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Griffiths MJ, Horne AW, Gibson DA, Roberts N, Saunders PTK. Endometriosis: recent advances that could accelerate diagnosis and improve care. Trends Mol Med 2024:S1471-4914(24)00166-7. [PMID: 38991858 DOI: 10.1016/j.molmed.2024.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Revised: 06/12/2024] [Accepted: 06/13/2024] [Indexed: 07/13/2024]
Abstract
Endometriosis is a common disorder associated with pain, gastrointestinal and urinary symptoms, infertility, and fatigue. It is defined by the presence of endometrial-like lesions found predominantly in the pelvis. Mechanisms that contribute to disease aetiology include changes in hormonal, inflammatory, and pain pathways. In this article, we focus on recent developments in imaging technologies, on our improved understanding of mechanisms contributing to infertility, on drug therapies that are in clinical trials, and on insights from studies on the gut that offer potential to support self-management strategies. We postulate that improvements in the quality of life of patients will be accelerated by reframing endometriosis as a multi-system disorder and learning from treatments targeting symptoms shared between endometriosis, neuroinflammatory, and gastrointestinal disorders.
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Affiliation(s)
- Meaghan J Griffiths
- Centre for Reproductive Health, Institute for Regeneration and Repair, The University of Edinburgh, Edinburgh BioQuarter, 4-5 Little France Drive, Edinburgh EH16 4UU, UK
| | - Andrew W Horne
- Centre for Reproductive Health, Institute for Regeneration and Repair, The University of Edinburgh, Edinburgh BioQuarter, 4-5 Little France Drive, Edinburgh EH16 4UU, UK
| | - Douglas A Gibson
- Centre for Reproductive Health, Institute for Regeneration and Repair, The University of Edinburgh, Edinburgh BioQuarter, 4-5 Little France Drive, Edinburgh EH16 4UU, UK
| | - Neil Roberts
- Centre for Reproductive Health, Institute for Regeneration and Repair, The University of Edinburgh, Edinburgh BioQuarter, 4-5 Little France Drive, Edinburgh EH16 4UU, UK
| | - Philippa T K Saunders
- Centre for Reproductive Health, Institute for Regeneration and Repair, The University of Edinburgh, Edinburgh BioQuarter, 4-5 Little France Drive, Edinburgh EH16 4UU, UK.
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Sokteang S, Tran C, Ou P, Ouk C, Pirtea P, de Ziegler D. Clinical Management of Infertility Associated with Endometriosis. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2024; 46:102409. [PMID: 38340984 DOI: 10.1016/j.jogc.2024.102409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 01/25/2024] [Indexed: 02/12/2024]
Abstract
OBJECTIVE This study aimed to review recent data that affected the clinical management of infertility associated with endometriosis. DATA SOURCES We completed a PubMed review of all articles that included the following keywords: endometriosis, infertility, IVF, and ART. STUDY SELECTION A study was selected based on the pertinence of the topic addressed in relation to the study's set objectives. DATA EXTRACTION AND SYNTHESIS All identified articles were first assessed based on a review of the abstract. Pertinent articles were reviewed in depth. CONCLUSION Endometriosis interferes with natural conception primarily by altering the quality of gametes-oocytes and sperm-and early-stage embryos. On the contrary, recent data indicate that gametes and early-stage embryos are not altered in the case of ART. Surgery-a classical approach in yesteryears-does appear to improve ART outcomes and may affect ovarian reserve and the number of oocytes retrieved in ART. Surgery is thus more rarely opted for today and only when necessary; proceeding to fertility preservation prior to surgery is recommended. When ART is performed in women with endometriosis, it is recommended to use an antagonist or progesterone-primed ovarian stimulation approach followed by deferred embryo transfer. In this case, GnRH (gonadotropin releasing hormone) agonist is preferred for triggering ovulation, as it limits the risk of cyst formation as well as ovarian hyperstimulation syndrome. Frozen embryo transfers are best performed in E2 (estradiol) and progesterone replacement cycle.
