A comparison of follicular response of ovaries to ovulation induction after laparoscopic ovarian cystectomy or fenestration and coagulation versus normal ovaries in patients with endometrioma

Impact of cystectomy versus ablation for endometrioma on ovarian reserve: a systematic review and meta-analysis

OBJECTIVE

To investigate whether cystectomy or ablation for endometrioma has less impact on ovarian reserve as evaluated by antral follicle count (AFC) and antimüllerian hormone (AMH) levels.

DESIGN

Systematic review and meta-analysis.

SETTING

Not applicable.

PATIENT(S)

Patients with endometriomas undergoing cystectomy or ablation.

INTERVENTION(S)

All prospective studies comparing cystectomy with ablation for endometrioma in the PubMed, EMBASE, MEDLINE and Web of Science until April 3, 2022 were retrieved and reviewed. Medical treatment used as adjuvant therapy for the surgery was excluded. Two authors assessed eligibility and risk of bias independently. The statistical data were pooled using the Review Manager software.

MAIN OUTCOME MEASURE(S)

The changes of AMH levels and AFC values in cystectomy group and ablation group, including intergroup comparisons and intragroup comparisons.

RESULT(S)

Four randomized clinical trials and 2 prospective cohort studies were eligible for the meta-analysis, with a total of 294 patients. In the intergroup comparisons, preoperative AFC values were similar with low heterogeneity, but postoperative AFC values were significantly lower in cystectomy than ablation (mean differences [MD], -1.33; 95% credible interval, -2.15 to -0.51; I² = 57%). In the intragroup comparisons of AFC values, sensitivity analyses showed a significant decrease in cystectomy (MD, -1.93; 95% credible interval, -2.40 to -1.45; I² = 0%) at 6-month follow-up, compared with no reduction in ablation. The intragroup comparisons of AMH levels supported negative effects on ovarian reserve of both cystectomy (MD, -1.26; 95% credible interval, -1.64 to -0.88; I² = 45%) and ablation (MD, -0.70; 95% credible interval, -1.07 to -0.32; I² = 0%).

CONCLUSION(S)

Both ablation and cystectomy have significantly detrimental effects on ovarian reserve as evaluated by AMH, but the ablation causes relatively less damage to ovarian reserve as appraised by AFC.

CLINICAL TRIAL REGISTRATION NUMBER

CRD42020152823;PROSPERO (york.ac.uk).

Efficacy of ablation and sclerotherapy for the management of ovarian endometrioma: A narrative review

Ovarian cystectomy is the preferred technique for the surgical management of ovarian endometrioma. However, other techniques such as ablation or sclerotherapy are also commonly used. The aim of this review is to summarize information regarding the efficacy of ablation and sclerotherapy compared to cystectomy in terms of ovarian reserve, the recurrence rate, and the pregnancy rate. Several studies comparing ablation versus cystectomy or sclerotherapy versus cystectomy in terms of the serum anti-Müllerian hormone (AMH) decrement, endometrioma recurrence, or the pregnancy rate were identified and summarized. Both ablation and cystectomy have a negative impact on ovarian reserve, but ablation results in a smaller serum AMH decrement than cystectomy. Nonetheless, the recurrence rate is higher after ablation than after cystectomy. More studies are needed to demonstrate whether the pregnancy rate is different according to whether patients undergo ablation or cystectomy. The evidence remains inconclusive regarding whether sclerotherapy is better than cystectomy in terms of ovarian reserve. The recurrence rates appear to be similar between sclerotherapy and cystectomy. There is not yet concrete evidence that sclerotherapy helps to improve the pregnancy rate via in vitro fertilization in comparison to cystectomy or no sclerotherapy.

Endometrioma and assisted reproductive technology: a review

PURPOSE

Endometriomas are a common cause of infertility necessitating assisted reproductive technology (ART). It had been previously thought that surgical removal of the endometriomas prior to ART would improve reproductive outcomes, but recent data suggests that surgical cystectomy might affect the ovarian reserve, decreasing the chances of ART success. The aim of this article is to review the literature on the effects of endometrioma surgery on ART outcomes providing an overview of the current evidence and assessing the need for further studies.

METHODS

A literature search was performed using PubMed and MEDLINE databases to identify studies that discuss endometriomas and assisted reproductive technology before versus after surgery.

RESULTS

In women with an endometrioma requiring ART, growing evidence suggests that surgery might result in damage to the ovarian reserve and further decrease chances of fertility. However, pregnancy rates, implantation rates, fertilization rates, and live birth rates seemed to be consistently similar across both groups.

CONCLUSION

The current evidence is inconclusive on whether endometriomas should be surgically removed prior to ART. Further large randomized controlled trials are needed for a definite answer, and until then, management should be individualized.

Appropriate surgical management of ovarian endometrioma: excision or drainage?

Endometriosis negatively impacts the lives of countless women around the world. When medical management fails to improve quality of life often women are left making a decision whether or not to proceed with surgery. With endometriomas, patient's surgical options include complete surgical removal or drainage via laparoscopy. Here, we review the literature to discuss both techniques, excision and drainage of endometriomas, and what the research supports for endometrioma management.

