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Skorupskaite K, Hardy M, Bhandari H, Yasmin E, Saab W, Seshadri S. Evidence based management of patients with endometriosis undergoing assisted conception: British fertility society policy and practice recommendations. HUM FERTIL 2024; 27:2288634. [PMID: 38226584 DOI: 10.1080/14647273.2023.2288634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 09/27/2023] [Indexed: 01/17/2024]
Abstract
Endometriosis is a chronic inflammatory condition in women of reproductive age, which can lead to infertility and pelvic pain. Endometriosis associated infertility is multifactorial in nature adversely affecting each step of the natural reproductive physiology and thereby processes and outcomes of Assisted Reproductive Technology (ART) cycles. These outcomes are further complicated by the subtype of endometriosis, being peritoneal, deep infiltrating and ovarian, which bear negative effects on ovarian reserve, response to stimulation, accessibility for oocyte retrieval, intraoperative safety and endometrial receptivity. There is still a lack of clear guidance about the role of surgery for ovarian endometriosis/endometriomas. This guideline evaluates the evidence of the impact of pelvic endometriosis and endometriomas on the outcome of ART and provides recommendations for management options before and during ART including intra-uterine insemination. Recommendations are made based on the current evidence for the management of patients with endometriosis across each step of ART with the primary aim of improving ART outcomes.
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Affiliation(s)
- Karolina Skorupskaite
- Edinburgh Fertility & Reproductive Endocrine Centre, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Madeleine Hardy
- Leeds Centre for Reproductive Medicine at Leeds Teaching Hospitals NHS Trust, Seacroft Hospital, Leeds, UK
| | - Harish Bhandari
- Leeds Centre for Reproductive Medicine at Leeds Teaching Hospitals NHS Trust, Seacroft Hospital, Leeds, UK
| | - Ephia Yasmin
- Reproductive Medicine Unit, University College London Hospital NHS Foundation Trust, London, UK
| | - Wael Saab
- The Centre for Reproductive & Genetic Health, London, UK
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Gwata N, Hui A, Wong L, Thee LJ, Tsaltas J, Mol B. A 24-Months Follow-Up Study of Individuals With Endometriosis Using Transvaginal Ultrasound. J Minim Invasive Gynecol 2024; 31:695-703. [PMID: 38692482 DOI: 10.1016/j.jmig.2024.04.010] [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: 01/29/2024] [Revised: 04/07/2024] [Accepted: 04/11/2024] [Indexed: 05/03/2024]
Abstract
STUDY OBJECTIVE To investigate the progression of deep infiltrating endometriosis using transvaginal ultrasound surveillance of patients undergoing conservative management. DESIGN Retrospective single cohort. SETTING Australian tertiary university hospital PATIENTS: One hundred twenty two women with endometriosis proven on transvaginal ultrasound who had not undergone surgical management. INTERVENTIONS The progression of endometriosis lesions demonstrated on transvaginal ultrasound in women receiving conservative management over the course of 24 months. MEASUREMENTS AND MAIN RESULTS A total of 122 patients fulfilled the inclusion criteria. All women had 2 ultrasounds that were performed at least 6 months apart. The median follow-up time was 490.5 days (255.4-725.6). At second scan, 22% (95% CI: 15-30%) of cohort experienced an increase in the number of endometriosis nodules compared to first scan, with 51% (95% CI: 42-60%) remaining static while 27% (95% CI: 19-35%) experienced a decrease. While there was no statistically significant difference in the volumes of uterosacral ligament, retro cervical, and bowel endometriosis, endometrioma volumes were significantly lower at second scan (Median = 3.24 mL, IQR = 0.6-16.87) as compared to the first scan (Median = 7.41 mL, IQR = 2.04-28.95), p <.001. CONCLUSION Individuals with deep infiltrating endometriosis are unlikely to see significant disease progression over time. Both surgical and nonsurgical interventions are effective in managing endometriosis in terms of endometriotic nodule size and number, as measured by ultrasound.