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Affiliation(s)
- Sean Sokteang
- Fertility Clinic of Cambodia (FCC), Phnom Penh, Kingdom of Cambodia
| | - Chloe Tran
- Fertility Clinic of Cambodia (FCC), Phnom Penh, Kingdom of Cambodia
| | - Pichetra Ou
- Fertility Clinic of Cambodia (FCC), Phnom Penh, Kingdom of Cambodia
| | - Chanpisey Ouk
- Fertility Clinic of Cambodia (FCC), Phnom Penh, Kingdom of Cambodia
| | - Paul Pirtea
- Fertility Clinic of Cambodia (FCC), Phnom Penh, Kingdom of Cambodia; Department of Ob-Gyn, Hopital Foch, Paris, France
| | - Dominique de Ziegler
- Fertility Clinic of Cambodia (FCC), Phnom Penh, Kingdom of Cambodia; Department of Ob-Gyn, Hopital Foch, Paris, France.
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Gayete-Lafuente S, Vilà Famada A, Albayrak N, Espinós Gómez JJ, Checa Vizcaíno MÁ, Moreno-Sepulveda J. Indirect markers of oocyte quality in patients with ovarian endometriosis undergoing IVF/ICSI: a systematic review and meta-analysis. Reprod Biomed Online 2024; 49:104075. [PMID: 38943812 DOI: 10.1016/j.rbmo.2024.104075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 04/08/2024] [Accepted: 04/16/2024] [Indexed: 07/01/2024]
Abstract
This systematic review and meta-analysis aimed to evaluate the impact of ovarian endometriomas (OMA) on indirect markers of oocyte quality in patients undergoing IVF, compared with women without anatomical or functional ovarian abnormalities. The search spanned original randomized controlled trials, case-control studies and cohort studies published in MEDLINE, the Cochrane Controlled Trials Register and the ClinicalTrials.gov database up to October 2023. Thirty-one studies were included in the meta-analysis, showing no significant differences in fertilization (OR 1.10, 95% CI 0.94-1.30), blastulation (OR 0.86, 95% CI 0.64-1.14) and cancellation (OR 1.06, 95% CI 0.78-1.44) rates. However, patients with OMA exhibited significantly lower numbers of total and mature (metaphase II) oocytes retrieved (mean difference -1.59, 95% CI -2.25 to -0.94; mean difference -1.86, 95% CI -2.46 to -1.26, respectively), and lower numbers of top-quality embryos (mean difference -0.49, 95% CI -0.92 to -0.06). The Ovarian Sensitivity Index was similar between the groups (mean difference -1.55, 95% CI -3.27 to 0.18). The lack of data published to date prevented meta-analysis on euploidy rate. In conclusion, although the presence of OMA could decrease the oocyte yield in patients undergoing IVF/intracytoplasmic sperm injection, it does not appear to have an adverse impact on oocyte quality.
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Affiliation(s)
- Sonia Gayete-Lafuente
- Obstetrics and Gynaecology Department, Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain; Department of Gynecology, Obstetrics and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA.
