Oocyte retrieval difficulties in women with ovarian endometriomas

Reproductive surgery remains an essential element of reproductive medicine

Background

Reproductive surgery has long been neglected and is perceived to be simple surgery that can be undertaken by all gynaecologists. However, given the ever-expanding knowledge in the field, reproductive surgery now comprises surgical interventions on female reproductive organs that need to be carefully planned and executed with consideration given to the individuals symptoms, function of the organ and fertility concerns.

Objectives

To discuss the different perspectives of reproductive surgeons and other gynaecological surgeons, e.g., gynaecological oncologists, and advanced minimally invasive surgeons, regarding diagnosis and management of pelvic pathology that affects reproductive potential. Furthermore, to highlight the gaps in knowledge and numerous controversies surrounding reproductive surgery, while summarising the current opinion on management.

Materials and Methods

Narrative review based on literature and the cumulative experience of the authors.

Main outcome measures

The paper does not address specific research questions.

Conclusions

Reproductive surgery encompasses all reproductive organs with the aim of alleviating symptoms whilst restoring and preserving function with careful consideration given to alternatives such as expectant management, medical treatments, and assisted reproductive techniques. It necessitates utmost technical expertise and sufficient knowledge of the female genital anatomy and physiology, together with a thorough understanding of and respect to of ovarian reserve, tubal function, and integrity of the uterine anatomy, as well as an up-to-date knowledge of alternatives, mainly assisted reproductive technology.

What is new?

A holistic approach to infertile women is only possible by focusing on the field of reproductive medicine and surgery, which is unattainable while practicing in multiple fields.

Indirect markers of oocyte quality in patients with ovarian endometriosis undergoing IVF/ICSI: a systematic review and meta-analysis

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.

Chapter 11. Endometriosis-related complications in women undergoing in-vitro fertilization

As a chronic inflammatory disease, endometriosis generates fibrosis and anatomic distortion, which add extra-challenges to assisted reproductive technology cycles and requires a personalized approach. Patients with endometriomas have significantly decreased ovarian reserve and the ultrasound examination tends to be challenging, possibly underestimating follicle counts. It is crucial to assess the feasibility of oocyte retrieval procedure during the initial examination of the patient, as the distortion of the pelvic anatomy, the presence of hydrosalpinges and endometriomas might render the procedure difficult and increase the risk of complications. Possible injury to adjacent organs and risk of infection must be considered. Assisted reproductive technology seems to have limited or no impact on endometriosis recurrence, pain symptom progression or the size of endometrioma.

Glucocorticoid supplementation during ovulation induction for assisted reproductive technology: a systematic review and meta-analysis

BACKGROUND

There is ongoing interest in glucocorticoid treatment during oocyte stimulation to treat infertility in women who have undergone Assisted Reproductive Technology (ART).

OBJECTIVE

This meta-analysis was performed to evaluate the efficiency and safety of adjuvant glucocorticoid therapy on pregnancy outcomes in infertile women undergoing ART cycles.

STUDY DESIGN

A literature search was performed in PubMed, EMBASE, Web of Science, and the Cochrane Library up to December 2022. To assess the efficacy and safety of additional glucocorticoid treatment during ovulation induction in women who underwent IVF or ICSI treatment, only randomized controlled trials were included.

RESULTS

Overall, glucocorticoid therapy during ovulation showed a nonsignificant effect of prednisolone improving the live birth rate (OR = 1.03, 95% CI [.75, 1.43], I² = .0%, p = .84), abortion rate (OR = 1.14, 95% CI [.62, 2.08], I² = 31%, p = .68), and implantation rate (OR = 1.1, 95% CI [.82, 1.5], I² = 8%, p = .52) of infertile women compared to the control group. The present meta-analysis revealed that the clinical pregnancy rate per cycle tended to increase after glucocorticoid treatment (OR = 1.29, 95% CI [1.02, 1.63], I² = 8%, p = .52).

CONCLUSIONS

The present meta-analysis suggested that ovarian stimulation prednisolone therapy does not significantly improve clinical outcomes in women undergoing IVF/ICSI. Although the results indicated that adjuvant glucocorticoid therapy during ovarian stimulation may increase the clinical pregnancy rate, subgroup analysis showed that it was affected by infertility factors, dose schedules, and length of treatment. Therefore, these results should be interpreted with caution.

