Fertility outcome of laparoscopic treatment in patients with severe endometriosis and repeated in vitro fertilization failures

Causal effects of endometriosis stages and locations on menstruation, ovulation, reproductive function, and delivery modes: a two-sample Mendelian randomization study

Background

Endometriosis is a chronic inflammatory disease of women during their reproductive years. The relationship between the severity and location of endometriosis and menstruation, ovulation, reproductive function, and mode of delivery remains unclear.

Methods

We explored the association between the various phenotypes of endometriosis and menstruation, ovulation, reproductive function, and mode of delivery, using two-sample Mendelian randomization (MR) and summary data on endometriosis stages and locations from the FinnGen consortium and women's menstruation, ovulation, reproductive function, and mode of delivery from OpenGWAS and ReproGen. Inverse-variance weighting was used for the primary MR analysis. In addition, a series of sensitivity analyses, confounding analyses, co-localization analyses, and multivariate MR analyses were performed.

Results

MR analysis showed a negative effect of moderate to severe endometriosis on age at last live birth (OR = 0.973, 95% CI: 0.960-0.986) and normal delivery (OR = 0.999, 95% CI: 0.998-1.000; values for endpoint were excluded), ovarian endometriosis on age at last live birth (OR = 0.976, 95% CI: 0.965-0.988) and normal delivery (OR = 0.999, 95% CI: 0.998-1.000; values for endpoint were excluded), and fallopian tubal endometriosis on excessive irregular menstruation (OR = 0.966, 95% CI: 0.942-0.990). Bidirectional MR analysis showed that age at menarche had a negative causal effect on intestinal endometriosis (OR = 0.417, 95% CI: 0.216-0.804). All MR analyses were confirmed by sensitivity analyses, and only the genetic effects of moderate to severe endometriosis on normal delivery and age at last live birth were supported by co-localization evidence.

Conclusion

Our findings deepen the understanding of the relationship between various types of endometriosis and menstruation, ovulation, reproductive function, and mode of delivery and clarify the important role of moderate to severe endometriosis.

Impact of Endometriosis Surgery on In Vitro Fertilization/Intracytoplasmic Sperm Injection Outcomes: a Systematic Review and Meta-analysis

Endometriosis-related infertility remains a therapeutic challenge. A burning issue in this field of research is determining whether pre-assisted reproductive technology (ART) surgery may be of some benefit in terms of reproductive outcomes. This systematic review and meta-analysis aimed at comparing ongoing pregnancy rates (OPR) and/or live birth rates (LBR) in patients who underwent endometriosis surgery before ART (IVF/ICSI) in comparison with patients who underwent first-line ART (IVF/ICSI). Searches were conducted from January 1990 to June 2021 on PubMed, Embase, and Cochrane Library using the following search terms: endometriosis, surgery, reproductive outcomes, and IVF/ICSI. The primary outcomes were OPR or LBR. A total of 19 studies were included in the meta-analysis. No statistically significant differences in LBR [0.91[0.63, 1.30]; I2 = 66%; n = 11], OPR [1.28[0.66, 2.49]; I2 = 60%; n = 3], and early pregnancy loss rate [0.88[0.62, 1.25]; I2 = 0%; n = 7] per cycle were found when comparing patients who underwent endometriosis surgery before IVF/ICSI and those who did not. After the exclusion of the studies with high risks of bias, the LBR per cycle was significantly reduced in the case of surgical treatment before IVF/ICSI [0.53[0.33, 0.86]; I2 = 30%; n = 4]. These data urge the clinician to carefully weigh the pros and cons before referring infertile patients with endometriosis to surgery before IVF, highlighting the key role of multidisciplinary referral centers.

Systematic review and meta-analysis on the effect of adjuvant gonadotropin-releasing hormone agonist (GnRH-a) on pregnancy outcomes in women with endometriosis following conservative surgery

BACKGROUND

Endometriosis frequently results in pain and infertility. While conservative surgery offers some relief, it often falls short of ensuring satisfactory pregnancy outcomes. Adjuvant GnRH-a is administered post-surgery to mitigate recurrence; however, its impact on pregnancy outcomes remains debated. This study endeavors to assess the efficacy of adjuvant GnRH-a in enhancing pregnancy outcomes post-conservative surgery in endometriosis patients.

METHODS

Databases including PubMed, Embase, the Cochrane Library, Medline (Ovid), Web of Science, and Scopus were rigorously searched up to 02 August 2023, without linguistic constraints. Identified articles were screened using strict inclusion and exclusion criteria. Evaluated outcomes encompassed pregnancy rate, live birth rate, miscarriage rate, ectopic pregnancy rate, multiple pregnancy rate, mean postoperative pregnancy interval, recurrence rate, and adverse reaction rate. The Cochrane risk of bias tool and the Jadad score evaluated the included studies' quality. Subgroup and sensitivity analysis were implemented to analyze the pooled results. A meta-analysis model expressed results as standardized mean difference (SMD) and Risk ratio (RR).

RESULTS

A total of 17 studies about 2485 patients were assimilated. Meta-analysis revealed that post-surgery, the GnRH-a cohort experienced a marginally elevated pregnancy rate (RR = 1.20, 95% CI = 1.02-1.41; P = 0.03) and a reduced mean time to conceive (RR = -1.17, 95% CI = -1.70- -0.64; P < 0.0001). Contrarily, other evaluated outcomes did not exhibit notable statistical differences.

CONCLUSIONS

Incorporating adjuvant GnRH-a following conservative surgery may be deemed beneficial for women with endometriosis, especially before Assisted Reproductive Technology (ART). Nonetheless, owing to pronounced heterogeneity, subsequent research is warranted to substantiate these potential advantages conclusively.

