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Massarotti C, Cimadomo D, Spadoni V, Conforti A, Zacà C, Carosso AR, Vaiarelli A, Venturella R, Vitagliano A, Busnelli A, Cozzolino M, Borini A. Female fertility preservation for family planning: a position statement of the Italian Society of Fertility and Sterility and Reproductive Medicine (SIFES-MR). J Assist Reprod Genet 2024; 41:2521-2535. [PMID: 39030346 PMCID: PMC11405660 DOI: 10.1007/s10815-024-03197-4] [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: 04/09/2024] [Accepted: 07/03/2024] [Indexed: 07/21/2024] Open
Abstract
PURPOSE This position statement by the Italian Society of Fertility and Sterility and Reproductive Medicine (SIFES-MR) aims to establish an optimal framework for fertility preservation outside the standard before oncological therapies. Key topics include the role of fertility units in comprehensive fertility assessment, factors impacting ovarian potential, available preservation methods, and appropriate criteria for offering such interventions. METHODS The SIFES-MR writing group comprises Italian reproductive physicians, embryologists, and scientists. The consensus emerged after a six-month period of meetings, including extensive literature review, dialogue among authors and input from society members. Final approval was granted by the SIFES-MR governing council. RESULTS Fertility counselling transitions from urgent to long-term care, emphasizing family planning. Age, along with ovarian reserve markers, is the primary predictor of female fertility. Various factors, including gynecological conditions, autoimmune disorders, and prior gonadotoxic therapies, may impact ovarian reserve. Oocyte cryopreservation should be the preferred method. Women 30-34 years old and 35-39 years old, without known pathologies impacting the ovarian reserve, should cryopreserve at least 12-13 and 15-20 oocytes to achieve the same chance of a spontaneous live birth they would have if they tried to conceive at the age of cryopreservation (63% and 52%, respectively in the two age groups). CONCLUSIONS Optimal fertility counselling necessitates a long-term approach, that nurtures an understanding of fertility, facilitates timely evaluation of factors that may affect fertility, and explores fertility preservation choices at opportune intervals.
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Affiliation(s)
- Claudia Massarotti
- Physiopathology of Human Reproduction, IRCCS Ospedale Policlinico San Martino, Largo R. Benzi, 10, 16132, Genova, Italy.
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Health (DINOGMI Department), University of Genova, Genova, Italy.
| | - Danilo Cimadomo
- IVIRMA Global Reseach Alliance, Genera, Clinica Valle Giulia, Rome, Italy
| | | | - Alessandro Conforti
- Department of Neuroscience, Reproductive Science and Odontostomatology, University of Naples Federico II, Naples, Italy
| | - Carlotta Zacà
- IVIRMA Global Research Alliance, 9.Baby, Bologna, Italy
| | - Andrea Roberto Carosso
- Obstetrics and Gynecology 1U, Physiopathology of Reproduction and IVF Unit, Department of Surgical Sciences, Sant'Anna Hospital Città della Salute e della Scienza di Torino, University of Torino, Turin, Italy
| | - Alberto Vaiarelli
- IVIRMA Global Reseach Alliance, Genera, Clinica Valle Giulia, Rome, Italy
| | - Roberta Venturella
- Unit of Obstetrics and Gynecology, University of Catanzaro "Magna Grecia", Catanzaro, Italy
| | - Amerigo Vitagliano
- First Unit of Obstetrics and Gynecology, Department of Interdisciplinary Medicine (DIM), University of Bari, Bari, Italy
| | - Andrea Busnelli
- Department of Obstetrics and Gynecology, IRCCS Humanitas Research Hospital, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Mauro Cozzolino
- IVIRMA Global Research Alliance, IVI Roma, Rome, Italy
- IVIRMA Global Research Alliance, Fundación IVI-IIS la Fe, Valencia, Spain
| | - Andrea Borini
- IVIRMA Global Research Alliance, 9.Baby, Bologna, Italy
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Naem A, Krentel H, Moawad G, Naem J, Venezia R, Etrusco A, Terzic S, Laganà AS. Hormonal Therapies before in vitro fertilization in women with endometriosis: The Minotaur's Labyrinth and the Ariadne's Thread. Best Pract Res Clin Obstet Gynaecol 2024; 95:102500. [PMID: 38772765 DOI: 10.1016/j.bpobgyn.2024.102500] [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: 11/25/2023] [Accepted: 05/02/2024] [Indexed: 05/23/2024]
Abstract
Endometriosis-related infertility is one of the most debated topics in reproductive medicine. In recent years, prolonged pre-cycle hormonal regimens gained attention as a mean of improving the assisted reproduction technologies (ART) success rates in endometriosis patients. GnRH agonists, dienogest, medroxyprogesterone acetate, and aromatase inhibitors are the most studied medications. Conflicting results and a high risk of bias exist in almost all of the conducted studies in the field. However, current evidence suggests that pre-cycle treatment with GnRH agonists may be beneficial for patients with stage III/IV endometriosis. Dienogest and medroxyprogesterone acetate-based progestin-primed ovarian stimulation protocol was shown to be comparable to the prolonged GnRH agonists protocol. Finally, aromatase inhibitors seem to be of limited benefit to the assisted reproductive outcomes of endometriosis patients. Although it is challenging to draw any clinical conclusions, pre-cycle hormonal treatments seem to be best indicated in endometriosis patients who had previously failed ART treatment.
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Affiliation(s)
- Antoine Naem
- Department of Obstetrics, Gynecology, Gynecologic Oncology and Senology, Bethesda Hospital Duisburg, 47053 Duisburg, Germany; Faculty of Mathematics and Computer Science, University of Bremen, 28359 Bremen, Germany.
| | - Harald Krentel
- Department of Obstetrics, Gynecology, Gynecologic Oncology and Senology, Bethesda Hospital Duisburg, 47053 Duisburg, Germany
| | - Gaby Moawad
- Department of Obstetrics and Gynecology, George Washington University, Washington, DC 20037, USA; The Center for Endometriosis and Advanced Pelvic Surgery, Washington, DC 22101, USA
| | - Joelle Naem
- Faculty of Medicine of Damascus University, Damascus, Syria
| | - Renato Venezia
- Unit of Obstetrics and Gynecology, "Paolo Giaccone" Hospital, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90127 Palermo, Italy
| | - Andrea Etrusco
- Unit of Obstetrics and Gynecology, "Paolo Giaccone" Hospital, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90127 Palermo, Italy
| | - Sanja Terzic
- Department of Medicine, School of Medicine, Nazarbayev University, Zhanybek-Kerey Khans Street 5/1, Astana 010000, Kazakhstan
| | - Antonio Simone Laganà
- Unit of Obstetrics and Gynecology, "Paolo Giaccone" Hospital, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90127 Palermo, Italy
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Miquel L, Liotta J, Pivano A, Gnisci A, Netter A, Courbiere B, Agostini A. Ethanol endometrioma sclerotherapy: safety through 8 years of experience. Hum Reprod 2024; 39:733-741. [PMID: 38327007 DOI: 10.1093/humrep/deae014] [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: 02/03/2023] [Revised: 01/06/2024] [Indexed: 02/09/2024] Open
Abstract
STUDY QUESTION What are the complications of transvaginal ethanol sclerotherapy for the treatment of endometriomas? SUMMARY ANSWER Sclerotherapy is a reliable, minimally invasive method applicable in outpatient procedures but with specific and potential life-threatening complications that need to be identified and prevented. WHAT IS KNOWN ALREADY There are currently few data on the use of transvaginal ethanol sclerotherapy, and we mainly note septic complications. STUDY DESIGN, SIZE, DURATION A retrospective observational cohort study was carried out. The study was conducted at an academic hospital and included 126 women aged 31.9 ± 5.5 years (mean ± SD), between November 2013 and June 2021. We analyzed a total of 157 ethanol sclerotherapy treatment (EST), treated by 131 EST procedures, in 126 women. PARTICIPANTS/MATERIALS, SETTING, METHODS The study included women with an indication for transvaginal ethanol sclerotherapy. Indications were women with at least one endometrioma over 10 mm, isolated or associated with other endometriosis locations, requiring treatment for pain or infertility before assisted reproductive treatment. We followed a standardized transvaginal ethanol sclerotherapy procedure consisting of an ultrasound-guided transvaginal puncture of one or more endometriomas under general anesthesia. The cyst content was completely removed and flushed with saline solution. Ethanol (96%) was injected at 60% of the initial volume of the endometrioma, remained in the cyst for 10 min and was then completely removed. Ethanol loss was defined as a loss of 5 ml or more than 10% of the initial volume of the injected ethanol. Failure was defined by the contraindication of endometrioma puncture because of interposition of the digestive tract, ethanol loss in the previous endometrioma treated (in case of multiple ESTs), failure to aspirate the endometriotic fluid, contraindication to start ethanol injection owing to saline solution leakage, or contraindication to continue ethanol injection owing to suspicions of ethanol leakage at sonography. Intraoperative complications were defined by ethanol loss, positive blood alcohol level, and ethanol intoxication. Postoperative complications were defined by fever, biological inflammatory syndrome, and ovarian abscess. Complications were classified according to the Clavien and Dindo surgical classification, which is a system for classifying postoperative complications in five grades of increasing severity. MAIN RESULTS AND THE ROLE OF CHANCE We reported a total of 17/157 (10.8%) transvaginal ethanol sclerotherapy failures during 14/131 (10.7%) transvaginal ethanol sclerotherapy procedures in 13/126 (10.3%) women. In the same sets of data, complication was reported for 15/157 (9.5%) transvaginal ethanol sclerotherapy in 13/131 (9.9%) transvaginal ethanol sclerotherapy procedures in 13/126 (10.3%) women. Nine of 126 women (7.1%) had a grade I complication, one (0.8%) had a grade II complication (medical treatment for suspicion of pelvic infection), two (1.6%) had a grade III complication (ovarian abscess) and one (0.8%) had a grade IV complication (ethanol intoxication). We did not observe any grade V complications. LIMITATIONS, REASONS FOR CAUTION This was a retrospective study and pain assessment not considered. The benefit-risk balance of endometrioma transvaginal ethanol sclerotherapy was not evaluated. WIDER IMPLICATIONS OF THE FINDINGS Our study is the first to evaluate the complications of transvaginal ethanol sclerotherapy with such a large cohort of women in a standardized protocol. Transvaginal ethanol sclerotherapy seems to be an effective alternative to laparoscopic surgery in the management of endometriomas and limits the alteration of ovarian reserve. Transvaginal ethanol sclerotherapy is a reliable, minimally invasive method applicable on an outpatient basis. The majority of complications are Clavien-Dindo ≤IV, for which preventative measures, or at least early diagnosis and treatment, can be easily performed. The risk of ethanol intoxication is rare, but it is a life-threatening risk that must be avoided by appropriate implementation and promotion of the sclerotherapy procedures. STUDY FUNDING/COMPETING INTEREST(S) None. TRIAL REGISTRATION NUMBER Aix Marseille University's ethics committee registration number 2021-06-03-01.
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Affiliation(s)
- L Miquel
- Department of Obstetrics Gynecology and Reproductive Medicine, Pôle femmes parents enfants, La Conception University Hospital, Marseille, France
| | - J Liotta
- Department of Obstetrics Gynecology and Reproductive Medicine, Pôle femmes parents enfants, La Conception University Hospital, Marseille, France
| | - A Pivano
- Department of Obstetrics Gynecology and Reproductive Medicine, Pôle femmes parents enfants, La Conception University Hospital, Marseille, France
| | - A Gnisci
- Department of Obstetrics Gynecology and Reproductive Medicine, Pôle femmes parents enfants, La Conception University Hospital, Marseille, France
| | - A Netter
- Department of Obstetrics Gynecology and Reproductive Medicine, Pôle femmes parents enfants, La Conception University Hospital, Marseille, France
- Department of Mediterranean Institute of marine and terrestrial Biodiversity and Ecology, Aix Marseille Univ, Avignon Université, CNRS, IRD, IMBE, Marseille, France
| | - B Courbiere
- Department of Obstetrics Gynecology and Reproductive Medicine, Pôle femmes parents enfants, La Conception University Hospital, Marseille, France
- Department of Mediterranean Institute of marine and terrestrial Biodiversity and Ecology, Aix Marseille Univ, Avignon Université, CNRS, IRD, IMBE, Marseille, France
| | - A Agostini
- Department of Obstetrics Gynecology and Reproductive Medicine, Pôle femmes parents enfants, La Conception University Hospital, Marseille, France
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Tilak P, Bawaskar PA, Badge A, Nair N, Kalbande A, Muley PP. Overcoming Infertility Challenges: A Case Report on the Management of Ovarian Endometriomas and Successful Pregnancy With Intracytoplasmic Sperm Injection and Platelet-Rich Plasma Perfusion. Cureus 2024; 16:e56468. [PMID: 38638734 PMCID: PMC11024876 DOI: 10.7759/cureus.56468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Accepted: 03/19/2024] [Indexed: 04/20/2024] Open
Abstract
Endometriosis and infertility are clinically associated. The therapeutic approaches for endometriosis, whether medical or surgical, yield distinct outcomes for a woman's potential for achieving conception, whether through natural means or with the aid of assisted reproductive technology (ART). In this case report, a 29-year-old female and her 32-year-old partner, married for the last five years, sought assistance at our fertility clinic after having one failed in vitro fertilization (IVF) cycle. The patient had a history of dysmenorrhea and deep dyspareunia, suggesting the presence of an ovarian cyst. Transabdominal ultrasound and laparoscopy confirmed the existence of ovaries with adhesions and a chocolate cyst measuring 8 cm × 6 cm in dimensions. Cystectomy of ovarian endometriomas enhances the rate of spontaneous conception and reduces pain. Moreover, it has the potential to enhance the outcome of IVF. The successful outcome achieved through ART, specifically the intracytoplasmic sperm injection cycle, underscores the importance of technological advancements in overcoming infertile barriers. This case report exemplifies the personalized and innovative approaches available to couples undergoing fertility treatment.
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Affiliation(s)
- Priyal Tilak
- Clinical Embryology, School of Allied Health Sciences, Datta Meghe Institute of Higher Education & Research, Nagpur, IND
| | - Pranita A Bawaskar
- Clinical Embryology, School of Allied Health Sciences, Datta Meghe Institute of Higher Education & Research, Nagpur, IND
| | - Ankit Badge
- Microbiology, Datta Meghe Medical College, Datta Meghe Institute of Higher Education & Research, Nagpur, IND
| | - Nancy Nair
- Clinical Embryology, School of Allied Health Sciences, Datta Meghe Institute of Higher Education & Research, Nagpur, IND
| | - Avanti Kalbande
- Obstetrics and Gynaecology, Datta Meghe Medical College, Datta Meghe Institute of Higher Education & Research, Nagpur, IND
| | - Pranjali P Muley
- Physiology, Datta Meghe Medical College, Datta Meghe Institute of Higher Education & Research, Nagpur, IND
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Ruaux E, Nougaret S, Gavrel M, Charlot M, Devouassoux-Shisheboran M, Golfier F, Thomassin-Naggara I, Rousset P. Endometriosis MR mimickers: T1-hyperintense lesions. Insights Imaging 2024; 15:19. [PMID: 38267748 PMCID: PMC10808095 DOI: 10.1186/s13244-023-01587-3] [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: 06/27/2023] [Accepted: 11/25/2023] [Indexed: 01/26/2024] Open
Abstract
Endometriosis is a chronic and disabling gynecological disease that affects women of reproductive age. Magnetic resonance imaging (MRI) is considered the cornerstone radiological technique for both the diagnosis and management of endometriosis. While MRI offers higher sensitivity compared to ultrasonography, it is prone to false-positive results, leading to decreased specificity. False-positive findings can arise from various T1-hyperintense conditions on fat-suppressed T1-weighted images, resembling endometriotic cystic lesions in different anatomical compartments. These conditions include hemorrhage, hyperproteic content, MRI artifacts, feces, or melanin. Such false positives can have significant implications for patient care, ranging from incorrect diagnoses to unnecessary medical or surgical interventions and subsequent follow-up. To address these challenges, this educational review aims to provide radiologists with comprehensive knowledge about MRI criteria, potential pitfalls, and differential diagnoses, ultimately reducing false-positive results related to T1-hyperintense abnormalities.Critical relevance statementMRI has a 10% false-positive rate, leading to misdiagnosis. T1-hyperintense lesions, observed in the three phenotypes of pelvic endometriosis, can also be seen in various other causes, mainly caused by hemorrhages, high protein concentrations, and artifacts.Key points• MRI in endometriosis has a 10% false-positive rate, leading to potential misdiagnosis.• Pelvic endometriosis lesions can exhibit T1-hyperintensity across their three phenotypes.• A definitive diagnosis of a T1-hyperintense endometriotic lesion is crucial for patient management.• Hemorrhages, high protein concentrations, lipids, and artifacts are the main sources of T1-hyperintense mimickers.