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Affiliation(s)
- Nyasha Gwata
- Department of Gynaecological Endoscopy and Endometriosis Surgery, Monash Health (Drs. Gwata and Tsaltas), Bentleigh East, Australia.
| | - Ally Hui
- Monash University (Dr. Hui), Melbourne, Australia
| | - Lufee Wong
- Monash Health (Drs. Wong and Thee), Clayton, Australia
| | - Li Jing Thee
- Monash Health (Drs. Wong and Thee), Clayton, Australia
| | - Jim Tsaltas
- Department of Gynaecological Endoscopy and Endometriosis Surgery, Monash Health (Drs. Gwata and Tsaltas), Bentleigh East, Australia
| | - Ben Mol
- Department of Obstetrics and Gynaecology, Monash University (Dr. Mol), Clayton, Australia
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Younis JS, Taylor HS. The impact of ovarian endometrioma and endometriotic cystectomy on anti-Müllerian hormone, and antral follicle count: a contemporary critical appraisal of systematic reviews. Front Endocrinol (Lausanne) 2024; 15:1397279. [PMID: 38800489 PMCID: PMC11116636 DOI: 10.3389/fendo.2024.1397279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 04/24/2024] [Indexed: 05/29/2024] Open
Abstract
Currently, three crucial questions regarding the reliability of ovarian reserve measures in women with ovarian endometrioma during the reproductive age are being discussed. Firstly, the effects of endometriotic cystectomy on short and long-term ovarian reserve. Secondly, the accuracy of serum anti-Müllerian hormone (AMH) and antral follicle count (AFC) in estimating ovarian reserve in these cases. Thirdly, the impact of endometrioma itself on the ovarian reserve over time in such cases. The purpose of the present review is to critically assess available systematic reviews and meta-analyses that have explored these questions. Nine eligible reviews were found following a systematic search on PubMed.com and similarly assessed. These reviews varied considerably regarding the level of evidence, as per an identical comprehensive scoring system. Moderate to high-quality evidence demonstrates that endometriotic cystectomy, by the stripping technique, adversely affects ovarian reserve in the short and long term, up to 9-18 months post-surgery. Damage to ovarian reserve was considerable but more pronounced in bilateral cases than unilateral cases, equivalent to 39.5% and 57.0%, respectively. Repeat endometriotic cystectomy is detrimental to ovarian reserve. The impact of endometrioma diameter on ovarian reserve before or after surgery is still unclear. Moderate to high-quality evidence, relying on simultaneous assessment of both ovarian reserve measures, shows that AMH is sensitive while AFC is not in cases undergoing ovarian cystectomy. AMH should be the biomarker of choice for counseling and managing women with endometrioma in their reproductive age, especially before surgery. While there is some evidence to show that endometrioma per se may harm ovarian reserve, this evidence is not robust, and there is good-quality evidence to challenge this notion. It is necessary to conduct further targeted RCTs, systematic reviews, and meta-analyses based on solid methodological grounds to increase the level of evidence, refine quantitative estimates, investigate open questions, and decrease heterogeneity.