REGISTRATION NUMBER

CRD42023448280.

What is the impact of endometriosis and the AFS stage on cumulative pregnancy rates in IVF programs?

BACKGROUND

Endometriosis is commonly observed in infertile women and can be staged with regard to severity [e.g. according to the American Fertility Society (AFS) classification]. This condition can cause infertility through impaired oocyte quality, fertilization disorders, tubal lesions, adhesions, deep infiltration, and adenomyosis. Although women with endometriosis often turn to in vitro fertilization (IVF) programs, the literature data on IVF outcomes are sometimes contradictory (i.e. the same as in other etiologies of infertility, or worse). The objective of the present study was to assess and compare pregnancy rates in women with and without endometriosis and according to the endometriosis stage.

METHODS

We retrospectively studied clinical and ongoing pregnancy rates in IVF and the cumulative pregnancy rates after frozen/thawed embryo transfers, in women without endometriosis (group A) or with endometriosis (group B). We further compared groups in which endometriosis was staged according to the revised AFS classification: stage 1/2 (group C), stage 3/4 (group D, without endometrioma), and endometrioma alone (group E).

RESULTS

We documented 430 cycles in group A and 460 in group B (including 56 in group C, 88 in group D and 316 in group E). After fresh or frozen/thawed embryo transfers, the differences in ongoing pregnancy rates between groups A and B were not significant. However the cumulative rates per couple were significantly lower (p < 0.05) in group D.

CONCLUSIONS

We recommend IVF for women with endometriosis because the pregnancy rates are similar to those observed for women with other types of infertility. This approach is in line with the international guidelines issued by assisted reproductive technology societies. These results again raise the question of whether surgical resection of deep infiltrating endometriosis (stage 3/4) should be recommended before admission to an IVF program. Trial registration This study was approved by an institutional review board (CPP Ouest VI, Brest, France): reference: B2020CE.43.

Progress on the Endometrium

The endometrium is a dynamic tissue that facilitates mammalian internal reproduction and thus, the ability to deliver live born progeny that are more easily protected from predators. This tissue is unique in its ability to undergo cyclic regeneration and destruction in the absence of pregnancy. Ovarian steroids guide endometrial proliferation and maturation promoting its receptivity and selectivity with regards to blastocyst implantation. It is decidualization, terminal stromal maturation, that prevents the trophoblast from breeching containment of the uterus and allows for endometrial sloughing should pregnancy not occur. Endometrial pathology is highly variable and therefore a wide array of diagnostic measures are required for its interrogation. There remains no single test that can distinguish between all potential issues and it is critical that appropriate and evidence-based endometrial assessment is carried out. Emerging data on developmental markers, inflammatory mediators, and bacterial profiling offer hope that conditions including endometriosis, cancer, infertility, and implantation failure will be more easily and less invasively diagnosed. This will allow for a more timely and targeted approach to intervention. Accordingly, assessing novel measures requires an evidence-based approach prior to their mass utilization.

Surgical management of endometriosis to optimize fertility

PURPOSE OF REVIEW

Surgery is an integral element of treatment for infertility caused by endometriosis. This review summarizes the purported mechanisms of infertility in endometriosis, as well as the impacts of surgery for endometriosis on fertility, including pregnancy achieved spontaneously and with assisted reproductive technology (ART).

RECENT FINDINGS

Endometriosis' effect on fertility is multifactorial. The sequela of increased inflammation resulting from endometriosis causes alterations in ovarian, tubal, and uterine function. Removing or destroying these lesions reduces inflammation. Surgical treatment of both early-stage endometriosis and deeply infiltrating endometriosis improves spontaneous pregnancy rates and ART pregnancy rates. Conventional or robotic laparoscopy is the preferred surgical approach.

SUMMARY

Endometriosis has detrimental effects on fertility, including negative impacts on oocyte, tubal, and endometrial function. Laparoscopic surgery for endometriosis elevates both spontaneous and ART pregnancy rates above those achieved with expectant management alone. The resection or destruction of endometriosis implants reduces inflammation, which likely improves the multifactorial infertility related to endometriosis. This topic is complex and controversial; more research in the form of high-quality randomized control trials is needed.

Oocyte donation outcomes in endometriosis patients with multiple IVF failures

RESEARCH QUESTION

What are the reproductive outcomes and the prognostic factors of live birth rates in patients with endometriosis referred to oocyte donation after multiple IVF failures?

DESIGN

Observational cohort study including all women with endometriosis-related infertility and two or more failed IVF/intracytoplasmic sperm injection (ICSI) cycles referred to oocyte donation between January 2013 and June 2022. Endometriosis was diagnosed based on published imaging criteria, and was confirmed histologically in women who had a history of surgery for endometriosis. The main outcome measured was the cumulative live birth rate (CLBR). The characteristics of women who had a live birth were compared with those who did not using univariate and multivariate analysis to identify determinant factors of fertility outcome.

RESULTS

Fifty-seven patients underwent 90 oocyte donation cycles after 244 failed autologous IVF cycles. The mean ± SD age of the population was 36.8 ± 3.3 years, with a mean duration of infertility of 3.6 ± 2.2 years, and a mean number of autologous IVF/ICSI cycles of 4.4 ± 2.3 cycles per patient. Three patients (5.3%) had superficial peritoneal endometriosis, two patients (3.5%) had ovarian endometriomas, and 52 patients (91.2%) had deep infiltrating endometriosis, among which 30 patients (57.7%) had bowel lesions. Thirty patients (52.6%) had associated adenomyosis. Overall, CLBR per patient was 36/57 (63.2%). After multivariate analysis, only being nulligravida (P=0.002) remained an independent negative predictive factor of the live birth rate. Previous surgery did not impact reproductive outcomes.

