Prospective assessment of the impact of endometriomas and their removal on ovarian reserve and determinants of the rate of decline in ovarian reserve

Efficacy of colchicine and melatonin in the treatment of rat endometriosis model: An animal study

OBJECTIVE

This study investigates the therapeutic effects of colchicine and melatonin on endometriotic implants in an experimentally created endometriosis model in rats.

STUDY DESIGN

Forty-four adult female Wistar albino rats weighing between 260 and 300 g, 8 weeks old, were selected for the study. The unilateral uterine horn of rats with a bicornuate uterus was excised for 1 cm, washed with sterile saline, incised longitudinally, and the endometrium was exposed. A 0.5*0.5 cm endometrial tissue sample taken with a scalpel was implanted with suturing (4/0 Vicryl) to the abdominal wall. Forty-four rats were divided into four groups. Group 1 was randomized as the endometriosis group (control), Group 2 as endometriosis + colchicine treatment, Group 3 as endometriosis + melatonin treatment, and Group 4 as the endometriosis + melatonin + colchicine treatment group. The colchicine (Sigma Chemical Co., St Louis, Missouri) group was administered orally at a dose of 0.1 mg/kg, and the Melatonin group orally at a dose of melatonin (20 mg/kg per day). Treatment continued daily for 30 days.

RESULTS

In the post-treatment focal diameter measurements, the endometrial focal diameter in the colchicine and colchicine + melatonin group was significantly lower than the control group (p=0.026). Bcl-2 levels of the colchicine group were lower than the control group and the melatonin group (p=0.021).

CONCLUSION

Colchicine and melatonin reduce adhesion to the peritoneal surface in ectopic endometrial cells. It also acts by increasing apoptosis and decreasing cell survival.

Female fertility preservation for family planning: a position statement of the Italian Society of Fertility and Sterility and Reproductive Medicine (SIFES-MR)

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.

Endometrioma surgery: Hit with your best shot (But know when to stop)

Ovarian endometriomas (OEs) are commonly detected by ultrasound in individuals affected by endometriosis. Although surgery was widely regarded in the past as the gold standard for treating OEs, especially in the case of large cysts, the surgical management of OEs remains debated. Firstly, OEs often represent the "tip of the iceberg" of underlying deep endometriosis, and this should be considered when treating OEs to ameliorate patients' pain for focusing on the surgical objectives and providing better patient counseling. In the context of fertility care, OEs may have a detrimental effect on ovarian reserve through structural alterations, inflammatory responses, and oocyte reserve depletion. Conversely, the surgical approach may exacerbate the decline within the same ovarian reserve. While evidence suggests no improvement in in-vitro fertilization (IVF) outcomes following OE surgery, further studies are needed to understand the impact of OE surgery on spontaneous fertility. Therefore, optimal management of OEs is based on individual patient and fertility characteristics such as the woman's age, length of infertility, results of ovarian reserve tests, and surgical background. Among the available surgical approaches, cystectomy appears advantageous in terms of reduced recurrence rates, and traditionally, bipolar coagulation has been used to achieve hemostasis following this approach. Driven by concerns about the negative impact on ovarian reserve, alternative methods to obtain hemostasis include suturing the cyst bed, and novel methodologies such as CO2 laser and plasma energy have emerged as viable surgical options for OEs. In instances where sonographic OE features are non-reassuring, surgery should be contemplated to obtain tissue for histological diagnosis and rule out eventual ovarian malignancy.

Ethanol Sclerotherapy in the Management of Ovarian Endometrioma: Technical Considerations for Catheter- and Needle-Directed Sclerotherapy

PURPOSE

To provide technical guidance on applying catheter-directed and needle-directed ethanol sclerotherapy for endometriomas and present the results of these sclerotherapy methods.

MATERIALS AND METHODS

From January 2015 to March 2021, the results of the patients with symptomatic ovarian endometriomas who underwent needle-directed or catheter-directed sclerotherapy were evaluated, retrospectively. The decision to apply which sclerotherapy technique was made during the procedure for each patient considering the following factors: cyst size, cyst location, cyst viscosity, and tissue rigidity.