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Affiliation(s)
- Johnny S. Younis
- Reproductive Medicine, Department of Obstetrics and Gynecology, Tzafon Medical Center, Poriya, Israel
- Azrieili Faculty of Medicine in Galilee, Bar-Ilan University, Safed, Israel
| | - Hugh S. Taylor
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT, United States
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4
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Thiel PS, Donders F, Kobylianskii A, Maheux-Lacroix S, Matelski J, Walsh C, Murji A. The Effect of Hormonal Treatment on Ovarian Endometriomas: A Systematic Review and Meta-Analysis. J Minim Invasive Gynecol 2024; 31:273-279. [PMID: 38190884 DOI: 10.1016/j.jmig.2024.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 12/27/2023] [Accepted: 01/03/2024] [Indexed: 01/10/2024]
Abstract
OBJECTIVE To evaluate the effect of hormonal suppression of endometriosis on the size of endometriotic ovarian cysts. DATA SOURCES The authors searched MEDLINE, PubMed, Cochrane Central Register of Controlled Trials, Embase, and ClinicalTrials.gov from January 2012 to December 2022. METHODS OF STUDY SELECTION We included studies of premenopausal women undergoing hormonal treatment of endometriosis for ≥3 months. The authors excluded studies involving surgical intervention in the follow-up period and those using hormones to prevent endometrioma recurrence after endometriosis surgery. Risk of bias was assessed with the Newcastle-Ottawa Scale and Cochrane Risk of Bias Tool. The protocol was registered in PROSPERO (CRD42022385612). TABULATION, INTEGRATION, AND RESULTS The primary outcome was the mean change in endometrioma volume, expressed as a percentage, from baseline to at least 6 months. Secondary outcomes were the change in volume at 3 months and analyses by class of hormonal therapy. The authors included 16 studies (15 cohort studies, 1 randomized controlled trial) of 888 patients treated with dienogest (7 studies), other progestins (4), combined hormonal contraceptives (2), and other suppressive therapy (3). Globally, the decrease in endometrioma volume became statistically significant at 6 months with a mean reduction of 55% (95% confidence interval, -40 to -71; 18 treatment groups; 730 patients; p <.001; I2 = 96%). The reduction was the greatest with dienogest and norethindrone acetate plus letrozole, followed by relugolix and leuprolide acetate. The volume reduction was not statistically significant with combined hormonal contraceptives or other progestins. There was high heterogeneity, and studies were at risk of selection bias. CONCLUSION Hormonal suppression can substantially reduce endometrioma size, but there is uncertainty in the exact reduction patients may experience.
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Affiliation(s)
- Peter S Thiel
- Department of Obstetrics and Gynecology (Drs. Thiel, Kobylianskii, and Murji), Mount Sinai Hospital, Toronto, ON, Canada; Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON, Canada (Drs. Thiel, Kobylianskii, and Murji)
| | - Francesca Donders
- Department of Obstetrics, Gynecology, and Reproduction, Université Laval, Quebec City, QC, Canada (Drs. Donders and Maheux-Lacroix)
| | - Anna Kobylianskii
- Department of Obstetrics and Gynecology (Drs. Thiel, Kobylianskii, and Murji), Mount Sinai Hospital, Toronto, ON, Canada; Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON, Canada (Drs. Thiel, Kobylianskii, and Murji)
| | - Sarah Maheux-Lacroix
- Department of Obstetrics, Gynecology, and Reproduction, Université Laval, Quebec City, QC, Canada (Drs. Donders and Maheux-Lacroix)
| | - John Matelski
- Biostatistics Research Unit, University Health Network, Toronto, ON, Canada (Matelski)
| | - Chris Walsh
- Library Services (Dr. Walsh), Mount Sinai Hospital, Toronto, ON, Canada
| | - Ally Murji
- Department of Obstetrics and Gynecology (Drs. Thiel, Kobylianskii, and Murji), Mount Sinai Hospital, Toronto, ON, Canada; Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON, Canada (Drs. Thiel, Kobylianskii, and Murji).