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Affiliation(s)
- Edouard Ruaux
- Department of Radiology, Hospices Civils de Lyon, Lyon Sud University Hospital, Lyon 1 Claude Bernard University, 165 Chemin du Grand Revoyet, EMR 3738, 69495, Pierre Bénite, France
| | - Stéphanie Nougaret
- Department of Radiology, Montpellier Cancer Institute, U1194, Montpellier University, 34295, Montpellier, France
| | - Marie Gavrel
- Department of Radiology, Hospices Civils de Lyon, Lyon Sud University Hospital, Lyon 1 Claude Bernard University, EMR 3738, Pierre Bénite, France
| | - Mathilde Charlot
- Department of Radiology, Hospices Civils de Lyon, Lyon Sud University Hospital, Lyon 1 Claude Bernard University, EMR 3738, Pierre Bénite, France
| | - Mojgan Devouassoux-Shisheboran
- Department of Pathology, Hospices Civils de Lyon, Lyon Sud University Hospital, Lyon 1 Claude Bernard University, 69495, Pierre Bénite, France
| | - François Golfier
- Department of Gynecology and Obstetrics, Hospices Civils de Lyon, Lyon Sud University Hospital, Lyon 1 Claude Bernard University, EMR 3738, 69495, Pierre Bénite, France
| | - Isabelle Thomassin-Naggara
- Department of Radiology, Service Imageries Radiologiques et Interventionnelles Spécialisées, Hôpital Tenon, Assistance Publique Hôpitaux de Paris, Sorbonne Université, 75020, Paris, France
| | - Pascal Rousset
- Department of Radiology, Hospices Civils de Lyon, Lyon Sud University Hospital, Lyon 1 Claude Bernard University, 165 Chemin du Grand Revoyet, EMR 3738, 69495, Pierre Bénite, France.
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Paffoni A, Casalechi M, De Ziegler D, Cicinelli E, Somigliana E, Viganò P, Vitagliano A. Live Birth After Oocyte Donation In Vitro Fertilization Cycles in Women With Endometriosis: A Systematic Review and Meta-Analysis. JAMA Netw Open 2024; 7:e2354249. [PMID: 38294811 PMCID: PMC10831577 DOI: 10.1001/jamanetworkopen.2023.54249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 12/05/2023] [Indexed: 02/01/2024] Open
Abstract
Importance Although multiple mechanisms have been proposed to explain the infertility related to endometriosis, there are no conclusive data on the association of endometriosis with endometrial receptivity. The oocyte donation model in assisted reproduction technology (ART) cycles can clarify this issue. Objective To explore the association of a history of endometriosis with ART outcomes in recipients of oocyte donation. Data Sources In this systematic review and meta-analysis, electronic databases were searched from inception until August 31, 2023, using combinations of relevant keywords. Moreover, we retrieved data from the databases of the Society for Assisted Reproductive Technology (SART) in the US and the Human Fertilization and Embryology Authority (HFEA) in the United Kingdom. Study Selection Observational studies were included if they investigated the impact of endometriosis on ART outcomes with donor oocytes. Data Extraction and Synthesis Publicly available data related to ART from various sources were gathered, and a retrospective aggregate and nonaggregate analysis using registries of in vitro fertilization cycles with oocyte or embryo donation was conducted. Main Outcomes and Measures The primary outcome was live birth rate (LBR) following oocyte donor cycles. The effect measures of comparisons between groups are presented as odds ratios (ORs) with a 95% CI. Results This study analyzed 7212 oocyte donation cycles from 4 studies for the meta-analysis, along with 162 082 cycles from 2 registries (137 182 from SART and 24 900 from HFEA). No significant differences between the groups were observed in the meta-analysis of published data after adjusting for confounding factors (OR, 0.54; 95% CI, 0.19-1.57). A statistically significant lower LBR was identified in women with endometriosis when analyzing the aggregate data from SART and HFEA databases (OR, 0.89; 95% CI, 0.81-0.97). Conclusions and Relevance This study found a modest decrease in LBR among women with a history of endometriosis, although only results from the pooled analysis of registry data and not those from the meta-analysis reached statistical significance. These findings suggest that a marginal impairment of uterine receptivity may contribute to infertility mechanisms in women affected by endometriosis.
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Affiliation(s)
| | - Maíra Casalechi
- Human Reproduction Unit of the Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Dominique De Ziegler
- Department of Obstetrics, Gynecology and Human Reproduction, Hospital Foch, Suresnes, France
| | - Ettore Cicinelli
- First Unit of Obstetrics and Gynecology, Department of Interdisciplinary Medicine, University of Bari, Bari, Italy
| | - Edgardo Somigliana
- Infertility Unit, Department of Obstetrics and Gynecology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Paola Viganò
- Infertility Unit, Department of Obstetrics and Gynecology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Amerigo Vitagliano
- First Unit of Obstetrics and Gynecology, Department of Interdisciplinary Medicine, University of Bari, Bari, Italy
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Nadă ES, Coroleucă CB, Coroleucă CA, Brătilă E. Ovarian Stimulation for In Vitro Fertilization and Reproductive Outcome after Surgical Treatment of Endometriosis Compared with Tubal Factor Infertility. Clin Pract 2023; 14:1-12. [PMID: 38391397 PMCID: PMC10887715 DOI: 10.3390/clinpract14010001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 12/15/2023] [Accepted: 12/18/2023] [Indexed: 02/24/2024] Open
Abstract
Endometriosis is a common cause of infertility among reproductive-age women. A low ovarian reserve is associated with the presence of endometriotic cysts, and this is accentuated even more after surgery. Patients with a history of endometrioma are a special category of poor ovarian reserve requiring in vitro fertilization (IVF). The aim of this retrospective study was to evaluate the characteristics and outcome of ovarian stimulation and embryo transfer in women with a history of ovarian surgery for endometrioma compared with a control group with tubal factor infertility. A total of 146 patients had previous laparoscopic cystectomy for endometrioma (group A) and their IVF results were compared with 136 patients with documented tubal obstruction (group B). In both groups, the most frequently used ovarian stimulation protocol was the short antagonist in 84.24% versus 80.88%. The number of stimulation days was between 6 and 15 days in the two groups with a mean value of 12.76 days in group A and 9.47 days in group B. The clinical pregnancy rate was 26.77% in the endometrioma group and 39.68% in the tubal obstruction group. Patients with a history of endometrioma are less likely to conceive than those with tubal obstruction despite having similar ovarian reserve and stimulation results.
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Affiliation(s)
- Elena-Silvia Nadă
- Department of Obstetrics and Gynecology, "Carol Davila" University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Department of Obstetrics and Gynecology, "Prof. Dr. Panait Sîrbu" Clinical Hospital of Obstetrics and Gynecology, 060251 Bucharest, Romania
| | - Cătălin Bogdan Coroleucă
- Department of Obstetrics and Gynecology, "Prof. Dr. Panait Sîrbu" Clinical Hospital of Obstetrics and Gynecology, 060251 Bucharest, Romania
| | - Ciprian Andrei Coroleucă
- Department of Obstetrics and Gynecology, "Carol Davila" University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Department of Obstetrics and Gynecology, "Prof. Dr. Panait Sîrbu" Clinical Hospital of Obstetrics and Gynecology, 060251 Bucharest, Romania
| | - Elvira Brătilă
- Department of Obstetrics and Gynecology, "Carol Davila" University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Department of Obstetrics and Gynecology, "Prof. Dr. Panait Sîrbu" Clinical Hospital of Obstetrics and Gynecology, 060251 Bucharest, Romania
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Honde C, Agostini A, Pivano A, Piechon L, Courbiere B, Netter A. [Management of endometriomas in France: A survey of practices]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2023; 51:408-414. [PMID: 37353080 DOI: 10.1016/j.gofs.2023.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 04/02/2023] [Accepted: 06/17/2023] [Indexed: 06/25/2023]
Abstract
OBJECTIVES To present an overview of French practices for the management of endometriomas. METHODS We carried out a nationwide survey of practices concerning the management of endometriomas between October 2021 and January 2022. This study was carried out by means of two questionnaires sent to surgical centers used to treat endometriosis (n=62) and to Assisted Reproductive Technology (ART) centers (n=102). RESULTS At the end of the survey, 39/62 (62.9%) surgical teams from the centers contacted had given a response and 51/102 (50.0%) from ART centers. Laparoscopic cystectomy was the technique most frequently used by almost two thirds of the surgical teams (61%) when there was no known infertility, whereas it was the most common technique for only 14% of the ART teams. On the contrary, ultrasound-guided sclerotherapy was the most frequent technique for more than half of the ART teams (56%) and for only 8% of the surgical teams. In case of recurrence, 49% of surgical teams would choose ultrasound-guided sclerotherapy. Prior to IVF, 73% of ARP teams stated that they 'rarely' treated endometriomas. CONCLUSION The results of our study show a certain variability in practices between different centers and depending on the presence or absence of infertility for the management of endometriomas in France.
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Affiliation(s)
- C Honde
- Department of Gynecology and Obstetrics, AP-HM, Assistance publique-Hôpitaux de Marseille, Marseille, France
| | - A Agostini
- Department of Gynecology and Obstetrics, AP-HM, Assistance publique-Hôpitaux de Marseille, Marseille, France
| | - A Pivano
- Department of Gynecology and Obstetrics, AP-HM, Assistance publique-Hôpitaux de Marseille, Marseille, France
| | - L Piechon
- Department of Gynecology and Obstetrics, AP-HM, Assistance publique-Hôpitaux de Marseille, Marseille, France
| | - B Courbiere
- Department of Gynecology and Obstetrics, AP-HM, Assistance publique-Hôpitaux de Marseille, Marseille, France; Institut méditerranéen de biodiversité et d'écologie marine et continentale (IMBE), Aix Marseille University, CNRS, IRD, Avignon University, Marseille, France
| | - A Netter
- Department of Gynecology and Obstetrics, AP-HM, Assistance publique-Hôpitaux de Marseille, Marseille, France; Institut méditerranéen de biodiversité et d'écologie marine et continentale (IMBE), Aix Marseille University, CNRS, IRD, Avignon University, Marseille, France.
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Petrozza JC, Fitz V, Bhagavath B, Carugno J, Kwal J, Mikhail E, Nash M, Barakzai SK, Roque DR, Bregar AJ, Findley J, Neblett M, Flyckt R, Khan Z, Lindheim SR. Surgical approach to 4 different reproductive pathologies by 3 different gynecologic subspecialties: more similarities or differences? Fertil Steril 2023; 119:377-389. [PMID: 36574916 DOI: 10.1016/j.fertnstert.2022.12.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 12/19/2022] [Indexed: 12/25/2022]
Affiliation(s)
- John C Petrozza
- Division of Reproductive Medicine and IVF, Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Victoria Fitz
- Division of Reproductive Medicine and IVF, Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Bala Bhagavath
- Department of Obstetrics and Gynecology, University of Wisconsin, Madison, Wisconsin
| | - Jose Carugno
- Obstetrics, Gynecology and Reproductive Sciences Department, Minimally Invasive Gynecology Unit, University of Miami, Miller School of Medicine, Miami, Florida
| | - Jaclyn Kwal
- Obstetrics, Gynecology and Reproductive Sciences Department, Minimally Invasive Gynecology Unit, University of Miami, Miller School of Medicine, Miami, Florida
| | - Emad Mikhail
- Division of Gynecologic Subspecialties, Department of Obstetrics and Gynecology, University of South Florida Health Morsani College of Medicine, Tampa, Florida
| | - Moawad Nash
- Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics & Gynecology, University of Florida College of Medicine, Gainesville, Florida
| | - Syem K Barakzai
- Division of Gynecologic Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Dario R Roque
- Division of Gynecologic Oncology, Feinberg School of Medicine, Northwestern University
| | - Amy J Bregar
- Division of Gynecologic Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Joseph Findley
- Department of Obstetrics and Gynecology, University Hospitals of Cleveland, Beachwood, Ohio
| | - Michael Neblett
- Division of Reproductive Endocrinology and Infertility, Mayo Clinic, Rochester, Minnesota
| | - Rebecca Flyckt
- Department of Obstetrics and Gynecology, University Hospitals of Cleveland, Beachwood, Ohio
| | - Zaraq Khan
- Division of Reproductive Endocrinology and Infertility, Mayo Clinic, Rochester, Minnesota
| | - Steven R Lindheim
- Department of Obstetrics and Gynecology, Boonshoft School of Medicine, Wright State University, Dayton, Ohio; Department of Obstetrics and Gynecology, University of Central Florida, Orlando, Florida; Center for Reproductive Medicine Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People's Republic of China.
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10
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Delli Carpini G, Giannella L, Di Giuseppe J, Montanari M, Fichera M, Pizzagalli D, Meccariello ML, Palazzo P, Valenza C, Francucci A, Ciavattini A. Effect of the mode of delivery on the risk of endometriosis recurrence: a retrospective cohort study. Fertil Steril 2022; 118:1080-1087. [PMID: 36243596 DOI: 10.1016/j.fertnstert.2022.08.849] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 08/18/2022] [Accepted: 08/19/2022] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To evaluate the risk of endometriosis recurrence according to the mode of delivery (cesarean section vs. vaginal birth) in patients who had become pregnant with a live birth after surgery for endometriosis. DESIGN A retrospective cohort study. A Cox proportional-hazards regression was performed to evaluate the risk factors for endometriosis recurrence at 36 months of follow-up after the last pregnancy. SETTING Academic hospital. PATIENT(S) Patients who have had ≥1 pregnancy with a live birth following conservative surgery for ovarian endometriosis performed from January 2009 to December 2016 at our institution. INTERVENTION(S) Patients who underwent ≥1 cesarean section after surgery for endometriosis. MAIN OUTCOME MEASURES The recurrence rate of endometriosis after live-birth pregnancies obtained after the first surgery for endometriosis. RESULTS Patients with a history of ≥1 cesarean section after surgery for endometriosis have a higher risk of endometriosis recurrence than the patients who have had a vaginal birth, with an adjusted hazard ratio of 2.25 (95% confidence interval, 1.27-3.96). CONCLUSION A cesarean section after surgery for endometriosis is associated with a twofold high risk of endometriosis recurrence with respect to vaginal birth. A different follow-up approach may be needed in those patients, and avoiding inappropriate indications for cesarean sections in pregnant patients with a history of surgery for endometriosis is necessary.
