a decline in oocyte quality, reduced fertilization and embryo development, and impaired implantation. To navigate these limitations, we scrutinized available literature for studies specifically designed to address distinct phases of the IVF process. Utmost consideration was given to intra-patient ovarian response comparisons in women with unilateral endometriomas and to studies applying a meticulous matching to control confounders. The following observations have been drawn: 1) endometriosis has a negligible impact on ovarian response. A slight reduction in stimulation response can only be observed for endometriomas larger than 4 cm. Follicular steroidogenesis is unaffected; 2) oocyte quality is not hampered. Fertilization rates are similar, and intracytoplasmic sperm injection (ICSI) is not justified. Embryonic development is uncompromised, with no increase in aneuploidy rate; 3) endometrial receptivity is either unaffected or only slightly impacted. In conclusion, our study suggests that, aside from the well-known negative effect on ovarian reserve from excisional endometrioma surgeries, endometriosis does not significantly affect IVF outcomes.
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Affiliation(s)
- Edgardo Somigliana
- Academic Center for Research on Adenomyosis and Endometriosis, Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
- Dipartimento Area Materno Infantile, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Letizia Li Piani
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | | | - Noemi Salmeri
- Gynecology and Obstetrics Unit, IRCCS San Raffaele Scientific Institute and Vita-Salute San Raffaele University, Milan, Italy
| | - Michele Orsi
- Dipartimento Area Materno Infantile, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Laura Benaglia
- Dipartimento Area Materno Infantile, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Paolo Vercellini
- Academic Center for Research on Adenomyosis and Endometriosis, Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
- Dipartimento Area Materno Infantile, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Paola Vigano'
- Dipartimento Area Materno Infantile, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
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Mifsud JM, Pellegrini L, Cozzolino M. Oocyte Cryopreservation in Women with Ovarian Endometriosis. J Clin Med 2023; 12:6767. [PMID: 37959232 PMCID: PMC10649633 DOI: 10.3390/jcm12216767] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 10/14/2023] [Accepted: 10/23/2023] [Indexed: 11/15/2023] Open
Abstract
Ovarian endometriosis is a gynecological condition that is closely associated with infertility-from its pathogenesis to treatment modalities, this condition presents a challenge both for patients and clinicians alike when seeking conception, due to low AMH levels, peritoneal inflammation, and the inadvertent removal of healthy ovarian parenchyma at surgery. In fact, around half of endometriosis patients seeking fertility require tertiary-level assisted reproduction techniques to achieve a live birth. Oocyte cryopreservation, a procedure initially designed for oncology patients, has emerged over recent years as a very promising treatment strategy for patients who have been diagnosed with ovarian endometriosis in order to preserve their fertility and obtain a live birth at a later stage in their lives. Counseling patients about oocyte preservation techniques at an early stage in the diagnosis, ideally before the age of 35 and especially prior to any surgical treatment, provides an excellent opportunity to discuss future fertility and the benefits associated with oocyte cryopreservation.
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Affiliation(s)
- Judith-Marie Mifsud
- IVIRMA Global Research Alliance, IVIRMA Roma, 00169 Rome, Italy; (J.-M.M.); (L.P.)
| | - Livia Pellegrini
- IVIRMA Global Research Alliance, IVIRMA Roma, 00169 Rome, Italy; (J.-M.M.); (L.P.)
| | - Mauro Cozzolino
- IVIRMA Global Research Alliance, IVIRMA Roma, 00169 Rome, Italy; (J.-M.M.); (L.P.)
- IVIRMA Global Research Alliance, IVI Foundation, Instituto de Investigación Sanitaria La Fe (IIS La Fe), 46026 Valencia, Spain
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7
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Kobayashi H, Yoshimoto C, Matsubara S, Shigetomi H, Imanaka S. Current Understanding of and Future Directions for Endometriosis-Related Infertility Research with a Focus on Ferroptosis. Diagnostics (Basel) 2023; 13:diagnostics13111926. [PMID: 37296777 DOI: 10.3390/diagnostics13111926] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 04/25/2023] [Accepted: 05/30/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND To date, the development of therapy for endometriosis and disease-related infertility remains a major challenge. Iron overload caused by periodic bleeding is a hallmark of endometriosis. Ferroptosis is an iron- and lipid-reactive oxygen species-dependent type of programmed cell death that is distinct from apoptosis, necrosis, and autophagy. This review summarizes the current understanding of and future directions for the research and treatment of endometriosis and disease-related infertility, with the main focus on the molecular basis of ferroptosis in endometriotic and granulosa cells. METHODS Papers published between 2000 and 2022 in the PubMed and Google Scholar databases were included in this review. RESULTS Emerging evidence suggests that ferroptosis is closely linked to the pathophysiology of endometriosis. Endometriotic cells are characterized by ferroptosis resistance, whereas granulosa cells remain highly susceptible to ferroptosis, suggesting that the regulation of ferroptosis is utilized as an interventional target for research into the treatment of endometriosis and disease-related infertility. New therapeutic strategies are urgently needed to efficiently kill endometriotic cells while protecting granulosa cells. CONCLUSIONS An analysis of the ferroptosis pathway in in vitro, in vivo, and animal research enhances our understanding of the pathogenesis of this disease. Here, we discuss the role of ferroptosis modulators as a research approach and potential novel treatment for endometriosis and disease-related infertility.
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Affiliation(s)
- Hiroshi Kobayashi
- Department of Gynecology and Reproductive Medicine, Ms.Clinic MayOne, 871-1 Shijo-cho, Kashihara 634-0813, Japan
- Department of Obstetrics and Gynecology, Nara Medical University, 840 Shijo-cho, Kashihara 634-8522, Japan
| | - Chiharu Yoshimoto
- Department of Obstetrics and Gynecology, Nara Medical University, 840 Shijo-cho, Kashihara 634-8522, Japan
- Department of Obstetrics and Gynecology, Nara Prefecture General Medical Center, 2-897-5 Shichijyonishi-machi, Nara 630-8581, Japan
| | - Sho Matsubara
- Department of Obstetrics and Gynecology, Nara Medical University, 840 Shijo-cho, Kashihara 634-8522, Japan
- Department of Medicine, Kei Oushin Clinic, 5-2-6 Naruo-cho, Nishinomiya 663-8184, Japan
| | - Hiroshi Shigetomi
- Department of Obstetrics and Gynecology, Nara Medical University, 840 Shijo-cho, Kashihara 634-8522, Japan
- Department of Gynecology and Reproductive Medicine, Aska Ladies Clinic, 3-3-17 Kitatomigaoka-cho, Nara 634-0001, Japan
| | - Shogo Imanaka
- Department of Gynecology and Reproductive Medicine, Ms.Clinic MayOne, 871-1 Shijo-cho, Kashihara 634-0813, Japan
- Department of Obstetrics and Gynecology, Nara Medical University, 840 Shijo-cho, Kashihara 634-8522, Japan
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8
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Bonavina G, Taylor HS. Endometriosis-associated infertility: From pathophysiology to tailored treatment. Front Endocrinol (Lausanne) 2022; 13:1020827. [PMID: 36387918 PMCID: PMC9643365 DOI: 10.3389/fendo.2022.1020827] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 10/06/2022] [Indexed: 11/13/2022] Open
Abstract
Despite the clinically recognized association between endometriosis and infertility, the mechanisms implicated in endometriosis-associated infertility are not fully understood. Endometriosis is a multifactorial and systemic disease that has pleiotropic direct and indirect effects on reproduction. A complex interaction between endometriosis subtype, pain, inflammation, altered pelvic anatomy, adhesions, disrupted ovarian reserve/function, and compromised endometrial receptivity as well as systemic effects of the disease define endometriosis-associated infertility. The population of infertile women with endometriosis is heterogeneous, and diverse patients' phenotypes can be observed in the clinical setting, thus making difficult to establish a precise diagnosis and a single mechanism of endometriosis related infertility. Moreover, clinical management of infertility associated with endometriosis can be challenging due to this heterogeneity. Innovative non-invasive diagnostic tools are on the horizon that may allow us to target the specific dysfunctional alteration in the reproduction process. Currently the treatment should be individualized according to the clinical situation and to the suspected level of impairment. Here we review the etiology of endometriosis related infertility as well as current treatment options, including the roles of surgery and assisted reproductive technologies.