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5
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Giacomini E, Pagliardini L, Minetto S, Pinna M, Kleeman F, Bonesi F, Makieva S, Pavone V, Reschini M, Papaleo E, Candiani M, Somigliana E, Viganò P. The relationship between CYP19A1 gene expression in luteinized granulosa cells and follicular estradiol output in women with endometriosis. J Steroid Biochem Mol Biol 2024; 237:106439. [PMID: 38048918 DOI: 10.1016/j.jsbmb.2023.106439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 11/09/2023] [Accepted: 11/27/2023] [Indexed: 12/06/2023]
Abstract
Endometriosis was claimed to negatively affect the intrafollicular environment, hindering oocyte competence. Previous studies evaluated expression levels of cytochrome P450 aromatase (CYP19A) in granulosa and cumulus oophorus cells collected from endometriosis women, but results are controversial. To further investigate the intrafollicular environment whose alteration may potentially disturb ovarian steroidogenesis in endometriosis, gene expression of CYP19A and of its upstream enzymes, StAR and 3βHSD was assessed in luteinized granulosa cells isolated from follicular fluids (FF) collected during Assisted Reproduction Technology (ART) procedures in women with stage III-IV disease and from subjects without the condition. In a subgroup of patients, cumulus oophorus cells (COCs) were also assessed for CYP19A, StAR and 3βHSD gene expression. No difference in mRNA expression of CYP19A1, StAR and 3βHSD in both granulosa cells and COCs was observed between the two groups of patients. No significant difference was also found between estradiol FF levels detected in endometriosis patients (median=873, IQR=522-1221 ng/ml)) and control patients (median=878, IQR=609-1137 ng/ml). To gain more insight into the intrafollicular regulation of CYP19A in patients with endometriosis, associations between expression of the analyzed genes, systemic and follicular 17β-estradiol levels and ART outcomes were assessed. While in the control group, levels of CYP19A1, StAR and 3βHSD transcripts significantly correlated with follicular estradiol levels (adjusted R² of 0.60), no significant association was detected in affected women (adjusted R² of 0.23). After stratification of the populations based on the presence of the disease, CYP19A1 expression was shown to correlate with the number of oocytes retrieved [β:- 1.214;95%CI: - 2.085 - (-0.343); p = 0.007] in the control group while this association was not present in patients with endometriosis [β:- 0.003; 95%CI:- 0.468-0.461; p = 0.988)]. These results do not support data from the literature indicating a reduced aromatase expression in granulosa cells of affected women, but they highlight a potential subtle mechanism affecting the ovulation process in these women.
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Affiliation(s)
- Elisa Giacomini
- Reproductive Sciences Laboratory, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Luca Pagliardini
- Reproductive Sciences Laboratory, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Sabrina Minetto
- Reproductive Sciences Laboratory, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Monica Pinna
- Infertility Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Fabiola Kleeman
- Reproductive Sciences Laboratory, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesca Bonesi
- Reproductive Sciences Laboratory, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Sofia Makieva
- Reproductive Sciences Laboratory, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Valentina Pavone
- Reproductive Sciences Laboratory, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marco Reschini
- Infertility Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Enrico Papaleo
- Centro Scienze della Natalità, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Massimo Candiani
- Department of Obstetrics and Gynecology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Edgardo Somigliana
- Infertility Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Paola Viganò
- Reproductive Sciences Laboratory, IRCCS San Raffaele Scientific Institute, Milan, Italy
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Leone Roberti Maggiore U, Chiappa V, Ceccaroni M, Roviglione G, Savelli L, Ferrero S, Raspagliesi F, Spanò Bascio L. Epidemiology of infertility in women with endometriosis. Best Pract Res Clin Obstet Gynaecol 2024; 92:102454. [PMID: 38183767 DOI: 10.1016/j.bpobgyn.2023.102454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 12/21/2023] [Indexed: 01/08/2024]
Abstract
Endometriosis is a benign, chronic, inflammatory condition affecting up to 10 % of women and characterised by the presence of glands and stroma tissue outside the uterus. Epidemiological and clinical studies demonstrate a consistent association between endometriosis and infertility. However, this relationship is far to be clearly understood and several mechanisms are involved. Available data show that patients with endometriosis have an increased estimated risk of infertility between two and four times compared with the general population. On the other hand, the probability of patients with infertility to have endometriosis is reported up to about 50 % of the cases. Future studies should aim to better elucidate the mechanisms behind endometriosis-associated infertility in order to offer the more appropriate and tailored management for the patients.