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Affiliation(s)
- Giovanni Delli Carpini
- Gynecologic Section, Department of Odontostomatologic and Specialized Clinical Sciences, Università Politecnica delle Marche, Ancona, Italy
| | - Luca Giannella
- Gynecologic Section, Department of Odontostomatologic and Specialized Clinical Sciences, Università Politecnica delle Marche, Ancona, Italy
| | - Jacopo Di Giuseppe
- Gynecologic Section, Department of Odontostomatologic and Specialized Clinical Sciences, Università Politecnica delle Marche, Ancona, Italy
| | - Michele Montanari
- Gynecologic Section, Department of Odontostomatologic and Specialized Clinical Sciences, Università Politecnica delle Marche, Ancona, Italy
| | - Mariasole Fichera
- Gynecologic Section, Department of Odontostomatologic and Specialized Clinical Sciences, Università Politecnica delle Marche, Ancona, Italy
| | - Davide Pizzagalli
- Gynecologic Section, Department of Odontostomatologic and Specialized Clinical Sciences, Università Politecnica delle Marche, Ancona, Italy
| | - Maria Liberata Meccariello
- Gynecologic Section, Department of Odontostomatologic and Specialized Clinical Sciences, Università Politecnica delle Marche, Ancona, Italy
| | - Paola Palazzo
- Gynecologic Section, Department of Odontostomatologic and Specialized Clinical Sciences, Università Politecnica delle Marche, Ancona, Italy
| | - Carmine Valenza
- Gynecologic Section, Department of Odontostomatologic and Specialized Clinical Sciences, Università Politecnica delle Marche, Ancona, Italy
| | - Alessio Francucci
- Gynecologic Section, Department of Odontostomatologic and Specialized Clinical Sciences, Università Politecnica delle Marche, Ancona, Italy
| | - Andrea Ciavattini
- Gynecologic Section, Department of Odontostomatologic and Specialized Clinical Sciences, Università Politecnica delle Marche, Ancona, Italy.
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11
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Bonavina G, Taylor HS. Endometriosis-associated infertility: From pathophysiology to tailored treatment. Front Endocrinol (Lausanne) 2022; 13:1020827. [PMID: 36387918 PMCID: PMC9643365 DOI: 10.3389/fendo.2022.1020827] [Citation(s) in RCA: 51] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 10/06/2022] [Indexed: 11/13/2022] Open
Abstract
Despite the clinically recognized association between endometriosis and infertility, the mechanisms implicated in endometriosis-associated infertility are not fully understood. Endometriosis is a multifactorial and systemic disease that has pleiotropic direct and indirect effects on reproduction. A complex interaction between endometriosis subtype, pain, inflammation, altered pelvic anatomy, adhesions, disrupted ovarian reserve/function, and compromised endometrial receptivity as well as systemic effects of the disease define endometriosis-associated infertility. The population of infertile women with endometriosis is heterogeneous, and diverse patients' phenotypes can be observed in the clinical setting, thus making difficult to establish a precise diagnosis and a single mechanism of endometriosis related infertility. Moreover, clinical management of infertility associated with endometriosis can be challenging due to this heterogeneity. Innovative non-invasive diagnostic tools are on the horizon that may allow us to target the specific dysfunctional alteration in the reproduction process. Currently the treatment should be individualized according to the clinical situation and to the suspected level of impairment. Here we review the etiology of endometriosis related infertility as well as current treatment options, including the roles of surgery and assisted reproductive technologies.
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Affiliation(s)
- Giulia Bonavina
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT, United States
| | - Hugh S Taylor
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT, United States
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12
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Hao M, Liu X, Guo SW. Activation of α7 nicotinic acetylcholine receptor retards the development of endometriosis. Reprod Biol Endocrinol 2022; 20:85. [PMID: 35658970 PMCID: PMC9166516 DOI: 10.1186/s12958-022-00955-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 05/09/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Women with endometriosis have been shown to have a reduced vagal tone as compared with controls and vagotomy promoted while vagus nerve stimulation (VNS) decelerated the progression of endometriosis in mice. Extensive research also has shown that the activation of the cholinergic anti-inflammatory pathway by VNS activates α7 nicotinic acetylcholine receptor (α7nAChR), potently reducing inflammation. Yet whether α7nAChR plays any role in endometriosis is unknown. We evaluated its expression in normal endometrium, ovarian and deep endometriotic lesions, and evaluated its role in the development of endometriosis. METHODS Immunohistochemistry analyses of α7nAChR in endometriotic lesions as well as control endometrium, and quantification of tissue fibrosis by Masson trichrome staining were performed. Mouse experiments were conducted to evaluate the impact of α7nAChR activation or suppression on lesional progression and possible therapeutic effect. Finally, in vitro experiments were conducted to evaluate the effect of activation of α7nAChR on epithelial-mesenchymal transition (EMT), fibroblast-to-myofibroblast transdifferentiation (FMT), smooth muscle metaplasia (SMM) and fibrogenesis in an endometriotic epithelial cell line and primary endometriotic stromal cells derived from ovarian endometrioma tissue samples. RESULTS Immunostaining of α7nAChR was significantly reduced in human endometriotic epithelial cells as compared with their counterpart in normal endometrium. Lesional α7nAChR staining levels correlated negatively with lesional fibrosis and the severity of dysmenorrhea. The α7nAChR agonist significantly impeded the development of endometriotic lesions in mouse models possibly through hindrance of EMT and FMT. It also demonstrated therapeutic effects in mice with induced deep endometriosis. Treatment of endometriotic epithelial and stromal cells with an α7nAChR agonist significantly abrogated platelet-induced EMT, FMT and SMM, and suppressed cellular contractility and collagen production. CONCLUSIONS α7nAChR is suppressed in endometriotic lesions, and its activation by pharmacological means can impede EMT, FMT, SMM, and fibrogenesis of endometriotic lesions. As such, α7nAChR can be rightfully viewed as a potential target for therapeutic invention. TRIAL REGISTRATION Not applicable.
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Affiliation(s)
- Meihua Hao
- Shanghai Obstetrics and Gynecology Hospital, Fudan University, Shanghai, 200011, China
| | - Xishi Liu
- Shanghai Obstetrics and Gynecology Hospital, Fudan University, Shanghai, 200011, China
- Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Fudan University, Shanghai, China
| | - Sun-Wei Guo
- Shanghai Obstetrics and Gynecology Hospital, Fudan University, Shanghai, 200011, China.
- Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Fudan University, Shanghai, China.
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13
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Gale J, Singh SS. A Practical Approach to Fertility Considerations in Endometriosis Surgery. Obstet Gynecol Clin North Am 2022; 49:241-256. [DOI: 10.1016/j.ogc.2022.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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14
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Coccia ME, Nardone L, Rizzello F. Endometriosis and Infertility: A Long-Life Approach to Preserve Reproductive Integrity. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:6162. [PMID: 35627698 PMCID: PMC9141878 DOI: 10.3390/ijerph19106162] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 05/01/2022] [Accepted: 05/06/2022] [Indexed: 02/04/2023]
Abstract
Laparoscopic surgery was originally considered the gold standard in the treatment of endometriosis-related infertility. Assisted reproductive technology (ART) was indicated as second-line treatment or in the case of male factor. The combined approach of surgery followed by ART proved to offer higher chances of pregnancy in infertile women with endometriosis. However, it was highlighted how pelvic surgery for endometriosis, especially in cases of ovarian endometriomas, could cause iatrogenic damage due to ovarian reserve loss, adhesion formation (scarring), and ischemic damage. Furthermore, in the last few years, the trend to delay the first childbirth, recent technological advances in ultrasound diagnosis, and technological progress in clinical and laboratory aspects of ART have certainly influenced the approach to infertility and endometriosis with, ART assuming a more relevant role. Management of endometriosis should take into account that the disease is chronic and involves the reproductive system. Consequently, treatment and counselling should aim to preserve the chances of pregnancy for the patient, even if it is not associated with infertility. This review will analyse the evolution of the management of infertility associated with endometriosis and propose an algorithm for treatment decision-making based on the most recent acquisitions.
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Affiliation(s)
- Maria Elisabetta Coccia
- Department of Biomedical, Experimental and Clinical Sciences “Mario Serio”, University of Florence, 50134 Florence, Italy;
| | - Luca Nardone
- Department of Biomedical, Experimental and Clinical Sciences “Mario Serio”, University of Florence, 50134 Florence, Italy;
| | - Francesca Rizzello
- Assisted Reproductive Technology Centre, Careggi University Hospital, 50134 Florence, Italy;
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15
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Tetramethylpyrazine Retards the Progression and Fibrogenesis of Endometriosis. Reprod Sci 2022; 29:1170-1187. [PMID: 35099777 PMCID: PMC8907108 DOI: 10.1007/s43032-021-00813-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 11/25/2021] [Indexed: 12/18/2022]
Abstract
The development of more efficacious, non-hormonal therapeutics for endometriosis is still an unmet medical need begging to be fulfilled. Growing evidence indicates that endometriotic lesions are wounds undergoing repeated tissue injury and repair, and, as such, platelets play an important role in lesional progression. Tetramethylpyrazine (TMP), a compound derived from a herb that has been used for thousands of years to combat “blood stasis” in traditional Chinese medicine, is a prescription drug in China for the treatment of cerebrovascular disorders. We tested the hypothesis that TMP can decelerate lesional progression through arresting epithelial-mesenchymal transition (EMT), fibroblast-to-myofibroblast transdifferentiation (FMT), and fibrogenesis. We found in our in vitro experiments that TMP treatment suppresses platelet-induced EMT, FMT, cellular contractility, and collagen production in a concentration-dependent manner. We also showed that in a mouse model of endometriosis, treatment with TMP significantly reduced lesion weight and the extent of lesional fibrosis and improved hyperalgesia, mostly likely through the reduction of lesional aggregation of platelets and the lesional expression of markers of EMT, FMT, and fibrogenesis. In light of our results and in view of its excellent safety profiles, TMP appears to be a promising drug candidate for treating endometriosis.
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16
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Endometrioma surgery-a systematic review and meta-analysis of the effect on antral follicle count and anti-Müllerian hormone. Am J Obstet Gynecol 2022; 226:33-51.e7. [PMID: 34265271 DOI: 10.1016/j.ajog.2021.06.102] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 06/25/2021] [Accepted: 06/29/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Accurate preoperative counseling about whether an endometriotic cystectomy has a detrimental effect on the ovarian reserve has been a considerable challenge, because studies assessing the postoperative antral follicle counts and anti-Müllerian hormone levels have reported conflicting results. Our objective was to explore the impact of endometriotic cystectomy on both the anti-Müllerian hormone levels and antral follicle counts, with focus on prospective studies in which both variables were measured for each woman concurrently (overcoming unmeasured confounding), in the same setting (overcoming surgical technique differences), and at the same 3 postoperative time points, namely early (1-6 weeks), intermediate (2-6 months) and late (9-18 months), to overcome time-sensitive changes. DATA SOURCES Databases of PubMed, ClinicalTrials.gov, the Cochrane Library, Web of Science, and EBSCO were searched between January 2000 and October 2020. STUDY ELIGIBILITY CRITERIA Only prospective cohort studies that evaluated the impact of endometriotic stripping cystectomy on anti-Müllerian hormone levels and antral follicle counts in the same women, at matching time points, and in the same setting were eligible. STUDY APPRAISAL AND SYNTHESIS METHODS Two authors performed the screening and data extraction independently. RESULTS A total of 14 prospectively designed studies were eligible for the meta-analysis and included 650 women. The included studies had a low risk of bias. The postoperative weighted mean differences in serum anti-Müllerian hormone levels dropped significantly when compared with the preoperative levels by an estimated 1.77 ng/mL (95% confidence interval, 0.77-2.77; P<.001), 1.17 ng/mL (95% confidence interval, 0.66-1.67; P<.001), and 2.13 ng/mL (95% confidence interval, 1.61-2.65; P<.001) at the early (1-6 weeks), intermediate (2-6 months), and late (9-18 months) time points, respectively. This corresponded to a mean reduction in serum anti-Müllerian hormone levels at each of the 3-time points of 44.4%, 35.1%, and 54.2%, respectively. Conversely, the postoperative weighted mean difference in the antral follicle count estimates did not change significantly at any of the 3 time points; the early antral follicle count was 0.70 (95% confidence interval, -2.71 to 3.56; P=.63), the intermediate count was -0.94 (95% confidence interval, -2.53 to 0.65; P=.25), and the late count was 2.58 (95% confidence interval, -0.43 to 5.58; P=.09). Overall, high levels of heterogeneity were encountered (I2 ranging between 92% and 94% for the anti-Müllerian hormone levels and between 94% and 98% for the antral follicle counts at the 3 time points), which were attenuated when similar anti-Müllerian hormone assays were compared, and the meta-regression suggested that age did not contribute to heterogeneity. CONCLUSION Endometriotic cystectomies are associated with a significant reduction in the serum anti-Müllerian hormone levels but not in the antral follicle counts, with the detrimental effects on the anti-Müllerian hormone levels consistently detectable at the early-, intermediate-, and late-postoperative time points. In women with endometrioma, the anti-Müllerian hormone level may provide a more accurate assessment of the risk for iatrogenic depletion of the ovarian reserve.
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Alborzi S, Askary E, Keramati P, Moradi Alamdarloo S, Poordast T, Ashraf MA, Shomali Z, Namavar Jahromi B, Zahiri Sorouri Z. Assisted reproductive technique outcomes in patients with endometrioma undergoing sclerotherapy vs laparoscopic cystectomy: Prospective cross-sectional study. Reprod Med Biol 2021; 20:313-320. [PMID: 34262399 PMCID: PMC8254172 DOI: 10.1002/rmb2.12386] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 04/11/2021] [Accepted: 04/13/2021] [Indexed: 12/02/2022] Open
Abstract
PURPOSE The authors compared assisted reproductive technique (ART) outcomes and the recurrence rate of endometrioma in the infertile patients undergoing sclerotherapy vs laparoscopic ovarian cystectomy. METHODS In this prospective cross-sectional study, a total of 101 infertile patients, with unilateral endometriomas, were divided into two groups. The first group (n = 57) underwent ART after 1 year of unsuccessful spontaneous pregnancy after laparoscopic ovarian cystectomy; the second group (n = 44) had ethanol sclerotherapy (EST) at the time of oocyte retrieval. The authors measured the number of oocytes, clinical pregnancy rate (CPR), live birth rate (LBR), complication, and recurrence of endometriomas as the primary and secondary outcomes. RESULTS The two groups had no significant differences in baseline characteristics and ovarian stimulation markers and also total number of oocytes. 42.1% and 34.1% of the patients (n = 24 and 15) had clinical pregnancy, and 38.6% and 29.5% (n = 22 and 13) had live birth following ART cycles in the surgery group and sclerotherapy group (P = .41, 0.34). The recurrence rates were 14.0% and 34.1% in the surgery and sclerotherapy groups (P = .017, X 2 = 5.67). CONCLUSIONS Ethanol sclerotherapy can be a good alternative to surgery concerning the treatment of endometrioma; however, the recurrence of the disease in this group is significantly higher.