Endometrioma and reproductive issues: a well-informed patient may be the driver for change

Endometriosis affects a great proportion of women during their reproductive years and may impair female fertility in several ways. Ovarian endometrioma (OE) is the most frequent phenotype and growing evidence suggest an endometrioma-mediated damage to the ovary, ovarian reserve and oocyte quality. Traditionally, surgery has been the first-line treatment in cases of OE. Great advances in assisted reproduction and fertility preservation techniques opened new possibilities towards a more conservative approach. Herein we discuss multiple mechanisms responsible for the deterioration of the reproductive capacity in cases of OE as well as the pros and cons of different treatment options. The management of endometrioma-related subfertility remains controversial and it will depend on patient's intentions and priorities. In the "internet era" patients tend to be hyper-informed and more participative, but they are often misguided and misinformed. Thus, doctors should be able to convert these individuals into well-informed patients in order to facilitate the process of shared decision making, which is extremely relevant in the context of OEs.

Ovarian responsiveness in assisted reproductive technology after CO2 fiber laser vaporization for endometrioma treatment: preliminary data

BACKGROUND

Data about endometrioma ablation using energies with little thermal spread reported good results in terms of ovarian reserve and postoperative pregnancy rates. The aim of the present study was to assess the impact of one step CO<inf>2</inf> fiber laser vaporization for endometrioma on subsequent controlled ovarian stimulation.

METHODS

This prospective observational cohort study included a consecutive series of infertile patients who have undergone CO<inf>2</inf> fibre laser vaporization for endometrioma treatment. The primary endpoint was to assess the number of follicles per ovary growing during controlled ovarian stimulation. The secondary endpoints included the number of oocytes retrieved, the total number of embryos obtained and the cumulative clinical pregnancy rate per patient treated.

RESULTS

Twenty-six patients underwent assisted reproductive technology after surgery for endometriosis-related infertility. In unilateral operated ovaries at the end of controlled ovarian stimulation no significant differences emerged from comparison of total recruited follicles in the operated ovary and in the contralateral ovary (P=0.55). If considering only bilateral endometriomas, the number of recruited follicles at the end of controlled ovarian stimulation was similar in both operated ovaries (P=0.79). The number of cumulative clinical pregnancies was 15 (57.7%; 95% CI: 38.5-76.9%). When comparing women aged ≤35 years to those aged >35 years, controlled ovarian stimulation outcomes were significantly higher in the younger patients. Age at the time of assisted reproductive technology was the only independent predictor for follicular growth during ovarian hyperstimulation (95% CI: -1.27 to -0.116, P=0.027).

CONCLUSIONS

CO2 laser-treated endometrioma is associated with favorable reproductive assisted reproductive technology outcomes.

Long-term Recurrence of Endometriosis in Women with Subfertility Caused by Endometriosis: A Comparison of the Efficacy of Surgery and Assisted Reproductive Technology as Fertilization Treatment Approaches

Background: The evolution of fertility treatment methods such as laparoscopic surgery and assisted reproductive technology (ART) leads to an increased chance for conception in women with endometriosis. However, it is still not clear which treatment is more likely to result in endometriosis recurrence. Objectives: The current study aimed at assessing the recurrence rate of endometriosis and its main determinants following fertility treatment with surgery or ART. Methods: The current historical cohort study was conducted on 51 consecutive women with endometriosis undergoing fertilization procedures, including laparoscopic surgery (n = 42) and ART (n = 9) in Tehran from 2006 to 2016. All patients with complete hospital records were enrolled in the study. The patients in the two groups were followed up for five years for endometriosis recurrence. Results: Within the follow-up time, the rate of endometriosis recurrence in patients of the surgery and ART groups was 28.6% and 44.4%, respectively, indicating no significant difference between the groups (P = 0.436). In this regard, the 1-, 2-, and 3-year recurrence-free survival rate in the ART group was 87.5%, 50.0%, and 50.0%, and in the surgery group was 96.9%, 90.6%, and 70.5%, respectively. Using the Cox proportional hazard modeling adjusted for baseline variables, the method of fertilization (ART or surgery) could not affect the rate of long-term recurrence of endometriosis (odds ratio = 1.428, 95% confidence interval: 0.177 - 9.900, P = 0.784). Conclusions: The method of fertilization treatment-e g, surgery, and ART- may not affect the rate of endometriosis recurrence in women with subfertility caused by endometriosis.

The success of various endometrioma treatments in infertility: A systematic review and meta-analysis of prospective studies

BACKGROUND

Endometriosis is seen in 0.5%-5% of fertile and 25%-40% of infertile women. To investigate this conflict between gynecologists that ovarian endometriomas should be removed or not before making any decision about pregnancy among infertile women, the authors decided to carry out a systematic review and meta-analysis to compare the effect of various available therapeutic methods and notice the impact of these options on women's pregnancy rate.