CONCLUSION

This study suggests that oocyte donation appears to be a viable option to optimize the live birth rate in women with endometriosis-related infertility and recurrent IVF failures.

Review of Endometrial Receptivity Array: A Personalized Approach to Embryo Transfer and Its Clinical Applications

Successful outcomes of in vitro fertilization (IVF) rely on both the formation of a chromosomally normal embryo and its implantation in a receptive endometrium. Pre-implantation genetic testing for aneuploidy (PGT-A) has been widely accepted as a tool to assess the viability of an embryo. In 2011, the endometrial receptivity array (ERA) was first published as a tool to determine when the endometrium is most receptive to an embryo, commonly referred to as the "window of implantation" (WOI). The ERA uses molecular arrays to assess proliferation and differentiation in the endometrium and screens for inflammatory markers. Unlike PGT-A, there has been dissent within the field concerning the efficacy of the ERA. Many studies that contest the success of the ERA found that it did not improve pregnancy outcomes in patients with an already-good prognosis. Alternatively, studies that utilized the ERA in patients with repeated implantation failure (RIF) and transfer of known euploid embryos demonstrated improved outcomes. This review aims to describe the ERA as a novel technique, review the various settings that the ERA may be used in, such as natural frozen embryo transfer (nFET) and hormone replacement therapy frozen embryo transfer (HRT-FET), and provide a summary of the recent clinical data for embryo transfers in patients with RIF utilizing the ERA.

Reproductive and postsurgical outcomes of infertile women with deep infiltrating endometriosis

Background

This study aimed to summarize and analyze clinical characteristics and reproductive outcomes in postoperative deep infiltrating endometriosis (DIE).

Methods

This retrospective cohort study included 55 reproductive-aged patients who were diagnosed with DIE, wished to conceive and underwent resection surgery at the Obstetrics and Gynecology Hospital, Fudan University, from January 2009–June 2017. Those with any plausible infertility factor or abnormalities in the partner’s semen analysis were excluded. Patient characteristics, preoperative symptoms, infertility history, intraoperative findings and reproductive outcomes were followed up and recorded. Risk factors for reproductive outcomes were identified for women who became pregnant versus those who did not by univariate logistic regression. Additionally, pre- and postoperative endometriosis health profile questionnaire-30 (EHP-30), Knowles–Eccersley–Scott Symptom questionnaire (KESS), Cox Menstrual Symptom Scale (CMSS) and Female Sexual Function Index (FSFI) scores were used to evaluate the effect of DIE surgery on quality of life.

Results

The average age was 30.22 ± 3.62 years, with no difference between the pregnancy and nonpregnancy groups. The average follow-up time was 26.57 ± 14.51 months. There were 34 pregnancies (61.82%): 24 (70.59%) conceived spontaneously and 10 (29.41%) by in vitro fertilization (IVF). Twenty-eight patients (82.35%) had term deliveries. The interval between operation and pregnancy was 10.33 ± 5.6 (1–26) months. Univariate analysis showed that a lower endometriosis fertility index (EFI) score (EFI < 8) was a risk factor for infertility (OR: 3.17 (1.15–10.14), p = .044). For patients with incomplete surgery, postoperative gonadotropin-releasing hormone agonist (GnRHa) administration improved the pregnancy rate (p < 0.05). Regarding quality of life, there was significant improvement (p < 0.05) in the postoperative EHP-30, KESS and CMSS scores compared with preoperative scores in both groups. Although there was no obvious difference in FSFI scores, significant improvement in dyspareunia was observed (p < 0.05).

Conclusions

Overall, the postoperative pregnancy rate of DIE patients was 61.82%. Surgical management of DIE for patients with complaints of pain and with pregnancy intentions was feasible and effective. Long-term expectant treatment should not be advised for patients with lower EFI scores (EFI < 8), and postoperative IVF–ET may be a good choice. More cases should be enrolled for further study, and randomized studies are required.

ESHRE guideline: endometriosis

STUDY QUESTION

How should endometriosis be diagnosed and managed based on the best available evidence from published literature?

SUMMARY ANSWER

The current guideline provides 109 recommendations on diagnosis, treatments for pain and infertility, management of disease recurrence, asymptomatic or extrapelvic disease, endometriosis in adolescents and postmenopausal women, prevention and the association with cancer.

WHAT IS KNOWN ALREADY

Endometriosis is a chronic condition with a plethora of presentations in terms of not only the occurrence of lesions, but also the presence of signs and symptoms. The most important symptoms include pain and infertility.

STUDY DESIGN SIZE DURATION

The guideline was developed according to the structured methodology for development of ESHRE guidelines. After formulation of key questions by a group of experts, literature searches and assessments were performed. Papers published up to 1 December 2020 and written in English were included in the literature review.

PARTICIPANTS/MATERIALS SETTING METHODS

Based on the collected evidence, recommendations were formulated and discussed within specialist subgroups and then presented to the core guideline development group (GDG) until consensus was reached. A stakeholder review was organized after finalization of the draft. The final version was approved by the GDG and the ESHRE Executive Committee.