| | - Anna Vilà Famada
- Department of Obstetrics and Gynaecology, Catalan Health Institute, Barcelona, Spain
| | - Nazli Albayrak
- Department of Obstetrics and Gynaecology, Acibadem University School of Medicine, Istanbul, Turkey
| | - Juan José Espinós Gómez
- Obstetrics and Gynaecology Department, Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain; Fertty Clinic, Barcelona, Spain
| | - Miguel Ángel Checa Vizcaíno
- Fertty Clinic, Barcelona, Spain; Faculty of Medicine and Life Sciences, Pompeu Fabra University, Barcelona, Spain
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Aguiar LDF, da Cunha GDSP, Cordido KAAT, Coelho1 FAC, Carvalho TMO. Randomized prospective study comparing conventional In Vitro Fertilization technique to Intravaginal Culture with the INVOCELL™ device for 3 and 5 days. JBRA Assist Reprod 2023; 27:360-366. [PMID: 37014952 PMCID: PMC10712802 DOI: 10.5935/1518-0557.20220042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 09/16/2022] [Indexed: 08/02/2023] Open
Abstract
OBJECTIVE The objective was to analyse and compare the formation and quality of the embryos developed using conventional in vitro fertilization (IVF) and IVC techniques with an INVOCell™ device. METHODS Two groups were formed, with eight couples in each, one in culture for three days (D3) and another in culture for five days (D5), using intravaginal culture technique with an INVOcell device and a conventional in vitro fertilization technique. RESULTS Embryo formation in Group D5 showed 46.7% (IVC) and 40% (IVF) of recovered blastocysts. In the group D5, the conventional IVF, better embryo development dynamics was observed, with 66% of expanded blastocysts, against 28% in the IVC. Group D3 showed 75% (IVC) and 53% (IVF) of embryo formation. Embryonic quality in Group D3 demonstrated that IVF embryos had a better synchrony in the number and quality of blastomeres. All embryos recovered in Group D3, in both techniques, did not show fragmentation. The pH of the medium contained in the INVOCell™ device in both Groups D5 and D3 showed no differences. The means were 7.26 and 7.25, respectively. The pH of the medium used in IVF was 7.29 in both groups. Microbiological analyzes of the culture media contained in the INVOCell™ devices used in Group D5 were negative. CONCLUSIONS The results showed that the IVC technique, using the INVOCell™ device, provided a healthy and balanced environment for the development and obtaining of quality embryos with three and five days of culture.
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Affiliation(s)
- Lilian de Freitas Aguiar
- Centro de Infertilidade e Medicina Fetal do Norte Fluminense,
Campos dos Goytacazes, RJ, Brasil
- Instituto de Biofísica Carlos Chagas Filho, Universidade
Federal do Rio de Janeiro, UFRJ, RJ, Brasil
| | - Gisele dos Santos Pessanha da Cunha
- Centro de Infertilidade e Medicina Fetal do Norte Fluminense,
Campos dos Goytacazes, RJ, Brasil
- Instituto de Biofísica Carlos Chagas Filho, Universidade
Federal do Rio de Janeiro, UFRJ, RJ, Brasil
| | | | - Francisco Augusto Colucci Coelho1
- Centro de Infertilidade e Medicina Fetal do Norte Fluminense,
Campos dos Goytacazes, RJ, Brasil
- Faculdade de Medicina de Campos, Campos dos Goytacazes, RJ,
Brasil
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Impact of endometriosis on embryo quality and endometrial receptivity in women undergoing assisted reproductive technology. Reprod Biol 2023; 23:100733. [PMID: 36821944 DOI: 10.1016/j.repbio.2023.100733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 01/11/2023] [Accepted: 01/15/2023] [Indexed: 02/24/2023]
Abstract
ART is an important treatment method for infertile patients with endometriosis. However, the effects of endometriosis on embryo quality and endometrial receptivity remain unclear. Thus, we aimed to simultaneously investigate the impact of endometriosis and its stage on embryo quality and endometrial receptivity in women undergoing ART. We retrospectively analyzed the data from patients with and without endometriosis who underwent oocyte retrieval and/or high-quality embryos transfer between July 2015 and December 2020, including 1312 IVF cycles and 608 IVF or frozen-thawed embryo transfer (FET) cycles, respectively. The endometriosis group had a lower percentage of good cleavage-stage embryos and fertilization rates than those in the control group (p = 0.038 and 0.008, respectively). The number of retrieved oocytes, MII oocytes, cleavage, blastocysts, and blastulation rates was comparable between two groups. We found no significant difference in clinical pregnancy, implantation, live birth, miscarriage, or multiple pregnancy rates between the two groups among patients who transferred high-quality embryos. Stratification analysis showed that patients with stage III-IV endometriosis had fewer retrieved oocytes than those with stage I-II endometriosis (p = 0.012) and marginally fewer retrieved oocytes than the control group (p = 0.051). The stage I-II group had the lowest percentage of good cleavage-stage embryos, which was significantly lower than that of the control group (p = 0.043). In FET cycles, patients with stage III-IV endometriosis had a higher miscarriage rate than those in the control group (p = 0.023). Our results suggest that endometriosis does not alter endometrial receptivity but affects embryo quality, oocyte fertilization ability, and ovarian response.