METHODS

This review is based on PRISMA recommendations with an electronic search using the following databases: PubMed, Scopus, Google scholar, etc, from 2000 to 2018, in the English language. The studies compare pregnancy rate based on four different treatment types of OMAs between infertile women: (surgery + ART, surgery + spontaneous pregnancy, aspiration ± sclerotherapy + ART, and ART alone).

MAIN FINDINGS

At least eight prospective studies were included, in which 553 infertile women were compared in terms of treatment methods of OMAs before trying to become pregnant.

CONCLUSION

Treatments are usually based on the patient's clinical condition and must be individual, with the purpose of relieving pain, improving fertility, or both. The authors do not have not any significant difference between our four groups of study; however, the success of surgical procedure compared to other methods was higher and the success of ART alone was the least.

Recurrent endometriosis: a battle against an unknown enemy

Recurrence of endometriosis after conservative surgery is not an uncommon finding. There is no uniformity, however, on what the term 'recurrence' means. Recurrence is variously defined in the literature as the relapse of pain, clinical or instrumental detection of an endometriotic lesion, repeat rise in CA 125 levels, or evidence of recurrence found during repeat surgery. Consequently, the reported recurrence rate varies widely (0-89%) in the different series, depending on its definition and the type of study performed. As endometriosis recurrence seems to be an indeterminate enemy, we set out to examine exactly what we were fighting in our everyday battle. In this narrative review, we aimed to seek an answer to questions related to endometriosis recurrence, some of which are often asked by our patients.

Endometrioma, fertility, and assisted reproductive treatments: connecting the dots

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.

[Surgical management of endometrioma: Different alternatives in term of pain, fertility and recurrence. CNGOF-HAS Endometriosis Guidelines]

Surgical management of ovarian endometrioma is most often part of a global approach of endometriosis pathology. Isolated endometrioma are rare. Laparoscopic cystectomy is the gold standard for surgical management of endometrioma. Nevertheless, this technique impacts the ovarian function. The hemostasis of the ovarian cyst bed should be performed to conserve the ovarian stroma. Ultrasonography-guided cyst aspiration, laparoscopic drainage and simple bipolar coagulation are not recommended as first line of treatment. Based on the actual literature, we cannot state the place of laser-vaporization and plasma-energy ablation in surgical management. Ethanol sclerotherapy could be an alternative to treat recurrent endometrioma. Uncompleted surgical removal of endometriosis lesions increases the recurrence rate. Endometriosis management should take into account the research and treatment of all the pelvic lesion, especially before surgical management of endometrioma. In this context, the evaluation of ovarian reserve could be useful before surgery.

The effect of surgical management of endometrioma on the IVF/ICSI outcomes when compared with no treatment? A systematic review and meta-analysis

Objective

To assess the impact of surgical management of endometrioma on the outcome of assisted reproduction treatment (ART).

Design

A systematic review and meta-analysis.

Setting

Department of reproductive medicine at teaching university hospital, UK.

Patients

Subfertile women with endometrioma undergoing ART.

Interventions

Surgical removal of endometrioma or expectant management.

Main outcome measures

Clinical pregnancy rate, pregnancy rate, live birth rate, number of oocytes retrieved and number of embryos available and ovarian response to gonadotrophins.

Results

An extensive search of electronic databases for articles published from inception to September 2016 yielded 11 eligible studies for meta-analysis. Meta-analysis was conducted comparing surgery versus no treatment of endometrioma. There were no significant differences in pregnancy rate per cycle, clinical pregnancy rate and live birth rate between women who underwent surgery for endometrioma and those who did not.

Conclusion

Current evidence suggests that women with endometriosis-related infertility have similar cycle outcomes to other patients going through ART. It is pertinent for clinicians to assess the risks of surgical intervention on ovarian reserve prior to initiating therapy.

Surgical outcomes of laparoscopic endometriosis surgery: a 6 year experience

OBJECTIVES

The aim of the present study was to review 6 year experience on the surgical outcomes of laparoscopic endometriosis surgery.

METHODS

A cohort study was performed in Shiraz University of Medical Sciences using data from medical records of 1315 cases of patients with endometriosis undergoing laparoscopic surgery with follow-up of 6 to 72 months.

RESULTS

This study concerned a cohort of 1315 patients diagnosed with endometriosis operated between April 2010 and April 2016, 1086 (82.5%) of whom were in stage III and IV; 968 (73.61%) had endometrioma (regardless of having deep infiltrative endometriosis [DIE] or peritoneal involvement) and 347 (26.39%) of patients had either DIE or peritoneal involvement without endometrioma. Regarding the patients, unilateral endometrioma was statistically significant in the left ovary (p = .002). One hundred and thirty-three (10.7%) rectal wall, 7 (0.32%) sigmoid colon, 4 (0.18%) vagina, 125 (5.6%) ureter and 33 (1.52) bladder involvements were detected. Prior to operation, the pain VAS score was 8.23 ± 2.03, which decreased to 4.46 ± 2.47 in 93.07% of patients. Fifty-three patients (6.56%) needed reoperation. Sixty-six (33.1%) infertile women had spontaneous pregnancy and 15 (25%) became pregnant using intrauterine insemination (IUI) or assisted reproductive technique (ART) post-operatively.