MAIN RESULTS AND THE ROLE OF CHANCE

This guideline aims to help clinicians to apply best care for women with endometriosis. Although studies mostly focus on women of reproductive age, the guideline also addresses endometriosis in adolescents and postmenopausal women. The guideline outlines the diagnostic process for endometriosis, which challenges laparoscopy and histology as gold standard diagnostic tests. The options for treatment of endometriosis-associated pain symptoms include analgesics, medical treatments and surgery. Non-pharmacological treatments are also discussed. For management of endometriosis-associated infertility, surgical treatment and/or medically assisted reproduction are feasible. While most of the more recent studies confirm previous ESHRE recommendations, there are five topics in which significant changes to recommendations were required and changes in clinical practice are to be expected.

LIMITATIONS REASONS FOR CAUTION

The guideline describes different management options but, based on existing evidence, no firm recommendations could be formulated on the most appropriate treatments. Also, for specific clinical issues, such as asymptomatic endometriosis or extrapelvic endometriosis, the evidence is too scarce to make evidence-based recommendations.

WIDER IMPLICATIONS OF THE FINDINGS

The guideline provides clinicians with clear advice on best practice in endometriosis care, based on the best evidence currently available. In addition, a list of research recommendations is provided to stimulate further studies in endometriosis.

STUDY FUNDING/COMPETING INTERESTS

The guideline was developed and funded by ESHRE, covering expenses associated with the guideline meetings, with the literature searches and with the dissemination of the guideline. The guideline group members did not receive payments. C.M.B. reports grants from Bayer Healthcare and the European Commission; Participation on a Data Safety Monitoring Board or Advisory Board with ObsEva (Data Safety Monitoring Group) and Myovant (Scientific Advisory Group). A.B. reports grants from FEMaLE executive board member and European Commission Horizon 2020 grant; consulting fees from Ethicon Endo Surgery, Medtronic; honoraria for lectures from Ethicon; and support for meeting attendance from Gedeon Richter; A.H. reports grants from MRC, NIHR, CSO, Roche Diagnostics, Astra Zeneca, Ferring; Consulting fees from Roche Diagnostics, Nordic Pharma, Chugai and Benevolent Al Bio Limited all paid to the institution; a pending patent on Serum endometriosis biomarker; he is also Chair of TSC for STOP-OHSS and CERM trials. O.H. reports consulting fees and speaker's fees from Gedeon Richter and Bayer AG; support for attending meetings from Gedeon-Richter, and leadership roles at the Finnish Society for Obstetrics and Gynecology and the Nordic federation of the societies of obstetrics and gynecology. L.K. reports consulting fees from Gedeon Richter, AstraZeneca, Novartis, Dr KADE/Besins, Palleos Healthcare, Roche, Mithra; honoraria for lectures from Gedeon Richter, AstraZeneca, Novartis, Dr KADE/Besins, Palleos Healthcare, Roche, Mithra; support for attending meetings from Gedeon Richter, AstraZeneca, Novartis, Dr KADE/Besins, Palleos Healthcare, Roche, Mithra; he also has a leadership role in the German Society of Gynecological Endocrinology (DGGEF). M.K. reports grants from French Foundation for Medical Research (FRM), Australian Ministry of Health, Medical Research Future Fund and French National Cancer Institute; support for meeting attendance from European Society for Gynaecological Endoscopy (ESGE), European Congress on Endometriosis (EEC) and ESHRE; She is an advisory Board Member, FEMaLe Project (Finding Endometriosis Using Machine Learning), Scientific Committee Chair for the French Foundation for Research on Endometriosis and Scientific Committee Chair for the ComPaRe-Endometriosis cohort. A.N. reports grants from Merck SA and Ferring; speaker fees from Merck SA and Ferring; support for meeting attendance from Merck SA; Participation on a Data Safety Monitoring Board or Advisory Board with Nordic Pharma and Merck SA; she also is a board member of medical advisory board, Endometriosis Society, the Netherlands (patients advocacy group) and an executive board member of the World Endometriosis Society. E.S. reports grants from National Institute for Health Research UK, Rosetrees Trust, Barts and the London Charity; Royalties from De Gruyter (book editor); consulting fees from Hologic; speakers fees from Hologic, Johnson & Johnson, Medtronic, Intuitive, Olympus and Karl Storz; Participation in the Medicines for Women's Health Expert Advisory Group with Medicines and Healthcare Products Regulatory Agency (MHRA); he is also Ambassador for the World Endometriosis Society. C.T. reports grants from Merck SA; Consulting fees from Gedeon Richter, Nordic Pharma and Merck SA; speaker fees from Merck SA, all paid to the institution; and support for meeting attendance from Ferring, Gedeon Richter and Merck SA. The other authors have no conflicts of interest to declare.

DISCLAIMER

This guideline represents the views of ESHRE, which were achieved after careful consideration of the scientific evidence available at the time of preparation. In the absence of scientific evidence on certain aspects, a consensus between the relevant ESHRE stakeholders has been obtained. Adherence to these clinical practice guidelines does not guarantee a successful or specific outcome, nor does it establish a standard of care. Clinical practice guidelines do not replace the need for application of clinical judgement to each individual presentation, nor variations based on locality and facility type. ESHRE makes no warranty, express or implied, regarding the clinical practice guidelines and specifically excludes any warranties of merchantability and fitness for a particular use or purpose (Full disclaimer available at www.eshre.eu/guidelines.).

Assisted reproductive technique outcomes in patients with endometrioma undergoing sclerotherapy vs laparoscopic cystectomy: Prospective cross-sectional study

PURPOSE

The authors compared assisted reproductive technique (ART) outcomes and the recurrence rate of endometrioma in the infertile patients undergoing sclerotherapy vs laparoscopic ovarian cystectomy.