Endometriosis affects the number of retrieved oocytes but not early embryonic development and live birth: a retrospective analysis of 716 IVF cycles

To investigate the potential effect of endometriosis on embryo development and clinical outcomes, a retrospective analysis of 716 women undergoing their first standard in vitro fertilization (sIVF) cycles (205 endometriosis and 511 with tubal factor infertility) was performed. The endometriosis group included women with an ultrasonographic or surgical diagnosis. Control subjects were women diagnosed with tubal factor infertility by laparoscopy or hysterosalpingogram. The primary outcome of the study was live birth. Cumulative live birth was also assessed in a subgroups analysis. After adjusting for confounders we found no significant difference in fertilization rate, blastulation, top-quality blastocyst, live birth, cumulative live birth (subgroups analysis) and miscarriage rate. In the endometriosis group, the number of retrieved oocytes was smaller (6.94 ± 4.06 Vs 7.50 ± 4.6, adjusted p < 0.05). We observed a statistically significant difference in the percentage of day-3 embryos with ≥8 blastomeres (33.12 ± 22.72 endometriosis vs, 40.77 ± 27.62 tubal factor, adjusted p < 0.01) and a negative correlation between the presence of endometriomas and a number of retrieved oocytes [B coefficient =-1.41, 95%CI (-2.31-0.51), adjusted p = 0.002]. Our results suggest that endometriosis affects the number of retrieved oocytes but not embryo development and live birth.

Endometriosis and IVF treatment outcomes: unpacking the process

Advanced endometriosis is associated with a reduction of IVF success. Surgical damage to the ovarian reserve following the excision of endometriomas has been claimed as a critical factor in the explanation of this detrimental effect. However, it is generally inferred that other mechanisms might also hamper IVF success in affected women. They include diminished responsiveness to ovarian stimulation, altered steroidogenesis, a decline in oocyte quality, reduced fertilization and embryo development, and impaired implantation. To navigate these limitations, we scrutinized available literature for studies specifically designed to address distinct phases of the IVF process. Utmost consideration was given to intra-patient ovarian response comparisons in women with unilateral endometriomas and to studies applying a meticulous matching to control confounders. The following observations have been drawn: 1) endometriosis has a negligible impact on ovarian response. A slight reduction in stimulation response can only be observed for endometriomas larger than 4 cm. Follicular steroidogenesis is unaffected; 2) oocyte quality is not hampered. Fertilization rates are similar, and intracytoplasmic sperm injection (ICSI) is not justified. Embryonic development is uncompromised, with no increase in aneuploidy rate; 3) endometrial receptivity is either unaffected or only slightly impacted. In conclusion, our study suggests that, aside from the well-known negative effect on ovarian reserve from excisional endometrioma surgeries, endometriosis does not significantly affect IVF outcomes.

Prevalence and clinical effect of caesarean scar defects in women undergoing IVF

RESEARCH QUESTION

How common are caesarean scar defects (isthmocele) among patients who have had previous caesarean delivery undergoing IVF for secondary infertility? Does the presence of isthmocele affect the chances of success of IVF?

DESIGN

In this cohort study, women referred to an Italian public assisted reproduction centre between January 2016 and April 2021 were retrospectively reviewed. Women with a history of caesarean delivery and an indication for IVF were selected. On the basis of the local policy, all patients with a history of caesarean section underwent saline contrast sonography (SCS). Sonographic evaluation was standardized.

RESULTS

One hundred and forty-four women were eligible, of whom 22 declined SCS and eight decided to delay pregnancy seeking. Overall, 114 women were available for data analysis. Seventy-six women were diagnosed with caesarean scar defects, corresponding to a prevalence of 67% (95% CI 58 to 75%). Baseline characteristics of women with and without isthmocele were similar. Conversely, the clinical pregnancy rate (adjusted OR 0.31, 95% CI 0.13 to 0.72) and live birth rate (adjusted OR 038, 95% CI 0.17 to 0.86) were significantly lower among affected women. No associations between specific sonographic defect characteristics and IVF outcome could be identified.

CONCLUSIONS

Caesarean scar defects are common among women with a history of caesarean section requiring IVF. The presence of these lesions may reduce the chance of success of the procedure.

Adherence to the Mediterranean diet and the risk of unexpected poor response to ovarian stimulation in IVF cycles

RESEARCH QUESTION

Can preconception adherence to a Mediterranean diet influence the rate of poor response to ovarian stimulation in IVF cycles?

DESIGN

The impact of dietary habits on the success of IVF is controversial. Inconsistencies may be explained by confounders associated with the use of pregnancy as an outcome as well as by a reductionist view of diet that focuses on single components rather than on food patterns. This cross-sectional study analysed adherence to a Mediterranean diet in women with unexpected poor response to ovarian stimulation. Main inclusion criteria were: age 18-39 years, normal weight, preserved ovarian reserve and starting dose of gonadotrophins of 150-225 IU/day. Adherence to the Mediterranean diet was assessed through a Mediterranean diet score (MDS). Unexpected poor ovarian response was defined as the retrieval of ≤3 suitable oocytes.