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Spencer S, Lazaridis A, Grammatis A, Hirsch M. The treatment of endometriosis-associated infertility. Curr Opin Obstet Gynecol 2022; 34:300-314. [PMID: 36036476 DOI: 10.1097/gco.0000000000000806] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To review the recent evidence around the treatment of infertility in patients with endometriosis. RECENT FINDINGS The management of endometriosis associated infertility remains challenging. There have been an increasing number of prospective observational studies highlighting the role of surgery to enhance assisted conception amongst those with deep rectovaginal endometriosis. Further validation studies confirm the role of the endometriosis fertility index in prediction of reproductive outcomes after surgery, and confirm that it can be employed in counselling patients prior to surgery on their likelihood of spontaneous conception. Further randomized trials are required to establish the role of surgically treating superficial and deep endometriosis and both spontaneous and assisted conception outcomes. SUMMARY Endometriosis continues to present challenges in counselling patients with regards to their fertility prospects. This article reviews the recent research findings that may assist in the management of patients with endometriosis associated infertility.
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Affiliation(s)
- Stuart Spencer
- Oxford Endometriosis CaRe Centre, Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford
| | - Alexandros Lazaridis
- Oxford Endometriosis CaRe Centre, Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford
| | - Alexandros Grammatis
- Centre for Reproductive Medicine, Barts Health NHS Trust, London, United Kingdom
| | - Martin Hirsch
- Oxford Endometriosis CaRe Centre, Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford
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Bourdon M, Dahan Y, Maignien C, Patrat C, Bordonne C, Marcellin L, Chapron C, Santulli P. Influence of endometrioma size on assisted reproductive technology outcomes. Reprod Biomed Online 2022; 45:1237-1246. [DOI: 10.1016/j.rbmo.2022.08.097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 08/02/2022] [Accepted: 08/05/2022] [Indexed: 11/24/2022]
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Esmaeilzadeh S, Ghorbani M, Abdolahzadeh M, Chehrazi M, Jorsaraei SG, Mirabi P. Stages of endometriosis: Does it affect oocyte quality, embryo development and fertilization rate? JBRA Assist Reprod 2022; 26:620-626. [PMID: 36350241 PMCID: PMC9635609 DOI: 10.5935/1518-0557.20220051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
OBJECTIVE To investigate the effect of endometriosis and its different stages over Intracytoplasmic Sperm Injection (ICSI) outcomes among infertile women without previous history of ovarian surgery. METHODS A total of 440 women enrolled in ICSI cycles were recruited and divided into two groups: endometriosis (n=220) and control group (n=220). Endometriosis patients without previous surgical treatment and with diagnostic laparoscopy were further stratified based on disease stage. Clinical and laboratory parameters, ovarian reserve markers, the number and quality of oocytes and embryos and fertilization rate were analyzed and compared among the various severity grades of endometriosis and the control group. RESULTS Patients with advanced endometriosis had significantly fewer retrieved oocytes with small effect size (p<0.001, η2=0.04), lower metaphase II oocytes (p<0.001, η2=0.09) and fewer total numbers of embryos (p<0.001, η2=0.11) compared with less severe disease or women with tubal factor infertility. The fertilization rate in women with severe endometriosis was similar to that of the control group and in those with minimal/mild endometriosis (p=0.187). CONCLUSIONS Severe endometriosis negatively affects ovarian response, oocyte quality and embryos. However, fertilization rate is not different among the various stages of endometriosis.