CONCLUSION

Surgical treatment of endometriosis seems to be an effective treatment. DIE can be present in the absence of endometrioma. The rate of left endometrioma is higher due to the pressure effect of the sigmoid colon. Nonetheless, if an expert surgeon performs this procedure, not only the rate of post-operative complications, but also the possibility of recurrence would decrease.

Endometriosis and Infertility: A Systematic Review

Endometriosis is one of the most common gynaecological conditions affecting 6% to 12% of women in the reproductive age group. It can be found in 35% to 45% of women who are trying to conceive and are infertile. Infertility is one of the most common problems associated with endometriosis. This review will look at the evidence that endometriosis may lead to infertility and the data looking at whether surgical correction of endometriosis may improve fertility outcomes.

Pregnancy Rates after Intrauterine Insemination in Moderate to Severe Endometriosis: A Systematic Review and Meta-analysis of Observational Studies

To evaluate the efficacy and safety of intrauterine insemination (IUI) in moderate to severe endometriosis patients, a systematic review and meta-analysis was conducted since the role of this treatment strategy in these patients is a matter of debate in the literature. Systematic searches were performed in PubMed, EMBASE, Cinahl, and The Cochrane Library from inception to September 1, 2016. Studies including moderate to severe endometriosis patients reporting pregnancy rates after IUI were selected. The primary outcome was live birth after IUI treatment compared to expectant management. Secondary noncomparative outcomes were live birth and clinical pregnancy, which were presented as weighed mean pregnancy rates. Nineteen articles (2 unclear design, 11 retrospective, 6 prospective) were included for the analysis. Our primary outcome measure was only addressed by one study, showing an odds ratio of 1.77 (95% confidence interval [CI], 0.86–3.63) on live birth favoring IUI versus no treatment. The calculated weighed mean live birth and clinical pregnancy rate per patient was 20.3% (95% CI, 11.2–29.4) and 32.7% (95% CI, 21.3– 44.0), respectively. This meta-analysis of observational data showed that IUI could be a feasible treatment in moderate to severe endometriosis. Whether this treatment should be structurally offered prior to in vitro fertilization needs to be investigated in a randomized, controlled trial, including time-to-pregnancy, safety, and cost-effectiveness.

Variation in outcome reporting in endometriosis trials: a systematic review

OBJECTIVE

We reviewed the outcomes and outcome measures reported in randomized controlled trials and their relationship with methodological quality, year of publication, commercial funding, and journal impact factor.

DATA SOURCES

We searched the following sources: (1) Cochrane Central Register of Controlled Trials, (2) Embase, and (3) MEDLINE from inception to November 2014.

STUDY ELIGIBILITY

We included all randomized controlled trials evaluating a surgical intervention with or without a medical adjuvant therapy for the treatment of endometriosis symptoms.

STUDY DESIGN

Two authors independently selected trials, assessed methodological quality (Jadad score; range, 1-5), outcome reporting quality (Management of Otitis Media with Effusion in Cleft Palate criteria; range, 1-6), year of publication, impact factor in the year of publication, and commercial funding (yes or no). Univariate and bivariate analyses were performed using Spearman Rh and Mann-Whitney U tests. We used a multivariate linear regression model to assess relationship associations between outcome reporting quality and other variables.

RESULTS

There were 54 randomized controlled trials (5427 participants), which reported 164 outcomes and 113 outcome measures. The 3 most commonly reported primary outcomes were dysmenorrhea (10 outcome measures; 23 trials), dyspareunia (11 outcome measures; 21 trials), and pregnancy (3 outcome measures; 26 trials). The median quality of outcome reporting was 3 (interquartile range 4-2) and methodological quality 3 (interquartile range 5-2). Multivariate linear regression demonstrated a relationship between outcome reporting quality with methodological quality (β = 0.325; P = .038) and year of publication (β = 0.067; P = .040). No relationship was demonstrated between outcome reporting quality with journal impact factor (Rho = 0.190; P = .212) or commercial funding (P = .370).

CONCLUSION

Variation in outcome reporting within published endometriosis trials prohibits comparison, combination, and synthesis of data. This limits the usefulness of research to inform clinical practice, enhance patient care, and improve patient outcomes. In the absence of a core outcome set for endometriosis we recommend the use of the 3 most common pain (dysmenorrhea, dyspareunia, and pelvic pain) and subfertility (pregnancy, miscarriage, and live birth) outcomes. International consensus among stakeholders is needed to establish a core outcome set for endometriosis trials.

