Risk factors associated with changes in serum anti-Müllerian hormone levels before and after laparoscopic cystectomy for endometrioma

Background

The objective of our study was to investigate the risk factors for a decrease in ovarian reserve in patients with endometriomas after standardized laparoscopic procedures and evaluation to provide corresponding clinical guidance for patients with fertility requirements.

Methods

Anti-Müllerian hormone (AMH) levels and other clinical data from 233 patients with endometriomas and 57 patients with non-endometrioma ovarian cysts admitted to the Peking Union Medical College Hospital between January 2018 and September 2023 were prospectively analysed. The pretreatment AMH levels of the study groups were compared to assess the impact of endometrioma on ovarian reserve, and the decrease in AMH after treatment was analysed to determine potential risk factors contributing to this change.

Results

Pretreatment AMH levels did not significantly differ between patients with endometriomas and those with non-endometrioma ovarian cysts. Within the endometrioma group, older age, higher body mass index (BMI), and shorter menstrual cycles were found to be associated with decreased AMH levels prior to treatment (p<0.05). Participants presenting with bilateral cysts, advanced surgical staging, or a completely enclosed Douglas pouch demonstrated significantly lower levels of AMH prior to treatment compared to those without these conditions (p<0.05). Furthermore, their AMH levels further declined within one year after undergoing laparoscopic cystectomy (p<0.05). However, there was no difference in AMH levels after surgery between patients who successfully became pregnant and those who did not (p>0.05).

Conclusion

Laparoscopic removal of endometriomas can adversely affect ovarian reserve, especially during bilateral cysts removal and when patients are diagnosed as having a higher stage of endometriosis, further impacting ovarian function. It should be noted that a decrease in AMH levels may not necessarily indicate an absolute decline in fertility. Therefore, it is crucial to conduct thorough patient evaluations and provide comprehensive patient education to offer appropriate guidance for fertility preservation.

Noninvasive diagnostic imaging for endometriosis part 2: a systematic review of recent developments in magnetic resonance imaging, nuclear medicine and computed tomography

Endometriosis affects 1 in 9 women, taking 6.4 years to diagnose using conventional laparoscopy. Non-invasive imaging enables timelier diagnosis, reducing diagnostic delay, risk and expense of surgery. This review updates literature exploring the diagnostic value of specialist endometriosis magnetic resonance imaging (eMRI), nuclear medicine (NM) and computed tomography (CT). Searching after the 2016 IDEA consensus, 6192 publications were identified, with 27 studies focused on imaging for endometriosis. eMRI was the subject of 14 papers, NM and CT, 11, and artificial intelligence (AI) utilizing eMRI, 2. eMRI papers describe diagnostic accuracy for endometriosis, methodologies, and innovations. Advantages of eMRI include its: ability to diagnose endometriosis in those unable to tolerate transvaginal endometriosis ultrasound (eTVUS); a panoramic pelvic view, easy translation to surgical fields; identification of hyperintense iron in endometriotic lesions; and ability to identify super-pelvic lesions. Sequence standardization means eMRI is less operator-dependent than eTVUS, but higher costs limit its role to a secondary diagnostic modality. eMRI for deep and ovarian endometriosis has sensitivities of 91-93.5% and specificities of 86-87.5% making it reliable for surgical mapping and diagnosis. Superficial lesions too small for detection in larger capture sequences, means a negative eMRI doesn't exclude endometriosis. Combined with thin sequence capture and improved reader expertise, eMRI is poised for rapid adoption into clinical practice. NM labeling is diagnostically limited in absence of suitable unique marker for endometrial-like tissue. CT studies expose the reproductively aged to radiation. AI diagnostic tools, combining independent eMRI and eTVUS endometriosis markers, may result in powerful capability. Broader eMRI use, will optimize standards and protocols. Reporting systems correlating to surgical anatomy will facilitate interdisciplinary preoperative dialogues. eMRI endometriosis diagnosis should reduce repeat surgeries with mental and physical health benefits for patients. There is potential for early eMRI diagnoses to prevent chronic pain syndromes and protect fertility outcomes.

Surgical Management of Ovarian Endometrioma: Impact on Ovarian Reserve Parameters and Reproductive Outcomes

Ovarian endometriomas have a negative impact on a patient's reproductive potential and are likely to cause a reduction in ovarian reserve. The most commonly employed ovarian reserve parameters are anti-Müllerian hormone (AMH) and antral follicular count (AFC). Surgical management options of endometrioma include cystectomy, ablative methods, ethanol sclerotherapy and combined techniques. The optimal surgical approach remains a matter of debate. Our review aimed to summarize the literature on the impact of surgical management of endometrioma on AMH, AFC and fertility outcomes. Cystectomy may reduce recurrence rates and increase chances of spontaneous conception. However, a postoperative reduction in AMH is to be anticipated, despite there being evidence of recovery during follow-up. The reduction in ovarian reserve is likely multi-factorial. Cystectomy does not appear to significantly reduce, and may even increase, AFC. Ablative methods achieve an ovarian-tissue-sparing effect, and improved ovarian reserve, compared to cystectomy, has been demonstrated. A single study reported on AMH and AFC post sclerotherapy, and both were significantly reduced. AMH levels may be useful in predicting the chances of conception postoperatively. None of the aforementioned approaches has a clearly demonstrated superiority in terms of overall chances of conception. Surgical management of endometrioma may, overall, improve the probability of pregnancy. Evidence on its value before medically assisted reproduction (MAR) is conflicting; however, a combination of surgery followed by MAR may achieve the optimal fertility outcome. In view of the complexity of available evidence, individualization of care, combined with optimal surgical technique, is highly recommended.

Endometrial receptivity in adenomyosis and/or endometriosis

A narrative review of endometrial receptivity in adenomyosis and/or endometriosis revealed that this parameter is difficult to assess in natural conception because both disorders alter natural fertility. Recent data emanating from assisted reproductive technology have allowed the study of endometrial receptivity in women affected by adenomyosis and endometriosis. This has upended our views on the effects of these 2 disorders on embryo implantation. Today, the very existence of altered receptivity in assisted reproductive technology is questioned. In this context, we now know that frozen euploid blastocyst transfers in estradiol and progesterone cycles have unaltered outcomes in both adenomyosis and endometriosis.

Factors affecting the distribution of serum anti-müllerian hormone levels among infertile Asian women: a multi-nation, multi-centre, and multi-ethnicity prospective cohort study

STUDY QUESTION

How do age, ethnicity, and other characteristics affect serum anti-mullerian hormone (AMH) levels in Asian women undergoing fertility treatment?

SUMMARY ANSWER

Age, ethnicity, obesity (BMI ≥ 30 kg/m2), and polycystic ovarian syndrome (PCOS) significantly impacted serum AMH levels, with the rate of decrease accelerating as age increased; a concentration of 4.0 ng/ml was the optimal cut-off for diagnosis of PCOS.

WHAT IS KNOWN ALREADY

There are significant differences in ovarian reserve among women from different races and ethnicities, and Asian women often have poorer reproductive outcomes during assisted reproductive treatment cycles.