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Affiliation(s)
- Giulia Bonavina
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT, United States
| | - Hugh S Taylor
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT, United States
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Bila J, Dotlic J, Radjenovic SS, Vidakovic S, Tulic L, Micic J, Stojnic J, Babovic I, Dmitrovic A, Chiantera V, Laganà AS, Terzic M. Predictive Value of Basal Serum Progesterone for Successful IVF in Endometriosis Patients: The Need for a Personalized Approach. J Pers Med 2022; 12:jpm12101639. [PMID: 36294778 PMCID: PMC9605137 DOI: 10.3390/jpm12101639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 09/02/2022] [Accepted: 09/27/2022] [Indexed: 11/07/2022] Open
Abstract
The data regarding the role of progesterone (P4) in reproductive events of endometriosis patients are limited. This prospective study aimed to examine the predictive value of basal P4 serum levels for successful in vitro fertilization (IVF) in patients with primary infertility and endometriosis. The study included 73 patients divided according to endometriosis treatment (surgery vs. control—no treatment). The general data, basal hormonal status, and pregnancy rates were determined for every patient. Clinical pregnancy was achieved in 40.3% of patients, and more often in patients treated for endometriosis before IVF. The regression analysis showed that higher basal P4 serum levels were associated with achieving pregnancy through IVF. When regression was adjusted for the patient and IVF characteristics, higher basal P4 serum levels were associated with pregnancy achievement in both groups of women, along with the basal serum levels of FSH, LH, and AMH; EFI score; and stimulation protocol. The ROC analysis showed that the basal P4 serum level for successful IVF should be ≥0.7ng/mL. The basal P4 serum level cut-off for IVF success in endometriosis patients was determined for the first time. Constructed models for IVF success prediction emphasize the importance of determining the basal P4 serum levels for the personalized treatment of endometriosis-related infertility.
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Affiliation(s)
- Jovan Bila
- Clinic of Obstetrics and Gynecology, University Clinical Centre of Serbia, Dr Koste Todorovica 26, 11000 Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Dr Subotica Starijeg 8, 11000 Belgrade, Serbia
- Correspondence: ; Tel.: +381-11-361-5592; Fax: +381-11-361-5603
| | - Jelena Dotlic
- Clinic of Obstetrics and Gynecology, University Clinical Centre of Serbia, Dr Koste Todorovica 26, 11000 Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Dr Subotica Starijeg 8, 11000 Belgrade, Serbia
| | - Svetlana Spremovic Radjenovic
- Clinic of Obstetrics and Gynecology, University Clinical Centre of Serbia, Dr Koste Todorovica 26, 11000 Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Dr Subotica Starijeg 8, 11000 Belgrade, Serbia
| | - Snezana Vidakovic
- Clinic of Obstetrics and Gynecology, University Clinical Centre of Serbia, Dr Koste Todorovica 26, 11000 Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Dr Subotica Starijeg 8, 11000 Belgrade, Serbia
| | - Lidija Tulic
- Clinic of Obstetrics and Gynecology, University Clinical Centre of Serbia, Dr Koste Todorovica 26, 11000 Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Dr Subotica Starijeg 8, 11000 Belgrade, Serbia
| | - Jelena Micic
- Clinic of Obstetrics and Gynecology, University Clinical Centre of Serbia, Dr Koste Todorovica 26, 11000 Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Dr Subotica Starijeg 8, 11000 Belgrade, Serbia
| | - Jelena Stojnic
- Clinic of Obstetrics and Gynecology, University Clinical Centre of Serbia, Dr Koste Todorovica 26, 11000 Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Dr Subotica Starijeg 8, 11000 Belgrade, Serbia
| | - Ivana Babovic
- Clinic of Obstetrics and Gynecology, University Clinical Centre of Serbia, Dr Koste Todorovica 26, 11000 Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Dr Subotica Starijeg 8, 11000 Belgrade, Serbia
| | - Aleksandar Dmitrovic
- Clinic of Obstetrics and Gynecology, University Clinical Centre of Serbia, Dr Koste Todorovica 26, 11000 Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Dr Subotica Starijeg 8, 11000 Belgrade, Serbia
| | - Vito Chiantera
- Unit of Gynecologic Oncology, ARNAS “Civico-Di Cristina-Benfratelli”, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90127 Palermo, Italy
| | - Antonio Simone Laganà
- Unit of Gynecologic Oncology, ARNAS “Civico-Di Cristina-Benfratelli”, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90127 Palermo, Italy
| | - Milan Terzic
- Department of Medicine, School of Medicine, Nazarbayev University, Zhanybek-Kerey Khans Street, 5/1, Nur-Sultan 010000, Kazakhstan or
- Clinical Academic Department of Women’s Health, National Research Center for Maternal and Child Health, Corporate Fund “University Medical Center”, Turan Ave. 32, Nur-Sultan 010000, Kazakhstan
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, 300 Halket Street, Pittsburgh, PA 15213, USA
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Ottolina J, Vignali M, Papaleo E, Viganò P, Somigliana E, Ferrari S, Liprandi V, Belloni G, Reschini M, Candiani M, Vercellini P, Benaglia L. Surgery versus IVF for the treatment of infertility associated to ovarian and deep endometriosis (SVIDOE: Surgery Versus IVF for Deep and Ovarian Endometriosis). Clinical protocol for a multicenter randomized controlled trial. PLoS One 2022; 17:e0271173. [PMID: 35921357 PMCID: PMC9348732 DOI: 10.1371/journal.pone.0271173] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 06/23/2022] [Indexed: 11/18/2022] Open
Abstract
The management of endometriosis-related infertility is still a challenging issue. Women can be managed with either surgery or in vitro fertilization (IVF). The decision is tailored to the patients considering pros and cons of both approaches. Surgery might increase the chances of natural conception and relieve symptoms. IVF may be more effective, but costs are higher and unoperated women face some peculiar additional risks during the procedure and pregnancy. The unavailability of randomized trials comparing the two strategies hampers the possibility to provide precise estimates. This Randomized Controlled Trial (RCT) aims at filling this gap. This is a multicenter, non-blinded, randomized controlled trial with parallel groups and allocation 1:1. Three Italian Academic Infertility Units will be involved. Main inclusion criteria are infertility for more than one year, age less than 40 years and a sonographic diagnosis of endometriosis (ovarian endometriomas or deep peritoneal lesions). Previous IVF and previous surgery for endometriosis are exclusion criteria. Women will be randomized to either surgery and then natural pregnancy seeking or a standard program of three IVF cycles. The primary aim is the comparison of live birth rate between the two groups (IVF versus surgery) within one year of randomization. The secondary aim is the evaluation of cost-effective profile of the two interventions. The present study can influence the clinical practice of infertility treatment in women with endometriosis. From a public health perspective, information on the more cost-effective clinical management strategy would consent a wiser allocation of resources. Trial registration:NCT04743167, registered on 8 February 2021.