METHODS

In this prospective cross-sectional study, a total of 101 infertile patients, with unilateral endometriomas, were divided into two groups. The first group (n = 57) underwent ART after 1 year of unsuccessful spontaneous pregnancy after laparoscopic ovarian cystectomy; the second group (n = 44) had ethanol sclerotherapy (EST) at the time of oocyte retrieval. The authors measured the number of oocytes, clinical pregnancy rate (CPR), live birth rate (LBR), complication, and recurrence of endometriomas as the primary and secondary outcomes.

RESULTS

The two groups had no significant differences in baseline characteristics and ovarian stimulation markers and also total number of oocytes. 42.1% and 34.1% of the patients (n = 24 and 15) had clinical pregnancy, and 38.6% and 29.5% (n = 22 and 13) had live birth following ART cycles in the surgery group and sclerotherapy group (P = .41, 0.34). The recurrence rates were 14.0% and 34.1% in the surgery and sclerotherapy groups (P = .017, X 2 = 5.67).

CONCLUSIONS

Ethanol sclerotherapy can be a good alternative to surgery concerning the treatment of endometrioma; however, the recurrence of the disease in this group is significantly higher.

Sonographic Signs of Adenomyosis in Women with Endometriosis Are Associated with Infertility

We compared the prevalence of ultrasound signs of adenomyosis in women with endometriosis who underwent surgery to those who were managed conservatively. This was a retrospective study of women evaluated at a tertiary endometriosis referral center who underwent 2D/3D transvaginal ultrasound. Adenomyosis diagnosis was based on the presence of at least three sonographic signs. The study group subsequently underwent laparoscopic surgery while the control group continued conservative management. Statistical analysis compared the two groups for demographics, symptoms, clinical data, and sonographic findings. The study and control groups included 244 and 158 women, respectively. The presence of any, 3+, or 5+ sonographic signs of adenomyosis was significantly more prevalent in the study group (OR = 1.93–2.7, p < 0.004, 95% CI; 1.24–4.09). After controlling for age, for all findings but linear striations, the OR for having a specific feature was higher in the study group. Women in the study group with ≥ 5 sonographic signs of adenomyosis had more than twice the risk of experiencing infertility (OR = 2.31, p = 0.012, 95% CI; 1.20–4.45). Sonographic signs of adenomyosis are more prevalent in women with symptomatic endometriosis who underwent surgery compared with those who continued conservative management. Women with 5+ findings have a significantly increased risk of infertility. Adenomyosis on ultrasound should be considered in the management decisions regarding these patients.

Changes in anti-müllerian hormone after ultrasound guided aspiration and ethanol sclerotic therapy of ovarian cyst

OBJECTIVE

To evaluate the effect of transvaginal ultrasound-guided aspiration and ethanol sclerotherapy on anti-müllerian hormone (AMH) in patients with ovarian endometriomas.

SETTING

Teaching hospital affiliated with Chang Gung University, Taipei.

MATERIAL AND METHODS

We retrospectively reviewed 124 patients, with ovarian endometriomas who underwent transvaginal aspiration and sclerotherapy of endometrioma(s) at a tertiary medical center, Chang Gung Memorial Hospital, Taipei, Taiwan. Preoperative evaluation included AMH, midcycle serum CA-125 level, and ultrasonography to exclude possibility of malignancies. Patients underwent ultrasonographic guided transvaginal aspiration and sclerotherapy with 95% ethanol irrigation of the cystic cavity. Patients were grouped into group 1, n = 44, retention of ethanol, and group 2, n = 80, no retention. Serum AMH level was checked at 6 months after aspiration. Those who were infertile prior to therapy were followed up for subsequent pregnancies (either by assisted reproductive technologies, or by natural conception).

RESULTS

The mean pre-operative AMH levels for the group without retention of ethanol and with ethanol retention were 3.80 and 3.06 respectively (p > 0.05). The change in AMH at 6-month follow up for retained group patients was significantly more than for non-retained group patients, with mean decrease of 0.72 (23.6%) and 0.10 (2.7%) respectively (p < 0.05). 54.5% (retained) and 47.2% (non-retained) of patients failed to achieve pregnancy during the observation period.

CONCLUSIONS

Transvaginal aspiration of endometriomas followed by sclerotherapy with ethanol can be effective in preserving ovarian reserve, provided that no ethanol is left in situ.

BCL-6 Overexpression as a Predictor for Endometriosis in Patients Undergoing In Vitro Fertilization

OBJECTIVE

To evaluate the positive predictive value (PPV) of endometrial BCL-6 overexpression as a noninvasive screening test endometriosis in patients undergoing in vitro fertilization (IVF).

METHODS

Retrospective cohort study at a university-affiliated private practice. Inclusion criteria were reproductive age females currently undergoing IVF with a diagnosis of unexplained infertility or unexplained recurrent pregnancy loss. Those with endometrial BCL-6 overexpression underwent laparoscopic surgery with an indication for treatment of suspected endometriosis. The primary outcome was the PPV of endometrial BCL-6 testing to surgically diagnose endometriosis. Statistical analysis was performed using SPSS v.25.0.

RESULTS

Seventy-five patients met inclusion criteria for our study. The PPV of BCL-6 testing for endometriosis was 96%. Of those patients without endometriosis, 100% had other inflammatory pelvic pathologies, which were diagnosed and treated at the time of laparoscopy.

CONCLUSIONS

Endometrial BCL-6 overexpression has a high PPV for diagnosing endometriosis and can help identify a patient population that may require surgical treatment before embryo transfer.