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Affiliation(s)
| | - Valentina Chiappa
- Gynecologic Oncology Unit, Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy
| | - Marcello Ceccaroni
- Department of Obstetrics and Gynecology, Gynecologic Oncology and Minimally Invasive Pelvic Surgery, International School of Surgical Anatomy, IRCCS "Sacro Cuore - Don Calabria" Hospital, Negrar di Valpolicella, Verona, Italy
| | - Giovanni Roviglione
- Department of Obstetrics and Gynecology, Gynecologic Oncology and Minimally Invasive Pelvic Surgery, International School of Surgical Anatomy, IRCCS "Sacro Cuore - Don Calabria" Hospital, Negrar di Valpolicella, Verona, Italy
| | - Luca Savelli
- Obstetrics and Gynecology Unit, Morgagni-Pierantoni Hospital, Forlì, Italy
| | - Simone Ferrero
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genoa, Italy; Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Francesco Raspagliesi
- Gynecologic Oncology Unit, Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy
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7
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Somigliana E, Piani LL, Paffoni A, Salmeri N, Orsi M, Benaglia L, Vercellini P, Vigano' P. Endometriosis and IVF treatment outcomes: unpacking the process. Reprod Biol Endocrinol 2023; 21:107. [PMID: 37936154 PMCID: PMC10629090 DOI: 10.1186/s12958-023-01157-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 10/26/2023] [Indexed: 11/09/2023] Open
Abstract
Advanced endometriosis is associated with a reduction of IVF success. Surgical damage to the ovarian reserve following the excision of endometriomas has been claimed as a critical factor in the explanation of this detrimental effect. However, it is generally inferred that other mechanisms might also hamper IVF success in affected women. They include diminished responsiveness to ovarian stimulation, altered steroidogenesis, a decline in oocyte quality, reduced fertilization and embryo development, and impaired implantation. To navigate these limitations, we scrutinized available literature for studies specifically designed to address distinct phases of the IVF process. Utmost consideration was given to intra-patient ovarian response comparisons in women with unilateral endometriomas and to studies applying a meticulous matching to control confounders. The following observations have been drawn: 1) endometriosis has a negligible impact on ovarian response. A slight reduction in stimulation response can only be observed for endometriomas larger than 4 cm. Follicular steroidogenesis is unaffected; 2) oocyte quality is not hampered. Fertilization rates are similar, and intracytoplasmic sperm injection (ICSI) is not justified. Embryonic development is uncompromised, with no increase in aneuploidy rate; 3) endometrial receptivity is either unaffected or only slightly impacted. In conclusion, our study suggests that, aside from the well-known negative effect on ovarian reserve from excisional endometrioma surgeries, endometriosis does not significantly affect IVF outcomes.
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Affiliation(s)
- Edgardo Somigliana
- Academic Center for Research on Adenomyosis and Endometriosis, Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
- Dipartimento Area Materno Infantile, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Letizia Li Piani
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | | | - Noemi Salmeri
- Gynecology and Obstetrics Unit, IRCCS San Raffaele Scientific Institute and Vita-Salute San Raffaele University, Milan, Italy
| | - Michele Orsi
- Dipartimento Area Materno Infantile, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Laura Benaglia
- Dipartimento Area Materno Infantile, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Paolo Vercellini
- Academic Center for Research on Adenomyosis and Endometriosis, Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
- Dipartimento Area Materno Infantile, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Paola Vigano'
- Dipartimento Area Materno Infantile, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
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Zareii A, Askary E, Ghahramani A, Chamanara K, Abadi AKH, Afzalzadeh A. Evaluation of endometrioma size effect on ovarian reserve, embryo quality and pregnancy outcome after in vitro fertilization cycle; a cross-sectional study. BMC Womens Health 2023; 23:327. [PMID: 37344833 DOI: 10.1186/s12905-023-02482-1] [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: 09/26/2022] [Accepted: 06/14/2023] [Indexed: 06/23/2023] Open
Abstract