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Affiliation(s)
- Saeed Alborzi
- Department of Obstetrics and GynecologyLaparoscopy Research CenterSchool of MedicineShiraz University of Medical SciencesShirazIran
| | - Elham Askary
- Department of Obstetrics and GynecologyInfertility Research CenterSchool of MedicineShiraz University of Medical SciencesShirazIran
| | - Pegah Keramati
- Department of Obstetrics and GynecologySchool of MedicineShiraz University of Medical SciencesShirazIran
| | - Shaghayegh Moradi Alamdarloo
- Department of Obstetrics and GynecologyInfertility Research CenterSchool of MedicineShiraz University of Medical SciencesShirazIran
| | - Tahereh Poordast
- Department of Obstetrics and GynecologyInfertility Research CenterSchool of MedicineShiraz University of Medical SciencesShirazIran
| | - Mohammad Ali Ashraf
- Department of Obstetrics and GynecologySchool of MedicineShiraz University of Medical SciencesShirazIran
| | - Zahra Shomali
- Department of Obstetrics and GynecologySchool of MedicineShiraz University of Medical SciencesShirazIran
| | - Behieh Namavar Jahromi
- Department of Obstetrics and GynecologyLaparoscopy Research CenterSchool of MedicineShiraz University of Medical SciencesShirazIran
| | - Ziba Zahiri Sorouri
- Department of Obstetrics and GynecologyLaparoscopy Research CenterSchool of MedicineGuilan University of Medical SciencesRashtIran
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Cobo A, García-Velasco JA, Remohí J, Pellicer A. Oocyte vitrification for fertility preservation for both medical and nonmedical reasons. Fertil Steril 2021; 115:1091-1101. [DOI: 10.1016/j.fertnstert.2021.02.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 02/01/2021] [Accepted: 02/05/2021] [Indexed: 12/17/2022]
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19
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Preoperative and perioperative intervention reduces the risk of recurrence of endometriosis in mice caused by either incomplete excision or spillage and dissemination. Reprod Biomed Online 2021; 43:379-393. [PMID: 34330642 DOI: 10.1016/j.rbmo.2021.04.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 03/15/2021] [Accepted: 04/20/2021] [Indexed: 11/23/2022]
Abstract
RESEARCH QUESTION Can preoperative or perioperative intervention reduce the risk of recurrence of endometriosis caused by either incomplete excision or spillage and dissemination? DESIGN A mouse model of endometriosis recurrence caused by spillage and dissemination was first established using 24 female Balb/c mice. The spillage and dissemination model was used to test the efficacy of preoperative use of ketorolac, perioperative use of aprepitant and combined use of propranolol and andrographolide in a prospective, randomized mouse experiment involving 75 mice. The efficacy of these preoperative and perioperative interventions in a mouse recurrence model caused by incomplete excision was also tested using 72 mice. In all experiments, the baseline body weight and hotplate latency of all mice were measured and recorded before the induction of endometriosis, before the primary surgery and before sacrifice. In addition, all lesions were excised, weighed and processed for quantification and immunohistochemistry analysis of E-cadherin, α-SMA, VEGF, ADRB2 and putative markers of recurrence PR-B, p-p65, as well as Masson trichrome staining. RESULTS All interventions substantially and significantly suppressed the outgrowth of endometriotic lesions and reduced the risk of recurrence caused by either spillage and dissemination or incomplete excision (P = 0.0007 to 0.042). These interventions also significantly attenuated the generalized hyperalgesia, inhibited the staining of α-SMA, p-p65, VEGF and ADRB2 but increased staining of E-cadherin and PR-B, resulting in reduced fibrosis. CONCLUSION Given the excellent safety profiles of these drugs, these data strongly suggest that preoperative and perioperative intervention may potentially reduce the risk of endometriosis recurrence effectively.
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20
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Kahyaoglu I, Gülerman C, Yılmaz N, Ceran MU, Ozgu-Erdinc AS, Kahyaoglu S, Bardakcı Y, Engin Üstün Y. Does endometrioma surgery affect assisted reproductive technologies cycle outcome in patients with decreased ovarian reserve diagnosed by Bologna criteria? JOURNAL OF ENDOMETRIOSIS AND PELVIC PAIN DISORDERS 2021. [DOI: 10.1177/22840265211012119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives: Data regarding whether the assisted reproductive technologies (ART) outcome of patients with decreased ovarian reserve (DOR) secondary to an endometrioma surgery differs from that of patients with DOR secondary to other etiologies is limited. The aim of this study was to compare the ART outcomes of DOR patients diagnosed by Bologna criteria secondary to a previous endometrioma surgery with DOR patients without a history of an endometrioma surgery. Methods: This retrospective cohort study was conducted in the assisted reproduction unit of a tertiary research and education hospital. Medical records of the patients with DOR were reviewed retrospectively. Group I included 23 cycles of DOR patients secondary to a previous endometrioma surgery and Group II consisted of 260 cycles of DOR patients without a history of endometrioma surgery. Results: No significant difference was demonstrated between groups regarding demographic features except for the age (32 (24–41) in Group I vs 35 (23–47) in Group II, p = 0.031). The data comparing the controlled ovarian stimulation parameters and ART outcomes showed similar results in both groups. No statistically significant difference was found between groups regarding pregnancy rates per transfer (23% vs 22.2 %) and per cycle (13% vs 15.4%) ( p > 0.05). Conclusion: Cycle outcomes of DOR patients secondary to an endometrioma surgery did not differ from that of DOR without an endometrioma surgery history.
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Affiliation(s)
- Inci Kahyaoglu
- Department of Obstetrics and Gynecology, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Cavidan Gülerman
- Department of Obstetrics and Gynecology, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Nafiye Yılmaz
- Department of Obstetrics and Gynecology, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Mehmet Ufuk Ceran
- Department of Gynecology and Obstetrics, Konya Medical and Research Center, Baskent University School of Medicine, Konya, Turkey
| | - Ayşe Seval Ozgu-Erdinc
- Department of Obstetrics and Gynecology, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Serkan Kahyaoglu
- Department of Obstetrics and Gynecology, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Yesim Bardakcı
- Histology and Embryology, Zekai Tahir Burak Women’s Health Research and Education Hospital, Ankara, Turkey
| | - Yaprak Engin Üstün
- Department of Obstetrics and Gynecology, University of Health Sciences, Etlik Zübeyde Hanım Women’s Health Training and Research Hospital, Ankara, Turkey
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Does Ovarian Endometriosis Increase Oocyte Sensitivity to ICSI-Induced Mechanical Damage? J Clin Med 2021; 10:jcm10081757. [PMID: 33919510 PMCID: PMC8073272 DOI: 10.3390/jcm10081757] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 04/14/2021] [Accepted: 04/16/2021] [Indexed: 11/24/2022] Open
Abstract
Some studies have shown that ICSI obtains poorer results than conventional IVF in women with ovarian endometriosis, suggesting that oocytes could be sensitive to ICSI-induced mechanical damage. The aims of this study were to clarify (a) whether ovarian endometriosis could induce peculiar fragility in the oocyte, so that ICSI would finally result harmful, and (b) whether endometrioma removal before IVF could be advisable in order to avoid any hypothetical detrimental effect. We retrospectively studied 368 women, 203 with in situ endometrioma (128 of which underwent ICSI, 75 conventional IVF) and 164 who received laparoscopic stripping of endometrioma before ICSI. For women with in situ endometrioma, cIVF and ICSI outcome was comparable for all parameters studied, including the clinical pregnancy rate per embryo transfer (PR/ET: 31.8% vs. 39.5% in the cIVF and ICSI groups) and cumulative live birth rate per ovum pick-up (CLBR/OPU: 24.4% vs. 27.7%). ICSI outcome was similar comparing women with in situ endometrioma and women previously submitted to laparoscopic stripping of cysts (CLPR/OPU 27.7% vs. 25.3%). Our findings suggest that (a) in women with in situ endometrioma ICSI may be performed, when needed, without harming oocytes and compromising the outcome and (b) that there is no advantage in removing endometrioma before ICSI.
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Liu W, Sha T, Huang Y, Guo Z, Yan L, Ma J. Factors Influencing the Live Birth Rate Following Fresh Embryo Transfer Cycles in Infertile Women After Endometrioma Cystectomy. Front Med (Lausanne) 2021; 8:622087. [PMID: 33718403 PMCID: PMC7947290 DOI: 10.3389/fmed.2021.622087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 01/04/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Reproductive outcomes after fresh in vitro fertilization/intracytoplasmic sperm injection-embryo transfer (IVF/ICSI-ET) cycles are diverse in infertile women with a history of ovarian cystectomy for endometriomas. We aimed to develop a logistic regression model based on patients' characteristics including number of embryos transferred and stimulation protocols to predict the live birth rate in fresh IVF/ICSI-ET cycles for such patients. Methods: We recruited 513 infertile women with a history of ovarian cystectomy for endometriomas who underwent their first fresh ET with different stimulation protocols following IVF/ICSI cycles in our unit from January 2014 to December 2018. One or two embryo are implanted. Clinical and laboratory parameters potentially affecting the live birth rate following fresh ET cycles were analyzed. Univariable and multivariable analyses were performed to assess the relationship between predictive factors and live birth rate. Results: The overall live birth rate was 240/513 (46.8%). Multivariable modified Poisson regression models showed that two factors were significantly lowers the probability of live birth: female age ≥ 5 years (aOR 0.603; 95% CI 0.389-0.933; P = 0.023); BMI range 21-24.99 kg/m2 compared with BMI <21 kg/m2 (aOR 0.572; 95% CI 0.372-0.881, P = 0.011). And two factors significantly increased the probability of live birth: AFC >7 (aOR 1.591; 95% CI 1.075-2.353; P = 0.020); two embryos transferred (aOR 1.607; 95% CI 1.089-2.372; P = 0.017). Conclusions: For these infertile women who had undergone ovarian cystectomy for endometriosis, female age <35 years, AFC > 7, and two embryos transferred might achieve better clinical fresh IVF/ICSI-ET outcomes. BMI <21 kg/m2 or ≥25 kg/m2 might also have positive effects on the live birth rate, but different ovarian stimulation protocols had no significant effects. However, a larger sample size may be needed for further study.
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Affiliation(s)
- Wei Liu
- School of Medicine, Cheeloo College of Medicine, Shandong University, Jinan, China.,Center for Reproductive Medicine, Cheeloo College of Medicine, Hospital Affiliated to Shandong University, Shandong University, Jinan, China.,Department of Obstetrics and Gynecology, Shanxi Bethune Hospital, Shanxi Medical University, Taiyuan, China
| | - Tongye Sha
- Department of Obstetrics, Rizhao Hospital of Traditional Chinese Medicine, Rizhao, China
| | - Yuzhen Huang
- Center for Reproductive Medicine, Cheeloo College of Medicine, Hospital Affiliated to Shandong University, Shandong University, Jinan, China
| | - Zizhen Guo
- School of Medicine, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Lei Yan
- School of Medicine, Cheeloo College of Medicine, Shandong University, Jinan, China.,Center for Reproductive Medicine, Cheeloo College of Medicine, Hospital Affiliated to Shandong University, Shandong University, Jinan, China
| | - Jinlong Ma
- School of Medicine, Cheeloo College of Medicine, Shandong University, Jinan, China.,Center for Reproductive Medicine, Cheeloo College of Medicine, Hospital Affiliated to Shandong University, Shandong University, Jinan, China
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Yin Y, Mao Y, Liu A, Shu L, Yuan C, Cui Y, Hou Z, Liu J. Insufficient Cumulus Expansion and Poor Oocyte Retrieval in Endometriosis-Related Infertile Women. Reprod Sci 2021; 28:1412-1420. [PMID: 33409880 DOI: 10.1007/s43032-020-00410-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 11/22/2020] [Indexed: 11/25/2022]
Abstract
Endometriosis (EMs) is a common cause for female infertility, leading to the need for in vitro fertilization (IVF). In clinics, we found the operative oocyte retrieval to be more or less difficult in women with EMs. We hypothesized that EMs may be involved in the insufficient cumulus expansion that partially explained the lower oocyte retrieval in EMs-related infertile women undergoing assisted reproductive technology (ART). To explore whether the insufficient cumulus expansion exists in EMs-related infertile women and whether there is a possible relationship between the insufficient cumulus expansion and the clinical phenomenon of difficulty in oocyte retrieval. Those infertile women undergoing IVF recorded in our database between January 2013 and October 2017 were included. The expression levels of cumulus expansion-related genes (HAS2/PTGS2/PTX3/TNFAIP6) in the cumulus cells (CCs) from 19 infertile women with EMs and 24 controls were analyzed by real-time PCR. After that, 635 women with EMs-associated infertility (the EMs group) and 4634 women with male factor-associated infertility (the control group) were included in the retrospective analysis. The clinical outcomes were compared between the two groups. The relative mRNA levels of cumulus expansion-related genes were significantly decreased in the CCs from those infertile women with EMs when compared to the control group (all p < 0.05), especially the expression of PTGS2. The mean oocyte retrieval rates (proportion of obtained oocytes in punctured follicles) were (76.33 ± 2.58)% and (71.80 ± 0.58)% (p < 0.01). The mean numbers of flushing times per follicle were 1.11 ± 0.65 and 3.86 ± 1.53 (p < 0.001). The lower expression of cumulus expansion-related genes in CCs suggests the insufficient cumulus expansion in EMs-related infertile women, which partially explains a possible mechanism related to poor oocyte retrieval.
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Affiliation(s)
- Yaoxue Yin
- State Key Laboratory of Reproductive Medicine, Center of Clinical Reproductive Medicine, First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Yundong Mao
- State Key Laboratory of Reproductive Medicine, Center of Clinical Reproductive Medicine, First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Anthony Liu
- Life IVF Center, 3500 Barranca Pkwy, Suite 300, Irvine, CA, 92608, USA
| | - Li Shu
- State Key Laboratory of Reproductive Medicine, Center of Clinical Reproductive Medicine, First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Chun Yuan
- State Key Laboratory of Reproductive Medicine, Center of Clinical Reproductive Medicine, First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Yugui Cui
- State Key Laboratory of Reproductive Medicine, Center of Clinical Reproductive Medicine, First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Zhen Hou
- State Key Laboratory of Reproductive Medicine, Center of Clinical Reproductive Medicine, First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China.
| | - Jiayin Liu
- State Key Laboratory of Reproductive Medicine, Center of Clinical Reproductive Medicine, First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China.
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24
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Cobo A, Coello A, de Los Santos MJ, Giles J, Pellicer A, Remohí J, García-Velasco JA. Number needed to freeze: cumulative live birth rate after fertility preservation in women with endometriosis. Reprod Biomed Online 2021; 42:725-732. [PMID: 33573907 DOI: 10.1016/j.rbmo.2020.12.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 12/15/2020] [Accepted: 12/29/2020] [Indexed: 11/16/2022]
Abstract
RESEARCH QUESTION How does the number of oocytes used affect the cumulative live birth rate (CLBR) in endometriosis patients who had their oocytes vitrified for fertility preservation? DESIGN Retrospective observational study including data from 485 women with endometriosis who underwent fertility preservation from January 2007 to July 2018. Survival curves and Kaplan-Meier plots were used to analyse the CLBR according to the number of vitrified oocytes used. Endometriosis curves were compared with plots developed using elective fertility preservation (EFP) patients as control group. Log-rank, Breslow and Tarone-Ware tests were used to compare the survival curves. RESULTS The CLBR increased as the number of oocytes used per patient rose, reaching 89.5% (95% confidence interval [CI] 80.0-99.1%) using 22 oocytes. Higher outcomes were observed in young women (≤35 years old versus >35 years old). In the younger group, the CLBR was 95.4% (95% CI 87.2-103.6%) using approximately 20 oocytes versus 79.6% (95% CI 58.1-101.1%) in older women (log-rank [Mantel-Cox] P = 0.002). The mean age was higher in EFP patients (37.2 ± 4.9 versus 35.7 ± 3.7; P < 0.001). The outcome was better in the endometriosis group as compared with EFP: a CLBR of 89.5% (95% CI 80.0-99.1%) versus 59.9% (95% CI 51.4-68.6%) when 22 oocytes were used (log-rank [Mantel-Cox] P < 0.00001). CONCLUSION The probability of live birth increases as the number of oocytes used increases in patients with endometriosis, but better outcomes were observed among young women. The information provided here may be of interest to both patients and treating physicians for counselling purposes.