RESULTS

Both needle-directed (n = 34 cysts) and catheter-directed (n = 34 cysts) sclerotherapy techniques were effective, with a 100% technical success rate and a 97% clinical success rate. In two of 34 cysts (6%) treated with needle-directed sclerotherapy, recurrence was detected and successfully retreated with catheter-directed sclerotherapy. Significant reductions in cyst size, pain, and serum cancer antigen 125 levels (p < 0.05) were noted. Serum anti-Müllerian hormone levels remained unaffected, indicating preserved ovarian reserve (p > 0.05). Among those treated for infertility, the pregnancy rate was 54% (n = 6/11). The mean ± SD cyst size decline was greater in catheter-directed sclerotherapy than needle-directed sclerotherapy (5.5 ± 3.1 cm vs. 4.0 ± 2.1 cm, p < 0.05). However, the pretreatment cyst volumes were considerably higher in catheter-directed sclerotherapy group (202.0 ± 233.5 mL vs. 78.8 ± 59.7 mL, p < 0.05) and were associated with significant post-treatment volume decrease (p < 0.05).

CONCLUSION

The choice between catheter-directed and needle-directed ethanol sclerotherapy should be determined during the procedure, with a preference for catheter-directed sclerotherapy when feasible. Crucial factors in making this decision include cyst size, cyst location, cyst viscosity, and tissue rigidity. Level of evidence Level 3, non-controlled retrospective cohort study.

Clinical Management of Infertility Associated with Endometriosis

OBJECTIVE

This study aimed to review recent data that affected the clinical management of infertility associated with endometriosis.

DATA SOURCES

We completed a PubMed review of all articles that included the following keywords: endometriosis, infertility, IVF, and ART.

STUDY SELECTION

A study was selected based on the pertinence of the topic addressed in relation to the study's set objectives.

DATA EXTRACTION AND SYNTHESIS

All identified articles were first assessed based on a review of the abstract. Pertinent articles were reviewed in depth.

CONCLUSION

Endometriosis interferes with natural conception primarily by altering the quality of gametes-oocytes and sperm-and early-stage embryos. On the contrary, recent data indicate that gametes and early-stage embryos are not altered in the case of ART. Surgery-a classical approach in yesteryears-does appear to improve ART outcomes and may affect ovarian reserve and the number of oocytes retrieved in ART. Surgery is thus more rarely opted for today and only when necessary; proceeding to fertility preservation prior to surgery is recommended. When ART is performed in women with endometriosis, it is recommended to use an antagonist or progesterone-primed ovarian stimulation approach followed by deferred embryo transfer. In this case, GnRH (gonadotropin releasing hormone) agonist is preferred for triggering ovulation, as it limits the risk of cyst formation as well as ovarian hyperstimulation syndrome. Frozen embryo transfers are best performed in E2 (estradiol) and progesterone replacement cycle.

Analysis of factors affecting pregnancy rate after laparoscopic surgery for infertility associated with endometriosis

OBJECTIVE

To analyze the factors that might influence the pregnancy rate in patients with infertility related to endometriosis (EMs) after undergoing laparoscopic surgery, providing guidance for our clinical diagnostic and therapeutic decision-making.

METHODS

A retrospective analysis was conducted on clinical records and 1-year postoperative pregnancy outcomes of 335 patients diagnosed with endometriosis-related infertility via laparoscopic surgery, admitted to our department from January 2018 to December 2020.

RESULTS

The overall pregnancy rate for patients with endometriosis (EMs) related infertility 1-year post-surgery was 57.3 %, with the highest pregnancy rate observed between 3 to 6 months after surgery. Factors such as Body Mass Index (BMI) (P = 0.515), presence of dysmenorrhea (P = 0.515), previous pelvic surgery (P = 0.247), type of EMs pathology (P = 0.893), and preoperative result of serum carbohydrate antigen 125 (CA125)（P = 0.615）had no statistically significant effect on postoperative pregnancy rates. The duration of infertility (P = 0.029), coexistence of adenomyosis (P = 0.042), surgery duration (P = 0.015), intraoperative blood loss (P = 0.050), preoperative result of serum anti-Müllerian hormone (AMH) (P = 0.002) and age greater than 35 (P = 0.000) significantly impacted postoperative pregnancy rates. The post-surgery pregnancy rate in patients with mild (Stage I-II) EMs was notably higher than those with moderate to severe (Stage III-IV) EMs (P = 0.009). Age (P = 0.002), EMs stage (P = 0.018), intraoperative blood loss (P = 0.010) and adenomyosis (P = 0.022) were the factors that affected the postoperative live birth rate.