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Affiliation(s)
- Sedighe Esmaeilzadeh
- Infertility and Reproductive Health Research Center. Health
Research Institute, Babol University of Medical Sciences, Babol, Iran
| | - Mahsa Ghorbani
- Infertility and Reproductive Health Research Center. Health
Research Institute, Babol University of Medical Sciences, Babol, Iran
| | - Maryam Abdolahzadeh
- Infertility and Reproductive Health Research Center. Health
Research Institute, Babol University of Medical Sciences, Babol, Iran
| | - Mohammad Chehrazi
- Department of Biostatistics and Epidemiology, School of Medicine,
Babol University of Medical Sciences, Babol, Iran
| | - Sayed Gholamali Jorsaraei
- Infertility and Reproductive Health Research Center. Health
Research Institute, Babol University of Medical Sciences, Babol, Iran
| | - Parvaneh Mirabi
- Infertility and Reproductive Health Research Center. Health
Research Institute, Babol University of Medical Sciences, Babol, Iran ,Corresponding author: Parvaneh Mirabi, Fatemezahra
Infertility and Reproductive Health Research Center, Health Research Institute,
Babol University of Medical Sciences, Torkemahale Babol, Iran. E-mail:
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Vatsa R, Sethi A. Impact of endometriosis on female fertility and the management options for endometriosis-related infertility in reproductive age women: a scoping review with recent evidences. MIDDLE EAST FERTILITY SOCIETY JOURNAL 2021. [DOI: 10.1186/s43043-021-00082-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Endometriosis is a chronic inflammatory condition with varied presentation, which ultimately leads to chronic pelvic pain and infertility. It is a psychological and economic burden to the women and their families.
Main body of abstract
The literature search was performed on the following databases: MEDLINE, Google Scholar, Scopus, EMBASE, Global health, the COCHRANE library, and Web of Science. We searched the entirety of those databases for studies published until July 2020 and in English language. The literature search was conducted using the combination of the Medical Subject heading (MeSH) and any relevant keywords for “endometriosis related infertility and management” in different orders. The modalities of treatment of infertility in these patients are heterogeneous and inconclusive among the infertility experts. In this article, we tried to review the literature and look for the evidences for management of infertility caused by endometriosis. In stage I/II endometriosis, laparoscopic ablation leads to improvement in LBR. In stage III/IV, operative laparoscopy better than expectant management, to increase spontaneous pregnancy rates. Repeat surgery in stage III/IV rarely increases fecundability as it will decrease the ovarian reserve, and IVF will be better in these patients. The beneficial impact of GnRH agonist down-regulation in ART is undisputed. Dienogest is an upcoming and new alternative to GnRH agonist, with a better side effect profile. IVF + ICSI may be beneficial as compared to IVF alone. Younger patients planned for surgery due to pain or any other reason should be given the option of fertility preservation.
Short conclusion
In women with endometriosis-related infertility, clinician should individualize management, with patient-centred, multi-modal, and interdisciplinary integrated approach.