STUDY DESIGN, SIZE, DURATION

A population-based multi-nation, multi-centre, multi-ethnicity prospective cohort study of 4613 women was conducted from January 2020 to May 2021. Infertile women of 20-43 years of age were enrolled. The exclusion criteria included: age <20 or >43, non-Asian ethnicity, and missing critical data.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Participants were Asian women of Chinese, Japanese, Korean, Thai, Vietnamese, Malay, Indian, and Indonesian ethnicities from 12 IVF centres across Asia. These women were all naïve to ovarian stimulation cycles and attended IVF centres for fertility assessment. The AMH measurement was performed using an AMH automated assay on a clinically validated platform.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 4556 infertile Asian women were included in the final analyses. The mean ± SD for serum AMH concentrations (ng/ml) across specific age groups were: overall, 3.44 ± 2.93; age <30, 4.58 ± 3.16; 30-31, 4.23 ± 3.23; 32-33, 3.90 ± 3.06; 34-35, 3.21 ± 2.65; 36-37, 2.74 ± 2.44; 38-39, 2.30 ± 1.91; 40 and above, 1.67 ± 2.00. The rate of AMH decrease was ∼0.13 ng/ml/year in patients aged 25-33 and 0.31 ng/ml/year in women aged 33-43. The highest rates of PCOS were found in Indians (18.6%), Malays (18.9%), and Vietnamese (17.7%). Age (P < 0.001), ethnicity (P < 0.001), obesity (P = 0.007), PCOS (P < 0.001), and a history of endometrioma cystectomy (P = 0.01) were significantly associated with serum AMH values. Smoking status, pretreatment with GnRH agonist (GnRHa) or the oral contraceptive pill (OCP), freezing-thawing of blood samples, and sampling on Day 2 to Day 5 of the menstrual cycle or randomly did not appear to affect serum AMH levels. An AMH concentration of 4.0 ng/ml was the optimal cut-off for PCOS diagnosis with a sensitivity of 71.7% and specificity of 75.8% (AUC = 0.81, CI 95%: 0.79-0.83; P < 0.001).

LIMITATIONS, REASONS FOR CAUTION

The incidence of PCOS was supposedly high in this cohort as some IVF clinics were tertiary referral centres for managing specific fertility issues encountered by women with PCOS. Treatment with GnRHa or OCP before AMH testing was regionally and ethnically confined, mostly in Hong Kong SAR and Japan. Moreover, this reference for serum AMH value is limited to Asian women of the ethnicities examined and may not apply to other ethnicities not included in the study.

WIDER IMPLICATIONS OF THE FINDINGS

This is the first study to collate and construct age-specific reference ranges for serum AMH levels using the same bioassay on Asian women of different ethnicities. The findings of this investigation can assist clinicians to counsel and prognosticate about Asian women's ovarian reserve and reproductive potential, thus providing better strategies for personalized fertility interventions.

STUDY FUNDING/COMPETING INTEREST(S)

This study was technically supported by Ferring Pharmaceuticals and received no specific grant from any funding agency. All authors have no competing interests to disclose.

TRIAL REGISTRATION NUMBER

NCT04203355.

Impact of Ovarian Endometrioma and Surgery on Reproductive Outcomes: A Single-Center Spanish Cohort Study

Anti-Müllerian hormone (AMH) and antral follicular count (AFC) decrease in women with ovarian endometrioma (OMA) and in vitro fertilization (IVF). In addition, these parameters drop even further when women with OMA undergo surgery. In this study, the primary aim was to compare the reproductive variables in IVF-treated women with and without endometriosis. The secondary aim was to explore if the reproductive variables were modified by endometrioma surgery. In this retrospective study, 244 women undergoing IVF were enrolled at the Hospital Universitario La Paz (Madrid, Spain). Women were categorized as OMA not surgically treated (OMA; n = 124), OMA with surgery (OMA + S; n = 55), and women with infertility issues not related to OMA (control; n = 65). Demographic and clinical variables, including age, body mass index (BMI), and reproductive (AMH, AFC, number of extracted oocytes, and transferred embryos) and obstetrical data (biochemical pregnancy and fetal heart rate at 6 weeks) were collected. Adjusted logistic regression models were built to evaluate reproductive and pregnancy outcomes. The models showed that women with OMA (with and without surgery) had significantly decreased levels of AMH and AFC and numbers of cycles and C + D embryos. Women with OMA + S had similar rates of pregnancy to women in the control group. However, women with OMA had lower biochemical pregnancy than controls (aOR = 0.08 [0.01; 0.50]; p-value = 0.025). OMA surgery seems to improve pregnancy outcomes, at least until 6 weeks of gestation. However, it is important to counsel the patients about surgery expectations due to the fact that endometrioma itself reduces the quality of oocytes.

Does Endometriosis Impact the Composition of Follicular Fluid in IL6 and AMH? A Case-Control Study

OBJECTIVE

The aim of this study was to compare follicular liquid levels of IL6 and AMH in women with and without endometriosis and to evaluate their potential impact on ICSI outcomes.

MATERIALS AND METHODS

It is a prospective case-control study conducted on 25 women with proven endometriosis and 50 patients diagnosed with other causes of infertility. All these patients were candidates for ICSI cycles. Their follicular fluid was collected at the time of oocyte retrieval and used to evaluate IL-6 and AMH titers by electro-chemiluminescent immunoassay (Cobas e411-Roche).

RESULTS

The IL-6 levels in follicular fluid were higher in the endometriosis group than in the control group (152.3 vs. 19.9 pg/mL; p = 0.02). The median level for AMH was 2.2 ± 1.88 ng/mL with no statistical difference between the two groups (2.2 vs. 2.7 ng/mL, p = 0.41). No significant correlation between the follicular IL6 and AMH levels was observed.

CONCLUSIONS

The oocyte quality seems to be preserved in patients with endometriosis with the adequate response to ovarian stimulation. High levels of follicular IL6 are in accordance with the inflammatory phenomenon of the disease; however, this increase has no impact on ICSI outcomes.

Endometriosis-associated infertility diagnosis based on saliva microRNA signatures

RESEARCH QUESTION

Can a saliva-based miRNA signature for endometriosis-associated infertility be designed and validated by analysing the human miRNome?

DESIGN

The prospective ENDOmiARN study (NCT04728152) included 200 saliva samples obtained between January 2021 and June 2021 from women with pelvic pain suggestive of endometriosis. All patients underwent either laparoscopy, magnetic resonance imaging, or both. Patients diagnosed with endometriosis were allocated to one of two groups according to their fertility status. Data analysis consisted of identifying a set of miRNA biomarkers using next-generation sequencing, and development of a saliva-based miRNA signature of infertility among patients with endometriosis based on a random forest model.

RESULTS

Among the 153 patients diagnosed with endometriosis, 24% (n = 36) were infertile and 76% (n = 117) were fertile. Small RNA-sequencing of the 153 saliva samples yielded approximately 3712 M raw sequencing reads (from ∼13.7 M to ∼39.3 M reads/sample). Of the 2561 known miRNAs, the feature selection method generated a signature of 34 miRNAs linked to endometriosis-associated infertility. After validation, the most accurate signature model had a sensitivity, specificity and area under the curve of 100%.

CONCLUSION

A saliva-based miRNA signature for endometriosis-associated infertility is reported. Although the results still require external validation before using the signature in routine practice, this non-invasive tool is likely to have a major effect on care provided to women with endometriosis.