An Update on Surgical versus Expectant Management of Ovarian Endometriomas in Infertile Women

Ovarian endometriomas are a common manifestation of endometriosis that can represent a more severe stage of the disease. There is much debate over the treatment of these cysts in infertile women, particularly before use of assisted reproductive technologies. Evidence exists that supports surgical excision of ovarian endometriomas, as well as evidence that cautions against surgical intervention. Certain factors need to be examined closely before proceeding with surgery or continuing with expectant management. These include the patient's symptoms, age, ovarian reserve, size and laterality of the cyst, prior surgical treatment, and level of suspicion for malignancy. The most recent evidence appears to suggest that certain patient profiles may benefit from proceeding directly to in vitro fertilization (IVF). These include symptomatic infertile patients, especially those that are older, those that have diminished ovarian reserve, those that have bilateral endometriomas, or those that have had prior surgical treatment. Although endometriomas can be detrimental to the ovarian reserve, surgical therapy may further lower a woman's ovarian reserve. Nevertheless, the presence of an endometrioma does not appear to adversely affect IVF outcomes, and surgical excision of endometriomas does not appear to improve IVF outcomes. Regardless of treatment plan, infertile patients with endometriomas must be counseled appropriately before choosing either treatment path.

Surgical diminished ovarian reserve after endometrioma cystectomy versus idiopathic DOR: comparison of in vitro fertilization outcome

STUDY QUESTION

Does the live birth rate after IVF depend on the etiology of diminished ovarian reserve (DOR)?

SUMMARY ANSWER

IVF outcome and live birth rate are significantly impaired in women with DOR caused by a previous cystectomy for endometrioma compared with women with idiopathic DOR.

WHAT IS KNOWN ALREADY

The safety of the surgical treatment of endometriomas is being discussed in terms of damage to ovarian reserve. Several studies have reported a poor response to controlled ovarian stimulation and a significantly impaired IVF outcome in women with DOR consecutive to an endometrioma cystectomy compared with women with tubal factor infertility.

STUDY DESIGN, SIZE, DURATION

Retrospective case-control study conducted in women aged under 40 treated in our Reproductive Medicine Center between January 2010 and January 2014 for a DOR defined by anti-Müllerian hormone level <2 ng/ml. Two groups of patients were selected: group A included patients with a DOR diagnosed after cystectomy(s) for endometrioma(s), group B included patients with an idiopathic DOR. In each group, subgroups of patients 'poor ovarian responders', based on the ESHRE criteria ('Bologna criteria'), have been established.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A total of 51 patients in group A were matched to 116 patients in group B, representing respectively 125 and 243 IVF cycles. Among them, 39 patients in group A and 78 patients in group B validated strictly by the Bologna criteria, representing 99 and 189 IVF cycles, respectively. Each patient underwent a controlled ovarian hyperstimulation and IVF with fresh embryo transfer. Primary end-point was the live birth rate. Secondary end-points were the number of retrieved oocytes, fertilization rate, implantation rate, clinical pregnancy rate, spontaneous abortion rate and cycle cancelation rate.

MAIN RESULTS AND THE ROLE OF CHANCE

Significantly lower pregnancy (11.2% in group A versus 20.6% in group B, P = 0.02) and live birth (7.2 versus 16.9% respectively, P = 0.01) rates per cycle were assessed in women in group A compared with women in group B. The same results were obtained in the Bologna criteria subgroup analysis with a significantly lower pregnancy (9.1 versus 20.1%, P = 0.016) and live birth (5.1 versus 15.3%, P = 0.001) rates per cycle in women in subgroup A compared with women in subgroup B. Patients in group A required significantly higher gonadotrophins doses (2881 IU ± 1111 versus 2526 IU ± 795, P = 0.005), longer ovarian stimulation (10.6 Days ± 2.8 versus 9.9 Days ± 2.4, P = 0.019) and higher cancelation rate for poor response (12 versus 6.2%, P = 0.05). Despite a mean number of retrieved oocytes similar with the group B (5.4 ± 3.1 and 5.1 ± 3.2, NS), and a significantly higher fertilization rate (65.7 versus 47.2%, P < 0.001), women in group A showed a significantly lower implantation rate (7.2 versus 13.5%, P = 0.03). Abortion rate, ectopic pregnancy rate and multiple pregnancy rate were similar in both groups.

LIMITATIONS, REASONS FOR CAUTION

Data were collected retrospectively using the database of our Department. Sample size is relatively small but our study provides statistically significant evidence that the chances of IVF success are decreased in women with DOR after cystectomy for endometrioma. Further larger series are needed to confirm these findings.

WIDER IMPLICATIONS OF THE FINDINGS

To our knowledge, this is the first study evaluating IVF outcome in patients with DOR after cystectomy(s) for endometrioma(s) versus in patients with an idiopathic DOR. In addition to the risk of damaging ovarian reserve, we hypothesize that endometrioma surgery would not have qualitative benefits on results in IVF in patients with DOR.

STUDY FUNDING/COMPETING INTERESTS

The authors have no competing interests to declare.

Current strategies for endometriosis management

Endometriosis is a common gynecologic disorder that persists throughout the reproductive years. Although endometriosis is a surgical diagnosis, medical management with ovarian suppression remains the mainstay of long-term management with superimposed surgical intervention when needed. The goal of surgery should be excision or ablation of all visible disease to minimize risk of recurrence and need for repeat surgeries. When infertility is the presenting symptom, surgical therapy in addition to assisted reproductive technology can improve chances of conception; however, the treatment approach depends on stage of disease and other patient characteristics that affect fecundity.