RESULTS

A total of 296 women were included, of whom 47 (15.9%) showed an unexpected poor response. A clear dose-related association with tertiles of MDS was not observed in the univariate analysis. However, in the multivariate analysis, the risk of unexpected poor response was significantly lower for women in the second tertile of MDS compared with the first tertile (adjusted odds ratio [OR] 0.29, 95% confidence interval [CI] 0.11-0.76) and for women in the second and third tertiles, grouped together, compared with the first tertile (adjusted OR 0.34, 95% CI 0.14-0.82).

CONCLUSIONS

Low adherence to a Mediterranean diet could be a risk factor for unexpected poor ovarian response.

Oocyte Cryopreservation in Patients with Endometriosis: Current Knowledge and Number Needed to Treat

The rise of oocytes cryopreservation (OOC) in assisted reproductive techniques allows fertility preservation (FP) in an increasing number of indications. Endometriosis, a highly prevalent disease, potentially impairing ovarian reserve, seems, therefore, an interesting indication for it. The purpose of this study is to summarize the available evidence concerning FP by OOC in women with endometriosis and to calculate the number needed to treat (NNT). In total, 272 articles related to this topic were identified in PubMed. Eight studies were eligible for the review. In order to shed some light, a SWOT analysis was performed and the argument pros and cons were developed. The NNT calculated of OOC was 16, meaning that 16 women need to perform an OOC for one of them to have a child that she would not have had without this technique. In conclusion, OOC must be discussed with patients who suffer from endometriosis since it is an effective technique of FP, which can allow these patients to succeed a pregnancy that they otherwise would not have achieved. Nevertheless, it should not be performed in all patients as there is still a lack of robust socio-economic and risk–benefit data.

Surgery versus IVF for the treatment of infertility associated to ovarian and deep endometriosis (SVIDOE: Surgery Versus IVF for Deep and Ovarian Endometriosis). Clinical protocol for a multicenter randomized controlled trial

The management of endometriosis-related infertility is still a challenging issue. Women can be managed with either surgery or in vitro fertilization (IVF). The decision is tailored to the patients considering pros and cons of both approaches. Surgery might increase the chances of natural conception and relieve symptoms. IVF may be more effective, but costs are higher and unoperated women face some peculiar additional risks during the procedure and pregnancy. The unavailability of randomized trials comparing the two strategies hampers the possibility to provide precise estimates. This Randomized Controlled Trial (RCT) aims at filling this gap. This is a multicenter, non-blinded, randomized controlled trial with parallel groups and allocation 1:1. Three Italian Academic Infertility Units will be involved. Main inclusion criteria are infertility for more than one year, age less than 40 years and a sonographic diagnosis of endometriosis (ovarian endometriomas or deep peritoneal lesions). Previous IVF and previous surgery for endometriosis are exclusion criteria. Women will be randomized to either surgery and then natural pregnancy seeking or a standard program of three IVF cycles. The primary aim is the comparison of live birth rate between the two groups (IVF versus surgery) within one year of randomization. The secondary aim is the evaluation of cost-effective profile of the two interventions. The present study can influence the clinical practice of infertility treatment in women with endometriosis. From a public health perspective, information on the more cost-effective clinical management strategy would consent a wiser allocation of resources.

Trial registration:NCT04743167, registered on 8 February 2021.

Endometrial microbiome: sampling, assessment, and possible impact on embryo implantation

There is growing interest on the potential clinical relevance of the endometrial microbiome. However, insufficient attention has been given to the methodology of sampling. To minimize contamination, we advocate the use of the double-lumen catheters commonly employed for the embryo transfer. Endometrial fluid samples obtained from 53 women scheduled for IVF were studied for microbiome characterization. Control samples from the vagina of these same women were concomitantly obtained. Samples were analysed by V3-V4-V6 regions of 16S rRNA gene sequencing with Next Generation Sequencing technique. Endometrial Lactobacillus-dominant cases were uncommon compared to previous evidence, being observed in only 4 (8%) women. Taxonomy markedly differed between the endometrial and vaginal microbiomes composition. The most common bacterial genera coincided in only 4 (8%) women. The comparison between women who did and did not subsequently become pregnant failed to identify any microorganism associated with the success of the procedure. However, the endometrial biodiversity resulted higher among pregnant women. Shannon's Equitability index in pregnant and non pregnant women was 0.76 [0.57-0.87] and 0.55 [0.51-0.64], respectively (p = 0.002). In conclusion, the use of embryo transfer catheters for testing the endometrial microbiome is promising. The scant concordance with vaginal samples supports the validity of this approach. Moreover, our study highlighted a possible beneficial role of a higher biodiversity on endometrial receptivity.