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Affiliation(s)
- Jessica Ottolina
- Department of Gynecology and Obstetrics, San Raffaele Scientific Institute, Milan, Italy
- * E-mail:
| | - Michele Vignali
- Department of Biomedical Sciences for Health, Macedonio Melloni Hospital, University of Milan, Milan, Italy
| | - Enrico Papaleo
- Department of Gynecology and Obstetrics, San Raffaele Scientific Institute, Milan, Italy
| | - Paola Viganò
- Department of Gynecology and Obstetrics, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Edgardo Somigliana
- Department of Gynecology and Obstetrics, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Stefano Ferrari
- Department of Gynecology and Obstetrics, San Raffaele Scientific Institute, Milan, Italy
| | - Valeria Liprandi
- Department of Biomedical Sciences for Health, Macedonio Melloni Hospital, University of Milan, Milan, Italy
| | - Gaia Belloni
- Department of Biomedical Sciences for Health, Macedonio Melloni Hospital, University of Milan, Milan, Italy
| | - Marco Reschini
- Department of Gynecology and Obstetrics, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Massimo Candiani
- Department of Gynecology and Obstetrics, San Raffaele Scientific Institute, Milan, Italy
| | - Paolo Vercellini
- Department of Gynecology and Obstetrics, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Laura Benaglia
- Department of Gynecology and Obstetrics, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
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Bourdon M, Dahan Y, Maignien C, Patrat C, Bordonne C, Marcellin L, Chapron C, Santulli P. Influence of endometrioma size on assisted reproductive technology outcomes. Reprod Biomed Online 2022; 45:1237-1246. [DOI: 10.1016/j.rbmo.2022.08.097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 08/02/2022] [Accepted: 08/05/2022] [Indexed: 11/24/2022]
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12
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Endometriosis and Infertility: A Long-Life Approach to Preserve Reproductive Integrity. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19106162. [PMID: 35627698 PMCID: PMC9141878 DOI: 10.3390/ijerph19106162] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 05/01/2022] [Accepted: 05/06/2022] [Indexed: 02/04/2023]
Abstract
Laparoscopic surgery was originally considered the gold standard in the treatment of endometriosis-related infertility. Assisted reproductive technology (ART) was indicated as second-line treatment or in the case of male factor. The combined approach of surgery followed by ART proved to offer higher chances of pregnancy in infertile women with endometriosis. However, it was highlighted how pelvic surgery for endometriosis, especially in cases of ovarian endometriomas, could cause iatrogenic damage due to ovarian reserve loss, adhesion formation (scarring), and ischemic damage. Furthermore, in the last few years, the trend to delay the first childbirth, recent technological advances in ultrasound diagnosis, and technological progress in clinical and laboratory aspects of ART have certainly influenced the approach to infertility and endometriosis with, ART assuming a more relevant role. Management of endometriosis should take into account that the disease is chronic and involves the reproductive system. Consequently, treatment and counselling should aim to preserve the chances of pregnancy for the patient, even if it is not associated with infertility. This review will analyse the evolution of the management of infertility associated with endometriosis and propose an algorithm for treatment decision-making based on the most recent acquisitions.
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Nie J, Zhao C, Laganà AS, Liu X, Guo SW. Identification of lesional attributes of dysmenorrhea severity and the serum antimüllerian hormone levels in women with ovarian endometriomas. Fertil Steril 2022; 118:191-202. [DOI: 10.1016/j.fertnstert.2022.04.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 04/08/2022] [Accepted: 04/12/2022] [Indexed: 01/06/2023]
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14
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Behbehani S, Suárez-Salvador E, Yi J, Buras M, Kosiorek H, Magrina J. Pregnancy Rates After Surgical Resection of Deep Infiltrating Endometriosis in Patients with Infertility: A Systematic Review and Meta-Analysis. J Gynecol Surg 2022. [DOI: 10.1089/gyn.2021.0001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Sadikah Behbehani
- Department of Gynecological Surgery, Mayo Clinic Hospital, Phoenix, Arizona, USA
- Department of Obstetrics and Gynecology, University of California, Riverside, California, USA
| | - Elena Suárez-Salvador
- Department of Gynecological Surgery, Mayo Clinic Hospital, Phoenix, Arizona, USA
- Hospital Valle de Hebron of the Universidad Autonoma Barcelona, Barcelona, Spain
| | - Johnny Yi
- Department of Gynecological Surgery, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Matthew Buras
- Department of Health Sciences Research, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Heidi Kosiorek
- Department of Health Sciences Research, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Javier Magrina
- Department of Gynecological Surgery, Mayo Clinic Hospital, Phoenix, Arizona, USA
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Demirdag E, Guler I, Selvi I, Cevher Akdulum MF, Canan S, Erdem A, Erdem M. Analysis of 2438 cycles for the impact of endometrioma and its surgery on the IVF outcomes. Eur J Obstet Gynecol Reprod Biol 2021; 263:233-238. [PMID: 34242932 DOI: 10.1016/j.ejogrb.2021.06.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 05/24/2021] [Accepted: 06/22/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Management of ovarian endometrioma before IVF treatment is still challenging. We aimed to assess the effect of the pre-cycle surgical removal of endometriomas on IVF outcomes in a large number of cycles in patients undergoing IVF/ICSI treatment. Besides this, we also proposed to compare the cycle outcomes within both normo and poor responder patients to evaluate the impact of endometrioma and its surgery. STUDY DESIGN A retrospective cohort study was conducted in a private IVF clinic between September 2014 and December 2018. A total of 2438 IVF/ICSI cycles of 1936 patients were reviewed. Patients who had previous endometrioma surgery (Group 1), patients with non-operated endometrioma (Group 2), and patients without endometriosis, including tubal factor infertility confirmed by laparoscopy and unexplained infertility without endometrioma (Group 3) were analyzed in this study. RESULTS Total dose of gonadotropins was significantly higher in group 1 than others (p < 0.05). However, antral follicle counts, estradiol levels on the day of hCG trigger, the number of retrieved and metaphase II oocytes were significantly lower in group 1 than in other groups (p < 0.05). Poor response to gonadotropins was more frequent in group 1 as compared to other groups (47.9%, 34.3%, 35.5%, respectively) (p < 0.05). Cycle cancellation rates were significantly higher in group 1 than in other groups (6.7%, 1.4%, and 2.8%, respectively) (p < 0.05). Clinical pregnancy (CPR) and live birth rates (LBR) per cycle and embryo transfer were not different among groups. However, CPR per cycle and embryo transfer were significantly higher in the operated endometrioma group within unexpected poor responders (p = 0.023, p = 0.010, respectively). CPR and LBR per cycle and per embryo transfer were similar within normo-responder patients. Multiple logistic regression analysis revealed that female age and poor response to gonadotropins were the significant variables in predicting live birth (OR: 0.946, CI: 0.926-0.966, p < 0.001 and OR: 3.294, CI: 2.336-4.645, p < 0.001, respectively). CONCLUSION Pre-cyle removal of endometrioma may have an adverse impact on ovarian reserve, and pregnancy outcomes seem to be similar with or without surgery in patients undergoing IVF treatment. However, endometrioma surgery may be considered in the subsequent IVF cycles of patients with lower than expected ovarian response.