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Demirdag E, Guler I, Selvi I, Cevher Akdulum MF, Canan S, Erdem A, Erdem M. Analysis of 2438 cycles for the impact of endometrioma and its surgery on the IVF outcomes. Eur J Obstet Gynecol Reprod Biol 2021; 263:233-238. [PMID: 34242932 DOI: 10.1016/j.ejogrb.2021.06.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 05/24/2021] [Accepted: 06/22/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Management of ovarian endometrioma before IVF treatment is still challenging. We aimed to assess the effect of the pre-cycle surgical removal of endometriomas on IVF outcomes in a large number of cycles in patients undergoing IVF/ICSI treatment. Besides this, we also proposed to compare the cycle outcomes within both normo and poor responder patients to evaluate the impact of endometrioma and its surgery. STUDY DESIGN A retrospective cohort study was conducted in a private IVF clinic between September 2014 and December 2018. A total of 2438 IVF/ICSI cycles of 1936 patients were reviewed. Patients who had previous endometrioma surgery (Group 1), patients with non-operated endometrioma (Group 2), and patients without endometriosis, including tubal factor infertility confirmed by laparoscopy and unexplained infertility without endometrioma (Group 3) were analyzed in this study. RESULTS Total dose of gonadotropins was significantly higher in group 1 than others (p < 0.05). However, antral follicle counts, estradiol levels on the day of hCG trigger, the number of retrieved and metaphase II oocytes were significantly lower in group 1 than in other groups (p < 0.05). Poor response to gonadotropins was more frequent in group 1 as compared to other groups (47.9%, 34.3%, 35.5%, respectively) (p < 0.05). Cycle cancellation rates were significantly higher in group 1 than in other groups (6.7%, 1.4%, and 2.8%, respectively) (p < 0.05). Clinical pregnancy (CPR) and live birth rates (LBR) per cycle and embryo transfer were not different among groups. However, CPR per cycle and embryo transfer were significantly higher in the operated endometrioma group within unexpected poor responders (p = 0.023, p = 0.010, respectively). CPR and LBR per cycle and per embryo transfer were similar within normo-responder patients. Multiple logistic regression analysis revealed that female age and poor response to gonadotropins were the significant variables in predicting live birth (OR: 0.946, CI: 0.926-0.966, p < 0.001 and OR: 3.294, CI: 2.336-4.645, p < 0.001, respectively). CONCLUSION Pre-cyle removal of endometrioma may have an adverse impact on ovarian reserve, and pregnancy outcomes seem to be similar with or without surgery in patients undergoing IVF treatment. However, endometrioma surgery may be considered in the subsequent IVF cycles of patients with lower than expected ovarian response.
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Affiliation(s)
- Erhan Demirdag
- Department of Obstetrics and Gynecology, Gazi University, Faculty of Medicine, Emniyet Mahallesi, Gazeteci Yazar Muammer Yaşar Bostancı Sokak, 06560 Yenimahalle, Ankara, Turkey.
| | - Ismail Guler
- Department of Obstetrics and Gynecology, Gazi University, Faculty of Medicine, Emniyet Mahallesi, Gazeteci Yazar Muammer Yaşar Bostancı Sokak, 06560 Yenimahalle, Ankara, Turkey
| | - Ilknur Selvi
- IVF Clinic, Novaart IVF and Women Health Center, Çukurambar Mahallesi, 1425. Cadde, No:26, 06510 Çankaya, Ankara, Turkey
| | - Munire Funda Cevher Akdulum
- Department of Obstetrics and Gynecology, Gazi University, Faculty of Medicine, Emniyet Mahallesi, Gazeteci Yazar Muammer Yaşar Bostancı Sokak, 06560 Yenimahalle, Ankara, Turkey
| | - Sultan Canan
- Department of Obstetrics and Gynecology, Gazi University, Faculty of Medicine, Emniyet Mahallesi, Gazeteci Yazar Muammer Yaşar Bostancı Sokak, 06560 Yenimahalle, Ankara, Turkey
| | - Ahmet Erdem
- Department of Obstetrics and Gynecology, Gazi University, Faculty of Medicine, Emniyet Mahallesi, Gazeteci Yazar Muammer Yaşar Bostancı Sokak, 06560 Yenimahalle, Ankara, Turkey
| | - Mehmet Erdem
- Department of Obstetrics and Gynecology, Gazi University, Faculty of Medicine, Emniyet Mahallesi, Gazeteci Yazar Muammer Yaşar Bostancı Sokak, 06560 Yenimahalle, Ankara, Turkey
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