Reproductive capacity and recurrence of disease after surgery for moderate and severe endometriosis - a retrospective single center analysis

BACKGROUND

Endometriosis can be associated with considerable pain and sterility. After surgical excision of moderate or severe endometriosis lesions, the rate of recurrence reaches up to 67%. The objective of this retrospective study was to establish the recurrence and pregnancy rates following surgical resection of stage III/IV endometriosis lesions. Indications for operation were endometriosis symptoms, sonographic findings and/or infertility.

METHODS

A total of 456 patients who underwent stage III/IV endometriosis surgery between 2004 and 2014 were sent a questionnaire relating to their postoperative medical treatment, pregnancies, relief of symptoms and recurrence. Responses of 206 patients (45.2%) and their clinical data were analysed for this study.

RESULTS

A total of 66.5% (N = 137) of patients had stage III disease, and 33.5% (N = 69) had stage IV disease. The average age was 37 years (17-59). A total of 63.1% (N = 130) of surgeries were performed by laparoscopy, 21.8% (N = 45) were performed by laparotomy and 15% (N = 31) were performed by conversion. Complete resection of endometriosis lesions was achieved in 90.8% of patients (N = 187). After surgery, 48.5% (N = 100) of the women did not receive hormonal treatment; the main reason was the desire for children in 53%. Complete or partial relief in complaints was achieved in 93.2% (N = 192). The rate of recurrence was 21.8% (N = 45). The statistically significant factors that was associated with a higher risk to develop recurrence was an age < 35 (p < 0.005). After surgery, 65.8% (79/120) of patients who wished to have children became pregnant. There was a statistically significant association among a higher postoperative pregnancy rate and age < 35 (p < 0.003) in multivariate logistic regression analysis and laparoscopic surgical access in univariate logistic regression analysis (p < 0.01).

CONCLUSION

We assessed the high percentage of complete or partial relief of symptoms of 93.2%, the high postoperative pregnancy rate of 65.8% and the low rate of recurrence of 21.8% compared to international literature to be very encouraging for women suffering from moderate and severe endometriosis. Though laparoscopy is considered the 'gold standard'of endometriosis surgery, laparotomy still may be indicated in patients with extensive endometriosis especially to preserve reproductive function.

Rethinking mechanisms, diagnosis and management of endometriosis

Endometriosis is a chronic inflammatory disease defined as the presence of endometrial tissue outside the uterus, which causes pelvic pain and infertility. This disease should be viewed as a public health problem with a major effect on the quality of life of women as well as being a substantial economic burden. In light of the considerable progress with diagnostic imaging (for example, transvaginal ultrasound and MRI), exploratory laparoscopy should no longer be used to diagnose endometriotic lesions. Instead, diagnosis of endometriosis should be based on a structured process involving the combination of patient interviews, clinical examination and imaging. Notably, a diagnosis of endometriosis often leads to immediate surgery. Therefore, rethinking the diagnosis and management of endometriosis is warranted. Instead of assessing endometriosis on the day of the diagnosis, gynaecologists should consider the patient's 'endometriosis life'. Medical treatment is the first-line therapeutic option for patients with pelvic pain and no desire for immediate pregnancy. In women with infertility, careful consideration should be made regarding whether to provide assisted reproductive technologies prior to performing endometriosis surgery. Modern endometriosis management should be individualized with a patient-centred, multi-modal and interdisciplinary integrated approach.

Clinical approach to recurrent implantation failure: evidence-based evaluation of the endometrium

The endometrium is a dynamic, repetitively cycling tissue that mediates the implantation of the blastocyst. Evaluation of this complex tissue necessitates sophisticated methods that can assess its functional potential. Beginning in the 1950s with simple histological endometrial "dating," these methods have crossed into the molecular era with the use of arrays aimed at dating, functional tests that assess for proliferation and differentiation, and tests that screen for inflammatory markers. In addition to these specialized tests, histologic evaluation for pathologic conditions-such as growth disorders (i.e. polyps and hyperplasia), inflammatory lesions, and retained products of conception-are critical for a complete assessment of the patient with recurrent implantation failure. Whatever the means of testing, the goal is to reveal actionable findings that can assist in offering the best options to patients who have failed multiple transfers with high quality embryos.

Fertility After Ovarian Cystectomy: How Does Surgery Affect IVF/ICSI Outcomes?

Introduction For patients considering undergoing assisted reproductive techniques (ART), many concerns arise when persistent ovarian cysts are found. This large study aimed to determine how ovarian cyst removal affects success rates of IVF/ICSI therapies.

Methods 550 patients who underwent an IVF/ICSI treatment between 2002 and 2011 with a persistent ovarian cyst ≤ 5 cm before treatment were analyzed retrospectively. 328 patientsʼ preference was to undergo a laparoscopic cystectomy and 222 patients opted for a conservative management. Control subjects included 13 552 patients undergoing IVF/ICSI at the same period of time without an ovarian cyst.

Results After adjusting for age, patients with ovarian cysts without surgery needed a significant higher stimulation dose than the control group (2576.4 vs. 2207.5 IU, p < 0.001). However, on average, they had 1.13 (− 0.25 – 2.01) higher oocyte number retrieved compared to the operated patients (9.0 ± 5.5 vs. 8.2 ± 5.0) (p = 0.012). Patients after surgical cyst removal had a significant lower number of oocytes retrieved (MNOR) in comparison to the control group (8.2 ± 5.0 vs. 9.5 ± 5.4) (p = 0.00). Compared to controls, operated patients had similar clinical pregnancy rate (CPR) (34.2 vs. 33.5%) OR 1.031 (95% CI 0.817 – 1.302) (p = 0.815). Compared to controls, patients without surgery showed significant lower pregnancy rate (34.2 vs. 25,7%) OR 1.428 (95% CI 1.054 – 1.936) (p = 0.002) and lower live birth rate (LBR) (21.9 vs. 13.5%) OR 1.685 (95% CI 1.143 – 2.485) (p = 0.008).