Fertility preservation in women with benign gynaecological conditions

Although a wealth of data has been published regarding fertility preservation (FP) in women with malignant diseases who receive gonadotoxic treatment, the role of FP in non-malignant conditions has been studied to a much lesser extent. These include benign haematological, autoimmune, and genetic disorders, as well as a multitude of benign gynaecological conditions (BGCs) that may compromise ovarian reserve and/or reproductive potential due to pathogenic mechanisms or as a result of medical or surgical treatments. Alongside accumulating data that document the reproductive potential of cryopreserved oocytes and ovarian tissue, there is potential interest in FP for women with BGCs at risk of infertility; however, there are currently insufficient data about FP in women with BGCs to develop guidelines for clinical practice. The purpose of this article is to appraise the available evidence regarding FP for BGC and discuss potential strategies for FP based on estimated ovarian impairment and on short-term and long-term reproductive goals of patients. Cost-effectiveness considerations and patients' perspectives will also be discussed.

Hormonal treatments for endometriosis: The endocrine background

Endometriosis is a benign uterine disorder characterized by menstrual pain and infertility, deeply affecting women's health. It is a chronic disease and requires a long term management. Hormonal drugs are currently the most used for the medical treatment and are based on the endocrine pathogenetic aspects. Estrogen-dependency and progesterone-resistance are the key events which cause the ectopic implantation of endometrial cells, decreasing apoptosis and increasing oxidative stress, inflammation and neuroangiogenesis. Endometriotic cells express AMH, TGF-related growth factors (inhibin, activin, follistatin) CRH and stress related peptides. Endocrine and inflammatory changes explain pain and infertility, and the systemic comorbidities described in these patients, such as autoimmune (thyroiditis, arthritis, allergies), inflammatory (gastrointestinal/urinary diseases) and mental health disorders.The hormonal treatment of endometriosis aims to block of menstruation through an inhibition of hypothalamus-pituitary-ovary axis or by causing a pseudodecidualization with consequent amenorrhea, impairing the progression of endometriotic implants. GnRH agonists and antagonists are effective on endometriosis by acting on pituitary-ovarian function. Progestins are mostly used for long term treatments (dienogest, NETA, MPA) and act on multiple sites of action. Combined oral contraceptives are also used for reducing endometriosis symptoms by inhibiting ovarian function. Clinical trials are currently going on selective progesterone receptor modulators, selective estrogen receptor modulators and aromatase inhibitors. Nowadays, all these hormonal drugs are considered the first-line treatment for women with endometriosis to improve their symptoms, to postpone surgery or to prevent post-surgical disease recurrence. This review aims to provide a comprehensive state-of-the-art on the current and future hormonal treatments for endometriosis, exploring the endocrine background of the disease.

Infertility workup: identifying endometriosis

Endometriosis was classically diagnosed during diagnostic laparoscopies, which used to be routinely performed up until a decade ago or so. This practice fitted with the long-held belief that surgery was the gold standard for diagnosing endometriosis. Today, the abandon of routine diagnostic laparoscopies-in favor of assisted reproductive technology-first therapeutic approaches-has created a void for diagnosing endometriosis. Modern-day imaging techniques-ultrasound and magnetic resonance imaging-when used with a systematic approach have offered a reliable replacement option for diagnosing endometriosis. In infertility, endometriosis should be identified or excluded on the basis of past history or confirmation or exclusion suspicion on the basis of history and/or physical examination.

Endometrioma surgery-a systematic review and meta-analysis of the effect on antral follicle count and anti-Müllerian hormone

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.

Fertility preservation for patients affected by endometriosis should ideally be carried out before surgery

RESEARCH QUESTION

What prognostic factors relate to a high oocyte yield in fertility preservation for women affected by endometriosis?

DESIGN

Observational cohort study conducted in a tertiary care university hospital between April 2015 and January 2019. Women who had undergone fertility preservation with ovarian stimulation for oocytes and embryo vitrification for endometriosis were included. Prognostic factors associated with the number of oocytes retrieved after the first ovarian stimulation were analysed.

RESULTS

A total of 146 women who had undergone 258 ovarian stimulation cycles were included; 82 (56.2%) had undergone more than one ovarian stimulation cycle; 72.6% had at least one endometrioma lesion; and 36.3% had previously undergone surgery for endometriosis. After adjustment by multiple linear regression, the factors that significantly reduced the number of oocytes retrieved were previous history of surgery for ovarian endometriosis (coefficient -1.08; 95% CI -2.02 to -0.15; P = 0.024); women's age (-0.21; 95% CI -0.41 to -0.01; P = 0.039); and total dose of gonadotrophin used (-0.01; 95% CI -0.01 to -0.00; P = 0.047). Anti-Müllerian hormone serum level and gravidity positively correlated with an increase in the number of oocytes retrieved (1.65; 95% CI 1.13 to 2.17; P < 0.001 and 3.30; 95% CI 0.91 to 5.68; P = 0.007, respectively) after the first ovarian stimulation cycle.

CONCLUSION

A history of surgery for ovarian endometriosis was associated with significantly lower oocyte yields. Fertility preservation should be integrated into endometriosis management. Fertility preservation should ideally be made available to the patient before surgery.

The Clinical Outcome of Laparoscopic Surgery for Endometriosis on Pain, Ovarian Reserve, and Cancer Antigen 125 (CA-125): A Cohort Study

BACKGROUND

Endometriosis is an important cause of chronic pain and infertility. Surgery is considered the gold standard for diagnosis and treatment. In this study, we aim to describe the clinical outcomes of women who undergo laparoscopic surgery for endometriosis.

MATERIALS AND METHODS

In this cohort study, a total of 174 women who referred to Farmaniyeh Hospital, Tehran, Iran from August 2015 to December 2017 with surgical diagnoses of endometriosis stages III and IV enrolled. The participants' demographic, gynaecological, and clinical characteristics were recorded and they were asked to use a numeric rating scale (NRS) to record their severity of pain before and three months after surgery. Blood samples were also taken from the patients before and three months after surgery for measurement of serum levels of anti-Müllerian hormone (AMH) and cancer antigen 125 (CA-125). Data were analysed using SPSS version 21.

RESULTS

The patients had a mean age of 34.86 ± 6.47 years, 60.9% were married, and 49.4% were housewives. The primary indication for surgery was pain (68.4%), followed by both pain and infertility in the remainder of patients. Types of endometriotic lesions included endometrioma (19%), deep infiltrating endometriosis (DIE, 3.4%), and both endometrioma and DIE (77.6%). There was a reduction in pain from 6.79 ± 2.19 before surgery to 1.48 ± 1.68 after surgery; serum AMH levels reduced from 2.80 ± 1.86 ng/mL to 1.76 ± 1.40 ng/mL and CA125 reduced from 257.06 ± 220.25 U/mL to 23.27 ± 23.25 U/mL (all P<0.001). Of the 21.2% who experienced recurrence, 13.5% underwent additional surgery. The total additional surgery rate was 2.8%. Of the 55 patients with infertility, 78.1% became pregnant after surgery, 54.5% of which was spontaneous.

CONCLUSION

Surgical treatment of endometriosis had a favourable effect on the patients' pain and inflammation and resolved the patients' infertility with a minimal need for additional surgery.