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Affiliation(s)
- Erhan Demirdag
- Department of Obstetrics and Gynecology, Gazi University, Faculty of Medicine, Emniyet Mahallesi, Gazeteci Yazar Muammer Yaşar Bostancı Sokak, 06560 Yenimahalle, Ankara, Turkey.
| | - Ismail Guler
- Department of Obstetrics and Gynecology, Gazi University, Faculty of Medicine, Emniyet Mahallesi, Gazeteci Yazar Muammer Yaşar Bostancı Sokak, 06560 Yenimahalle, Ankara, Turkey
| | - Ilknur Selvi
- IVF Clinic, Novaart IVF and Women Health Center, Çukurambar Mahallesi, 1425. Cadde, No:26, 06510 Çankaya, Ankara, Turkey
| | - Munire Funda Cevher Akdulum
- Department of Obstetrics and Gynecology, Gazi University, Faculty of Medicine, Emniyet Mahallesi, Gazeteci Yazar Muammer Yaşar Bostancı Sokak, 06560 Yenimahalle, Ankara, Turkey
| | - Sultan Canan
- Department of Obstetrics and Gynecology, Gazi University, Faculty of Medicine, Emniyet Mahallesi, Gazeteci Yazar Muammer Yaşar Bostancı Sokak, 06560 Yenimahalle, Ankara, Turkey
| | - Ahmet Erdem
- Department of Obstetrics and Gynecology, Gazi University, Faculty of Medicine, Emniyet Mahallesi, Gazeteci Yazar Muammer Yaşar Bostancı Sokak, 06560 Yenimahalle, Ankara, Turkey
| | - Mehmet Erdem
- Department of Obstetrics and Gynecology, Gazi University, Faculty of Medicine, Emniyet Mahallesi, Gazeteci Yazar Muammer Yaşar Bostancı Sokak, 06560 Yenimahalle, Ankara, Turkey
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Necula D, Gmuer A, Mathis J. The impact of endometriosis on the outcome of assisted reproductive techniques: role of fertility preservation. Horm Mol Biol Clin Investig 2021; 43:113-121. [PMID: 33691349 DOI: 10.1515/hmbci-2020-0082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 02/18/2021] [Indexed: 11/15/2022]
Abstract
Endometriosis is one of the most common diseases associated with infertility. It requires different therapeutic approaches, depending on the type, whether superficial, ovarian or deep endometriotic nodules, clinical presentation, age or origin of infertility. Patients with endometriosis should be considered a group of high-risk for infertility and any intervention should be planned taking this consideration into account. For many years, surgery was the only tool in improving fertility outcomes. Nowadays, it remains the gold standard for the treatment of endometriosis, but it should be carefully used because of its harmful potential, leading to premature ovarian insufficiency and further infertility. With the development of modern assisted reproductive techniques (ART), which can offer better results in terms of fertility, the role of surgery progressively decreased. Nowadays, therapeutic approach is complex and multidisciplinary teams should be guiding individual treatment for each woman. Options include medical treatment, surgery, in vitro fertilization (IVF) or oocytes/embryo/ovarian tissue cryopreservation. There is a constant effort in developing diagnostic scores, in order to predict risk of infertility and create standard of practice, offering a long-term approach in terms of fertility preservation and quality of life.
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Affiliation(s)
- Daniel Necula
- Gynecology and Obstetrics Unit, Biel/Bienne Hospital, Biel, Switzerland
| | - Andrea Gmuer
- Gynecology and Obstetrics Unit, Biel/Bienne Hospital, Biel, Switzerland
| | - Jérôme Mathis
- Gynecology and Obstetrics Unit, Biel/Bienne Hospital, Biel, Switzerland
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17
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Wu Y, Yang R, Lan J, Lin H, Jiao X, Zhang Q. Ovarian Endometrioma Negatively Impacts Oocyte Quality and Quantity But Not Pregnancy Outcomes in Women Undergoing IVF/ICSI Treatment: A Retrospective Cohort Study. Front Endocrinol (Lausanne) 2021; 12:739228. [PMID: 34880831 PMCID: PMC8645929 DOI: 10.3389/fendo.2021.739228] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 10/30/2021] [Indexed: 11/26/2022] Open
Abstract
PURPOSE To determine the impact of ovarian endometrioma per se on in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) outcomes. METHODS This retrospective study was conducted using two groups. The endometrioma group consisted of 862 women with infertility who had ovarian endometriomas and underwent their first ovarian stimulation for IVF/ICSI treatment between January 2011 to December 2019 at a public university hospital. A non-endometrioma comparison group, comprising 862 women with other infertility factors, was matched according to maternal age, body mass index (BMI), and infertility duration. Ovarian reserve and response and IVF/ICSI and pregnancy outcomes between the two groups were analyzed. Multivariate logistic regression (MLR) analysis was conducted on the basis of clinical covariates assessed for their association with live birth. RESULTS The results showed that significantly lower antral follicle count (AFC), anti-Müllerian hormone (AMH), ovarian sensitivity index (OSI), oocyte maturation and fertilization rates, blastocyst rate, number of oocytes retrieved, and available embryos were found in women with endometrioma compared with the control, respectively (P < 0.05). The cumulative live birth rate per patient in women with endometrioma was lower than that of women without endometrioma (39.32% vs. 46.87%, P = 0.002). In women with endometrioma, those who underwent surgical intervention prior to IVF/ICSI treatment had higher maturation (86.03% vs. 83.42%, P = 0.003), fertilization (78.16% vs. 74.93%, P = 0.004), and top-quality embryo rates (42.94% vs. 39.93%, P = 0.097) but had fewer oocytes retrieved (8.01 ± 5.70 vs. 9.12 ± 6.69, P = 0.013) than women without surgery. However, live birth rates were comparable between women with endometrioma and women in the control group, regardless of whether they had a prior history of ovarian surgery. MLR analysis showed no correlation between endometrioma per se and live birth after being adjusted for number of top-quality embryos transferred and stage of embryo transfer. CONCLUSIONS The data from this study supported the conclusion that ovarian endometrioma negatively impacts oocyte quality and quantity, but not overall pregnancy outcomes, in women undergoing IVF/ICSI treatment. Endometrioma lowers the cumulative live birth rate by decreasing the number of embryos. Surgical excision of endometrioma prior to IVF/ICSI can partly improve oocyte maturation and fertilization rates but not pregnancy outcomes.