INTRODUCTION Investigation of endometrioma size and its laterality on the quality of the embryo in patients with endometrioma compared to healthy subjects. MATERIALS AND METHODS In this retrospective and cross-sectional study, 70 patients with unilateral and bilateral endometrioma were recruited and compared with 70 age-matched infertile patients as the control group in terms of AMH before ovum pick-up, embryo quality as well as pregnancy outcome. Additionally, in the case group, we divided both unilateral (n = 32) and bilateral endometrioma patients (n = 38) into three groups based on the size of endometrioma. (1-3 cm, 3-6 cm, 6-10 cm) RESULTS: There was no difference in terms of age, BMI, parity, and age of menarche between the case and control groups. Moreover, no significant difference was observed in the baseline level of AMH between the case 2.96 ± 2.72 ng/dl (0.21-11.3) and control 2.73 ± 2.39 (0.21-12.8) groups. (P = 0.59) There was also no significant difference concerning AMH level between unilateral 3.58 ± 3.20 ng/dl (0.21-12.8) and bilateral endometrioma 2.45 ± 2.14 (0.21 - 0.20) groups. In terms of the quality and number of embryos, there was no significant difference between the case and control groups. (P = 0.30) Although the AMH level decreased with the increase in endometrioma size, this difference was not statistically significant. (P = 0.07) There was no significant difference in terms of the embryo quality between the groups based on the size of endometrioma. (P = 0.77) In addition, no significant difference was observed between the case and control groups in the terms of birth weight and pregnancy complications, such as premature delivery, cesarean section rate, neonatal respiratory distress, jaundice, as well as hospitalization rate. Head circumference of the newborns was higher in the endometrioma group while their Apgar score was lower in the case compared to the control group. CONCLUSION The presence of endometrioma by itself does not affect the main result of IVF procedures, including the number and quality of embryos and pregnancy outcome. Thus, IVF and embryo preservation and even pregnancy before surgery seem to be reasonable for endometriotic patients.
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Affiliation(s)
- Afsson Zareii
- Department of Obstetrics and Gynecology, School of Medicine, Infertility Research Center, Shiraz University Of Medical Sciences, Shiraz, Iran
| | - Elham Askary
- Department of Obstetrics and Gynecology, School of Medicine, Infertility Research Center, Shiraz University Of Medical Sciences, Shiraz, Iran.
- Obstetrics and Gynecology Office, Shahid Faghihi Hospital, Zand Avenue, Shiraz, 7134844119, Iran.
| | - Ameneh Ghahramani
- Department of Obstetrics and Gynecology, School of Medicine, Infertility Research Center, Shiraz University Of Medical Sciences, Shiraz, Iran
| | - Kefayat Chamanara
- Department of Obstetrics and Gynecology, Shiraz University Of Medical Sciences, Shiraz, Iran
| | - Alimohammad Keshtvarz Hesam Abadi
- Clinical Research Development Center of Nemazee Hospital, Department of Statistics, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Azadeh Afzalzadeh
- Department of Obstetrics and Gynecology, Shiraz University Of Medical Sciences, Shiraz, Iran
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Ottolina J, Vignali M, Papaleo E, Viganò P, Somigliana E, Ferrari S, Liprandi V, Belloni G, Reschini M, Candiani M, Vercellini P, Benaglia L. Surgery versus IVF for the treatment of infertility associated to ovarian and deep endometriosis (SVIDOE: Surgery Versus IVF for Deep and Ovarian Endometriosis). Clinical protocol for a multicenter randomized controlled trial. PLoS One 2022; 17:e0271173. [PMID: 35921357 PMCID: PMC9348732 DOI: 10.1371/journal.pone.0271173] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 06/23/2022] [Indexed: 11/18/2022] Open
Abstract
The management of endometriosis-related infertility is still a challenging issue. Women can be managed with either surgery or in vitro fertilization (IVF). The decision is tailored to the patients considering pros and cons of both approaches. Surgery might increase the chances of natural conception and relieve symptoms. IVF may be more effective, but costs are higher and unoperated women face some peculiar additional risks during the procedure and pregnancy. The unavailability of randomized trials comparing the two strategies hampers the possibility to provide precise estimates. This Randomized Controlled Trial (RCT) aims at filling this gap. This is a multicenter, non-blinded, randomized controlled trial with parallel groups and allocation 1:1. Three Italian Academic Infertility Units will be involved. Main inclusion criteria are infertility for more than one year, age less than 40 years and a sonographic diagnosis of endometriosis (ovarian endometriomas or deep peritoneal lesions). Previous IVF and previous surgery for endometriosis are exclusion criteria. Women will be randomized to either surgery and then natural pregnancy seeking or a standard program of three IVF cycles. The primary aim is the comparison of live birth rate between the two groups (IVF versus surgery) within one year of randomization. The secondary aim is the evaluation of cost-effective profile of the two interventions. The present study can influence the clinical practice of infertility treatment in women with endometriosis. From a public health perspective, information on the more cost-effective clinical management strategy would consent a wiser allocation of resources. Trial registration:NCT04743167, registered on 8 February 2021.