Demographic, lifestyle, and reproductive determinants of serum anti-Müllerian hormone levels in adult women of reproductive age in Ilorin, North-Central Nigeria

Background

Anti-Müllerian hormone is a dimeric glycoprotein produced by the granulosa cells of preantral and small antral follicles of the ovaries. It is a reliable biomarker of ovarian reserve, ageing, and response in the management of women with infertility. However, there are few studies on the determinants of serum anti-Müllerian hormone in Nigerian women. This study aimed to investigate determinants of serum anti-Müllerian hormone among adult women of reproductive age. The study was a hospital-based cross-sectional study involving 161 women of reproductive age attending the gynaecology clinic and immunisation clinic of a Nigerian tertiary hospital. Baseline characteristics were collected using a semi-structured questionnaire. Serum anti-Müllerian hormone was quantified using enzyme-linked immunosorbent assay.

Results

In univariate analysis, age (B = − 0.035, P = 0.000), parity (B = − 0.080, P = 0.001), and infertility duration (B = − 0.050, P = 0.011) had a negative relationship with serum anti-Müllerian hormone, while ethnicity (B = 0.180, P = 0.040), body mass index (B = 0.015, P = 0.010), and cycle length (B = 0.042, P = 0.000) had a positive relationship with serum anti-Müllerian hormone. In multivariable analysis, all relationships except infertility duration persisted.

Conclusion

We found that age, ethnicity, parity, infertility duration, body mass index, and cycle length were associated with serum anti-Müllerian hormone. A large prospective population-based study is required to better understand factors that are associated with serum anti-Müllerian hormone in an ethnically diverse country like Nigeria.

Oocyte accumulation for fertility preservation in women with benign ovarian tumours with a history of previous surgery, multiple or large cysts

RESEARCH QUESTION

What are ovarian stimulation cycle outcomes and acceptance rates of an oocyte accumulation programme in young women with benign ovarian tumour (BOT)?

DESIGN

Retrospective cohort study conducted at the Academic Assisted Reproductive Technology and Fertility Preservation Centre, Lille University Hospital, between January 2016 and December 2019. The number of metaphase II oocytes per cycle and per patient after accumulation were evaluated. Two groups were identified for the analysis: endometrioma ('endometrioma') and dermoid, mucinous or serous cyst ('other cysts').

RESULTS

A total of 113 fertility-preservation cycles were analysed in 70 women aged 27.9 ± 4.8 years. Almost all women had undergone previous ovarian surgery before fertility preservation (89%). Mean anti-Müllerian hormone levels before ovarian stimulation was 12.5 ± 8.7 pmol/l. A total of 6.4 ± 3.4 oocytes were retrieved, and 4.3 ± 3.4 metaphase II (MII) oocytes were vitrified per cycle. All agreed to the oocyte accumulation programme and all underwent at least one cycle. To date, 36 (51%) patients achieved two or three fertility- preservation cycles. After accumulation, 7.0 ± 5.23 MII oocytes were vitrified per patient. No difference was found in ovarian response and oocyte cohort between the 'endometrioma' and 'other cysts' groups. Questionnaires completed after oocyte retrieval revealed abdominal bloating and pelvic pain in most patients, with no difference according to the type of cyst. No serious adverse events occurred.

CONCLUSIONS

Oocyte accumulation should be systematically offered to young women with BOT irrespective of histological type, as it seems to be well-tolerated. Long-term follow-up is needed to assess the efficiency of oocyte accumulation to optimize the chances of subsequent pregnancies.

Role of surgical treatment in endometriosis

Endometriosis can take one of three forms depending on its clinical presentation and management: endometriotic ovarian cyst (ovarian endometrioma), superficial or peritoneal endometriosis and deep infiltrating endometriosis (DIE).¹Among them, DIE is considered the most aggressive, and the patient is often affected by more than one type together. The therapeutic methodology should not be influenced by a combination of different types of endometriotic lesion. According to the clinical context and the patient's needs, the treatment of this pathology can be medical or surgical. Although medical therapy could improve endometriosis-associated symptoms, it never offers a definite treatment for symptomatic patients, who often require surgical treatment. The rationale behind endometriosis surgical treatment is to achieve the complete removal of all lesions through a one-step surgical procedure; to obtain promising long-term results for pelvic pain, recurrence rate, and fertility; and to protect the functionality of the involved organs. Achieving these results depends on the total removal of the pathology from the pelvis, in an attempt to preserve, as much as possible, the healthy tissues surrounding the site of the disease. The choice of a surgical approach rather than medical therapy is subject to the patient's expectations, such as pregnancy desire, the effectiveness of treatment compared to possible complications, the type of pain and its intensity, and the location and severity of the disease. In this context, surgical management using a multidisciplinary endometriosis team is an important factor for achieving good outcomes.

Increasing trend of serum antimullerian hormone level after long term follow up of endometrioma resection

Background:

Endometriosis is a chronic disease mostly affecting women at reproductive age. Some evidence suggests that surgery of ovarian endometrioma may have a detrimental effect on ovarian reserve. The aim of this study was to evaluate the changes of serum antimullerian hormone (AMH) levels in patients with endometrioma after cystectomy.

Methods:

A prospective study was performed at Nikan hospital on 58 patients with endometrioma who underwent laparoscopic cystectomy. Of them, 30 had unilateral endometrioma and 28 had bilateral endometrioma. Complete excision was done, pelvic endometriosis implants as well as deep infiltrative endometriosis was resected. Sutures were made for the closure of ovarian parenchyma and bleeding control. We did not use any hot energy devices such as cautery on ovaries for ablation, coagulation or resection of endometrioma. Serum AMH levels were measured preoperatively, 3, 9, and 15 months postoperatively.

Results:

Serum AMH levels decreased significantly from the preoperative sample (2.98 ± 2.47 ng/ml) to 3 months after laparoscopy (1.07 ± 1.06 ng/ml), then gradually increased 9 months (1.47 ± 1.16 ng/ml) and 15 months (1.95 ± 1.85 ng/ml) after surgery, without returning to the preoperative levels during the follow-up time of study.

Conclusion:

There is a fluctuation pattern in AMH levels from preoperative to 15-month follow-up after endometrioma surgery using only suture for ovarian hemostasis. Firstly, there is decline in AMH level 3 months after surgery, then an increasing trend was observed gradually up to 15 months after surgery. Controlled studies are needed to compare the effects of various cystectomy methods on the ovarian reserve after endometrioma surgery

Does large endometrioma per se increase AMH level?

Women with endometriosis, especially those with endometrioma, present a considerable challenge for ovarian reserve appraisal. This diagnostic difficulty arises from several fundamental questions inherently linked to patient management: the potential influence of endometrioma on ovarian reserve; the adverse effect of ovarian surgery on ovarian reserve; and the adequacy of the established ovarian reserve biomarkers, anti-Müllerian hormone and antral follicle count, to appraise ovarian reserve accurately in these women. Until recently, a key argument was that the development and growth of endometriomas is associated with a progressive damage to normal ovarian tissue, resulting in a concomitant reduction in serum AMH levels. Contrary to this widely accepted position; recent studies have reported that, in women with no previous history of ovarian surgery, AMH levels were increased in women with large endometriomas. These findings are surprising and, if replicated, would have substantial clinical implications. In this commentary, we would, however, urge caution before these reports lead to systematic changes in clinical practice, and recommend urgent replication as the finding linking large endometrioma to high serum AMH levels seems to be biologically implausible, and contradicts the existing extensive body of research.