CONCLUSION

For patients with EMs-related infertility undergoing laparoscopic surgery, factors such as age > 35 years, infertility duration > 3 years, concurrent adenomyosis, severe EMs, surgery duration ≥ 2 h, intraoperative blood loss ≥ 50 ml, and low AMH before surgery are detrimental for the pregnancy rate within the first postoperative year. However, BMI, dysmenorrhea, past history of pelvic surgery, EMs pathology types (ovarian, peritoneal, deep infiltrating),and preoperative result of serum CA125 barely show any statistical difference in their effect on postoperative pregnancy rates. In terms of postoperative live birth rate, age > 35 years, severe EMs, intraoperative blood loss ≥ 50 ml, and adenomyosis were adverse factors.

Ovarian reserve markers of women with superficial endometriosis

OBJECTIVE

Endometriosis affects up to 10% of reproductive age women and is associated with pelvic pain and subfertility. While previous studies have shown an association between deep and ovarian endometriosis to reduced ovarian reserve, there is no data on the effect of superficial endometriosis on ovarian reserve markers. Hence, we aimed to compare ovarian reserve markers of women with superficial endometriosis to that of women without endometriosis.

METHODS

This was a case control study in a tertiary medical center. The study group included women aged 18-40 with surgically and histopathology-proven superficial endometriosis with no deep lesions or ovarian involvement. The control group included women with no known or suspected endometriosis and was matched to the study group by age, BMI and parity. We excluded women with other known risk factors for ovarian failure and with other gynecological disorders. Participants completed a questionnaire with demographic, medical and gynecological data. Each patient underwent anti-Mullerian hormone (AMH) testing and an ultrasound to assess their antral follicular count (AFC). AMH and AFC were then compared between groups.

RESULTS

A total of 124 women participated in the study. Of these, 50% (n = 62) had surgically proven superficial endometriosis and 50% (n = 62) were without known or suspected endometriosis. Mean AMH levels of women with and without superficial endometriosis was 3.0 ± 2.8 ng/mL and 2.8 ± 1.9 ng/mL, respectively (P = 0.71). AFC also did not differ between groups (women with superficial endometriosis: 12.0 ± 6.6; women without endometriosis: 10.2 ± 5.0, P = 0.15).

CONCLUSIONS

In our cohort, superficial endometriosis was not associated with diminished ovarian reserve. While further studies are needed, to date, it does not appear to be justified to assess ovarian reserve for patients with superficial endometriosis.

Horizons in Endometriosis: Proceedings of the Montreux Reproductive Summit, 14-15 July 2023

Endometriosis is a complex and chronic gynaecological disorder that affects millions of women worldwide, leading to significant morbidity and impacting reproductive health. This condition affects up to 10% of women of reproductive age and is characterised by the presence of endometrial-like tissue outside the uterus, potentially leading to symptoms such as chronic pelvic pain, dysmenorrhoea, dyspareunia, and infertility. The Montreux summit brought a number of experts in this field together to provide a platform for discussion and exchange of ideas. These proceedings summarise the six main topics that were discussed at this summit to shed light on future directions of endometriosis classification, diagnosis, and therapeutical management. The first question addressed the possibility of preventing endometriosis in the future by identifying risk factors, genetic predispositions, and further understanding of the pathophysiology of the condition to develop targeted interventions. The clinical presentation of endometriosis is varied, and the correlation between symptoms severity and disease extent is unclear. While there is currently no universally accepted optimal classification system for endometriosis, several attempts striving towards its optimisation - each with its own advantages and limitations - were discussed. The ideal classification should be able to reconcile disease status based on the various diagnostic tools, and prognosis to guide proper patient tailored management. Regarding diagnosis, we focused on future tools and critically discussed emerging approaches aimed at reducing diagnostic delay. Preserving fertility in endometriosis patients was another debatable aspect of management that was reviewed. Moreover, besides current treatment modalities, potential novel medical therapies that can target underlying mechanisms, provide effective symptom relief, and minimise side effects in endometriotic patients were considered, including hormonal therapies, immunomodulation, and regenerative medicine. Finally, the question of hormonal substitution therapy after radical treatment for endometriosis was debated, weighing the benefits of hormone replacement.