Decidualization of endometriosis in a cohort of IVF-mediated pregnancies

Decidualization is the process of endometrial change in pregnancy, a phenomenon that can involve also ovarian endometriomas. However, the frequency of this event remains unknown. In addition, there is no evidence on the decidualization of deep invasive endometriosis (DIE). To shed more light on this issue, we prospectively recruited women with ovarian endometriomas or DIE who underwent IVF. They were subsequently excluded if they did not become pregnant or if they had a miscarriage. The evaluation was repeated in five time points during pregnancy and post-partum. The primary outcome was the rate of decidualized endometriomas at 11-13 weeks' gestation. Data from 45 endometriomas and 15 nodules were available for data analyses. At the 11-13 weeks' ultrasound, endometriomas' decidualization was observed in seven cases, corresponding to 16% (95% CI 8-29%). Subsequent assessments in pregnancy failed to identify any additional case. DIE also underwent significant changes during pregnancy. At the 11-13 weeks' ultrasound, lesions were increased in size and more vascularized. In conclusion, decidualization of ovarian endometriomas in IVF pregnancies is not rare. DIE may also undergo decidualization, but further evidence is needed for a robust and shared definition of this process.

Molecular Signatures Correlated With Poor IVF Outcomes: Insights From the mRNA and lncRNA Expression of Endometriotic Granulosa Cells

The outcomes of in vitro fertilization (IVF) for endometriotic women are significantly worse than for patients without ovarian endometriosis (OEM), as shown by fewer retrieved oocytes. However, the exact pathophysiological mechanism is still unknown. Thus, we conducted a prospective study that analyzed mRNA and lncRNA transcriptome between granulosa cells (GCs) from patients with fewer retrieved oocytes due to OEM and GCs from controls with male factor (MF) infertility using an RNA sequencing approach. We found a group of significantly differentially expressed genes (DEGs), including NR5A2, MAP3K5, PGRMC2, PRKAR2A, DEPTOR, ITGAV, KPNB1, GPC6, EIF3A, and SMC5, which were validated to be upregulated and negatively correlated with retrieved oocyte numbers in GCs of patients with OEM, while DUSP1 demonstrated the opposite. The molecular functions of these DEGs were mainly enriched in pathways involving mitogen-activated protein kinase (MAPK) signaling, Wnt signaling, steroid hormone response, apoptosis, and cell junction. Furthermore, we performed lncRNA analysis and identified a group of differentially expressed known/novel lncRNAs that were co-expressed with the validated DEGs and correlated with retrieved oocyte numbers. Co-expression networks were constructed between the DEGs and known/novel lncRNAs. These distinctive molecular signatures uncovered in this study are involved in the pathological regulation of ovarian reserve dysfunction in OEM patients.

Glucocorticoid therapy in assisted reproduction

As glucocorticoids are well-known as important regulators of stress and the immune system, their function and clinical use have elicited substantial interest in the field of reproduction. In particular, the effect of glucocorticoid therapy on endometrial receptivity during assisted reproduction, including in vitro fertilization (IVF) cycles, has led to a great deal of interest and controversy. However, previous studies have not been able to provide consistent and reliable evidence due to their small, non-controlled designs and use of different criteria. Considering the potential risk of exposure to glucocorticoids for mothers and fetuses in early pregnancy, the use of glucocorticoids in IVF cycles should be carefully evaluated, including the balance between risk and benefit. To date, there is no conclusive evidence that the use of glucocorticoids improves the pregnancy rate in IVF cycles with unselected subjects, and a further investigation should be considered with a proper study design.

The rate of oocytes with granular cytoplasm is higher in women with endometrioma in ICSI cycles

The purpose of this study was to investigate the impact of endometrioma on oocyte morphology and fertility outcome in intracytoplasmic sperm injection (ICSI)cycles. The study material was obtained from 114 ICSI cycles of infertile women aged between 20 and 38 years with ovarian endometriomas and unexplained infertility. In total, 644 mature oocytes were included in the analysis. The rates of specific oocyte morphological abnormalities were similar between the two groups however the central granulation rate was significantly higher in the group with endometrioma (p < .05). Fertilisation rate were not significantly different between the groups (p ≥ .05) however the numbers of metaphase 2 (MII) oocytes and embryos were lower in the endometrioma group (p ≤ .05). Endometrioma was associated with a higher rate of oocytes with granular cytoplasm, despite the fertilisation rate the numbers of the MII oocytes and embryo were affected.IMPACT STATEMENTWhat is already known on this subject? The association between endometrioma and infertility is a well-known condition, but the possible mechanisms of the effects of endometrioma on women's fertility is still debated and controversial. There is limited data on the effect of endometrioma on oocyte morphology. Low oocyte quality and lower fertilisation rates might be the main cause of adverse pregnancy outcomes during in vitro fertilisation/intracytoplasmic sperm injection cycles.What do the results of this study add? Endometrioma was associated with a higher rate of oocytes with granular cytoplasm, and lower metaphase 2 oocytes and embryos.What are the implications of these findings for clinical practice and/or further research? Future studies using further oocyte quality assessment methods and prospective observational studies including live-birth rate should be designed to better understand how endometrioma affects fertility outcomes.