Role of AMH in Prediction of Menopause

Anti-Müllerian Hormone (AMH) is produced by small antral follicles and has evolved over the past three decades as an assumed potential marker of the number of follicles in the human ovaries, also known as ovarian reserve. This quantitative measure, given the gradual decline over time and its non-replenishable feature, could be the dreamed marker for predicting the final exhaustion of ovarian storage: the post-menopause. This introductory chapter summarizes current knowledge with regard to the contribution of serum AMH measurements to predict age of normal menopause and critically discuss its potential in this regard. Furthermore, its predictive role in the context of menopause in association with several frequently occurring fertility disorders such as premature menopause, polycystic ovarian syndrome and endometriosis are discussed. Overall, while ovarian reserve markers including AMH are unmistakably related to age at menopause, they are insufficiently precise to inform on an individual's journey of ovarian aging.

Affected Ovary Relative Volume: A Novel Sonographic Predictor of Ovarian Reserve in Patients with Unilateral Endometrioma-A Pilot Study

BACKGROUND

The assessment of ovarian reserve in the case of endometrioma is of pivotal importance for planning a tailored management. However, both the antral follicle count (AFC) and the antimüllerian hormone (AMH) dosage are subject to a fair degree of variability in ovarian endometriosis. This study aimed to identify a sonographic parameter of ovarian reserve that could implement current available markers in patients with unilateral endometrioma.

METHODS

Patients with unilateral endometrioma admitted to our Endometriosis Center between March 2018 and April 2019 were enrolled. Transvaginal ultrasonography for the evaluation of eight sonographic indicators and AMH level determination were performed. The relationship between AMH level and each indicator was assessed.

RESULTS

Thirty-four women were included. There was a positive significant correlation between AMH level and the healthy ovary AFC (HO-AFC) (r = 0.36 p = 0.034). A stronger, negative correlation between AMH level and the ratio between the volume of the affected and the healthy ovary (affected ovary relative volume, AORV) (r = -0.47; p = 0.005) was evidenced. AORV had a satisfactory accuracy (AUC 0.73; CI 0.61-0.90; p = 0.0008), and the cut-off value of 5.96 had the best balance of sensitivity/specificity in distinguishing between patients with a good ovarian reserve (AMH ≥ 2 ng/mL) and those at risk of ovarian reserve depletion after excisional surgery.

CONCLUSION

AORV may be a useful tool to assess ovarian reserve in patients with unilateral endometrioma without previous surgery and to guide physicians in clinical management.

Reproductive Outcomes and Fertility Preservation Strategies in Women with Malignant Ovarian Germ Cell Tumors after Fertility Sparing Surgery

Malignant ovarian germ cell tumors are rare tumors that mainly affect patients of reproductive age. The aim of this study was to investigate the reproductive outcomes and fertility preservation strategies in malignant ovarian germ cell tumors after fertility-sparing surgery. Data in literature support that fertility-sparing surgery is associated with an excellent oncological outcome not only in early stages malignant ovarian germ cell tumors but also in advanced stages. Moreover, the possibility of performing conservative treatment should be considered even in case of relapse or advanced disease, given the high chemosensitivity. Indeed, available data have shown that menstrual function is maintained after platinum-based regimens in over 85-95% of patients with malignant ovarian germ cell tumors and rate of premature menopause reported in literature ranges between 3% and 7.4%, while premature ovarian failure rates are between 3.4% and 5%. Moreover, reproductive outcomes are about 80% with no increase in the risk of teratogenicity compared to general population. Therefore, conservative surgery for malignant ovarian germ cell tumors currently may represent a therapeutic option in patients who wish to preserve fertility but must be available for extended follow-up and after subscribing to informed consent.

Evaluation of physicians' practice patterns in France concerning fertility preservation in women with endometriosis

OBJECTIVE

We aim to evaluate the knowledge and physicians' practices concerning fertility preservation in women with endometriosis.

DESIGN

Descriptive, observational, national study using an online self-questionnaire, sent by email to French gynaecologists in October 2019 within 2 months.

RESULTS

We obtained 110 analyzable responses from mainly surgeons (54 %) and reproductive clinicians (19 %) with a good experience (average 15 years of practice). Amongst these practitioners, 91 % seemed aware of latest French recommendations on endometriosis issued in December 2017. The most commonly used surgical techniques for management of endometriomas were intra-peritoneal cystectomy (51 %), vaporization by plasma energy (29 %) and destruction by bipolar coagulation (8.5 %). Preoperative AMH was systematically or often prescribed by 78 % of the practitioners against 37.3 % who did it postoperatively. Furthermore, 74 % also considered and performed fertility preservation strategy to manage endometriosis. It was offered in situations of bilateral or recurrent endometrioma, but only 33 % offered it in unilateral endometrioma cases. In the cases recorded, vitrification of mature oocytes appears to be the most common fertility preservation technique (used by 87 % of the practitioners).

CONCLUSION

We observed in our population of sensitized practitioners a good and adequate knowledge concerning endometriosis physiopathology and recommendations for its management, with good information delivery to women. Operating techniques are adapted although information and education concerning fertility preservation indications seem necessary. The place of multidisciplinary concertation meeting in endometriosis appears essential both for discussion of surgical indications and for fertility preservation possibilities. Creation of dedicated structures should be encouraged.

Endometrioma and reproductive issues: a well-informed patient may be the driver for change

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.

Effect of endometrioma and its surgical excision on fertility (Review)

Endometrioma is the cystic lesion of ovaries originating from endometrial glands and stroma; it is identified in 17-44% of patients with endometriosis. Numerous existing studies have reported the association between endometrioma and infertility. However, an absolute cause-effect association requires further confirmation. Available evidence has suggested that ovarian reserve may be impaired by spatial occupation influences, local reaction or both, affecting the reproductive health of females. Given the increased focus on the pathophysiological mechanisms of endometrioma, surgical excision has commonly been considered to avoid further ovarian damage. However, the potential adverse effect of this surgery on the ovarian reserve has recently become a focal point. Whether or not surgical excision can facilitate subsequent conception in young females planning to be pregnant is controversial. As shown in the present review on the effects of endometrioma and its removal in females requiring assisted reproductive technology, prior surgery for endometrioma may not improve assisted fertility results and may further decrease the number of oocytes retrieved in the affected females. Subsequent studies are needed to ascertain the optimal management of infertility in the setting of endometriomas.

REASONS FOR ENDOMETRIOSIS-ASSOCIATED INFERTILITY

This article discusses the causes and mechanisms of the occurrence of infertility in endometriosis within the framework of versions and contraversions. The magnitude of the described problem is noted not only from a medical, but also from a socio-economic perspective. Four main factors of endometriosis-associated infertility were identified: tubal-peritoneal, ovarian, embryonic and endometrial. Given the inconsistency of scientific data, the need for further research is noted.

Do ovarian endometriomas affect ovarian response to ovarian stimulation for IVF/ICSI?

RESEARCH QUESTION

Does the presence of ovarian endometriomas affect ovarian response to ovarian stimulation after adjusting for age and ovarian reserve markers?

DESIGN

This retrospective cross-sectional study compared the ovarian response between patients with ovarian endometriomas and women with other infertility factors undergoing their first ovarian stimulation for IVF/intracytoplasmic sperm injection (ICSI). An age-specific nomogram model for the number of oocytes retrieved was built for both groups, and ovarian response was compared after adjusting for age, gonadotrophin dose, anti-Mullerian hormone (AMH) concentration and antral follicle count (AFC).