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18
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Vignali M, Solima E, Barbera V, Becherini C, Belloni GM. Approaching ovarian endometrioma with medical therapy. Minerva Obstet Gynecol 2020; 73:215-225. [PMID: 33314904 DOI: 10.23736/s2724-606x.20.04751-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Endometriosis is a chronic inflammatory gynecological disorder associated with pelvic pain symptoms and infertility. Ovarian cysts (endometriomas) are the most common localization of endometriosis in the pelvis. Considering non-invasive methods, transvaginal ultrasound has high sensitivity and specificity for endometrioma diagnosis. Laparoscopic removal of endometrioma is related to a damage to the ovarian reserve and should be limited to patients with suspicious cysts or unresponsive to medical treatment. The main goal of medical therapy of symptomatic endometrioma is the control of pain symptoms, while no benefits have been demonstrated in terms of improving fertility rates of women seeking pregnancy. The aim of medical treatment is the inhibition of ovulation, stop of menstruation and achievement of a stable hypo-hormonal milieu. Estroprogestins and progestins are indicated by guidelines as first line medications for symptomatic patients. Several hormonal treatments have been proposed for the treatment of symptomatic endometriomas. In particular, dienogest, a relatively new progestin, has shown promising results. Medical treatment should be conceived as a long-term treatment. Safety, tolerability, a low percentage of side effects and an easy route of administration are essential for patient acceptance and adherence to therapy.
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Affiliation(s)
- Michele Vignali
- Department of Biomedical Sciences for Health, M. Melloni Hospital, University of Milan, Milan, Italy -
| | - Eugenio Solima
- Department of Biomedical Sciences for Health, M. Melloni Hospital, University of Milan, Milan, Italy
| | - Valeria Barbera
- Department of Biomedical Sciences for Health, M. Melloni Hospital, University of Milan, Milan, Italy
| | - Chiara Becherini
- Department of Biomedical Sciences for Health, M. Melloni Hospital, University of Milan, Milan, Italy
| | - Gaia M Belloni
- Department of Biomedical Sciences for Health, M. Melloni Hospital, University of Milan, Milan, Italy
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19
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Miller CE. The Endometrioma Treatment Paradigm when Fertility Is Desired: A Systematic Review. J Minim Invasive Gynecol 2020; 28:575-586. [PMID: 33249267 DOI: 10.1016/j.jmig.2020.11.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 10/28/2020] [Accepted: 11/12/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To establish an endometrioma treatment paradigm (decision tree) in the treatment of an ovarian endometrioma through the review of current literature. DATA SOURCES A thorough literature search, including PubMed, Google Scholar, and the Cochrane Library, was performed from April 2020 to July 2020. The review was completed by using the following keywords: METHODS OF STUDY SELECTION: Articles published in English that addressed the endometrioma in regard to the following were included: (1) diagnosis, (2) treatment of pain on the basis of size and/or surgical intervention, (3) treatment of fertility on the basis of size and/or surgical intervention, (4) surgical technique, (5) in vitro fertilization success on the basis of size and/or surgical intervention, (6) risk of rupture at the time of egg retrieval, (7) impact on the antimüllerian hormone and antral follicle count postsurgery, and (8) impact on implantation. TABULATION, INTEGRATION, AND RESULTS Fifty-six articles were included in this systematic review. While conducting this literature review, several themes were noted. In general, the literature on the ovarian endometrioma seems to be homogeneous in regard to imaging the endometrioma, excision rather than desiccation for an endometrioma ≥3-cm causing pain and/or infertility, minimal use of bipolar energy at the time of ovarian surgery, and risk of severe infection secondary to inadvertent rupture of cysts during egg retrieval. Conversely, studies on the ovarian endometrioma are much more heterogeneous in terms of surgery and assisted reproductive technology, that is, whether surgery should be performed. Certainly, an endometrioma ≥5-cm should be excised before assisted reproductive technology. Moreover, it seems that the antral follicle count and implantation may be enhanced with surgery. CONCLUSION By completing an extensive literature review, an easy-to-use algorithm for the diagnosis, evaluation, and treatment of endometriomas was developed to help clinicians in their treatment of patients with endometriosis in the short and long terms.
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Affiliation(s)
- Charles E Miller
- Department of Clinical Sciences, Rosalind Franklin University of Medicine and Science, North Chicago; Department of Minimally Invasive Gynecologic Surgery, Advocate Lutheran General Hospital, Park Ridge, Illinois..
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20
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Barra F, Laganà AS, Scala C, Garzon S, Ghezzi F, Ferrero S. Pretreatment with dienogest in women with endometriosis undergoing IVF after a previous failed cycle. Reprod Biomed Online 2020; 41:859-868. [DOI: 10.1016/j.rbmo.2020.07.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 07/09/2020] [Accepted: 07/16/2020] [Indexed: 01/21/2023]
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21
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Jiang D, Nie X. Effect of endometrioma and its surgical excision on fertility (Review). Exp Ther Med 2020; 20:114. [PMID: 32989392 DOI: 10.3892/etm.2020.9242] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 07/31/2020] [Indexed: 01/06/2023] Open
Abstract
Endometrioma is the cystic lesion of ovaries originating from endometrial glands and stroma; it is identified in 17-44% of patients with endometriosis. Numerous existing studies have reported the association between endometrioma and infertility. However, an absolute cause-effect association requires further confirmation. Available evidence has suggested that ovarian reserve may be impaired by spatial occupation influences, local reaction or both, affecting the reproductive health of females. Given the increased focus on the pathophysiological mechanisms of endometrioma, surgical excision has commonly been considered to avoid further ovarian damage. However, the potential adverse effect of this surgery on the ovarian reserve has recently become a focal point. Whether or not surgical excision can facilitate subsequent conception in young females planning to be pregnant is controversial. As shown in the present review on the effects of endometrioma and its removal in females requiring assisted reproductive technology, prior surgery for endometrioma may not improve assisted fertility results and may further decrease the number of oocytes retrieved in the affected females. Subsequent studies are needed to ascertain the optimal management of infertility in the setting of endometriomas.