Ovarian cystectomy in endometriomas: Combined approach

Endometrioma is one of the most frequent adnexal masses in the premenopausal population, but the recommended treatment is still a subject of debate. Medical therapy is inefficient and can not be recommended in the management of ovarian endometriomas. The general consensus is that ovarian endometriomas larger than 4 cm should be removed, both to reduce pain and to improve spontaneous conception rates. The removal of ovarian endometriomas can be difficult, as the capsule is often densely adherent. While the surgical treatment of choice is surgical laparoscopy, for conservative treatment, the preferred method is modified combined cystectomy. Cystectomy can be destructive for the ovary, whereas ablation may be incomplete, with a greater risk of recurrence. To the best of our knowledge, the modified combined technique seems to be more efficient in the treatment of endometriomas.

[Presumed ovarian benign tumors and fertility]

We reviewed the studies about fertility-sparing in young patient presenting a benign ovarian tumor. It appears that more than the histologic nature of the ovarian cysts, it is the surgical treatment of the cyst which may decrease fertility. Some good practice of surgical procedures must be kept in mind when one manages a benign ovarian tumor in a young patient wishing to preserve her fertility: surgery should be avoided as much as possible; kystectomy is better than oophorectomy; no radical surgery should be done without pathological certitudes; electrocoagulation must be avoided on the cyst walls. In some situations, fertility is specially endangered: bilateral ovarian cysts, recurrence or strong probability of recurrence (endometriomas), poor ovarian reserve (previous chemo- or radiotherapy, age>35, premature ovarian failure). In these situations, a pre-operative assessment of the ovarian reserve could be useful. Beside the surgical 'good procedures', gamete cryopreservation procedures could be used. Cryopreservation of mature oocytes (after ovarian hyperstimulation) or in vitro mature oocytes (after antral follicle retrieval) can be proposed. Ovarian tissue cryopreservation is another option. Oocyte (or embryos) cryopreservation can be proposed before or after the surgery. The global management of benign ovarian tumors in young patients should be decided between surgeons and specialists in reproductive biology.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Gonadotrophin-releasing hormone analogues and endometriosis: current strategies and new insights

BACKGROUND

Endometriosis is an estrogen-dependent chronic inflammatory disease affecting 5% to 10% of women in reproductive age and has been reported also in adolescents. Its main clinical presentations are chronic pelvic pain and infertility.

OBJECTIVE

To provide a comprehensive review of the recently published data concerning the mechanism of action of gonadotrophin-releasing hormone analogues (GnRHas) as well as to analyze their role in the management of endometriosis-associated pain and infertility in addition to its value in adolescent cases. Furthermore, to provide practical recommendations and new insights based on the best available information.

METHODS

Systematic search was performed of the Cochrane Library and Medical Literature Analysis and Retrieval System Online database looking for the different trials, reviews and various guidelines relating to GnRHas usage in the management of endometriosis-associated pain, infertility and in adolescent cases.

RESULTS

From a pathophysiological perspective, there is a growing scientific evidence that GnRHas exert its therapeutic effects by their classical pituitary downregulation and via a direct effect on the endometrial cells themselves. Accordingly, they represent an important medical option for the management of different aspects of this enigmatic disease.

CONCLUSION

GnRHas have a valuable strategic role in treatment of endometriosis-associated pain and infertility as well as in adolescents above 16 years.

Redefining reproductive surgery

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

Deep infiltrating endometriosis is a determinant factor of cumulative pregnancy rate after intracytoplasmic sperm injection/in vitro fertilization cycles in patients with endometriomas

OBJECTIVE

To evaluate the cumulative pregnancy rate (CPR) per patient after in vitro fertilization/intracytoplasmic sperm injection (IVF-ICSI) cycles in patients with endometriomas and to evaluate the determinant factors of CPR per patient.

DESIGN

Retrospective study from January 2007 to October 2008.

SETTING

Tertiary care university hospital.

PATIENT(S)

103 patients who had undergone IVF treatment, comprising isolated endometriomas (n = 30) and endometriomas with associated deep infiltrating endometriosis (DIE) (n = 73).

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Clinical pregnancy rate after IVF-ICSI cycle.

RESULT(S)

The total number of cycles was 162, and the median number of cycles per patient was 1 (1 to 5). Fifty-eight women (56.3%) became pregnant. The total number of endometriomas and size of the largest endometrioma and bilateral endometriomas had no impact on the CPR per patient. Using multivariable analysis, the associated DIE and antimüllerian hormone serum level (≤ 1 ng/mL) were independent factors associated with a decrease in the pregnancy rate per patient. Overall, the CPR per patient was 73.7%, and it increased until the third cycle with no benefit for additional cycles. The CPR per patient for women with isolated endometriomas and women with endometriomas and associated DIE was 82.5% and 69.4%, respectively.

CONCLUSION(S)

Associated DIE has a negative impact on assisted reproduction results in patients with endometriomas. Moreover, our data show that after three IVF-ICSI cycles the CPR per patient is not improved and that surgery should be considered.