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Affiliation(s)
- Ana Cobo
- IVIRMA Valencia, Plaza de la Policía Local 3, Valencia 46015, Spain.
| | - Aila Coello
- IVIRMA Valencia, Plaza de la Policía Local 3, Valencia 46015, Spain
| | | | - Juan Giles
- IVIRMA Valencia, Plaza de la Policía Local 3, Valencia 46015, Spain
| | - Antonio Pellicer
- IVIRMA Valencia, Plaza de la Policía Local 3, Valencia 46015, Spain
| | - José Remohí
- IVIRMA Valencia, Plaza de la Policía Local 3, Valencia 46015, Spain
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25
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Is fertility preservation a necessity before endometriosis surgical treatment? GINECOLOGIA.RO 2021. [DOI: 10.26416/gine.31.1.2021.4329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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26
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Vaiarelli A, Venturella R, Cimadomo D, Conforti A, Pedri S, Bitonti G, Iussig B, Gentile C, Alviggi E, Santopaolo S, Zullo F, Rienzi L, Ubaldi FM. Endometriosis shows no impact on the euploid blastocyst rate per cohort of inseminated metaphase-II oocytes: A case-control study. Eur J Obstet Gynecol Reprod Biol 2020; 256:205-210. [PMID: 33246206 DOI: 10.1016/j.ejogrb.2020.11.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 11/02/2020] [Accepted: 11/06/2020] [Indexed: 12/31/2022]
Abstract
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.
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Affiliation(s)
- Alberto Vaiarelli
- Clinica Valle Giulia, GENERA Centers for Reproductive Medicine, Rome, Italy
| | - Roberta Venturella
- Magna Graecia University, Department of Experimental and Clinical Medicine, ART Center, Catanzaro, Italy.
| | - Danilo Cimadomo
- Clinica Valle Giulia, GENERA Centers for Reproductive Medicine, Rome, Italy; GENERA Veneto, GENERA Centers for Reproductive Medicine, Marostica, Italy; Clinica Ruesch, GENERA Centers for Reproductive Medicine, Naples, Italy
| | - Alessandro Conforti
- University "Federico II" of Naples, Department of Neuroscience, Reproductive Science and Odontostomatology, Italy
| | - Sara Pedri
- Magna Graecia University, Department of Experimental and Clinical Medicine, ART Center, Catanzaro, Italy
| | - Giovanna Bitonti
- Magna Graecia University, Department of Experimental and Clinical Medicine, ART Center, Catanzaro, Italy
| | - Benedetta Iussig
- GENERA Veneto, GENERA Centers for Reproductive Medicine, Marostica, Italy
| | - Cinzia Gentile
- GENERA Veneto, GENERA Centers for Reproductive Medicine, Marostica, Italy
| | - Erminia Alviggi
- Clinica Ruesch, GENERA Centers for Reproductive Medicine, Naples, Italy
| | - Serena Santopaolo
- Clinica Ruesch, GENERA Centers for Reproductive Medicine, Naples, Italy
| | - Fulvio Zullo
- Magna Graecia University, Department of Experimental and Clinical Medicine, ART Center, Catanzaro, Italy; University "Federico II" of Naples, Department of Neuroscience, Reproductive Science and Odontostomatology, Italy
| | - Laura Rienzi
- Clinica Valle Giulia, GENERA Centers for Reproductive Medicine, Rome, Italy; GENERA Veneto, GENERA Centers for Reproductive Medicine, Marostica, Italy; Clinica Ruesch, GENERA Centers for Reproductive Medicine, Naples, Italy
| | - Filippo Maria Ubaldi
- Clinica Valle Giulia, GENERA Centers for Reproductive Medicine, Rome, Italy; GENERA Veneto, GENERA Centers for Reproductive Medicine, Marostica, Italy; Clinica Ruesch, GENERA Centers for Reproductive Medicine, Naples, Italy
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27
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Cecchino GN, Cozzolino M, Roque M, García-Velasco JA. Endometrioma and reproductive issues: a well-informed patient may be the driver for change. ACTA ACUST UNITED AC 2020; 72:149-156. [PMID: 33000615 DOI: 10.23736/s0026-4784.20.04595-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Endometriosis affects a great proportion of women during their reproductive years and may impair female fertility in several ways. Ovarian endometrioma (OE) is the most frequent phenotype and growing evidence suggest an endometrioma-mediated damage to the ovary, ovarian reserve and oocyte quality. Traditionally, surgery has been the first-line treatment in cases of OE. Great advances in assisted reproduction and fertility preservation techniques opened new possibilities towards a more conservative approach. Herein we discuss multiple mechanisms responsible for the deterioration of the reproductive capacity in cases of OE as well as the pros and cons of different treatment options. The management of endometrioma-related subfertility remains controversial and it will depend on patient's intentions and priorities. In the "internet era" patients tend to be hyper-informed and more participative, but they are often misguided and misinformed. Thus, doctors should be able to convert these individuals into well-informed patients in order to facilitate the process of shared decision making, which is extremely relevant in the context of OEs.
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Affiliation(s)
- Gustavo N Cecchino
- Department of Gynecology, Federal University of São Paulo, São Paulo, Brazil - .,Department of Gynecology and Obstetrics, Rey Juan Carlos University, Madrid, Spain - .,Department of Reproductive Medicine, Mater Prime, São Paulo, Brazil -
| | - Mauro Cozzolino
- Department of Gynecology and Obstetrics, Rey Juan Carlos University, Madrid, Spain.,Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT, USA.,IVIRMA, IVI Foundation, Health Research Institute La Fe, Valencia, Spain
| | - Matheus Roque
- Department of Reproductive Medicine, Mater Prime, São Paulo, Brazil
| | - Juan A García-Velasco
- Department of Gynecology and Obstetrics, Rey Juan Carlos University, Madrid, Spain.,Department of Reproductive Medicine and Infertility, IVIRMA Madrid, Madrid, Spain
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28
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Miquel L, Preaubert L, Gnisci A, Resseguier N, Pivano A, Perrin J, Courbiere B. Endometrioma ethanol sclerotherapy could increase IVF live birth rate in women with moderate-severe endometriosis. PLoS One 2020; 15:e0239846. [PMID: 32986747 PMCID: PMC7521758 DOI: 10.1371/journal.pone.0239846] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 09/14/2020] [Indexed: 01/04/2023] Open
Abstract
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.
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Affiliation(s)
- Laura Miquel
- Department of Obstetrics Gynecology and Reproductive Medicine, Pôle femmes parents enfants, IVF Unit/ CECOS, AP-HM La Conception University Hospital, Marseille, France
| | - Lise Preaubert
- Department of Obstetrics Gynecology and Reproductive Medicine, Pôle femmes parents enfants, IVF Unit/ CECOS, AP-HM La Conception University Hospital, Marseille, France
| | - Audrey Gnisci
- Department of Obstetrics Gynecology and Reproductive Medicine, Pôle femmes parents enfants, IVF Unit/ CECOS, AP-HM La Conception University Hospital, Marseille, France
| | - Noémie Resseguier
- Research Unit EA 3279, Department of Public Health, Aix-Marseille University, Marseille, France
| | - Audrey Pivano
- Department of Obstetrics Gynecology and Reproductive Medicine, Pôle femmes parents enfants, IVF Unit/ CECOS, AP-HM La Conception University Hospital, Marseille, France
| | - Jeanne Perrin
- Department of Obstetrics Gynecology and Reproductive Medicine, Pôle femmes parents enfants, IVF Unit/ CECOS, AP-HM La Conception University Hospital, Marseille, France
- Aix Marseille Univ, Avignon Université, CNRS, IRD, IMBE, Marseille, France
| | - Blandine Courbiere
- Department of Obstetrics Gynecology and Reproductive Medicine, Pôle femmes parents enfants, IVF Unit/ CECOS, AP-HM La Conception University Hospital, Marseille, France
- Aix Marseille Univ, Avignon Université, CNRS, IRD, IMBE, Marseille, France
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29
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Guo SW, Martin DC. The perioperative period: a critical yet neglected time window for reducing the recurrence risk of endometriosis? Hum Reprod 2020; 34:1858-1865. [PMID: 31585460 DOI: 10.1093/humrep/dez187] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 07/11/2019] [Indexed: 12/11/2022] Open
Abstract
While surgery is commonly the management of symptomatic endometriosis when patients do not respond to medical or supportive therapy, recurrence after surgery poses a serious challenge, and repeat surgery increases the risk of premature ovarian failure, adhesion and organ injury. Conceivably, the recurrent endometriotic lesions could arise from minimal residual lesions (MRLs) or from de novo lesions. However, several lines of evidence suggest that the former is more likely. So far, most, if not all, efforts to combat recurrence have been focused on postoperative medication of hormonal drugs to reduce recurrence risk through lesional dormancy and possibly atrophy. However, the perioperative period may exert a disproportionally high impact on the risk of recurrence; it is likely to be amendable for possible intervention but has been generally neglected. Indeed, many perioperative factors are known to or conceivably could facilitate the recurrence of endometriosis through the suppression of cell-mediated immunity due to the activation of adrenergic signaling and the release of prostaglandins. Perioperative use of β-blockers and/or nuclear factor κB/jCycloxygenase 2 (NF-κB/COX-2) inhibitors may boost the cell-mediated immunity suppressed by surgery, resulting in the partial or even complete removal of MRLs and reduced recurrence risk. This is both biologically plausible and supported by a recent experimental study. We call for more research on possible perioperative interventions to reduce the recurrence risk of endometriosis. The potential payoff might be a substantial reduction in the risk of recurrence and cost when compared with the traditional approach of postoperative intervention.
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Affiliation(s)
- Sun-Wei Guo
- Shanghai OB/GYN Hospital, Fudan University, Shanghai, China.,Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Fudan University, Shanghai, China
| | - Dan C Martin
- School of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA.,Institutional Review Board, Virginia Commonwealth University, Richmond, VA, USA
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30
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Fallopian tube endometriosis in women undergoing operative video laparoscopy and its clinical implications. Fertil Steril 2020; 114:1040-1048. [PMID: 32826047 DOI: 10.1016/j.fertnstert.2020.05.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 05/12/2020] [Accepted: 05/18/2020] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To determine the incidence of fallopian tube endometriosis in patients undergoing laparoscopic surgery with a preoperative diagnosis of endometriosis, pelvic pain, infertility, or cystic adnexal mass. DESIGN Retrospective cross-sectional study. SETTING Gynecologic oncology and minimally invasive surgery practice. PATIENT(S) All patients who underwent surgery for endometriosis from July 2015 to June 2018 were included. Exclusion criteria were age ≥55 years, diagnosis of cancer, laparotomy, previous bilateral salpingectomy, and preoperative diagnosis other than endometriosis, pelvic pain, infertility, or cystic adnexal mass. INTERVENTION(S) Subjects were divided by those who did and those who did not have a salpingectomy at the time of surgery. MAIN OUTCOME MEASURE(S) Diagnosis of tubal endometriosis was based on macroscopic evidence of endometrial implants on the fallopian tube(s) noted within the operative report and microscopic evidence of endometriosis noted within the pathology report. RESULT(S) A total of 444 surgeries were performed and 185 met the study criteria. Among those, 153 (82.7%) had histologically diagnosed endometriosis within the abdominopelvic cavity. The incidence of tubal endometriosis was 11%-12% macroscopically and 42.5% microscopically after salpingectomy. Patients with tubal endometriosis were more likely to have severe disease. CONCLUSION(S) Among patients with endometriosis, the incidence of microscopic tubal endometriosis was significantly greater than that of macroscopic disease.
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31
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Zhang Z, Yuan Y, He L, Yao X, Chen J. Involvement of angiotensin II receptor type 1/NF-κB signaling in the development of endometriosis. Exp Ther Med 2020; 20:3269-3277. [PMID: 32855697 PMCID: PMC7444343 DOI: 10.3892/etm.2020.9071] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 06/24/2020] [Indexed: 12/15/2022] Open
Abstract
Endometriosis (EM) is a common disease in women; however, the signaling pathways and related genes underlying the mechanisms of EM remain unclear. The present study aimed to investigate the role of angiotensin II receptor type 1 (AGTR1) in the pathogenesis of EM. Human EM tissues were collected, and the expression levels of AGTR1 and NF-κB in the tissues were analyzed using immunochemistry and western blotting, while the estrogen levels in the EM tissues were determined by ELISA. In vitro human endometrial stromal cells were used to investigate the expression levels of AGTR1 following exposure to estrogen; the interaction between AGTR1 and NF-κB was determined using reverse transcription-quantitative PCR and western blotting; and the effects of AGTR1 on cell proliferation, as well as the apoptotic and migratory abilities of the cells were evaluated using WST-1 assays, wound healing assays and flow cytometry, respectively. It was observed that both the expression levels of AGTR1 and the activity of NF-κB were increased in human EM tissues and stromal cells, and this activation of AGTR1 subsequently increased the activity of NF-κB. Moreover, estrogen was found to regulate the expression levels of AGTR1 in stromal cells. The activation of AGTR1 was demonstrated to promote cell proliferation and migration, in addition to preventing cells from undergoing apoptosis. In conclusion, the present study suggested that the increased activity of the AGTR1-NF-κB axis following the decreased exposure to estrogen may be important for the pathogenesis of EM. In addition, AGTR1 may be a potential therapeutic target for the treatment of EM.
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Affiliation(s)
- Zhimin Zhang
- Department of Obstetrics, The Fourth Hospital of Shijiazhuang City, Shijiazhuang, Hebei 050011, P.R. China
| | - Yi Yuan
- Department of Obstetrics and Gynecology, Zhejiang Hospital, Hangzhou, Zhejiang 310030, P.R. China
| | - Lian He
- Hebei Key Laboratory of Integrative Medicine on Liver-Kidney Patterns, Institute of Integrative Medicine, College of Integrative Medicine, Hebei University of Chinese Medicine, Shijiazhuang, Hebei 050200, P.R. China
| | - Xiaoguang Yao
- Hebei Key Laboratory of Integrative Medicine on Liver-Kidney Patterns, Institute of Integrative Medicine, College of Integrative Medicine, Hebei University of Chinese Medicine, Shijiazhuang, Hebei 050200, P.R. China
| | - Jingwei Chen
- Hebei Key Laboratory of Integrative Medicine on Liver-Kidney Patterns, Institute of Integrative Medicine, College of Integrative Medicine, Hebei University of Chinese Medicine, Shijiazhuang, Hebei 050200, P.R. China
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32
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Luo M, Cai X, Yan D, Liu X, Guo SW. Sodium tanshinone IIA sulfonate restrains fibrogenesis through induction of senescence in mice with induced deep endometriosis. Reprod Biomed Online 2020; 41:373-384. [PMID: 32651107 DOI: 10.1016/j.rbmo.2020.04.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 03/02/2020] [Accepted: 04/08/2020] [Indexed: 02/06/2023]
Abstract
RESEARCH QUESTION Does sodium tanshinone IIA sulfonate (STS) induce cellular senescence in endometriotic lesions and thus restrict lesional development and fibrogenesis in a recently established mouse model of deep endometriosis? DESIGN Prospective randomized animal experiment in which deep endometriosis was induced in female Balb/C mice, which were then randomly divided into three groups (low-dose STS, high-dose STS and inert vehicle control) and received treatment for 2 weeks. All mice were then sacrificed and their lesions excised and harvested. Lesion weight was quantified and all lesion samples were subjected to histochemical analysis of the extent of lesional fibrosis by Masson trichrome staining, and of cellular senescence by senescence-associated β-galactosidase (SA-β-gal), along with immunohistochemistry analyses of p53, CCN1, activate Salvador 1 (Sav1), hyaluronan synthase 2 (HAS2), survivin, granulocyte-macrophage colony-stimulating factor (GM-CSF) and CD163-positive M2 macrophages. Plasma P-selectin and hyaluronic acid levels were also quantified. Hotplate testing was also administered before the induction, then before and after treatment. RESULTS STS treatment resulted in significantly reduced lesion weight, stalled lesional fibrogenesis and improved hyperalgesia, seemingly through the induction of cellular senescence by activating p53, Sav1 and CCN1 while suppressing HAS2, survivin and GM-CSF, resulting in increased apoptosis and reduced lesional infiltration of alternatively activated macrophages. In addition, STS treatment significantly reduced the plasma concentration of P-selectin and hyaluronic acid, possibly leading to reduced lesional platelet aggregation. CONCLUSIONS STS appears to be a promising compound for treating endometriosis. The results suggest that senescence may restrict lesional progression and fibrogenesis, and targeting the senescence pathway may have desirable therapeutic potential.