RESULTS

A total of 923 patients were included: 101 women with at least one ovarian endometrioma, and 822 patients with other infertility factors. Comparisons of the nomograms for the number of oocytes retrieved demonstrated that response was significantly lower for women with endometrioma when the results were adjusted for age the z-score for the number of oocytes retrieved (-0.49 ± 0.71 versus -0.20 ± 0.86; 95% confidence interval [CI] -0.47 to -0.12) and also after adjustment for the total dose of gonadotrophins and AMH values (z-score mean difference -0.338; 95% CI -0.54, -0.14). When the z-score was adjusted for gonadotrophin dose and AFC, the number of oocytes retrieved was comparable between the two groups (z-score mean difference -0.038; 95% CI -0.34 to 0.27).

CONCLUSIONS

Ovarian response after ovarian stimulation for IVF/ICSI in women with endometriomas is significantly lower than in controls after adjusting for age, gonadotrophin dose and AMH. Dose and protocol selection for ovarian stimulation in patients with endometrioma should be based on AFC rather than AMH, as the latter may be overestimated.

Effects of laparoscopic cystectomy on ovarian reserve in patients with endometrioma and dermoid cyst

Objective:

To compare the effects of laparoscopic cystectomy on ovarian reserve between women with endometrioma and dermoid cyst.

Materials and Methods:

Thirty-six patients were diagnosed as having endometrioma (group A) and 32 patients with dermoid cyst (group B) using ultrasonography. Preoperative anti-mullerian hormone (AMH) levels were measured and unilateral antral follicle counts (AFC) were calculated for the ovary side containing the cyst. Laparoscopic cystectomy was performed using the stripping technique for all participants. After 3 months, all participants were re-evaluated between the third and sixth day of their menstrual cycle to determine AFC and AMH levels.

Results:

The mean serum preoperative AMH level and AFC level were significantly lower in group A than in group B (p=0.001, p=0.002), respectively. At 3 months after the surgery, serum AMH levels decreased significantly in group A from 2.04±0.68 to 1.47±0.55 (p=0.001), and from 2.60±0.57 to 2.17±0.56 in group B (p=0.001). In group A, unilateral (operated side) AFC levels decreased significantly from 4.05±1.24 to 2.16±0.94 (p=0.001), and in group B, it decreased significantly from 4.93±0.94 to 3.40±0.87 (p=0.001). The decrease in AMH levels was significantly higher in group A than in group B (p=0.033). The decrease in AFC levels was also significantly higher in group A than in group B (p=0.044).

Conclusion:

Laparoscopic stripping has destructive effects on serum AMH levels and the operated side AFC levels after surgery for patients with endometrioma and dermoid cysts, and laparoscopic excision of endometrioma has more destructive effects on ovarian reserve than dermoid cysts.

Rethinking mechanisms, diagnosis and management of endometriosis

Endometriosis is a chronic inflammatory disease defined as the presence of endometrial tissue outside the uterus, which causes pelvic pain and infertility. This disease should be viewed as a public health problem with a major effect on the quality of life of women as well as being a substantial economic burden. In light of the considerable progress with diagnostic imaging (for example, transvaginal ultrasound and MRI), exploratory laparoscopy should no longer be used to diagnose endometriotic lesions. Instead, diagnosis of endometriosis should be based on a structured process involving the combination of patient interviews, clinical examination and imaging. Notably, a diagnosis of endometriosis often leads to immediate surgery. Therefore, rethinking the diagnosis and management of endometriosis is warranted. Instead of assessing endometriosis on the day of the diagnosis, gynaecologists should consider the patient's 'endometriosis life'. Medical treatment is the first-line therapeutic option for patients with pelvic pain and no desire for immediate pregnancy. In women with infertility, careful consideration should be made regarding whether to provide assisted reproductive technologies prior to performing endometriosis surgery. Modern endometriosis management should be individualized with a patient-centred, multi-modal and interdisciplinary integrated approach.

The success of various endometrioma treatments in infertility: A systematic review and meta-analysis of prospective studies

BACKGROUND

Endometriosis is seen in 0.5%-5% of fertile and 25%-40% of infertile women. To investigate this conflict between gynecologists that ovarian endometriomas should be removed or not before making any decision about pregnancy among infertile women, the authors decided to carry out a systematic review and meta-analysis to compare the effect of various available therapeutic methods and notice the impact of these options on women's pregnancy rate.

METHODS

This review is based on PRISMA recommendations with an electronic search using the following databases: PubMed, Scopus, Google scholar, etc, from 2000 to 2018, in the English language. The studies compare pregnancy rate based on four different treatment types of OMAs between infertile women: (surgery + ART, surgery + spontaneous pregnancy, aspiration ± sclerotherapy + ART, and ART alone).

MAIN FINDINGS

At least eight prospective studies were included, in which 553 infertile women were compared in terms of treatment methods of OMAs before trying to become pregnant.

CONCLUSION

Treatments are usually based on the patient's clinical condition and must be individual, with the purpose of relieving pain, improving fertility, or both. The authors do not have not any significant difference between our four groups of study; however, the success of surgical procedure compared to other methods was higher and the success of ART alone was the least.

The effects of endometrioma size and bilaterality on ovarian reserve

The aim of this study was to investigate the effects of endometrioma (OMAs) size and bilaterality on ovarian reserve. The patients with OMA were determined by ultrasonographic examination. Fifty patients with unilateral OMA (Group A), 30 patients with bilateral OMA (Group B), and 60 women without ovarian cysts (Group C) were included in this study. AMH levels were measured, and antral follicle count (AFC) was determined. The mean serum AMH levels were significantly lower in Group B than Groups C and A, and were significantly lower in Group A than Group C. There was a significant correlation between serum AMH level and OMA size in Group A (R = -.372, p = .008). OMAs per se appear to be associated with damage to the ovarian reserve. Increased OMA size is related to decreased AMH levels in patients with OMA. Bilateral OMAs have a more destructive effect on ovarian reserve.IMPACT STATEMENTWhat is already known on this subject? Previous Studies have demonstrated the effect of surgery on ovarian reserve but there have been contradictory findings reported about the effects of OMAs per se on serum AMH levels and it has not been clear what the relation between OMAs size and AMH levels is, if any.What the results of this study add? In this study, we found decreased AMH levels in patients with OMA. The results showed significant negative correlation between OMA size and AMH levels. The patients with bilateral OMAs had lower AMH levels than the unilateral ones.What the implications are of these findings for clinical practice and/or further research? Increasing OMA size might be harmful to ovarian reserve. Further studies should be done to evaluate whether increasing the size of the OMA is associated with a progressive decline in ovarian reserve and to better clarify the role of the OMAs per se or of laparoscopic surgery in the determination of damage to the ovarian reserve.

Endometriosis and cumulative live birth rate after fresh and frozen IVF cycles with single embryo transfer in young women: no impact beyond reduced ovarian sensitivity-a case control study

Purpose

To investigate the impact of symptomatic and surgically confirmed endometriosis on ovarian sensitivity index (OSI) and cumulative live-birth rates (LBR) using predominantly single embryo transfer (SET).

Methods

Cross-sectional case-control study in a University-based ART program. Women with symptomatic and surgically confirmed endometriosis (N = 172), who underwent IVF/ICSI at Karolinska University Hospital were compared to controls without clinically suspected endometriosis (N = 2585). Two thousand seven hundred fifty-seven patients underwent 8236 treatment cycles (4598 fresh and 3638 frozen cycles). Primary outcome measures included Ovarian Sensitivity Index (OSI) estimated as collected oocytes/FSH dose and cumulative LBR/oocyte pickup (OPU). Generalized estimated equation (GEE) model accounting for dependencies between consecutive treatments were applied. Secondary outcomes included number of oocytes, pregnancy rate per OPU and per ET, LBR per ET, and miscarriage rate.