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Affiliation(s)
- Danni Jiang
- Graduate School, Dalian Medical University, Dalian, Liaoning 116044, P.R. China
| | - Xiaocui Nie
- Department of Gynecology, Shenyang Women's and Children's Hospital, Shenyang, Liaoning 110011, P.R. China
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22
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Tian Z, Zhang Y, Zhang C, Wang Y, Zhu HL. Antral follicle count is reduced in the presence of endometriosis: a systematic review and meta-analysis. Reprod Biomed Online 2020; 42:237-247. [PMID: 33168492 DOI: 10.1016/j.rbmo.2020.09.014] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 08/16/2020] [Accepted: 09/08/2020] [Indexed: 12/29/2022]
Abstract
Studies suggest that the presence of endometriosis may lead to impaired ovarian reserve, while results evaluating the changes in antral follicle count (AFC) in endometriosis remain controversial. A systematic search returned 15 studies, of which nine compared AFC between patients with and without endometriosis, five articles reported differences in AFC between affected and unaffected ovaries in patients with unilateral ovarian endometriosis and one reported both of the above two situations. Overall results showed a significant decrease in AFC and anti-Müllerian hormone (AMH) and increase in serum FSH concentrations in patients with endometriosis when compared with controls. Additionally, the AFC for the ovary with the endometrioma was also significantly lower than that of the contralateral ovary in patients with unilateral ovarian endometriosis. Moreover, it appears that the AFC in patients with endometriosis where the ovaries are not affected or in early stage were not significantly different in the control group. These findings demonstrate that endometriosis is associated with reduced AFC and AMH and elevated serum concentrations of FSH, suggesting a reduction in ovarian reserve in patients with endometriosis, especially in those with ovarian endometrioma and advanced stage.
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Affiliation(s)
- Zhao Tian
- Department of Obstetrics and Gynecology, People's Hospital, Peking University, Beijing 100044, China
| | - Yang Zhang
- Department of Pediatrics, People's Hospital, Peking University, Beijing 100044, China
| | - Chen Zhang
- Department of Obstetrics and Gynecology, People's Hospital, Peking University, Beijing 100044, China
| | - Yue Wang
- Department of Obstetrics and Gynecology, People's Hospital, Peking University, Beijing 100044, China
| | - Hong-Lan Zhu
- Department of Obstetrics and Gynecology, People's Hospital, Peking University, Beijing 100044, China.
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23
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González-Foruria I, Soldevila PB, Rodríguez I, Rodríguez-Purata J, Pardos C, García S, Pascual MÁ, Barri PN, Polyzos NP. Do ovarian endometriomas affect ovarian response to ovarian stimulation for IVF/ICSI? Reprod Biomed Online 2020; 41:37-43. [PMID: 32456967 DOI: 10.1016/j.rbmo.2020.03.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 03/10/2020] [Accepted: 03/20/2020] [Indexed: 12/18/2022]
Abstract
RESEARCH QUESTION Does the presence of ovarian endometriomas affect ovarian response to ovarian stimulation after adjusting for age and ovarian reserve markers? DESIGN This retrospective cross-sectional study compared the ovarian response between patients with ovarian endometriomas and women with other infertility factors undergoing their first ovarian stimulation for IVF/intracytoplasmic sperm injection (ICSI). An age-specific nomogram model for the number of oocytes retrieved was built for both groups, and ovarian response was compared after adjusting for age, gonadotrophin dose, anti-Mullerian hormone (AMH) concentration and antral follicle count (AFC). RESULTS A total of 923 patients were included: 101 women with at least one ovarian endometrioma, and 822 patients with other infertility factors. Comparisons of the nomograms for the number of oocytes retrieved demonstrated that response was significantly lower for women with endometrioma when the results were adjusted for age the z-score for the number of oocytes retrieved (-0.49 ± 0.71 versus -0.20 ± 0.86; 95% confidence interval [CI] -0.47 to -0.12) and also after adjustment for the total dose of gonadotrophins and AMH values (z-score mean difference -0.338; 95% CI -0.54, -0.14). When the z-score was adjusted for gonadotrophin dose and AFC, the number of oocytes retrieved was comparable between the two groups (z-score mean difference -0.038; 95% CI -0.34 to 0.27). CONCLUSIONS Ovarian response after ovarian stimulation for IVF/ICSI in women with endometriomas is significantly lower than in controls after adjusting for age, gonadotrophin dose and AMH. Dose and protocol selection for ovarian stimulation in patients with endometrioma should be based on AFC rather than AMH, as the latter may be overestimated.
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Affiliation(s)
- Iñaki González-Foruria
- Dexeus Mujer, Department of Reproductive Medicine, Dexeus University Hospital, Barcelona, Spain.
| | - Pedro Barri Soldevila
- Dexeus Mujer, Department of Reproductive Medicine, Dexeus University Hospital, Barcelona, Spain
| | - Ignacio Rodríguez
- Dexeus Mujer, Department of Reproductive Medicine, Dexeus University Hospital, Barcelona, Spain
| | - Jorge Rodríguez-Purata
- Dexeus Mujer, Department of Reproductive Medicine, Dexeus University Hospital, Barcelona, Spain
| | - Clara Pardos
- Dexeus Mujer, Department of Reproductive Medicine, Dexeus University Hospital, Barcelona, Spain
| | - Sandra García
- Dexeus Mujer, Department of Reproductive Medicine, Dexeus University Hospital, Barcelona, Spain
| | - M Ángela Pascual
- Dexeus Mujer, Department of Reproductive Medicine, Dexeus University Hospital, Barcelona, Spain
| | - Pedro N Barri
- Dexeus Mujer, Department of Reproductive Medicine, Dexeus University Hospital, Barcelona, Spain
| | - Nikolaos P Polyzos
- Dexeus Mujer, Department of Reproductive Medicine, Dexeus University Hospital, Barcelona, Spain
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24
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Somigliana E, Palomino MC, Castiglioni M, Mensi L, Benaglia L, Vercellini P, Garcia-Velasco J. The impact of endometrioma size on ovarian responsiveness. Reprod Biomed Online 2020; 41:343-348. [PMID: 32475752 DOI: 10.1016/j.rbmo.2020.03.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 02/22/2020] [Accepted: 03/04/2020] [Indexed: 02/08/2023]
Abstract
RESEARCH QUESTION Available evidence shows that the presence of ovarian endometriomas does not interfere with the ovarian response to ovarian stimulation. However, the mean size of the endometriomas in these studies is generally small, and two recent investigations suggested that follicular development could be impaired when focusing on larger endometriomas. However, these studies could not identify a clear threshold above which endometriomas could become detrimental. DESIGN To identify this threshold, the study retrospectively selected women without a history of surgery for ovarian cysts who underwent IVF in the presence of unilateral endometriomas with a mean diameter between 20 and 49 mm. Selected women were divided into three categories of endometrioma size: 20-29 mm (group 1, n = 23), 30-39 mm (group 2, n = 2323), and 40-49 mm (group 3, n = 2321). Recruitment for each category was censored at about 21 women to ensure equal statistical power for each group. RESULTS The response to ovarian stimulation was equal or superior in the affected gonads in eight women (35%, 95% confidence interval [CI] 16-57%), seven women (30%, 95% CI 13-53%) and two women (10%, 95% CI 2-30%) in groups 1, 2 and 3, respectively. The median (interquartile range) number of developed follicles in the affected and intact ovaries was 6 (3-7) and 5 (4-9) in group 1 (P = 0.21), 4 (1-6) and 4 (3-7) in group 2 (P = 0.08), 5 (3-7), and 7 (4-8) in group 3 (P = 0.01), respectively. CONCLUSIONS The threshold to be used to distinguish between endometriomas that might and might not interfere with ovarian response is 4 cm in diameter.