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Affiliation(s)
- Min Luo
- Department of Obstetrics and Gynecology, Ningbo No. 7 Hospital, Ningbo Zhejiang 315200, China; These three authors contributed equally to this work
| | - Xianjun Cai
- Department of Obstetrics and Gynecology, Ningbo No. 7 Hospital, Ningbo Zhejiang 315200, China; These three authors contributed equally to this work
| | - Dingmin Yan
- Shanghai OB/GYN Hospital, Fudan University Shanghai 200090, China; These three authors contributed equally to this work
| | - Xishi Liu
- Shanghai OB/GYN Hospital, Fudan University Shanghai 200090, China; Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Fudan University Shanghai, China
| | - Sun-Wei Guo
- Shanghai OB/GYN Hospital, Fudan University Shanghai 200090, China; Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Fudan University Shanghai, China.
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Ottolina J, Ferrari S, Bartiromo L, Bonavina G, Salmeri N, Schimberni M, Makieva S, Tandoi I, Papaleo E, ViganÒ P, Candiani M. Ovarian responsiveness in assisted reproductive technology after CO2 fiber laser vaporization for endometrioma treatment: preliminary data. MINERVA ENDOCRINOL 2020; 45:288-294. [PMID: 32638581 DOI: 10.23736/s0391-1977.20.03256-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Data about endometrioma ablation using energies with little thermal spread reported good results in terms of ovarian reserve and postoperative pregnancy rates. The aim of the present study was to assess the impact of one step CO<inf>2</inf> fiber laser vaporization for endometrioma on subsequent controlled ovarian stimulation. METHODS This prospective observational cohort study included a consecutive series of infertile patients who have undergone CO<inf>2</inf> fibre laser vaporization for endometrioma treatment. The primary endpoint was to assess the number of follicles per ovary growing during controlled ovarian stimulation. The secondary endpoints included the number of oocytes retrieved, the total number of embryos obtained and the cumulative clinical pregnancy rate per patient treated. RESULTS Twenty-six patients underwent assisted reproductive technology after surgery for endometriosis-related infertility. In unilateral operated ovaries at the end of controlled ovarian stimulation no significant differences emerged from comparison of total recruited follicles in the operated ovary and in the contralateral ovary (P=0.55). If considering only bilateral endometriomas, the number of recruited follicles at the end of controlled ovarian stimulation was similar in both operated ovaries (P=0.79). The number of cumulative clinical pregnancies was 15 (57.7%; 95% CI: 38.5-76.9%). When comparing women aged ≤35 years to those aged >35 years, controlled ovarian stimulation outcomes were significantly higher in the younger patients. Age at the time of assisted reproductive technology was the only independent predictor for follicular growth during ovarian hyperstimulation (95% CI: -1.27 to -0.116, P=0.027). CONCLUSIONS CO2 laser-treated endometrioma is associated with favorable reproductive assisted reproductive technology outcomes.
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Affiliation(s)
- Jessica Ottolina
- Department of Gynecology, IRCCS San Raffaele Scientific Institute, Milan, Italy -
| | - Stefano Ferrari
- Department of Gynecology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Ludovica Bartiromo
- Department of Gynecology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giulia Bonavina
- Department of Gynecology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Noemi Salmeri
- Department of Gynecology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Matteo Schimberni
- Department of Gynecology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Sofia Makieva
- Division of Genetics and Cell Biology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Iacopo Tandoi
- Department of Gynecology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Enrico Papaleo
- Department of Gynecology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Paola ViganÒ
- Division of Genetics and Cell Biology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Massimo Candiani
- Department of Gynecology, IRCCS San Raffaele Scientific Institute, Milan, Italy
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Şükür YE, Özmen B, Yakıştıran B, Atabekoğlu CS, Berker B, Aytaç R, Sönmezer M. Endometrioma surgery is associated with increased risk of subsequent assisted reproductive technology cycle cancellation; a retrospective cohort study. J OBSTET GYNAECOL 2020; 41:259-262. [PMID: 32496142 DOI: 10.1080/01443615.2020.1754366] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The aim of this study was to assess the effect of laparoscopic removal of endometrioma on assisted reproductive technology (ART) outcome. A retrospective cohort study was conducted at a university hospital between January 2014 and December 2017. The ART group consisted of 26 women who underwent 44 ART cycles in the presence of ovarian endometrioma and the surgery group consisted of 53 women who underwent 58 ART cycles after laparoscopic removal of ovarian endometrioma/s. There were no statistically significant differences between the groups regarding demographic parameters and background features including cycle parameters. The live birth rates in the ART and Surgery groups per embryo transfer were 23.7 and 26.1%, respectively (p = .800). The rate of cycle cancellation due to poor response and/or failed oocyte retrieval was significantly higher in the Surgery group than ART group (13.7 vs. 0%, respectively; p = .018). In conclusion, cystectomy significantly increases the risk of cycle cancellation due to poor ovarian response, which might be catastrophic individually. However, it does not seem to affect the live birth rates.IMPACT STATEMENTWhat is already known on this subject? Both the presence of an endometrioma or surgical removal may have deleterious effects on fertility potential.What do the results of this study add? Our results confirm that although cystectomy has no benefit on the number of oocytes collected and live birth rate, it increases the risk of cycle cancellation significantly in assisted reproductive technology cycles following endometrioma surgery.What are the implications of these findings for clinical practice and/or further research? Postponing cystectomy until a freeze-all cycle may be the best option to maximise the number of oocytes retrieved and to maximise the ovarian response.
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Affiliation(s)
- Yavuz Emre Şükür
- Department of Obstetrics and Gynecology, Ankara University School of Medicine, Ankara, Turkey
| | - Batuhan Özmen
- Department of Obstetrics and Gynecology, Ankara University School of Medicine, Ankara, Turkey
| | - Betül Yakıştıran
- Department of Obstetrics and Gynecology, Ankara University School of Medicine, Ankara, Turkey
| | - Cem Somer Atabekoğlu
- Department of Obstetrics and Gynecology, Ankara University School of Medicine, Ankara, Turkey
| | - Bülent Berker
- Department of Obstetrics and Gynecology, Ankara University School of Medicine, Ankara, Turkey
| | - Ruşen Aytaç
- Department of Obstetrics and Gynecology, Ankara University School of Medicine, Ankara, Turkey
| | - Murat Sönmezer
- Department of Obstetrics and Gynecology, Ankara University School of Medicine, Ankara, Turkey
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Triantafyllidou O, Sigalos G, Gkoles L, Kastora S, Vakas P, Batsiou E, Vlahos N. The addition of clomiphene citrate to ovarian stimulation protocols for poor responders. Eur J Obstet Gynecol Reprod Biol 2020; 251:136-140. [PMID: 32502769 DOI: 10.1016/j.ejogrb.2020.05.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 05/13/2020] [Indexed: 10/24/2022]
Abstract
Poor ovarian response (POR) is one of the most challenging problems in assisted reproduction. Several strategies have been used to improve pregnancy rates. The use of Clomiphene Citrate (CC) has been shown to improve ovarian stimulation outcomes and decrease gonadotropin requirements in women of advanced reproductive age. However, the combination of CC and gonadotropins to improve pregnancy rates after in IVF in poor responders is still unexplored due to the small number of trials with few participants. This is a prospective cohort trial involving 12 patients diagnosed with poor ovarian response who underwent ovarian stimulation during the period between June 2015 and September of 2017. All patients were treated with the maximum dose of gonadotropins (hMG, 300 IU/day, hMG group) according to a short gonadotropin/GnRH antagonist protocol. In a subsequent cycle those patients underwent the same stimulation protocol with the addition of 100 mg of CC from day 3 to day 7 (CC-hMG group). Supplementation with 100 mg of CC resulted in a statistically significant increase in estradiol levels, number of follicles and number of oocytes retrieved, as well as an increase in the number of total embryos available for transfer. Furthermore, a significant reduction was observed in cancellation rates in the CC-hMG group. Two clinical pregnancies, which resulted in two live births and 3 biochemical pregnancies were achieved in the CC/hMG group. Furthermore, by employing open-source, biological data we identified a common gene (Estrogen Receptor 1, ESR1) between genetic targets of clomiphene treatment and POR which could explain the benefits of clomiphene in this group of patients. In conclusion, the addition of CC 100 mg to the stimulation regimen in women diagnosed with POR and previous failed IVF cycles could improve stimulation results, but this study could not demonstrate any benefit in terms of clinical pregnancies and live births. The effectiveness of this treatment requires further investigation.
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Affiliation(s)
- Olga Triantafyllidou
- Reproductive Medicine Unit, "Leto" Maternity Hospital, Mouson Str. 7-13, Athens, 11524, Greece.
| | - Giorgos Sigalos
- Reproductive Medicine Unit, "Leto" Maternity Hospital, Mouson Str. 7-13, Athens, 11524, Greece
| | - Laertis Gkoles
- Assisted Conception Unit "IAKENTRO", Fragokklisias Str. 15125, Athens, Greece
| | - Stavroula Kastora
- Reproductive Medicine Unit, "Leto" Maternity Hospital, Mouson Str. 7-13, Athens, 11524, Greece.
| | - Panagiotis Vakas
- 2(nd) Department of Obstetrics and Gynecology, Aretaieion Hospital, University of Athens, Vas. Sofias Str. 7, 11528, Greece
| | - Eugenia Batsiou
- Reproductive Medicine Unit, "Leto" Maternity Hospital, Mouson Str. 7-13, Athens, 11524, Greece
| | - Nikos Vlahos
- 2(nd) Department of Obstetrics and Gynecology, Aretaieion Hospital, University of Athens, Vas. Sofias Str. 7, 11528, Greece
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Yan D, Liu X, Xu H, Guo SW. Platelets induce endothelial-mesenchymal transition and subsequent fibrogenesis in endometriosis. Reprod Biomed Online 2020; 41:500-517. [PMID: 32709523 DOI: 10.1016/j.rbmo.2020.03.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Revised: 03/07/2020] [Accepted: 03/13/2020] [Indexed: 02/06/2023]
Abstract
RESEARCH QUESTION Do endometriotic lesions undergo endothelial-mesenchymal transition (EndoMT)? DESIGN Lesion samples from 30 patients with ovarian endometriomas and deep endometriosis, and control endometrial tissue samples from 30 women without endometriosis, were analysed. In-vitro experimentation using the human umbilical vein endothelial cell (HUVEC) line were conducted. Immunofluorescence staining and immunohistochemistry analysis using antibodies against endothelial cell and mesenchymal cell markers were conducted. The HUVEC cells were co-cultured with activated platelets or control medium with and without neutralization of TGF-β1 PDGFR, or both. Their morphology, proliferation and expression levels of genes and proteins known to be involved in EndoMT were evaluated, along with their migratory and invasive propensity, contractility and collagen production capability. RESULTS The proportion of CD31 and FSP-1 dual-positive cells in FSP-1+ fibroblasts was 74.7% (±5.4%) in ovarian endometrioma lesions, significantly higher than that in deep endometriosis lesions (26.8% ± 26.0%; P = 5.7 × 10-5), and was zero in normal endometrium. The extent of lesional fibrosis correlated positively with staining levels of the lesional mesenchymal markers FSP-1 and α-SMA (r = 0.91; P < 2.2 × 10-16, r = 0.81; P = 5.8 × 10-15, respectively). Human endothelial cells co-cultured with activated platelets acquire a morphology suggestive of EndoMT, concomitant with increased proliferation, loss of CD31 but marked increase in expression of mesenchymal markers. Morphological and gene and protein expression changes are accompanied by functional differentiation reflected by increased migratory and invasive capacity, contractility and collagen production. Neutralization of TGF-β1 and PDGFR signalling abolished platelet-induced EndoMT in human endothelial cells. CONCLUSIONS Multiple sources of myofibroblasts exist in endometriotic lesions, and implicates platelets, EndoMT, or both, as potential therapeutic targets for treating endometriosis.
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Affiliation(s)
- Dingmin Yan
- Shanghai Obstetrics and Gynecology Hospital, Fudan University, Shanghai 200011, China
| | - Xishi Liu
- Shanghai Obstetrics and Gynecology Hospital, Fudan University, Shanghai 200011, China; Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Fudan University, Shanghai, China
| | - Hong Xu
- Department of Obstetrics and Gynecology, Shanghai Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 100045, China
| | - Sun-Wei Guo
- Shanghai Obstetrics and Gynecology Hospital, Fudan University, Shanghai 200011, China; Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Fudan University, Shanghai, China.
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Supramaniam PR, Granne I, Ohuma EO, Lim LN, McVeigh E, Venkatakrishnan R, Becker CM, Mittal M. ICSI does not improve reproductive outcomes in autologous ovarian response cycles with non-male factor subfertility. Hum Reprod 2020; 35:583-594. [DOI: 10.1093/humrep/dez301] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Revised: 12/12/2019] [Accepted: 12/18/2019] [Indexed: 12/27/2022] Open
Abstract
Abstract
STUDY QUESTION
Does the method of fertilisation improve reproductive outcomes in poor ovarian response (POR) cycles when compared to all other ovarian response categories in the absence of male factor subfertility?
SUMMARY ANSWER
ICSI does not confer any benefit in improving the clinical pregnancy or live birth (LB) outcome in autologous ovarian response cycles in the absence of male factor subfertility when compared to IVF.
WHAT IS KNOWN ALREADY
ICSI is associated with an improved outcome when compared to IVF in patients with severe male factor subfertility.
STUDY DESIGN, SIZE, DURATION
A retrospective study involving 1 376 454 ART cycles, of which 569 605 (41.4%) cycles fulfilled the inclusion and exclusion criteria for all autologous ovarian response categories: 272 433 (47.8%) IVF cycles and 297 172 (52.2%) ICSI cycles. Of these, the POR cohort represented 62 641 stimulated fresh cycles (11.0%): 33 436 (53.4%) IVF cycles and 29 205 (46.6%) ICSI cycles.
PARTICIPANTS/MATERIALS, SETTING, METHOD
All cycles recorded on the anonymised Human Fertilisation and Embryology Authority (HFEA) registry database between 1991 and 2016 were analysed. All fresh cycles with normal sperm parameters, performed after 1998 were included: frozen cycles, donor oocyte and sperm usage, intrauterine insemination cycles, preimplantation genetic testing (PGT) for aneuploidies (PGT-A), PGT for monogenic/single gene defects (PGT-M), PGT for chromosomal structural arrangements (PGT-SR) cycles, where the reason for stimulation was for storage and unstimulated cycles were excluded.