Safety of in-vitro fertilization in women with endometriosis

Management of women with endometriosis in general is complex. It requires a multidisciplinary and tailored approach. The time of in-vitro fertilization (IVF) may be particularly complicated because women with the disease face peculiar additional risks. In particular, oocytes retrieval may be more difficult and women with endometriomas are exposed to a low but consistent risk of infection and ovarian abscess development. There are also concerns regarding progression of deep invasive peritoneal lesions and misdiagnosis of an occult early ovarian cancer. However, evidence on these latter points is more controversial. Taken together, this body evidence is generally reassuring and does not justify prophylactic surgery prior to IVF to shrink these risks. However, given the uncertainties, women with endometriosis must be informed in depth of these peculiar additional risks.

Assisted reproductive technology for women with endometriosis, a clinically oriented review

PURPOSE OF REVIEW

To discuss optimal management of an assisted reproductive technology (ART) cycle in women with endometriosis.

RECENT FINDINGS

New studies involving euploid embryo transfers provide more insight on the etiology of endometriosis-associated infertility. Oocyte competence to reach live birth seems unlikely to be affected by the disease. Routine medical or surgical treatment prior to an ART cycle does not appear beneficial. Short gonadotropin releasing hormone (GnRH) antagonist or progestin primed ovarian stimulation protocols seem to be proper first choices, depending on the intention for a fresh embryo transfer. Low-quality evidence supports frozen thawed over fresh embryo transfer. Ovarian stimulation for ART does not seem to be associated with symptom progression or recurrence.

SUMMARY

How endometriosis affects fertility is still unclear, but ART is an effective pragmatic treatment. Each woman with endometriosis must be assessed with a holistic approach, and in the absence of an indication for otherwise, ART cycles can be kept simple with patient-friendly protocols. Whether a frozen embryo transfer is better than a fresh one should be investigated.

Causes and Effects of Oocyte Retrieval Difficulties: A Retrospective Study of 10,624 Cycles

Oocyte retrieval is a routine procedure during the application of assisted reproduction technology. However, technical difficulties experienced during oocyte retrieval and the subsequent unsatisfactory number of oocytes obtained are rarely reported. The current study included 10,624 oocyte retrieval cycles from April 2015 to June 2018, and patients were followed up until February 2019. Patients were divided into two groups depending on whether the oocyte number obtained reached the >14-mm follicle number on the day of hCG administration. In the oocyte retrieval not satisfactory (ORNS) group, there were 1,294 cycles, and in the oocyte retrieval satisfactory (ORS) group, there were 9,330 cycles. ORNS patients were older, had a longer duration of infertility, had higher follicle-stimulating hormone, and were more likely to have endometriosis. The ORS group had a higher rate of the use of a follicular phase long-acting gonadotropin-releasing hormone (GnRH) agonist long ovarian stimulation protocol and a lower rate of the use of a luteal phase short-acting GnRH agonist long protocol. The ORNS group had fewer total number of days of FSH stimulation. On human chorionic gonadotropin day, the ORNS group had higher luteinizing hormone (LH), lower estradiol, and lower progesterone levels. After oocyte retrieval, the oocyte quality and fresh cycle transplantation rate were higher in the ORNS group. An unsatisfactory oocyte retrieval number did not influence the clinical pregnancy rate, miscarriage rate, or live birth rate during the fresh cycles. The cumulative pregnancy rate and the live birth rate were lower in the ORNS group. In conclusion, with a similar number of matured follicles, ORNS was more likely to occur in ovarian dysfunction patients. The follicular phase long-acting GnRH agonist long protocol had lower oocyte retrieval difficulty during IVF/ICSI. ORNS does not affect embryo quality or the fresh cycle pregnancy rate, but it significantly reduces the cumulative pregnancy rate and the live birth rate.

Endometriosis and spontaneous hemoperitoneum in pregnancy: evaluation of the magnitude of the risk in women becoming pregnant via in vitro fertilization

OBJECTIVE

To estimate the frequency of spontaneous hemoperitoneum in pregnancy (SHiP) in women with endometriosis achieving pregnancy with in vitro fertilization (IVF).