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Affiliation(s)
- Edgardo Somigliana
- Università degli Studi di Milano, Milan, Italy; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
| | | | - Marta Castiglioni
- Università degli Studi di Milano, Milan, Italy; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Laura Mensi
- Università degli Studi di Milano, Milan, Italy; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Laura Benaglia
- Università degli Studi di Milano, Milan, Italy; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Paolo Vercellini
- Università degli Studi di Milano, Milan, Italy; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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Alio L, Angioni S, Arena S, Bartiromo L, Bergamini V, Berlanda N, Bonin C, Busacca M, Candiani M, Centini G, D’Alterio MN, Di Cello A, Exacoustos C, Fedele L, Frattaruolo MP, Incandela D, Lazzeri L, Luisi S, Maiorana A, Maneschi F, Martire F, Massarotti C, Mattei A, Muzii L, Ottolina J, Perandini A, Perelli F, Pino I, Porpora MG, Raimondo D, Remorgida V, Seracchioli R, Solima E, Somigliana E, Sorrenti G, Venturella R, Vercellini P, Viganó P, Vignali M, Zullo F, Zupi E. When more is not better: 10 'don'ts' in endometriosis management. An ETIC * position statement. Hum Reprod Open 2019; 2019:hoz009. [PMID: 31206037 PMCID: PMC6560357 DOI: 10.1093/hropen/hoz009] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 12/09/2018] [Indexed: 02/07/2023] Open
Abstract
A network of endometriosis experts from 16 Italian academic departments and teaching hospitals distributed all over the country made a critical appraisal of the available evidence and definition of 10 suggestions regarding measures to be de-implemented. Strong suggestions were made only when high-quality evidence was available. The aim was to select 10 low-value medical interventions, characterized by an unfavorable balance between potential benefits, potential harms, and costs, which should be discouraged in women with endometriosis. The following suggestions were agreed by all experts: do not suggest laparoscopy to detect and treat superficial peritoneal endometriosis in infertile women without pelvic pain symptoms; do not recommend controlled ovarian stimulation and IUI in infertile women with endometriosis at any stage; do not remove small ovarian endometriomas (diameter <4 cm) with the sole objective of improving the likelihood of conception in infertile patients scheduled for IVF; do not remove uncomplicated deep endometriotic lesions in asymptomatic women, and also in symptomatic women not seeking conception when medical treatment is effective and well tolerated; do not systematically request second-level diagnostic investigations in women with known or suspected non-subocclusive colorectal endometriosis or with symptoms responding to medical treatment; do not recommend repeated follow-up serum CA-125 (or other currently available biomarkers) measurements in women successfully using medical treatments for uncomplicated endometriosis in the absence of suspicious ovarian cysts; do not leave women undergoing surgery for ovarian endometriomas and not seeking immediate conception without post-operative long-term treatment with estrogen-progestins or progestins; do not perform laparoscopy in adolescent women (<20 years) with moderate-severe dysmenorrhea and clinically suspected early endometriosis without prior attempting to relieve symptoms with estrogen-progestins or progestins; do not prescribe drugs that cannot be used for prolonged periods of time because of safety or cost issues as first-line medical treatment, unless estrogen-progestins or progestins have been proven ineffective, not tolerated, or contraindicated; do not use robotic-assisted laparoscopic surgery for endometriosis outside research settings. Our proposal is to better address medical and surgical approaches to endometriosis de-implementing low-value interventions, with the aim to prevent unnecessary morbidity, limit psychological distress, and reduce the burden of treatment avoiding medical overuse and allowing a more equitable distribution of healthcare resources.
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Muzii L, Di Tucci C, Di Feliciantonio M, Galati G, Di Donato V, Musella A, Palaia I, Panici PB. Antimüllerian hormone is reduced in the presence of ovarian endometriomas: a systematic review and meta-analysis. Fertil Steril 2019; 110:932-940.e1. [PMID: 30316440 DOI: 10.1016/j.fertnstert.2018.06.025] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 05/22/2018] [Accepted: 06/17/2018] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To evaluate if the presence of endometriomas impacts on the ovarian reserve as evaluated with antimüllerian hormone (AMH). DESIGN Systematic review and meta-analysis. SETTING Not applicable. PATIENT(S) Patients with unoperated endometriomas versus controls without endometriomas. INTERVENTION(S) Electronic databases searched up to June 2017 to identify articles evaluating AMH levels in patients with unoperated endometriomas versus controls without endometriomas. MAIN OUTCOME MEASURE(S) The primary analysis was aimed at evaluation of AMH levels (mean and SD) in patients with and without endometriomas. Secondary analyses were aimed at evaluating AMH levels in patients with ovarian endometriomas compared to patients with either non-endometriosis benign ovarian cysts or healthy ovaries. RESULT(S) Of the 39 studies evaluated in detail, 17 were included, for a total of 968 patients with endometriomas and 1874 without endometriomas. AMH was significantly lower in patients with unoperated endometriomas compared to patients with no endometriomas (mean difference -0.84, with 95% confidence interval [CI] -1.16 to -0.52). At secondary analyses, AMH in patients with endometriomas was significantly lower both versus non-endometriosis benign ovarian cysts (mean difference -0.85, 95% CI -1.37 to -0.32, and versus women with healthy ovaries (mean difference -0.61, 95% CI -0.99 to -0.24). CONCLUSION(S) Ovarian reserve evaluated with AMH is reduced in patients with ovarian endometriomas compared both to patients with other benign ovarian cysts, and to patients with healthy ovaries.