Minimally invasive gynecologic procedures

PURPOSE OF REVIEW

To evaluate different surgical options for the treatment of endometriomas. A heated debate is currently under way between advocates of excisional surgery and the ablative approach. With papers increasingly focusing on ovarian reserve after endometrioma surgery, a review was mandatory.

RECENT FINDINGS

Excisional and ablative surgery are well known procedures. This paper describes a combined technique that allows preservation of ovarian volume and antral follicle count. The question of postoperative ovarian reserve is widely discussed and the risk of malignancy is addressed.

SUMMARY

Some previously published reviews have probably too hastily concluded that excision is a better option than ablation. They failed to analyze the ovarian reserve, which is often significantly decreased after excisional surgery.This manuscript clearly explains the crucial importance of preserving the ovarian blood supply, as well as the ovarian cortex containing all primordial follicles, during surgery.

Ovarian cystectomy versus laser vaporization in the treatment of ovarian endometriomas: a randomized clinical trial with a five-year follow-up

OBJECTIVE

To investigate the effect of two laparoscopic techniques for treatment of ovarian endometriomas on recurrence rate.

DESIGN

Prospective randomized clinical trial.

SETTING

University teaching hospital.

PATIENT(S)

Ninety women with ovarian endometriomas.

INTERVENTION(S)

Patients were randomly selected to undergo either laparoscopic cystectomy (group 1) or laser vaporization (group 2) of ovarian endometrioma.

MAIN OUTCOME MEASURE(S)

Recurrence, evaluated by ultrasound scan examination, was assessed at 12 and 60 months of follow-up.

RESULT(S)

Endometrioma recurrence rate was higher, though not significantly different, in group 2 at 60 months of follow-up. Nevertheless, at 12 months of follow-up recurrences were statistically higher in group 2.

CONCLUSION(S)

The comparison between laparoscopic laser ablation and laparoscopic cystectomy for ovarian endometriomas after long-term follow-up showed earlier recurrences and a higher recurrence rate in the laser group, although at 5 years of follow-up there were no statistically significant differences.

Efficacy of laparoscopic stripping for ovarian cysts: histological and clinical findings

AIM

The aim of our study was to evaluate the efficacy of the laparoscopic stripping technique on benign ovarian masses with respect to healthy ovarian tissue.

MATERIAL AND METHODS

Seventy-six patients between 14 and 40 years of age were enrolled after receiving a diagnosis of mono-lateral ovarian cyst and underwent laparoscopic surgery for cyst excision with the stripping technique. Histological observations of these specimens were then performed and graded on a semiquantitative scale.

RESULTS

The 76 samples included 36 endometriotic cysts, 18 dermoid cysts, 12 serous cysts, and 10 mucinous cysts. Only 26 of the endometriomas showed histological evidence of healthy ovarian tissue that, however, differed morphologically from normal ovarian tissue.

CONCLUSION

The laparoscopic stripping technique used for the excision of different ovarian cysts is a practice that safeguards the organ.

Interventions for women with endometrioma prior to assisted reproductive technology

BACKGROUND

Endometriomata are cysts of endometriosis in the ovaries. As artificial reproductive technology (ART) cycles involve oocyte pickup from the ovaries, endometriomata may interfere with the outcome of ART.

OBJECTIVES

To determine the effectiveness and safety of surgery, medical treatment, combination therapy or no treatment for improving reproductive outcomes among women with endometriomata, prior to undergoing ART cycles.

SEARCH STRATEGY

The review authors searched: Cochrane Menstrual Disorders and Subfertility Group Specialised Register of trials, CENTRAL (The Cochrane Library), EMBASE, MEDLINE, PubMed, PsycINFO, CINAHL, DARE, trial registers for ongoing and registered trials, citation indexes, conference abstracts on the ISI Web of Knowledge, Clinical Study Results, OpenSIGLE (July 2010) and handsearched Fertility and Sterility (2008 to 2010).

SELECTION CRITERIA

Randomised controlled trials of any medical, surgical or combination therapy or expectant management for endometriomata prior to ART.

DATA COLLECTION AND ANALYSIS

The trials were independently identified and assessed for risk of bias by two authors. The authors of the trials that were potentially eligible for inclusion were contacted for additional information. Outcomes were expressed as Peto odds ratios and mean differences (MD).

MAIN RESULTS

Eleven trials were identified of which seven were excluded and four with 312 participants were included.No trial reported live birth outcomes. One trial compared gonadotropin-releasing hormone (GnRH) agonist with GnRH antagonist. There was no evidence of a difference for clinical pregnancy rate (CPR), however the number of mature oocytes retrieved (NMOR) was greater with GnRH agonists (MD -1.60, 95% CI -2.44 to -0.76) and the ovarian response was increased (estradiol (E2) levels on day of human chorionic gonadotropin (hCG) injection) (MD -456.30, 95% CI -896.06 to -16.54).Surgery (aspiration or cystectomy) versus expectant management (EM) showed no evidence of a benefit for clinical pregnancy with either technique. Aspiration was associated with greater NMOR (MD 0.50, 95% CI 0.02 to 0.98) and increased ovarian response (E2 levels on day of hCG injection) (MD 685.3, 95% CI 464.50 to 906.10) compared to EM.Cystectomy was associated with a decreased ovarian response to controlled ovarian hyperstimulation (COH) (MD -510.00, 95% CI -676.62 to -343.38); no evidence of an effect on the NMOR compared to EM. Aspiration versus cystectomy showed no evidence of a difference in CPR or the NMOR.