MAIN RESULTS AND THE ROLE OF CHANCE
ICSI did not confer any benefit in improving the LB outcome when compared to conventional IVF per treatment cycle (PTC), when adjusted for female age, number of previous ART treatment cycles, number of previous live births through ART, oocyte yield, stage of transfer, method of fertilisation and number of embryos transferred in the POR cohort (adjusted odds ratio [a OR] 1.03, 99.5% confidence interval [CI] 0.96–1.11, P = 0.261) and all autologous ovarian response categories (aOR 1.00, 99.5% CI 0.98–1.02, P = 0.900). The mean fertilisation rate was statistically lower for IVF treatment cycles (64.7%) when compared to ICSI treatment cycles (67.2%) in the POR cohort (mean difference −2.5%, 99.5% CI −3.3 to −1.6, P < 0.001). The failed fertilisation rate was marginally higher in IVF treatment cycles (17.3%, 95% binomial exact 16.9 to 17.7%) when compared to ICSI treatment cycles (17.0%, 95% binomial exact 16.6 to 17.4%); however, this did not reach statistical significance (P = 0.199). The results followed a similar trend when analysed for all autologous ovarian response categories with a higher rate of failed fertilisation in IVF treatment cycles (4.8%, 95% binomial exact 4.7 to 4.9%) when compared to ICSI treatment cycles (3.2%, 95% binomial exact 3.1 to 3.3%) (P < 0.001).
LIMITATIONS, REASONS FOR CAUTION
The quality of data is reliant on the reporting system. Furthermore, success rates through ART have improved since 1991, with an increased number of blastocyst-stage embryo transfers. The inability to link the treatment cycle to the individual patient meant that we were unable to calculate the cumulative LB outcome per patient.
WIDER IMPLICATIONS OF THE FINDINGS
This is the largest study to date which evaluates the impact of method of fertilisation in the POR patient and compares this to all autologous ovarian response categories. The results demonstrate that ICSI does not confer any benefit in improving reproductive outcomes in the absence of male factor subfertility, with no improvement seen in the clinical pregnancy or LB outcomes following a fresh treatment cycle.
STUDY FUNDING/COMPETING INTEREST(S)
The study received no funding. C.M.B. is a member of the independent data monitoring group for a clinical endometriosis trial by ObsEva. He is on the scientific advisory board for Myovant and medical advisory board for Flo Health. He has received research grants from Bayer AG, MDNA Life Sciences, Volition Rx and Roche Diagnostics as well as from Wellbeing of Women, Medical Research Council UK, the NIH, the UK National Institute for Health Research and the European Union. He is the current Chair of the Endometriosis Guideline Development Group for ESHRE and was a co-opted member of the Endometriosis Guideline Group by the UK National Institute for Health and Care Excellence (NICE). I.G. has received research grants from Bayer AG, Wellbeing of Women, the European Union and Finox.
TRIAL REGISTRATION NUMBER
Not applicable.
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Affiliation(s)
- P R Supramaniam
- John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 9DU, UK
| | - I Granne
- John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 9DU, UK
- Oxford Endometriosis CaRe Centre, Nuffield Department of Women’s and Reproductive Health, University of Oxford, Oxford OX3 9DU, UK
- Oxford Reproductive Medicine, The Manor Hospital, Oxford OX3 7RP, UK
| | - E O Ohuma
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford OX3 7BN, UK
- Centre for Global Child Health & Child Health Evaluative Sciences, Hospital for Sick Children, Toronto, Canada M5G 2L3
| | - L N Lim
- John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 9DU, UK
- Oxford Reproductive Medicine, The Manor Hospital, Oxford OX3 7RP, UK
| | - E McVeigh
- John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 9DU, UK
- Oxford Endometriosis CaRe Centre, Nuffield Department of Women’s and Reproductive Health, University of Oxford, Oxford OX3 9DU, UK
- Oxford Reproductive Medicine, The Manor Hospital, Oxford OX3 7RP, UK
| | - R Venkatakrishnan
- Department of Obstetrics and Gynaecology, University Hospitals of Derby and Burton NHS Foundation Trust, Derby DE22 3NE, UK
| | - C M Becker
- John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 9DU, UK
- Oxford Endometriosis CaRe Centre, Nuffield Department of Women’s and Reproductive Health, University of Oxford, Oxford OX3 9DU, UK
- Oxford Reproductive Medicine, The Manor Hospital, Oxford OX3 7RP, UK
| | - M Mittal
- Department of Obstetrics and Gynaecology, Wolfson Fertility Center, St Mary’s and Hammersmith Hospitals, Imperial College Healthcare NHS Trust, London W2 1NY, UK
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Lee D, Kim SK, Lee JR, Jee BC. Management of endometriosis-related infertility: Considerations and treatment options. Clin Exp Reprod Med 2020; 47:1-11. [PMID: 32088944 PMCID: PMC7127898 DOI: 10.5653/cerm.2019.02971] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 07/10/2019] [Accepted: 09/05/2019] [Indexed: 02/06/2023] Open
Abstract
Endometriosis is a common inflammatory disease in women of reproductive age and is one of the major causes of infertility. Endometriosis causes a sustained reduction of ovarian reserve through both physical mechanisms and inflammatory reactions, which result in the production of reactive oxygen species and tissue fibrosis. The severity of endometriosis is related to ovarian reserve. With regard to infertility treatment, medical therapy as a neoadjuvant or adjuvant to surgical therapy has no definite beneficial effect. Surgical treatment of endometriosis can lead to ovarian injury during the resection of endometriotic tissue, which leads to the deterioration of ovarian reserve. To overcome this disadvantage, a multistep technique has been proposed to minimize the reduction of ovarian reserve. When considering surgical treatment of endometriosis in patients experiencing infertility, it should be kept in mind that ovarian reserve can be reduced both due to endometriosis itself and by the process of removing endometriosis. In cases of mild- to moderate-stage endometriosis, intrauterine insemination with ovarian stimulation after surgical treatment may increase the likelihood of pregnancy. In cases of severe endometriosis, the characteristics of the patient should be considered in a multidisciplinary manner to determine the prioritization of treatment modalities, including surgical treatment and assisted reproduction methods such as in vitro fertilization. The risk of cancer, complications after pregnancy, and infection during oocyte retrieval should also be considered when making treatment decisions.
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Affiliation(s)
- Dayong Lee
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Seul Ki Kim
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
| | - Jung Ryeol Lee
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
| | - Byung Chul Jee
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
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Guo H, Gao H, Li J, Cong Y, Chen Q, Wang Y, Zhu Q, Lyu Q, Wu L, Chai W, Kuang Y. Impacts of medroxyprogesterone acetate on oocytes and embryos: matched case-control study in women with stage III-IV ovarian endometriosis undergoing controlled ovarian hyperstimulation for in vitro fertilization. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:377. [PMID: 32355821 PMCID: PMC7186739 DOI: 10.21037/atm.2020.02.15] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background This study investigated the effects of medroxyprogesterone acetate (MPA) on the oocytes and embryos in patients with advanced endometriosis who had a normal ovarian reserve and tubal infertility and received controlled ovarian hyperstimulation (COH) and explored the characteristics and pregnancy outcomes in subsequent frozen-thawed embryo transfer (FET) cycles. Methods In this prospective controlled study, 150 advanced endometriosis patients involving 150 in vitro fertilisation/intracytoplasmic sperm injection (IVF/ICSI) cycles and 163 FET cycles and 150 age-matched tubal infertility patients requiring 150 IVF/ICSI cycles and 115 FET cycles were recruited. Patients with endometriosis were sub-grouped into surgery group (n=102) (they were diagnosed with ovarian endometriomas and underwent 102 IVF/ICSI and 115FET cycles) and aspiration group (n=48) [they had ovarian "chocolate" cysts (>3 cm) that were aspirated and underwent 48 IVF/ICSI and 74 FET cycles]. Results Lower oocyte retrieval rate was noted in the endometriosis group than in the control group. Similar oocyte yield and peak estrogen (E2) level were found in two groups. The rates of mature oocyte, fertilization, cleavage, high-quality embryo, viable embryo, cancellation, implantation, and clinical pregnancy were similar between two groups. A higher oocyte yield was observed in the EMS cyst group than in the surgery group. Conclusions The ovary response, oocytes, embryos and pregnancy outcome were not influenced by the advanced endometriosis and the use of MPA and also independent of endometrioma or cyst surgery.
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Affiliation(s)
- Haiyan Guo
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Center for Specialty Strategy Research of Shanghai Jiao Tong University China Hospital Development Institute, Shanghai 200011, China
| | - Hongyuan Gao
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Center for Specialty Strategy Research of Shanghai Jiao Tong University China Hospital Development Institute, Shanghai 200011, China
| | - Jianghui Li
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Center for Specialty Strategy Research of Shanghai Jiao Tong University China Hospital Development Institute, Shanghai 200011, China
| | - Yanyan Cong
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Center for Specialty Strategy Research of Shanghai Jiao Tong University China Hospital Development Institute, Shanghai 200011, China
| | - Qiuju Chen
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Center for Specialty Strategy Research of Shanghai Jiao Tong University China Hospital Development Institute, Shanghai 200011, China
| | - Yun Wang
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Center for Specialty Strategy Research of Shanghai Jiao Tong University China Hospital Development Institute, Shanghai 200011, China
| | - Qianqian Zhu
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Center for Specialty Strategy Research of Shanghai Jiao Tong University China Hospital Development Institute, Shanghai 200011, China
| | - Qifeng Lyu
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Center for Specialty Strategy Research of Shanghai Jiao Tong University China Hospital Development Institute, Shanghai 200011, China
| | - Ling Wu
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Center for Specialty Strategy Research of Shanghai Jiao Tong University China Hospital Development Institute, Shanghai 200011, China
| | - Weiran Chai
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Center for Specialty Strategy Research of Shanghai Jiao Tong University China Hospital Development Institute, Shanghai 200011, China
| | - Yanping Kuang
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Center for Specialty Strategy Research of Shanghai Jiao Tong University China Hospital Development Institute, Shanghai 200011, China
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Zhao F, Lan Y, Chen T, Xin Z, Liang Y, Li Y, Wang S, Zhang J, Yang X. Live birth rate comparison of three controlled ovarian stimulation protocols for in vitro fertilization-embryo transfer in patients with diminished ovarian reserve after endometrioma cystectomy: a retrospective study. J Ovarian Res 2020; 13:23. [PMID: 32113477 PMCID: PMC7049193 DOI: 10.1186/s13048-020-00622-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 02/10/2020] [Indexed: 12/31/2022] Open
Abstract
Background Women with endometriosis and previous cystectomy may respond less well to gonadotropin stimulation, which results in fewer oocytes retrieved and poor pregnancy outcomes. Choosing an appropriate protocol for such populations is essential. This study involved an analysis of the effect of different controlled ovarian stimulation (COS) protocols on the clinical outcomes of in vitro fertilization-embryo transfer (IVF-ET) in women with diminished ovarian reserve (DOR) who underwent ovarian endometrioma cystectomy. Methods A total of 342 patients that underwent IVF-ET treatment at the Beijing Obstetrics and Gynecology Hospital from January 1, 2013 to April 30, 2018 were included in this retrospective study. The patients were distributed into three groups according to the COS protocols, namely prolonged GnRH-agonist (Group A, n = 113), GnRH-antagonist (Group B, n = 121), and long GnRH-agonist (Group C, n = 108). The clinical and laboratory parameters of the three protocols were analyzed and a logistic regression of clinical pregnancy and live births was conducted. Results There were no significant differences in the age, infertility duration, basic follicle stimulation hormone (FSH), luteinizing hormone (LH), or estradiol (E2) levels as well as other baseline characteristics among groups (P > 0.05). The total gonadotrophin (Gn) dosage and duration tended to be less in the GnRH-antagonist group than in the others (P < 0.05). No significant differences were found in the implantation rate and clinical pregnancy rate among the groups, but the prolonged GnRH-agonist group showed the highest rates. In addition, no significant differences were present in the number of retrieved oocytes, oocyte fertilization rate, embryo utilization rate, live birth rate, abortion rate, ectopic pregnancy rate, or multiple pregnancy rate in the three groups (P > 0.05). Age had a significant effect on both clinical pregnancy and live birth. Conclusion For those DOR patients who had undergone ovarian endometriosis cystectomy, the prolonged GnRH-agonist protocol may achieve better clinical IVF-ET outcomes, but there were no significant differences from the other groups. The GnRH-antagonist protocol may reduce the cost and time of drug treatment. Age should be considered for its influence on pregnancy outcome. However, a larger sample size may be needed for further study.
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Affiliation(s)
- Feiyan Zhao
- Department of Human Reproductive Medicine, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, 251 Yao jia yuan Road, Chaoyang District, Beijing, 100026, China
| | - Yonglian Lan
- Department of Human Reproductive Medicine, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, 251 Yao jia yuan Road, Chaoyang District, Beijing, 100026, China
| | - Tong Chen
- Department of Human Reproductive Medicine, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, 251 Yao jia yuan Road, Chaoyang District, Beijing, 100026, China
| | - Zhimin Xin
- Department of Human Reproductive Medicine, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, 251 Yao jia yuan Road, Chaoyang District, Beijing, 100026, China
| | - Yu Liang
- Department of Human Reproductive Medicine, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, 251 Yao jia yuan Road, Chaoyang District, Beijing, 100026, China
| | - Ying Li
- Department of Human Reproductive Medicine, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, 251 Yao jia yuan Road, Chaoyang District, Beijing, 100026, China
| | - Shuyu Wang
- Department of Human Reproductive Medicine, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, 251 Yao jia yuan Road, Chaoyang District, Beijing, 100026, China
| | - Jun Zhang
- Department of Human Reproductive Medicine, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, 251 Yao jia yuan Road, Chaoyang District, Beijing, 100026, China.
| | - Xiaokui Yang
- Department of Human Reproductive Medicine, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, 251 Yao jia yuan Road, Chaoyang District, Beijing, 100026, China.
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Kim SJ, Kim SK, Lee JR, Suh CS, Kim SH. Oocyte cryopreservation for fertility preservation in women with ovarian endometriosis. Reprod Biomed Online 2020; 40:827-834. [PMID: 32295746 DOI: 10.1016/j.rbmo.2020.01.028] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 01/20/2020] [Accepted: 01/28/2020] [Indexed: 01/25/2023]
Abstract
RESEARCH-QUESTION What is the clinical usefulness of oocyte cryopreservation for fertility preservation in women with ovarian endometriosis? DESIGN Clinical characteristics were retrospectively analysed in 34 women with endometrioma before a planned ovarian cystectomy. Ovarian stimulation outcomes were compared according to laterality. A one-to-one propensity score-matched analysis was conducted to compare ovarian stimulation outcomes of the first cycle in patients with endometrioma undergoing fertility preservation with those in infertile patients without endometrioma who underwent IVF treatment. The number of oocytes cryopreserved in repeated ovarian stimulation cycles was analysed. RESULTS The mean endometrioma size at diagnosis was 6.0 ± 2.5 cm. The mean age, serum anti-Mullerian hormone levels and number of oocytes cryopreserved were 30.7 ± 5.9 years, 1.85 ± 1.14 ng/ml, and 4.8 ± 3.2, respectively. The number of oocytes cryopreserved in bilateral endometrioma compared with unilateral endometrioma patients was 4.1 ± 2.9 versus 5.7 ± 3.4 (P = 0.600). In the propensity score-matched cohort (n = 22 per group), the number of oocytes retrieved was significantly lower in the patients with endometrioma undergoing fertility preservation compared with that in infertile patients without endometrioma (5.4 ± 3.8 versus 8.1 ± 4.8; P = 0.045). A total of 13 (38.2%) patients with endometrioma underwent repeated stimulation. The median (interquartile range) number of cryopreserved oocytes at the first and the second cycle were 3.0 (2.5-6.0) and 5.0 (2.5-7.5), respectively. CONCLUSIONS Women with endometrioma should be counselled about oocyte cryopreservation for fertility preservation before surgery. The number of cryopreserved oocytes can be increased by repeated oocyte retrieval.