Results

Patients diagnosed with endometriosis had significantly fewer oocytes collected (8.47 vs. 9.54, p = 0.015) and lower OSI (p = 0.011) than controls. There were no differences in cycle cancelations (p = 0.59) or miscarriages (p = 0.95) between the two groups. Cumulative LBR/OPU did not differ between women with endometriosis and controls (35.6% vs. 34.7%, respectively, p = 0.83). In both groups, more than 60% of women had consecutive FETs after fresh ETs (p = 0.49) with SET in > 70% of cases. The results were similar whether ovarian endometrioma was present or not.

Conclusions

Our data support that a diagnosis of endometriosis, with or without present endometrioma, does not negatively affect ART cumulative results. The impact of endometriosis was discernible on OSI but not on clinical relevant outcomes including pregnancy and LBR.

Preoperative serum anti-Müllerian hormone level is a potential predictor of ovarian endometrioma severity and postoperative fertility

OBJECTIVE

To establish a model for predicting revised American Society of Reproductive Medicine (rASRM) scores before endometrioma surgery based on serum anti-Müllerian hormone (AMH) level and to identify factors that might reliably predict postoperative fertility of women diagnosed with endometrioma.

STUDY DESIGN

The study population was composed of 134 women with endometrioma, 58 with benign cyst, and 115 with non-ovarian lesion. Preoperative serum AMH level and clinical parameters were compared among three groups. Univariate correlation analyses and multivariate linear regression modeling with a stepwise method were performed for constructing an rASRM scores prediction model. Cox regression analysis was then used to identify predictive variables of spontaneous pregnancy following surgical treatment of endometrioma.

RESULTS

Preoperative AMH level were significantly lower in the endometrioma group than in the other two groups (p < 0.001). Multivariate linear regression analysis revealed that age (β=-0.324, p < 0.001), rASRM scores (β=-0.298, p < 0.001) and serum CA125 level (β=-0.176, p = 0.026) independently and negatively correlated with serum AMH level. Cox regression analysis of women with endometrioma who underwent surgical resection indicated that older age (per five-year increase, HR: 0.517; 95% CI, 0.299-0.896) and higher serum AMH level (cut-off value: >3.68 ng/ml, HR: 2.383; 95% CI, 1.093-5.197) were independent predictors for postoperative fertility.

CONCLUSION

Patients with advanced staged endometriosis tended to have a lower serum AMH level while postoperative infertility was more likely to occur in older patients with a lower level of serum AMH. Thus, timely detection of AMH levels to assess the severity of ovarian endometriosis and possibility for postoperative pregnancy success is necessary to ensure that optimal medical treatment can be provided.

Oligo-anovulation is not a rarer feature in women with documented endometriosis

OBJECTIVE

To study the prevalence of oligo-anovulation in women suffering from endometriosis compared to that of women without endometriosis.

DESIGN

A single-center, cross-sectional study.

SETTING

University hospital-based research center.

PATIENT (S)

We included 354 women with histologically proven endometriosis and 474 women in whom endometriosis was surgically ruled out between 2004 and 2016.

INTERVENTION

None.

MAIN OUTCOME MEASURE(S)

Frequency of oligo-anovulation in women with endometriosis as compared to that prevailing in the disease-free reference group.

RESULTS

There was no difference in the rate of oligo-anovulation between women with endometriosis (15.0%) and the reference group (11.2%). Regarding the endometriosis phenotype, oligo-anovulation was reported in 12 (18.2%) superficial peritoneal endometriosis, 12 (10.6%) ovarian endometrioma, and 29 (16.6%) deep infiltrating endometriosis.

CONCLUSION(S)

Endometriosis should not be discounted in women presenting with oligo-anovulation.

Antimüllerian hormone is reduced in the presence of ovarian endometriomas: a systematic review and meta-analysis

OBJECTIVE

To evaluate if the presence of endometriomas impacts on the ovarian reserve as evaluated with antimüllerian hormone (AMH).

DESIGN

Systematic review and meta-analysis.

SETTING

Not applicable.

PATIENT(S)

Patients with unoperated endometriomas versus controls without endometriomas.

INTERVENTION(S)

Electronic databases searched up to June 2017 to identify articles evaluating AMH levels in patients with unoperated endometriomas versus controls without endometriomas.

MAIN OUTCOME MEASURE(S)

The primary analysis was aimed at evaluation of AMH levels (mean and SD) in patients with and without endometriomas. Secondary analyses were aimed at evaluating AMH levels in patients with ovarian endometriomas compared to patients with either non-endometriosis benign ovarian cysts or healthy ovaries.

RESULT(S)

Of the 39 studies evaluated in detail, 17 were included, for a total of 968 patients with endometriomas and 1874 without endometriomas. AMH was significantly lower in patients with unoperated endometriomas compared to patients with no endometriomas (mean difference -0.84, with 95% confidence interval [CI] -1.16 to -0.52). At secondary analyses, AMH in patients with endometriomas was significantly lower both versus non-endometriosis benign ovarian cysts (mean difference -0.85, 95% CI -1.37 to -0.32, and versus women with healthy ovaries (mean difference -0.61, 95% CI -0.99 to -0.24).

CONCLUSION(S)

Ovarian reserve evaluated with AMH is reduced in patients with ovarian endometriomas compared both to patients with other benign ovarian cysts, and to patients with healthy ovaries.

Assisted reproduction in endometriosis

Endometriosis - a disease causing pain and infertility - is encountered in nearly 50% of infertile women. While medical treatment is effective on pain and recurrence of symptoms after surgical excision, it is of no help for treating infertility for which the only options considered are surgery and ART. Surgery enhances the chances of conceiving naturally during the 12-18 ensuing months irrespective of the stage of the disease. Surgery however is of no help when ART is considered, as it does not improve outcome and can only harm the ovarian response to stimulation. Today therefore, ART is commonly the primary option to be considered in women whose infertility is associated with endometriosis and whose ovarian reserve is compromised and/or who are over 35 years of age. When, ART is envisioned it is best to opt for a segmented ART approach with agonist trigger, freeze all and deferred embryo transfer.

Accuracy of anogenital distance and anti-Müllerian hormone in the diagnosis of endometriosis without surgery

OBJECTIVE

To assess the predictive ability of a combination of anogenital distance (AGD) and anti-Müllerian hormone (AMH) to diagnosis the presence of endometriosis without surgery.

METHODS

The present study included women diagnosed with endometriosis and a control group who attended the "Virgen de la Arrixaca" University Hospital, Murcia, Spain, between September 1, 2014, and May 31, 2015. Serum concentrations of AMH were measured, and two AGD measurements were obtained: from the anterior clitoral surface to the upper verge of the anus (AGD_AC ), and from the posterior fourchette to the upper verge of the anus (AGD_AF ). Data were assessed by receiver operator characteristic (ROC) curves.