AUTHORS' CONCLUSIONS

There was no evidence of an effect on reproductive outcomes in any of the four included trials. Further RCTs of management of endometrioma in women undergoing ART are required.

The interovarian variation in three-dimensional ultrasound markers of ovarian reserve in women undergoing baseline investigation for subfertility

OBJECTIVE

To evaluate differences in the three-dimensional (3D) ultrasound markers of ovarian reserve between the ovaries within an individual undergoing investigation for subfertility.

DESIGN

Prospective observational study.

SETTING

University-based assisted conception unit.

PATIENT(S)

Two hundred seventy women undergoing baseline early follicular phase ultrasound as an investigation for subfertility.

INTERVENTION(S)

Three-dimensional ultrasound scan in early follicular phase between days 2 and 5 of the menstrual cycle.

MAIN OUTCOME MEASURE(S)

Variations in 3D ultrasound markers of ovarian reserve between the two ovaries within same individual.

RESULT(S)

Two hundred fifteen subjects were analyzed for ovarian volume and antral follicle count, and 205 subjects for 3D power Doppler indices. Significant differences were noted (median, range) in the number of antral follicles measuring >6.0 mm and ovarian volume. Significant correlation was noted between the two ovaries in antral follicles measuring 6.0 mm or less, ovarian volume, and 3D power Doppler indices. On stratifying the antral follicles according to size using sonography-based automated volume calculation with postprocessing, maximum variation was seen in follicles measuring more than 6.0 mm as measured using limits of agreement.

CONCLUSION(S)

There are significant differences in the antral follicles measuring >6.0 mm and ovarian volume, as measured using 3D ultrasound, that require consideration when comparing the two ovaries within an individual.

Treatment of endometriosis with laparoscopic surgery today

Az endometriosis korszerű sebészi kezelésének célja a károsodott kismedencei anatómia helyreállításával az endometriosishoz társuló fájdalomtünetek csökkentése, illetve a teherbe esési esélyek javítása. Cikkünkben a különböző elhelyezkedésű kismedencei endometriosislaesiók eltávolításának műtéti lehetőségeit elemezzük. Az endometriosis sebészi kezelése döntően laparoszkópia útján valósul meg, míg a laparotomia alkalmazási köre egyre inkább beszűkült és csak speciális esetekre korlátozódik. A peritonealis endometriosis laesiói reszekció, elektrokoaguláció vagy lézervaporizáció segítségével kezelhetők, amelyek azonos mértékben csökkentik az endometriosishoz társuló fájdalomtüneteket, illetve javítják a teherbe esési esélyeket. Az endometrioma kezelésében hosszú éveken át kétféle műtéti megoldás terjedt el; a cisztatok eltávolítása az úgynevezett strippingtechnika segítségével, valamint a cisztatok megszüntetése az ablatiós műtéti technikával. Napjainkra egyértelműen bebizonyosodott, hogy a stripping előnyösebb az endometrioma ablatiójával szemben mind a fájdalomtünetek csökkenése, mind a reproduktív funkciók szempontjából. A mélyen infiltráló endometriosis kezelése jelenti a legnagyobb kihívást az endometriosis sebészetében. A mélyen infiltráló laesiók eltávolításában a lézertechnika alkalmazásának jut főszerep. A rectovaginalis septum endometriosisa esetén lézer segítségével a mélyen infiltráló laesio biztonsággal és maradéktalanul eltávolítható. Bélendometriosis esetén az érintett bélszakaszt szegmentális reszekcióval, discreszekcióval vagy az úgynevezett shavingtechnikával távolíthatjuk el. Leggyakrabban a szegmentális reszekciót alkalmazzuk, mivel egyedül ez esetben biztosítható a reszekciós szél biztos épsége. Az ureter endometriosisa esetén kisfokú érintettség mellett ureterolysis, míg obstruktív uropathia fennállásakor az ureter reszekciója javasolható. Az endometriosishoz társuló fájdalom hatékonyabb csökkentését célozza a praesacralis neurectomia és az uterusidegrost-ablatio. Ezen beavatkozások klinikai eredményessége azonban nem egyértelmű, az endometriosis kezelésében betöltött pontos szerepük tisztázása további vizsgálatokat igényel. Az endometriosis sebészetében a folyamatosan fejlődő műtéti technikák az endometriosislaesiók egyre teljesebb és hatékonyabb eltávolítását teszik lehetővé, amelynek köszönhetően egyre eredményesebben kezelhetők az endometriosishoz társuló klinikai tünetek és csökkenthető a betegség kiújulásának veszélye.