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Affiliation(s)
- Se Jeong Kim
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, 82 Gumiro 173 Beon-gil, Bundang-gu, Seongnam, Gyeonggi-do, Korea 13620; Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul Korea 03080; Department of Obstetrics and Gynecology, Fertility Center of CHA Gangnam Medical Center, CHA University School of Medicine, Seoul Korea 06125
| | - Seul Ki Kim
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, 82 Gumiro 173 Beon-gil, Bundang-gu, Seongnam, Gyeonggi-do, Korea 13620; Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul Korea 03080
| | - Jung Ryeol Lee
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, 82 Gumiro 173 Beon-gil, Bundang-gu, Seongnam, Gyeonggi-do, Korea 13620; Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul Korea 03080.
| | - Chang Suk Suh
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul Korea 03080
| | - Seok Hyun Kim
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul Korea 03080
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42
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Raad J, Rolland L, Grynberg M, Courbiere B, Mathieu d'Argent E. [Borderline Ovarian Tumours: CNGOF Guidelines for Clinical Practice - Fertility]. ACTA ACUST UNITED AC 2020; 48:330-336. [PMID: 32004782 DOI: 10.1016/j.gofs.2020.01.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVES Borderline ovarian tumours (BOT) represent around 15% of all ovarian neoplasms and are more likely to be diagnosed in women of reproductive age. Overall, given the epidemiological profile of BOT and their favourable prognosis, ovarian function and fertility preservation should be systematically considered in patients presenting these lesions. METHODS The research strategy was based on the following terms: borderline ovarian tumour, fertility, fertility preservation, infertility, fertility-sparing surgery, in vitro fertilization, ovarian stimulation, oocyte cryopreservation, using PubMed, in English and French. RESULTS AND CONCLUSIONS Fertility counselling should become an integral part of the clinical management of women with BOT. Patients with BOT should be informed that surgical management of BOT may cause damage ovarian reserve and/or peritoneal adhesions. Nomogram to predict recurrence, ovarian reserve markers and fertility explorations should be used to provide a clear and relevant information about the risk of infertility in patients with BOT. Fertility-sparing surgery should be considered for young women who wish preserving their fertility when possible. There is insufficient evidence to claim a causal relation between controlled ovarian stimulation (COS) and BOT. However, in case of poor prognosis factors, the use of COS should be considered cautiously through a multidisciplinary approach. In case of infertility after surgery for BOT, COS can be performed without delay, once histopathological diagnosis of BOT is confirmed. There is insufficient consistent evidence that fertility drugs and COS increase the risk of recurrence of BOT after conservative management. The conservative surgical treatment can be associated to oocyte cryopreservation considering the high risk of recurrence of the disease. In women with BOT recurrence in a single ovary and in women with bilateral ovarian involvement when the conservative management is not possible, other fertility preservation strategies are available, but still experimental.
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Affiliation(s)
- J Raad
- Service de médecine de la reproduction, hôpital Antoine-Béclère, 157, rue de la Porte-de-Trivaux, 92140 Clamart, France.
| | - L Rolland
- Centre clinicobiologique d'AMP, pôle femmes-Parents-Enfants, hôpital de La Conception, AP-HM, 147, boulevard Baille, 13005 Marseille, France
| | - M Grynberg
- Service de médecine de la reproduction, hôpital Antoine-Béclère, 157, rue de la Porte-de-Trivaux, 92140 Clamart, France; Service de médecine de la reproduction, hôpital Jean-Verdier, avenue du 14-Juillet, 93140 Bondy, France; Unité Inserm U1133, université Paris-Diderot, 75013 Paris, France
| | - B Courbiere
- Centre clinicobiologique d'AMP, pôle femmes-Parents-Enfants, hôpital de La Conception, AP-HM, 147, boulevard Baille, 13005 Marseille, France; CNRS, IRD, IMBE, Aix-Marseille université, Avignon université, 13005 Marseille, France
| | - E Mathieu d'Argent
- Service de gynécologie-obstétrique et médecine de la reproduction, hôpital Tenon, Assistance publique-Hôpitaux de Paris, 4, rue de la Chine, 75020 Paris, France; UMR_S938 université Pierre-et-Marie-Curie, Paris 6, institut universitaire de cancérologie (IUC), Paris, France
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Pregnancy and Live Birth Rates Are Comparable in Young Infertile Women Presenting with Severe Endometriosis and Tubal Infertility. Reprod Sci 2020; 27:1340-1349. [PMID: 31993996 DOI: 10.1007/s43032-020-00158-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Accepted: 11/25/2019] [Indexed: 12/16/2022]
Abstract
The aim of this study is to evaluate the effect of severe endometriosis in younger patients compared to tubal infertility on pregnancy and live birth rate undergoing in vitro fertilization (IVF). This prospective observational study included 294 women with severe endometriosis and 358 women with tubal factor as control who underwent IVF. Follicular fluid samples were collected during oocyte retrieval, and cytokines and angiogenic factors were estimated. The groups were sub-stratified based on age. Number of metaphase II oocytes, grade I/II embryos, pregnancy rate, miscarriage rate per pregnancy, and live birth rate were compared. Significantly elevated levels of cytokines and angiogenic molecules were observed in younger endometriosis patients when compared to tubal group (p < 0.001). Number of MII oocytes (p < 0.003) and grade I/II embryos (p < 0.001) were observed to be significantly lower in these women when compared with matched controls. Despite higher levels of inflammatory cytokines, angiogenic molecules, fewer MII oocytes, and grade I/II embryos, the younger endometriosis patients had similar pregnancy (OR 0.81; 95% CI 0.54-1.22; p = 0.31) and live birth rate (OR 0.78; 95% CI 0.5-1.2; p = 0.26) when compared with matched controls. In contrast, endometriosis patients of age ≥ 35 years had significantly less likelihood of live birth (OR 0.47; 95% CI 0.25-0.9; p = 0.02) and pregnancy rate (OR 0.46; 95% CI 0.22-0.95; p = 0.03), respectively, when compared with the matched controls. It appears that women with severe endometriosis have even chance of successful pregnancy if diagnosed at early age and sought for assisted reproductive technology to reduce its adverse effect on reproductive outcome.
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Assisted Reproductive Technology as a Transcutaneous Route for Bacterial Contamination of Ovarian Endometrioma with Coagulase-Negative Staphylococcus: Case Report and Review of the Literature. Infect Dis Obstet Gynecol 2019; 2019:4149587. [PMID: 31871398 PMCID: PMC6906832 DOI: 10.1155/2019/4149587] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Revised: 08/28/2019] [Accepted: 09/06/2019] [Indexed: 11/30/2022] Open
Abstract
Tubo-ovarian abscess may develop in women with endometrioma following assisted reproductive technology (ART). The infection, though rare, is typically late in onset and may present several months after the procedure, and in pregnancy—with the risks of abortion and premature labor. It is thought that transcutaneous oocyte retrieval during ART is the route for bacterial contamination resulting in infection of the endometrioma. Pathogens reported in the literature include Escherichia coli (E. coli) and Group B streptococcus (GBS) but Staphylococcus lugdunensis (S. lugdunensis), a coagulase-negative staphylococcus (CoNS), and groin and perineal skin commensal was isolated from the endometrioma in this case. We discuss the challenges in diagnosis and treatment of this rare condition and the implications of the discovery that an organism previously dismissed as a contaminant has emerged as a causative organism in severe, deep-seated infections of soft tissues in recent literature.
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Di Nisio V, Rossi G, Di Luigi G, Palumbo P, D'Alfonso A, Iorio R, Cecconi S. Increased levels of proapoptotic markers in normal ovarian cortex surrounding small endometriotic cysts. Reprod Biol 2019; 19:225-229. [PMID: 31416694 DOI: 10.1016/j.repbio.2019.08.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 08/02/2019] [Accepted: 08/03/2019] [Indexed: 02/07/2023]
Abstract
Endometriosis can impair fertility by reducing ovarian reserve and the production of good-quality oocytes. The surgical removal of endometriotic lesions is generally recommended for women who wish to conceive. In this paper we studied whether ovarian cortex adjacent to excised small (diameter ≤ 4 cm) endometriotic cyst (here referred as Cortex Surrounding Endometriotic Cyst, CSEC) showed signs of tissue damages by evaluating the expression of proteins involved in DNA repair and apoptosis. To this end, phosphorylated H2A.X, Chk1 and 2, ATM and ATR, Bcl-2, Bid, phosphorylated and total p53, caspases (9, 8 and 3), XIAP, phosphorylated and total NFκB were analyzed by western blot. Results showed that caspase 8, XIAP, p53/p-p53 and NFκB were more abundantly expressed in all samples of CSEC group in comparison with ovarian cortex of controls. Conversely, the levels of the other proteins were comparable between the two groups. In conclusion, these results suggest that NFκB, caspase 8 and p53/p-p53 elevated expressions in samples of CSEC can be considered as an early sign of tissue injury, indicating that ovarian cortex is already sensitized to apoptosis and inflammation. Therefore, excision of EC should occur very early, to avoid further ovarian damages.
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Affiliation(s)
- Valentina Di Nisio
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Gianna Rossi
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | | | - Paola Palumbo
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Angela D'Alfonso
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Roberto Iorio
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Sandra Cecconi
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy.
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Domniz N, Meirow D. Premature ovarian insufficiency and autoimmune diseases. Best Pract Res Clin Obstet Gynaecol 2019; 60:42-55. [PMID: 31495598 DOI: 10.1016/j.bpobgyn.2019.07.008] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 07/23/2019] [Indexed: 01/13/2023]
Abstract
Premature ovarian insufficiency (POI) is a clinical syndrome defined by loss of ovarian activity before the age of 40 years and has a potentially devastating effect upon women's health, both physically and psychologically. An underlying autoimmune disease has been identified in approximately 20% of patients with POI, the most common of which are disorders of the thyroid and adrenal glands. Nevertheless, in the majority of cases, the etiology is unknown. The damage mechanism to the ovary is usually caused by antibodies, and autoimmune POI is usually characterized by cellular infiltration of the theca cells of growing follicles by various inflammatory cells. Yet, other various factors and proteins of unknown clinical significance are present. The major diagnostic tool for otherwise idiopathic POI is the presence of autoantibodies against various ovarian components that strongly support the option of autoimmune etiology of POI. Treatment of the underlying cause of POI is the main strategy, although immunosuppressive therapy should be considered in a selected population of well-defined autoimmune POI and, as in idiopathic POI, in whom the resumption of ovarian activity is possible.
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Affiliation(s)
- Noam Domniz
- Dept. Obstetrics and Gynecology, Sheba Medical Center, Tel Aviv University, Tel Hashomer, 52651, Israel.
| | - Dror Meirow
- Dept. Obstetrics and Gynecology, Sheba Medical Center, Tel Aviv University, Tel Hashomer, 52651, Israel
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Zhang Z, Ruan L, Lu M, Yao X. Analysis of key candidate genes and pathways of endometriosis pathophysiology by a genomics-bioinformatics approach. Gynecol Endocrinol 2019; 35:576-581. [PMID: 30798642 DOI: 10.1080/09513590.2019.1576609] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Endometriosis is a common disease in women, but the signaling pathways and driven genes involved remain unclear. This study integrated four datasets to elucidate potential key candidate genes and pathways in endometriosis. Four expression profile datasets including 29 endometriosis lesions and 37 normal tissues were integrated and analyzed. Differentially expressed genes (DEGs) were sorted, and the gene ontology, pathway enrichment, and protein-protein interaction network of candidate genes were then analyzed. A total of 94 shared DEGs were identified from the four datasets. The DEGs were clustered based on functions and signaling pathways through the analysis of significant enrichment. Among the DEG protein-protein interaction network complex, 87 nodes/DEGs were identified. Furthermore, 18 central node genes were identified, and most of the corresponding genes were involved in the angiotensin system, smooth muscle contraction, cell junction organization, and lipoxin pathways. Through integrated bioinformatic analysis, we identified candidate genes and pathways in endometriosis, which could improve our understanding of endometriosis.
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Affiliation(s)
- Zhimin Zhang
- a The Department of Obstetrics , The Fourth Hospital of Shijiazhuang City , Shijiazhuang , China
| | - Lin Ruan
- b Hebei Key Laboratory of Integrative Medicine on Liver-Kidney Patterns , Hebei University of Chinese Medicine , Shijiazhuang , China
| | - Mingxuan Lu
- c College of Integrative Medicine , Hebei University of Chinese Medicine , Shijiazhuang , China
| | - Xiaoguang Yao
- b Hebei Key Laboratory of Integrative Medicine on Liver-Kidney Patterns , Hebei University of Chinese Medicine , Shijiazhuang , China
- c College of Integrative Medicine , Hebei University of Chinese Medicine , Shijiazhuang , China
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Chung JPW, Law TSM, Chung CHS, Mak JSM, Sahota DS, Li TC. Impact of haemostatic sealant versus electrocoagulation on ovarian reserve after laparoscopic ovarian cystectomy of ovarian endometriomas: a randomised controlled trial. BJOG 2019; 126:1267-1275. [DOI: 10.1111/1471-0528.15807] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/18/2019] [Indexed: 12/23/2022]
Affiliation(s)
- JPW Chung
- Department of Obstetrics and Gynaecology Prince of Wales Hospital The Chinese University of Hong Kong Shatin Hong Kong, SAR
| | - TSM Law
- Department of Obstetrics and Gynaecology Prince of Wales Hospital The Chinese University of Hong Kong Shatin Hong Kong, SAR
| | - CHS Chung
- Department of Obstetrics and Gynaecology Prince of Wales Hospital The Chinese University of Hong Kong Shatin Hong Kong, SAR
| | - JSM Mak
- Department of Obstetrics and Gynaecology Prince of Wales Hospital The Chinese University of Hong Kong Shatin Hong Kong, SAR
| | - DS Sahota
- Department of Obstetrics and Gynaecology Prince of Wales Hospital The Chinese University of Hong Kong Shatin Hong Kong, SAR
| | - TC Li
- Department of Obstetrics and Gynaecology Prince of Wales Hospital The Chinese University of Hong Kong Shatin Hong Kong, SAR
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Marcellin L, Santulli P, Bourdon M, Comte C, Maignien C, Just PA, Streuli I, Borghese B, Chapron C. Serum antimüllerian hormone concentration increases with ovarian endometrioma size. Fertil Steril 2019; 111:944-952.e1. [DOI: 10.1016/j.fertnstert.2019.01.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 01/09/2019] [Accepted: 01/09/2019] [Indexed: 10/27/2022]
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50
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Long Q, Zheng H, Liu X, Guo SW. Perioperative Intervention by β-Blockade and NF-κB Suppression Reduces the Recurrence Risk of Endometriosis in Mice Due to Incomplete Excision. Reprod Sci 2019; 26:697-708. [DOI: 10.1177/1933719119828066] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Qiqi Long
- Shanghai OB/GYN Hospital, Fudan University, Shanghai, Peoples Republic of China
| | - Hanxi Zheng
- Shanghai OB/GYN Hospital, Fudan University, Shanghai, Peoples Republic of China
| | - Xishi Liu
- Shanghai OB/GYN Hospital, Fudan University, Shanghai, Peoples Republic of China
- Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Fudan University, Shanghai, Peoples Republic of China
| | - Sun-Wei Guo
- Shanghai OB/GYN Hospital, Fudan University, Shanghai, Peoples Republic of China
- Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Fudan University, Shanghai, Peoples Republic of China
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