Conclusions Ovarian cystectomy did not negatively impact the pregnancy rate or the live birth rate compared to controls.

Could surgical management improve the IVF outcomes in infertile women with endometrioma?: a review

Endometriosis is a chronic inflammatory condition that affects fertility and could be toxic to the ovary. Endometrioma per se and surgical interventions for endometrioma significantly reduce the ovarian reserve. Therefore, to prepare for surgical intervention for endometrioma, the high-risk group with decreased ovarian reserve must be considered. There is no evidence to support the use of surgical intervention before in vitro fertilization (IVF) to improve the reproductive outcomes of subsequent IVF in infertile women with advanced-stage endometriosis or endometrioma. As surgical treatment has few benefits, IVF could be recommended immediately for aiding conception in these women. However, the reproductive prognosis of IVF may be worse in the more advanced stages of endometriosis. When dysmenorrhea is severe or when cancer is suspected, surgery prior to IVF may be necessary and justified. When the size of the endometrioma is very large, surgery could be required prior to IVF to facilitate access to follicles during oocyte retrieval or to improve the ovarian response to controlled ovarian stimulation. Prolonged pituitary downregulation in women with surgically diagnosed endometriosis may be helpful to increase the clinical pregnancy rate in subsequent IVF cycles. The purpose of this paper was to review the efficiency and clinical application of the surgical intervention and IVF for infertile women with advanced-stage endometriosis or endometrioma.

Endometriosis and in vitro fertilisation

The aim of the present review was to discuss a matter of concern in the clinical field of obstetrics/gynecology, namely the potency of in vitro fertilization (IVF) in the management of endometriosis-associated infertility. Endometriosis is a medical condition affecting one tenth of women in their fertile years, and accounts for up to 50% of infertile women. Thus, such high prevalence has established the necessity for investigating the effectiveness of available techniques in eradicating the disease and constraining infertility as well as the accompanying pain symptoms of endometriosis. The underlying mechanisms connecting endometriosis with low fecundity have been extensively studied, both in terms of genetic alterations and epigenetic events that contribute to the manifestation of an infertility phenotype in women with the disease. Several studies have dealt with the impact of IVF in pregnancy rates (PRs) on patients with endometriosis, particularly regarding women who wish to conceive. Results retrieved from studies and meta-analyses depict a diverse pattern of IVF success, underlining the involvement of individual parameters in the configuration of the final outcome. The ultimate decision on undergoing IVF treatment should be based on objective criteria and clinicians' experience, customized according to patients' individual needs.

[Deeply infiltrating endometriosis and infertility: CNGOF-HAS Endometriosis Guidelines]

Deeply infiltrating endometriosis is a severe form of the disease, defined by endometriotic tissue peritoneal infiltration. The disease may involve the rectovaginal septum, uterosacral ligaments, digestive tract or bladder. Deeply infiltrating endometriosis is responsible for disabling pain and infertility. The purpose of these recommendations is to answer the following question: in case of deeply infiltrating endometriosis associated infertility, what is the best therapeutic strategy? First-line surgery and then in vitro fertilization (IVF) in case of persistent infertility or first-line IVF, without surgery? After exhaustive literature analysis, we suggest the following recommendations: studies focusing on spontaneous fertility of infertile patients with deeply infiltrating endometriosis found spontaneous pregnancy rates about 10%. Treatment should be considered in infertile women with deeply infiltrating endometriosis when they wish to conceive. First-line IVF is a good option in case of no operated deeply infiltrating endometriosis associated infertility. Pregnancy rates (spontaneous and following assisted reproductive techniques) after surgery (deep lesions without colorectal involvement) varie from 40 to 85%. After colorectal endometriosis resection, pregnancy rates vary from 47 to 59%. The studies comparing the pregnancy rates after IVF, whether or not preceded by surgery, are contradictory and do not allow, to date, to conclude on the interest of any surgical management of deep lesions before IVF. In case of alteration of ovarian reserve parameters (age, AMH, antral follicle count), there is no argument to recommend first-line surgery or IVF. The study of the literature does not identify any prognostic factors, allowing to chose between surgical management or IVF. The use of IVF in the indication "deep infiltrating endometriosis" allows satisfactory pregnancy rates without significant risk, regarding disease progression or oocyte retrieval procedure morbidity.

[Management by assisted reproductive technology in women with endometriosis: CNGOF-HAS Endometriosis Guidelines]

Should the presence of endometriosis change the management of assisted reproductive technology? There is no difference in pregnancy rate after IVF between an agonist or antagonist protocol in patients with endometriosis, so the choice between one or the other of these protocols is free. But the review of the literature has shown an improvement in the chances of pregnancy in case of prolonged ovulation suppression before stimulation for IVF with a GnRH agonist analogue or with oral contraception, especially in cases of severe endometriosis. Endometriosis, regardless of the stage and type of lesions, would have no effect on the IVF results in terms of pregnancy rate and live birth rate, but with a lower number of oocytes collected, especially in cases of severe endometriosis. In a context of superficial endometriosis without pain and of infertility, surgical treatment of superficial endometriosis is not recommended just to increase the chances of pregnancy in IVF. Surgery may have a place in case of failure of IVF to improve the results of the ART. In case of recurrence of endometriosis, surgery is not better than IVF, a medico-surgical concertation is recommended. In addition, studies on ovulation stimulation for IVF do not show any aggravation of the symptoms associated with endometriosis lesions, or an acceleration of its progression, or an increase in the rate of recurrence of the disease.

