The Impact of laparoscopic surgery of peritoneal endometriosis and endometrioma on the outcome of ICSI cycles

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

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

Analysis of 2438 cycles for the impact of endometrioma and its surgery on the IVF outcomes

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.

Reproductive, obstetric, and perinatal outcomes of women with adenomyosis and endometriosis: a systematic review and meta-analysis

BACKGROUND

The reproductive impact of adenomyosis and endometriosis is widely researched but the extent of these impacts remains elusive. It has been demonstrated that endometriosis, in particular, is known to result in subfertility but endometriosis and adenomyosis are increasingly linked to late pregnancy complications such as those caused by placental insufficiency. At the molecular level, the presence of ectopic endometrium perturbs the endometrial hormonal, cellular, and immunological milieu, negatively influencing decidualization, placentation, and developmental programming of the embryo. It is unclear if and how such early aberrant reproductive development relates to pregnancy outcomes in endometriosis and adenomyosis.

OBJECTIVE AND RATIONALE

The aims of this systematic review and meta-analysis were to (i) investigate the association of adenomyosis and endometriosis with fertility, obstetric, and neonatal outcomes of women through both assisted reproduction and natural conception and (ii) determine whether endometriosis disease subtypes have specific impacts on different stages of the reproductive process.

SEARCH METHODS

A systematic literature review of NHS evidence electronic databases and the Cochrane database identified all comparative and observational studies between 1980 and December 2018 in any language on adenomyosis and endometriosis with fertility, obstetric, and neonatal outcomes (23 search terms used). A total of 104 papers were selected for data extraction and meta-analysis, with use of Downs and Black standardized checklist to evaluate quality and bias.

OUTCOMES

We found that endometriosis consistently leads to reduced oocyte yield and a reduced fertilization rate (FR), in line with current evidence. Milder forms of endometriosis were most likely to affect the fertilization (FR OR 0.77, CI 0.63-0.93) and earlier implantation processes (implantation rate OR 0.76, CI 0.62-0.93). The more severe disease by American Society for Reproductive Medicine staging (ASRM III and IV) influenced all stages of reproduction. Ovarian endometriosis negatively affects the oocyte yield (MD -1.22, CI -1.96, -0.49) and number of mature oocytes (MD -2.24, CI -3.4, -1.09). We found an increased risk of miscarriage in both adenomyosis and endometriosis (OR 3.40, CI 1.41-8.65 and OR 1.30, CI 1.25-1.35, respectively), and endometriosis can be associated with a range of obstetric and fetal complications including preterm delivery (OR 1.38, CI 1.01-1.89), caesarean section delivery (OR 1.98 CI 1.64-2.38), and neonatal unit admission following delivery (OR 1.29, CI 1.07-1.55).

WIDER IMPLICATIONS

Adenomyosis and the subtypes of endometriosis may have specific complication profiles though further evidence is needed to be able to draw conclusions. Several known pregnancy complications are likely to be associated with these conditions. The complications are possibly caused by dysfunctional uterine changes leading to implantation and placentation issues and therefore could potentially have far-reaching consequences as suggested by Barker's hypothesis. Our findings would suggest that women with these conditions should ideally receive pre-natal counselling and should be considered higher risk in pregnancy and at delivery, until evidence to the contrary is available. In order to expand our knowledge of these conditions and better advise on future management of these patients in reproductive and maternal medicine, a more unified approach to studying fertility and reproductive outcomes with longer term follow-up of the offspring and attention to the subtype of disease is necessary.

Analysis of factors related to fertility after endometriosis combined with infertility laparoscopic surgery