DESIGN

Retrospective case series.

SETTING

Referral academic assisted reproductive technology (ART) center.

PATIENT(S)

Three hundred and forty-eight women with a history of surgery for endometriosis and women with ovarian endometriomas or deep endometriotic nodules detected at basal transvaginal ultrasound performed before IVF cycle.

INTERVENTION(S)

Information obtained from patients' charts on basal characteristics, IVF cycle, and pregnancy outcomes, and binomial distribution model created to determine the 95% confidence interval (CI) of the proportion of SHiP.

MAIN OUTCOME MEASURE(S)

Rate of SHiP.

RESULT(S)

Overall, 362 pregnancies were included, among which 238 (66%) had a history of previous surgery for endometriosis and 231 (64%) had endometriosis detected at ultrasound (107 women, 30%, had both). Pregnancies were achieved after fresh and frozen cycles in 244 (67%) and 118 (33%) women, respectively. One case of SHiP was recorded, corresponding to a rate of 0.3%.

CONCLUSION(S)

In the general population of women with endometriosis undergoing IVF, SHiP is uncommon. Future studies should better identify the risk factors for SHiP to disentangle the subgroups of women at higher risk.

The Endometrioma Treatment Paradigm when Fertility Is Desired: A Systematic Review

OBJECTIVE

To establish an endometrioma treatment paradigm (decision tree) in the treatment of an ovarian endometrioma through the review of current literature.

DATA SOURCES

A thorough literature search, including PubMed, Google Scholar, and the Cochrane Library, was performed from April 2020 to July 2020. The review was completed by using the following keywords: METHODS OF STUDY SELECTION: Articles published in English that addressed the endometrioma in regard to the following were included: (1) diagnosis, (2) treatment of pain on the basis of size and/or surgical intervention, (3) treatment of fertility on the basis of size and/or surgical intervention, (4) surgical technique, (5) in vitro fertilization success on the basis of size and/or surgical intervention, (6) risk of rupture at the time of egg retrieval, (7) impact on the antimüllerian hormone and antral follicle count postsurgery, and (8) impact on implantation.

TABULATION, INTEGRATION, AND RESULTS

Fifty-six articles were included in this systematic review. While conducting this literature review, several themes were noted. In general, the literature on the ovarian endometrioma seems to be homogeneous in regard to imaging the endometrioma, excision rather than desiccation for an endometrioma ≥3-cm causing pain and/or infertility, minimal use of bipolar energy at the time of ovarian surgery, and risk of severe infection secondary to inadvertent rupture of cysts during egg retrieval. Conversely, studies on the ovarian endometrioma are much more heterogeneous in terms of surgery and assisted reproductive technology, that is, whether surgery should be performed. Certainly, an endometrioma ≥5-cm should be excised before assisted reproductive technology. Moreover, it seems that the antral follicle count and implantation may be enhanced with surgery.

CONCLUSION

By completing an extensive literature review, an easy-to-use algorithm for the diagnosis, evaluation, and treatment of endometriomas was developed to help clinicians in their treatment of patients with endometriosis in the short and long terms.

Endometriosis shows no impact on the euploid blastocyst rate per cohort of inseminated metaphase-II oocytes: A case-control study

OBJECTIVE

To evaluate the true impact of endometriosis on oocytes' competence defined as blastulation, euploidy and implantation rates.

DESIGN

Retrospective multicenter case-control study involving infertile couples undergoing ICSI with qPCR and trophectoderm biopsy-based PGT-A. Patients affected from endometriosis (n = 210) were diagnosed through transvaginal sonography or surgical history with histological confirmation. Each case was matched to two controls (n = 420) according to IVF clinic, maternal age at retrieval (38.6 ± 2.7 yr), number of previous failed IVF treatments (0.5 ± 0.8) and number of metaphase-II oocytes retrieved (6.1 ± 3.7 per patient). The primary outcome was the mean euploid blastocyst rate per cohort of inseminated metaphase-II oocytes. Other embryological, clinical, obstetric and neonatal outcomes were also evaluated.

RESULTS

The mean euploid blastocyst rate per cohort of inseminated metaphase-II oocytes was identical in the two groups (18 %±22 %) independently of maternal age. No difference was shown for all embryological outcomes investigated. The live birth rates per vitrified-warmed single euploid blastocyst transfer were also similar (67/158, 42 % in patients affected from endometriosis versus 132/327, 40 % in matched-controls). No difference was reported in the gestational and neonatal outcomes. The cumulative live birth delivery rates among completed cycles were also identical (61/201, 30 % versus 117/391, 30 % in endometriosis and matched-control groups, respectively) independently of maternal age.