Response to: Yazdani A. Surgery or in vitro fertilisation: The simplicity of this question belies its complexity. When all you have is a hammer, everything looks like a nail

This is perhaps the most apt mantra of IVF (in vitro fertilisation) as a treatment in Australasia in this day and age. It is also important to note the truth in the identification of IVF being low skill-based, largely independent of the practitioner, but more importantly costly, and with few exceptions, only available in the private sector. Such revelations really require a rethink of the entire reproductive endocrinology and infertility (CREI) subspecialty. In fact, if there is only one solution to all fertility problems - that of the 'effective IVF procedure' - why not do away completely with the clinician and simply have nurse practitioners who oversee the identified issue of an individual or couple wanting a pregnancy? This in conjunction with the outstanding scientific advances that led to the initiation and promulgation of IVF really would reduce costs by cutting out the unnecessary clinician middle-person who is unimportant in the equation. It may be that such cost reduction, the disbandment of the irrelevant subspecialty and protocol-driven, high-quality fertility checklists would allow this to be a publically accessible service for all, not just those who can afford it.

Factors associated with a poor prognosis for the IVF-ICSI live birth rate in women with rAFS stage III and IV endometriosis

PURPOSE

To assess the factors associated with a poor prognosis for a cumulative IVF live birth rate (LBR) in women with stage III and IV endometriosis according to the revised classification of the American Fertility Society (rAFS).

METHODS

A retrospective cohort study was conducted between January 1, 2010, and December 31, 2014, in our Reproductive Medicine Center. We analyzed different factors associated with a poor prognosis for a cumulative IVF LBR in women with rAFS stage III and IV endometriosis. A total of 101 patients were included, representing 232 IVF-ICSI cycles and 212 embryo transfers. The primary endpoint was the cumulative LBR per cycle and per patient.

RESULTS

The cumulative LBR per cycle was 14.7% (n = 34) and that per patient was 31.7% (n = 32). The cumulative LBR was significantly decreased by active smoking [_adjOR = 3.4, 95% CI (1.12-10.60), p = 0.031], poor ovarian response (POR) according to the Bologna criteria [_adjOR = 11.5, 95% CI (1.37-96.83), p = 0.024], and rAFS stage IV [_adjOR = 3.2, 95% CI (1.13-8.95), p = 0.024]. The cumulative LBR per women was 59.4% without factors associated with a poor prognosis and 25.6% in the case of one factor, and it decreased to 7.7% in the case of two or three factors (p < 0.001).

CONCLUSION

Active smoking, POR according to the Bologna criteria, and rAFS stage IV endometriosis had a negative impact on the IVF-ICSI cumulative LBR for women with rAFS stage III and IV endometriosis. Because smoking dramatically decreases the LBR with endometriosis, stopping smoking before IVF-ICSI should be strongly advised.

Prognostic factors for assisted reproductive technology in women with endometriosis-related infertility

BACKGROUND

Assisted reproductive technology is one of the therapeutic options offered for managing endometriosis-associated infertility. Yet, published data on assisted reproductive technology outcome in women affected by endometriosis are conflicting and the determinant factors for pregnancy chances unclear.

OBJECTIVE

We sought to evaluate assisted reproductive technology outcomes in a series of 359 endometriosis patients, to identify prognostic factors and determine if there is an impact of the endometriosis phenotype.

STUDY DESIGN

This was a retrospective observational cohort study, including 359 consecutive endometriosis patients undergoing in vitro fertilization or intracytoplasmic sperm injection, from June 2005 through February 2013 at a university hospital. Endometriotic lesions were classified into 3 phenotypes-superficial peritoneal endometriosis, endometrioma, or deep infiltrating endometriosis-based on imaging criteria (transvaginal ultrasound, magnetic resonance imaging); histological proof confirmed the diagnosis in women with a history of surgery for endometriosis. Main outcome measures were clinical pregnancy rates and live birth rates per cycle and per embryo transfer. Prognostic factors of assisted reproductive technology outcome were identified by comparing women who became pregnant and those who did not, using univariate and adjusted multiple logistic regression models.

RESULTS

In all, 359 endometriosis patients underwent 720 assisted reproductive technology cycles. In all, 158 (44%) patients became pregnant, and 114 (31.8%) had a live birth. The clinical pregnancy rate and the live birth rate per embryo transfer were 36.4% and 22.8%, respectively. The endometriosis phenotype (superficial endometriosis, endometrioma, or deep infiltrating endometriosis) had no impact on assisted reproductive technology outcomes. After multivariate analysis, history of surgery for endometriosis (odds ratio, 0.14; 95% confidence ratio, 0.06-0.38) or past surgery for endometrioma (odds ratio, 0.39; 95% confidence ratio, 0.18-0.84) were independent factors associated with lower pregnancy rates. Anti-müllerian hormone levels <2 ng/mL (odds ratio, 0.51; 95% confidence ratio, 0.28-0.91) and antral follicle count <10 (odds ratio, 0.27; 95% confidence ratio, 0.14-0.53) were also associated with negative assisted reproductive technology outcomes.

CONCLUSION

The endometriosis phenotype seems to have no impact on assisted reproductive technology results. An altered ovarian reserve and a previous surgery for endometriosis and/or endometrioma are associated with decreased pregnancy rates.