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Affiliation(s)
- Jessica Ottolina
- Department of Gynecology and Obstetrics, San Raffaele Scientific Institute, Milan, Italy
- * E-mail:
| | - Michele Vignali
- Department of Biomedical Sciences for Health, Macedonio Melloni Hospital, University of Milan, Milan, Italy
| | - Enrico Papaleo
- Department of Gynecology and Obstetrics, San Raffaele Scientific Institute, Milan, Italy
| | - Paola Viganò
- Department of Gynecology and Obstetrics, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Edgardo Somigliana
- Department of Gynecology and Obstetrics, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Stefano Ferrari
- Department of Gynecology and Obstetrics, San Raffaele Scientific Institute, Milan, Italy
| | - Valeria Liprandi
- Department of Biomedical Sciences for Health, Macedonio Melloni Hospital, University of Milan, Milan, Italy
| | - Gaia Belloni
- Department of Biomedical Sciences for Health, Macedonio Melloni Hospital, University of Milan, Milan, Italy
| | - Marco Reschini
- Department of Gynecology and Obstetrics, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Massimo Candiani
- Department of Gynecology and Obstetrics, San Raffaele Scientific Institute, Milan, Italy
| | - Paolo Vercellini
- Department of Gynecology and Obstetrics, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Laura Benaglia
- Department of Gynecology and Obstetrics, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
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Bourdon M, Dahan Y, Maignien C, Patrat C, Bordonne C, Marcellin L, Chapron C, Santulli P. Influence of endometrioma size on assisted reproductive technology outcomes. Reprod Biomed Online 2022; 45:1237-1246. [DOI: 10.1016/j.rbmo.2022.08.097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 08/02/2022] [Accepted: 08/05/2022] [Indexed: 11/24/2022]
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Nie J, Zhao C, Laganà AS, Liu X, Guo SW. Identification of lesional attributes of dysmenorrhea severity and the serum antimüllerian hormone levels in women with ovarian endometriomas. Fertil Steril 2022; 118:191-202. [DOI: 10.1016/j.fertnstert.2022.04.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 04/08/2022] [Accepted: 04/12/2022] [Indexed: 01/06/2023]
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Filippi F, Benaglia L, Alagna F, La Vecchia I, Biancardi R, Reschini M, Somigliana E, Vercellini P. Decidualization of endometriosis in a cohort of IVF-mediated pregnancies. Sci Rep 2022; 12:1524. [PMID: 35087168 PMCID: PMC8795262 DOI: 10.1038/s41598-022-05635-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 01/13/2022] [Indexed: 01/01/2023] Open
Abstract
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.
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Affiliation(s)
- Francesca Filippi
- Infertility Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via M. Fanti, 6, 20122, Milan, Italy
| | - Laura Benaglia
- Infertility Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via M. Fanti, 6, 20122, Milan, Italy
| | - Federica Alagna
- Infertility Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via M. Fanti, 6, 20122, Milan, Italy
| | - Irene La Vecchia
- Infertility Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via M. Fanti, 6, 20122, Milan, Italy
| | - Rossella Biancardi
- Centro Scienze Natalità, Gynecol/Obstet Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Marco Reschini
- Infertility Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via M. Fanti, 6, 20122, Milan, Italy
| | - Edgardo Somigliana
- Infertility Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via M. Fanti, 6, 20122, Milan, Italy.