CONCLUSIONS

Endometriosis might not impair oocyte developmental and reproductive competence, although its potential impact on the number of metaphase-II oocytes retrieved cannot be ignored. This information is critical for clinicians during counseling to outline an effective strategy to treat infertile patients affected from this condition. Future prospective studies are needed to evaluate the impact of endometriosis stage on euploidy rates.

Endometrioma ethanol sclerotherapy could increase IVF live birth rate in women with moderate-severe endometriosis

OBJECTIVE

To examine the impact of ethanol sclerotherapy (EST) for endometrioma on in vitro fertilization (IVF) cumulative live birth rates (CLBR) in women with moderate-severe endometriosis.

METHODS

This retrospective cohort study included women with moderate-severe endometriosis (revised American Fertility Society stage III-IV) and endometrioma who underwent IVF with the ultra-long agonist protocol. We compared two groups: women undergoing EST for endometrioma before IVF (EST group), and women whose endometrioma was left in situ during IVF (No-EST group). The primary outcome was the CLBR per IVF cycle, including fresh and frozen embryo transfers. The secondary endpoints included the complication rate, number of mature oocytes retrieved, clinical pregnancy rate and pregnancy loss rate.

RESULTS

Seventy-four women were included in the study, with 37 in the EST group and 37 in the No-EST group, representing 67 and 69 IVF cycles, respectively. The population and cycle characteristics were comparable between the two groups, especially the ovarian response to stimulation. The CLBR was significantly increased in the EST group compared to the No-EST group (31.3% vs. 14.5%, p = 0.03). The clinical and biochemical pregnancy rates were significantly increased in the EST group (37.3% vs. 15.9%, p = 0.01 and 43.3% vs. 23.2%, p = 0.01, respectively). Multivariate analysis revealed a significantly increased chance of live birth in women exposed to EST before IVF with an adjusted OR of 2.68 (95% confidence interval, CI: 1.13-6.36, p = 0.02). In the EST group, we reported one major complication Clavien and Dindo classification grade III, complication involving an ovarian abscess that required a laparoscopic drainage.

CONCLUSIONS

EST is an interesting technique to improve IVF success rates in women with moderate-severe endometriosis. EST could be discussed before IVF in infertile women.

Endometriosis Lowers the Cumulative Live Birth Rates in IVF by Decreasing the Number of Embryos but Not Their Quality

Endometriosis and infertility are closely linked, but the underlying mechanisms are still poorly understood. This study aimed to evaluate the impact of endometriosis on in vitro fertilization (IVF) parameters, especially on embryo quality and IVF outcomes. A total of 1124 cycles with intracytoplasmic sperm injection were retrospectively evaluated, including 155 cycles with endometriosis and 969 cycles without endometriosis. Women with endometriosis had significantly lower ovarian reserve markers (AMH and AFC), regardless of previous ovarian surgery. Despite receiving significantly higher doses of exogenous gonadotropins, they had significantly fewer oocytes, mature oocytes, embryos, and top-quality embryos than women in the control group. Multivariate analysis did not reveal any association between endometriosis and the proportion of top-quality embryo (OR = 0.87; 95% CI [0.66-1.12]; p = 0.3). The implantation rate and the live birth rate per cycle were comparable between the two groups (p = 0.05), but the cumulative live births rate was significantly lower in in the endometriosis group (32.1% versus 50.7%, p = 0.001), as a consequence of the lower number of frozen embryos. In conclusion, endometriosis lowers the cumulative live birth rates by decreasing the number of embryos available to transfer, but not their quality.

The role of diet in unexpected poor response to ovarian stimulation: a cross-sectional study

RESEARCH QUESTION

Is there an association between diet and poor ovarian response to ovarian stimulation in women with normal biomarkers of ovarian reserve?

DESIGN

Women eligible for IVF at an Academic Fertility Center were invited to participate in this prospective cross-sectional study. The main inclusion criteria were age 18-39 years, body mass index 18-25 kg/m², preserved ovarian reserve (antral follicle count 10-22 or anti-Müllerian hormone concentration 2-5 ng/ml) and a starting dose of gonadotrophins of 150-225 IU/day. Information on diet was obtained using a validated food frequency questionnaire. 'Unexpected poor ovarian response' was defined as the retrieval of three or fewer suitable oocytes. A logistic regression model was used to adjust for confounders.

RESULTS

Out of the 303 women enrolled in the study, 48 (16%) showed an unexpected poor ovarian response. The frequency of poor responders increased with increasing glycaemic load, carbohydrate intake and fibre intake. When comparing the third with the first tertile (reference), the adjusted odds ratios for these were 3.91 (95% confidence interval [CI] 1.11-13.83, P = 0.04), 4.78 (95% CI 1.23-18.51, P = 0.02) and 6.03 (95% CI 1.18-30.77, P = 0.07), respectively.