RESULTS

Women in the endometriosis group (n=57) had significantly shorter AGD_AF (22.8 ± 4.6 vs 27.2 ± 5.7 mm; P<0.001) and lower AMH (2.2 ± 2.5 vs 3.3 ± 1.9 ng/mL; P<0.003) compared with the control group (n=93). Women with serum AMH below the clinical cut-off (1 ng/mL) were 17.40-times more likely to have endometriosis (95% confidence interval [CI] 5.64-53.82). The area under the ROC curve of combined AMH and AGD_AF was 0.77 (95% CI 0.70-0.85).

CONCLUSION

The model for predicting endometriosis on the basis of AMH and AGD could be useful for clinicians and epidemiologists to improve diagnosis and prognosis of this condition.

The impact of the localisation of endometriosis lesions on ovarian reserve and assisted reproduction techniques outcomes

This case-control study was designed to evaluate the impact of endometriosis and the presence of endometrioma (OMA) per se on the serum anti-Müllerian hormone (AMH) level and also to compare the in vitro fertilisation/intracytoplasmic sperm injection (IVF/ICSI) outcomes after therapeutic surgery in endometriosis patients, according to the localisation of endometriosis lesions. One hundred and fifty two infertile women ≤40 years with suspicious symptoms were surgically evaluated to detect the aetiology of infertility at the Royan Institute during this study and, in parallel, 131 patients with a male factor infertility diagnosis were considered as the control group. The serum AMH level and IVF/ICSI outcomes were compared according to the nature and extension degree of endometriosis lesions. The results demonstrated that the existence of a deep infiltrating endometriosis (DIE) with and without OMA was associated with a significant decrease in AMH level, antral follicle count and ovarian sensitivity index (OSI) (p < .001 and p = .007, respectively). The multivariable logistic regression analysis adjusted for confounding factors indicated that the OSI and the existence of DIE with and without OMA were a significant predictive variable for clinical pregnancy and for live birth. On the basis of our results, the severity of endometriosis and the location of its lesions could affect an ovarian reserve and the ovarian stimulation outcomes. Impact Statement What is already known on this subject? Previous studies have evaluated the impact of endometrioma (OMA) on ovarian reserve and the assisted reproduction technology (ART) outcomes and controversial results have been reported; therefore, it seems that this topic still needs further research. What the results of this study add? In the present study, the effect of endometriosis lesions' localisation on ovarian reserve and the success rate of the in vitro fertilisation/intracytoplasmic sperm injection (IVF/ICSI) cycle after therapeutic surgery were compared with that of the control group. It was found that the existence of a deep infiltrating endometriosis (DIE) with and without OMA was associated with a significant decrease in the anti-Müllerian hormone (AMH) level, antral follicle count, ovarian sensitivity index (OSI), clinical pregnancy and live birth rates. What the implications are of these findings for clinical practice and/or further research? The results of this study has a practical value in the decision making process for the ovarian stimulation protocol in patients with the different severity of endometriosis and the counselling regarding the success rate of IVF or ICSI/embryo transfer cycles.

Ovarian Reserve Following Laparoscopic Ovarian Cystectomy vs Cyst Deroofing for Endometriomas

STUDY OBJECTIVE

Because laparoscopic ovarian cystectomy of endometriomas is known to adversely impact patient ovarian reserve, the search for other techniques of surgical management is ongoing. The present study was undertaken to evaluate laparoscopic cyst deroofing as a feasible alternative.

STUDY DESIGN

Prospective, randomized clinical trial (Canadian Task Force classification I).

SETTING

University maternity hospital.

PATIENTS

Women diagnosed with unilateral or bilateral ovarian endometriomas.

INTERVENTIONS

Patients were managed with either laparoscopic ovarian cystectomy or cyst deroofing.

MEASUREMENTS AND MAIN RESULTS

A total of 122 women with endometriomas were randomized to either laparoscopic cystectomy (group 1) or laparoscopic cyst deroofing (group 2). The primary endpoint was the effect on ovarian reserve based on changes in anti-Müllerian hormone (AMH) values. At 1 month postsurgery, anti-Müllerian hormone values were significantly decreased (p < .001) from preoperative values, from 4.25 ± 0.87 ng/mL to 1.66 ± 1.02 ng/mL in group 1 and from 4.2 ± 1.69 ng/mL to 2.15 ± 1.48 ng/mL in group 2. In addition, antral follicle count and ovarian volume decreased significantly (p < .001) in both groups by 1 month postsurgery. The decreases in these 3 parameters were more significant (p < .001) in group 1 than in group 2.

CONCLUSION

Laparoscopic cyst deroofing of endometriomas appears to be a promising alternative to laparoscopic cystectomy, with less postoperative decrease in ovarian reserve; however, the higher rate of endometrioma recurrence warrants future clinical research to determine the optimal surgical management of endometriomas.

Endometriosis and ART: A prior history of surgery for OMA is associated with a poor ovarian response to hyperstimulation

Background

Many women whose fertility may have been impaired by endometriosis require assisted reproductive technology (ART) in order to become pregnant. However, the influence of ovarian endometriosis (OMA) on ovarian responsiveness to hyperstimulation has not been clearly established.

Objective

To evaluate the risk of a poor ovarian response (POR) to stimulation and ART outcomes in women with OMA.

Materials and methods

We conducted a large observational controlled matched cohort study in a tertiary care university hospital between 01/10/2012 and 31/12/2015. After matching by age and anti-Müllerian hormone (AMH) levels, 201 infertile women afflicted with OMA (the OMA group) and 402 disease-free women (the control group) undergoing an ART procedure were included in the study. The main outcomes that we measured were a POR to hyperstimulation (i.e., ≤ 3 oocytes retrieved, or cancelled cycles), the clinical pregnancy rate, and the live birth rate.

All of the women with endometriosis underwent a pre-ART work-up, in order to obtain an accurate diagnosis and staging of their disease. An OMA diagnosis was based on published imaging criteria (obtained by transvaginal sonography or magnetic resonance imaging) or on histological analysis for patients with a prior history of endometriosis surgery. The statistical analyses were conducted using univariate and multivariate logistic regression models.

Results

The incidence of a POR to hyperstimulation was significantly higher for the OMA group than for the control group [62/201 (30.8%) versus 90/402 (22.3%), respectively; p = 0.02]. However, no significant differences were found between the OMA and the control group in terms of the clinical pregnancy rate [53/151 (35%) versus 134/324 (41.3%), respectively; p = 0.23] and the live birth rate [39/151 (25.8%) versus 99/324 (30.5%), respectively; p = 0.33]. By multivariate analysis, a prior history of surgery for OMA was found to be an independent factor associated with a POR to stimulation [OR = 2.1; 95% CI: 1.1–4.0], unlike OMA without a prior history of surgery [OR: 1.5; 95% CI: 0.9–2.2].

Conclusion

The presence of OMA during ART treatment increased the risk of a POR to hyperstimulation, although the live birth rate was not affected. Furthermore, having OMA and having previously undergone surgery for OMA was identified as an independent risk factor for a POR.

[Endometriosis and fertility preservation: CNGOF-HAS Endometriosis Guidelines]

Fertility preservation (FP) techniques are progressing rapidly these past few years thanks to the oocyte vitrification. Indication of FP techniques is now extended to non-oncological situation that may induce risk of premature ovarian failure. Ovarian endometriosis can lead to premature ovarian failure and further infertility due to the high risk of ovarian cysts recurrence and surgery. To date, there is no cohort study regarding FP and endometriosis as well as no recommendation. Our purpose is to review the arguments in favor of FP in this specific area and to elaborate strategies according to each clinical form.