To investigate the influence factors of laparoscopic postoperative pregnancy of patients with endometriosis and infertility, further validate the application of EFI scoring system in endometriosis, and to improve the pregnancy rate.A total of 258 patients with endometriosis and infertility who underwent laparoscopic surgery and follow-up treatment at Wuxi Maternal and Child Health Hospital from January 2015 to December 2016 were selected and divided into pregnant and non-pregnant groups according to whether they were pregnant. All patients were divided into 4 groups according to EFI score: group with EFI score ≥9, 7-8, 4-6, and <4, and divided into I, II, III, and IV groups according to AFS stages. The uterus-laparoscopic surgery was performed. The patients were followed up for 3 years. The factors affecting the pregnancy rate were analyzed. The pregnancy rate and pregnancy types were calculated at different time points.Multivariate analysis showed that age <35 years, infertility time <5 years, secondary infertility, EFI score, postoperative ART application were protection factors of postoperative pregnancy. The 3-year cumulative postoperative pregnancy rate was 75.6%. The cumulative pregnancy rate was 92.2% in group with EFI score ≥9, 85.9% in group with EFI score 7-8, 62.5% in group with EFI score 4-6 and 5.9% in group with EFI score <4, there was significant difference between the 4 groups (P < .05). The proportion of pregnancies in 6 months and 12 months was higher in patients with EFI score ≥7, 61.0% in patients with EFI score ≥9 and 41.1% in patients with EFI score ≥7. The highest natural pregnancy rate was 83.1% in group with EFI score ≥9, and there was significant difference between the 4 groups (P < .05).Age <35 years, infertility time <5 years, secondary infertility, EFI score and ART application were the protective factors of postoperative pregnancy. EFI score had positive significance in predicting and guiding the postoperative pregnancy of patients with endometriosis and infertility. According to EFI score, the pregnancy rate of patients with endometriosis and infertility can be significantly improved by strict management and active pregnancy program.

The impact of different etiologies of diminished ovarian reserve on pregnancy outcome in IVF-ET cycles

Background/aim

Diminished ovarian reserve (DOR) represents a major challenge in reproductive medicine, as it is often associated with poor ovarian stimulation response, high cycle cancellation rate, and low pregnancy rate. The aim of the present study is to compare the clinical pregnancy rates in intracytoplasmic sperm injection-embryo transfer (ICSI-ET) cycles in patients with different DOR etiologies.

Materials and methods

Patient data were recorded with a computer-based program called Success Estimation Using a Ranking Algorithm (SERA). Overall, 459 patients were divided into 3 groups according to their DOR etiologies (Group A: idiopathic, n = 81; Group B: age-related, n = 294; Group C: previous ovarian surgery, n = 84).

Results

Out of 459 stimulation cycles, 378 (82.4%) reached the oocyte retrieval stage, while 201 (43.8%) had embryo transfers. There was no significant difference between the patients with different DOR etiologies in terms of embryo transfer and cycle cancellation rate. The patients who had embryo transfer were 44 (52.4%) in Group A, 38 (46.9%) in Group B, and 119 (40.5%) in Group C. There were no significant differences between the three groups (P = 0.114). The percentages of women who had oocyte retrieval were 84.5% in Group A, 70% in Group B, and 80.3% in Group C (P = 0.104). While clinical pregnancy per transfer was 35.8% in Group A, 19.8% in Group B, and 29.5% in Group C, there was no statistically significant difference between the groups (P = 0.113).

Conclusion

Although ovulation induction and ICSI-ET outcomes, including clinical pregnancy and live birth rates, were not significantly different with regards to the etiology of DOR, young women with DOR may benefit from assisted reproductive techniques.

Live Birth Rate after Surgical and Expectant Management of Endometriomas after In Vitro Fertilization: A Systematic Review, Meta-Analysis, and Critical Appraisal of Current Guidelines and Previous Meta-Analyses

Controversy exists regarding surgical management of endometriomas in infertile women before in vitro fertilization (IVF) because growing evidence indicates that surgery may impair the ovarian response. The objective of the present systematic review and meta-analysis was to compare surgical and expectant management of endometriomas regarding IVF outcomes. Prospective and retrospective controlled studies were found via the Cochrane Library, Embase, and MEDLINE databases. Thirteen studies (1 randomized controlled trial and 12 observational studies, N = 2878) were pooled, and similar live birth rates were observed in the surgically and expectantly managed groups (odds ratio = 0.83; 95% confidence interval [CI], 0.56-1.22; p = .98). The clinical pregnancy rates (odds ratio = 0.83; 95% CI, 0.66-1.05; p = .86), the number of mature oocytes retrieved, and the miscarriage rates were not statistically different between study groups. However, the total number of oocytes retrieved was lower in the surgery group (mean difference = -1.51; 95% CI, -2.60 to -0.43; p = .02). Findings suggest that surgical management of endometriomas before IVF therapy yields similar live birth rates as expectant management. However, future properly designed randomized controlled trials are warranted.