| | - Paolo Vercellini
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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Orlando MS, Yao M, Chang OH, Shippey E, Bosko T, Cadish L, Falcone T, Kho RM. Perioperative outcomes in a nationwide sample of patients undergoing surgical treatment of ovarian endometriomas. Fertil Steril 2021; 117:444-453. [PMID: 34802687 DOI: 10.1016/j.fertnstert.2021.10.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 10/08/2021] [Accepted: 10/08/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To evaluate the perioperative outcomes of premenopausal women undergoing cystectomy or oophorectomy for ovarian endometriomas (OMAs) and other benign neoplasms. DESIGN Retrospective cohort study. SETTING Clinical database containing information from 580 US hospitals. PATIENT(S) Women 18 to 50 years old who underwent ovarian cystectomy or oophorectomy for benign indications between 2010 and 2020. INTERVENTION(S) We compared procedure route, length of hospital stay, and complication rates by surgical indication (OMA vs. other benign neoplasms) and surgical procedure (cystectomy vs. oophorectomy). MAIN OUTCOME MEASURE(S) Thirty-day perioperative adverse events following adnexal surgery, including conversion to laparotomy, blood transfusion, ileus, urinary tract injury, bowel injury, readmission, and death. RESULT(S) We identified 120,208 ovarian cystectomies (28,182 OMAs and 92,026 other indications) and 53,476 oophorectomies (8,622 OMAs and 44,854 other indications). During cystectomy, patients with OMAs more commonly experienced conversion to laparotomy (5.1% vs. 3.1%) and readmission (8.5% vs. 7.1%). For oophorectomies, patients with OMAs less frequently had minimally invasive surgery (55.8% vs. 64.8%) or outpatient procedures (33.8% vs. 41.8%). Urinary tract and bowel injuries were rare. Multivariable logistic regression demonstrated that the presence of OMA predicted composite complications during cystectomy (adjusted odds ratio [aOR] 1.23, 95% confidence interval [CI] 1.18-1.28) but not during oophorectomy (aOR 1.05, 95% CI 0.99-1.12). Patients with OMAs had 1.37 times the odds of a composite complication during oophorectomy than during cystectomy (95% CI 1.28-1.47). CONCLUSION(S) Patients undergoing ovarian cystectomy for OMAs had higher rates of perioperative adverse events than patients undergoing ovarian cystectomy for other benign neoplasms. Laparotomies were performed more often during oophorectomies for OMAs than for other benign indications.
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Affiliation(s)
- Megan S Orlando
- Department of Obstetrics and Gynecology, Women's Health Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Meng Yao
- Department of Quantitative Health Sciences, Section of Biostatistics, Cleveland Clinic, Cleveland, Ohio
| | - Olivia H Chang
- Department of Obstetrics and Gynecology, Women's Health Institute, Cleveland Clinic, Cleveland, Ohio
| | | | | | - Lauren Cadish
- Department of Obstetrics and Gynecology, Providence Saint John's Health Center, Santa Monica, California
| | - Tommaso Falcone
- Department of Obstetrics and Gynecology, Women's Health Institute, Cleveland Clinic, Cleveland, Ohio
| | - Rosanne M Kho
- Department of Obstetrics and Gynecology, Women's Health Institute, Cleveland Clinic, Cleveland, Ohio
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Benaglia L, Mensi L, DI Gesaro L, Somigliana E. Safety of in-vitro fertilization in women with endometriosis. Minerva Obstet Gynecol 2021; 73:333-340. [PMID: 34008387 DOI: 10.23736/s2724-606x.21.04711-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
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.
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Affiliation(s)
- Laura Benaglia
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy -
| | - Laura Mensi
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,University of Milan, Milan, Italy
| | - Luca DI Gesaro
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,University of Milan, Milan, Italy
| | - Edgardo Somigliana
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,University of Milan, Milan, Italy
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