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Affiliation(s)
- Ludovico Muzii
- Department of Obstetrics and Gynecology, "Sapienza" University of Rome, Rome, Italy.
| | - Chiara Di Tucci
- Department of Obstetrics and Gynecology, "Sapienza" University of Rome, Rome, Italy
| | | | - Giulia Galati
- Department of Obstetrics and Gynecology, "Sapienza" University of Rome, Rome, Italy
| | - Violante Di Donato
- Department of Obstetrics and Gynecology, "Sapienza" University of Rome, Rome, Italy
| | - Angela Musella
- Department of Obstetrics and Gynecology, "Sapienza" University of Rome, Rome, Italy
| | - Innocenza Palaia
- Department of Obstetrics and Gynecology, "Sapienza" University of Rome, Rome, Italy
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Endometrioma, fertility, and assisted reproductive treatments: connecting the dots. Curr Opin Obstet Gynecol 2019; 30:223-228. [PMID: 29847457 DOI: 10.1097/gco.0000000000000464] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW Surgery has traditionally been the primary treatment option for endometriosis-related infertility of any phenotype. However, advances and refinements of assisted reproductive technologies (ART) permit a more conservative approach in many scenarios. This review summarizes the latest findings in the field of reproductive medicine, which have supported a paradigm shift towards more conservative management of ovarian endometrioma. RECENT FINDINGS The presence of ovarian endometrioma per se is likely to impair ovarian reserve and alter ovarian functional anatomy. Conventional laparoscopic surgery is associated with significant risk of additional damage, and less invasive treatment approaches require further evaluation. With regard to infertile women with ovarian endometrioma who are scheduled for ART treatment, current data indicate that prior surgical intervention does not improve ART outcomes, and that controlled ovarian hyperstimulation (COH) does not affect quality of life or pain symptoms. SUMMARY Reproductive medicine physicians frequently encounter patients with ovarian endometrioma. The current evidence does not support the postponement of infertility treatment in favour of surgery, except in cases with severe symptoms or to improve follicle accessibility. Although these patients may exhibit diminished ovarian response to COH, their endometrial receptivity, aneuploidy rates, and fertility outcomes are similar to healthy controls. Surgery for ovarian endometrioma provides no benefits in ART treatments.
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Ovarian endometriosis and infertility: in vitro fertilization (IVF) or surgery as the first approach? Fertil Steril 2018; 110:1218-1226. [DOI: 10.1016/j.fertnstert.2018.10.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 10/02/2018] [Indexed: 01/01/2023]
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Somigliana E. Ovarian reserve, endometriomas, and surgery: research must go on. Fertil Steril 2018; 110:856-857. [DOI: 10.1016/j.fertnstert.2018.07.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Accepted: 07/18/2018] [Indexed: 10/28/2022]
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Chronic Niche Inflammation in Endometriosis-Associated Infertility: Current Understanding and Future Therapeutic Strategies. Int J Mol Sci 2018; 19:ijms19082385. [PMID: 30104541 PMCID: PMC6121292 DOI: 10.3390/ijms19082385] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2018] [Revised: 08/05/2018] [Accepted: 08/09/2018] [Indexed: 12/13/2022] Open
Abstract
Endometriosis is an estrogen-dependent inflammatory disease that affects up to 10% of women of reproductive age and accounts for up to 50% of female infertility cases. It has been highly associated with poorer outcomes of assisted reproductive technology (ART), including decreased oocyte retrieval, lower implantation, and pregnancy rates. A better understanding of the pathogenesis of endometriosis-associated infertility is crucial for improving infertility treatment outcomes. Current theories regarding how endometriosis reduces fertility include anatomical distortion, ovulatory dysfunction, and niche inflammation-associated peritoneal or implantation defects. This review will survey the latest evidence on the role of inflammatory niche in the peritoneal cavity, ovaries, and uterus of endometriosis patients. Nonhormone treatment strategies that target these inflammation processes are also included. Furthermore, mesenchymal stem cell-based therapies are highlighted for potential endometriosis treatment because of their immunomodulatory effects and tropism toward inflamed lesion foci. Potential applications of stem cell therapy in treatment of endometriosis-associated infertility in particular for safety and efficacy are discussed.
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Coccia ME, Rizzello F, Capezzuoli T, Evangelisti P, Cozzi C, Petraglia F. Bilateral Endometrioma Excision: Surgery-Related Damage to Ovarian Reserve. Reprod Sci 2018; 26:543-550. [DOI: 10.1177/1933719118777640] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Maria Elisabetta Coccia
- Department of Clinical and Experimental Biomedical Sciences, University of Florence, Florence, Italy
| | - Francesca Rizzello
- Assisted Reproduction Center, Careggi University Hospital, Florence, Italy
| | - Tommaso Capezzuoli
- Department of Clinical and Experimental Biomedical Sciences, University of Florence, Florence, Italy
| | - Paolo Evangelisti
- Assisted Reproduction Center, Careggi University Hospital, Florence, Italy
| | - Cinzia Cozzi
- Assisted Reproduction Center, Careggi University Hospital, Florence, Italy
| | - Felice Petraglia
- Department of Clinical and Experimental Biomedical Sciences, University of Florence, Florence, Italy
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Prefumo F, Rossi AC. Endometriosis, endometrioma, and ART results: Current understanding and recommended practices. Best Pract Res Clin Obstet Gynaecol 2018. [PMID: 29523392 DOI: 10.1016/j.bpobgyn.2018.01.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Endometriosis and infertility are linked in a complex relationship, and a number of different pathogenetic mechanisms may associate the two. Endometriosis is diagnosed in 6-8% of women undergoing ART. Women with endometriosis appear to have similar ART outcomes compared to controls in terms of live birth rates, despite a lower oocyte quality. Laparoscopy should not be routinely performed before ART with the only aim to diagnose mild or moderate endometriosis, but if the latter is found, surgical removal can be considered, as it might improve pregnancy rates. In case of more severe forms of the disease (endometrioma and deep infiltrating endometriosis), the benefits of surgery before ART are uncertain and must be balanced against risks. Management decisions should be individualized based on patient choice, age, associated symptoms, and the risk of repeat surgery.
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Affiliation(s)
- Federico Prefumo
- Department of Obstetrics and Gynaecology, University of Brescia, Brescia, Italy.
| | - A Cristina Rossi
- Clinic of Obstetrics and Gynaecology, Ospedale della Murgia, Bari, Italy
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Benaglia L, Castiglioni M, Paffoni A, Sarais V, Vercellini P, Somigliana E. Is endometrioma-associated damage to ovarian reserve progressive? Insights from IVF cycles. Eur J Obstet Gynecol Reprod Biol 2017; 217:101-105. [DOI: 10.1016/j.ejogrb.2017.08.034] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 08/21/2017] [Accepted: 08/29/2017] [Indexed: 12/27/2022]
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Coccia ME, Rizzello F. Impact of large ovarian endometriomas on the response to superovulation for in vitro fertilization: A retrospective study. Letter to the Editors. Eur J Obstet Gynecol Reprod Biol 2017; 216:263-264. [PMID: 28697929 DOI: 10.1016/j.ejogrb.2017.06.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Accepted: 06/26/2017] [Indexed: 11/19/2022]
Affiliation(s)
- Maria Elisabetta Coccia
- Department of Clinical and Experimental Biomedical Sciences, University of Florence, Florence, Italy
| | - Francesca Rizzello
- Department of Clinical and Experimental Biomedical Sciences, University of Florence, Florence, Italy.
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