CONCLUSIONS

Elevated dietary glycaemic load as well as carbohydrate intake and fibre intake is significantly associated with unexpected poor ovarian response. Future interventional studies should clarify whether dietary modification might restore normal response.

Dietary Carbohydrate Intake, Dietary Glycemic Load and Outcomes of In Vitro Fertilization: Findings from an Observational Italian Cohort Study

In recent decades, increasing attention has been paid to the influence of diet on reproductive health. Carbohydrates in diet affect glucose metabolism and multiple evidences showed the key role of insulin sensitivity in regulating female fertility. We designed a prospective cohort study to investigate the relation between dietary carbohydrate intake, glycemic load (GL) and the outcomes of assisted reproduction. A population of 494 female partners of couples referring to an Italian Fertility Center and eligible for in vitro fertilization (IVF) were enrolled in the study. On the day of the oocyte retrieval, information on their diet was obtained using a validated food frequency questionnaire (FFQ). We calculated the relative risk and 95% confidence interval of embryo transfer, clinical pregnancy and live birth according to the following dietary exposures: GL, glycemic index (GI) as well as the daily carbohydrate and fiber intake. A multiple regression model was used to account for the confounders. After adjusting for age, college degree, body mass index (BMI), leisure physical activity and previous assisted reproduction techniques (ART) cycles, no significant association was observed between the considered dietary exposures and the IVF outcomes. The roles of GL, carbohydrate intake and GI were assessed in strata of the cause of infertility and body mass index and no relation emerged in this further analysis. We found no clear association between the dietary carbohydrate quantity and quality and IVF outcomes in a cohort of infertile Italian women.

Peripheral Estrogens in Women with Endometriosis Undergoing IVF

A consistent body of in vitro evidence supports a detrimental effect of endometriosis on ovarian steroidogenesis, in particular the synthesis of estrogens. However, clinical evidence is scanty and methodologically weak. This study aimed at clarifying whether peripheral 17-β-estradiol during IVF are influenced by the presence of endometriosis. Women undergoing IVF were retrospectively reviewed. Cases were women with a diagnosis of endometriosis. Controls were matched to cases in a 1:1 ratio by study period, age, total number of developed follicles on the day of hCG administration, protocol of hyperstimulation, gonadotropin used, and starting dose. The primary outcome was the ratio between serum levels of 17-β-estradiol and the total number of developed follicles. Fifty-three women with endometriosis and 53 controls were selected. The median ratio (interquartile range) between serum 17-β-estradiol and the total number of developed follicles in the two groups was 207 (164-282) and 201 (144-268) pg/ml, respectively (p = 0.46). Sensitivity analyses on the magnitude of the follicular response, the history of surgery for endometriomas, and the presence of endometriomas did not show any subgroup at increased risk of peripheral estrogens impairment. Endometriosis does not influence peripheral levels of 17-β-estradiol during IVF. Our findings argue against a biologically relevant effect of the disease on ovarian estrogen-synthesis.

How common is real repeated implantation failure? An indirect estimate of the prevalence

RESEARCH QUESTION

What is the real prevalence of repeated implantation failure (RIF) and what reliable estimates can be given on the risk of false-positive diagnosis after two or three failed IVF attempts.

DESIGN

A recent theoretical model suggested that commonly used definitions (two or three failed IVF attempts in good-prognosis couples) may expose couples to substantial odds of overdiagnosis and overtreatment. This model, however, was theoretical and based on unproven assumptions that the pregnancy rate in the non-RIF population was 30% and the prevalence of RIF was 10%. In the present study, we applied this model to real data to distinguish the real prevalence of RIF and to provide more reliable estimates on the risk of false-positive diagnosis after two or three failed IVF attempts. To this aim, we retrospectively selected 1221 good-prognosis couples and evaluated pregnancy rates up to the third cycle.

RESULTS

The clinical pregnancy rate at first, second and third IVF cycle was 52%, 41% and 28%, respectively. A pregnancy rate of 61% was extrapolated in the non-RIF population and 15% among women who had experienced RIF. Therefore, the rate of false-positive diagnoses of RIF after two, three and six failed cycles would be 46%, 25%, and 2%, respectively.

CONCLUSIONS

Our analyses show that estimated prevalence of RIF is 15%. The frequently used definition of RIF based on three failed attempts (but not two) in good-prognosis couples seems justified. Physicians, however, should bear in mind that couples may be inappropriately labelled with this condition in one out of four cases.