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.

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

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

Initial Preoperative Hemoglobin Level Affects the Rate of Decline in Anti-Müllerian Hormone Levels after Laparoscopic Ovarian Cystectomy in Women with Ovarian Endometriosis

OBJECTIVES

To determine the factors affecting the decline in ovarian reserve following laparoscopic ovarian cystectomy (LOC) in women with ovarian endometriosis.

METHODS

This retrospective study included 22 women, aged 25-45 years, with regular menstrual cycles who underwent unilateral LOC and were diagnosed with ovarian endometriosis at a university hospital. Blood samples were collected preoperatively and on the third postoperative day to determine the serum anti-Müllerian hormone (AMH) levels for assessment of the decline in ovarian reserve during the early postoperative period.

RESULTS

The preoperative hemoglobin level, white blood cell count, and AMH level were associated with changes in the AMH level after unilateral LOC. Among these parameters, only the preoperative hemoglobin level was correlated with the rate of decline in postoperative AMH levels. The preoperative serum AMH level was correlated with the amount of postoperative AMH change but not with its rate of decline.

CONCLUSIONS

Preoperative hemoglobin levels may be associated with the rate of decline in AMH levels in the early postoperative period after unilateral LOC.

The Efficiency of Sclerotherapy for the Management of Endometrioma: A Systematic Review and Meta-Analysis of Clinical and Fertility Outcomes

Background and Objectives: The most common sites of implantation of endometriotic tissue are the ovaries. Endometriomas are present in most cases of endometriosis (up to 45%). Although laparoscopic cystectomy is the standard of care in endometrioma, new strategies have been set up to minimize iatrogenic injuries to ovarian tissue. Sclerotherapy consists of injecting alcohol into the endometrioma to denature the amino acidic components of its pseudocapsule. The aim of this systematic review and meta-analysis is to compare clinical and pregnancy outcomes in surgery and sclerotherapy. Materials and Methods: Following the recommendations in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, we systematically searched PubMed, EMBASE, Scopus, Google Scholar, Clinical-trials.gov, and the Cochrane Central Register of Controlled Trials databases in January 2023, adopting the string "Endometriosis and sclerotherapy". We made no limitations on the country and year of publication. We included the studies containing Success Rate (SR), Recurrence Rate (RR), Pregnancy Rate (PR) before and after the procedure. We used comparative studies for meta-analysis. Results: A total of 29 studies fulfilled inclusion criteria, 7 retrospective observational studies and 22 prospective studies. Eight comparative studies were enrolled in meta-analysis. Patients were analyzed concerning the number of recurrences and pregnancies in surgery, and compared with sclerotherapy. Four studies showed SR > 80.0%, and only two had SR < 80.0%, of which one consisted of tetracycline instillation. Only 1 study had 100% PR, the other 14 reported PR > 30.0%, whereas six had PR < 30.0%, of which one showed 0.0% PR with ethanol injection at two-thirds of the cyst fluid volume. Meta-analysis highlighted a non-significant lower incidence of recurrence in the surgery group compared to the sclerotherapy group (p = 0.87). In parallel, the surgery group showed a non-significant better PR than the sclerotherapy group (p = 0.08). Conclusions: Despite sclerotherapy having a minor incidence of postoperative complications compared to surgery, the latter is associated with a lower RR and better PR. However, those data assert the importance of a targeted therapy according to preoperative conditions and reproductive potential.

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.

Fertility Preservation in Women with Endometriosis

Several mechanisms have been implicated in the pathogenesis of endometriosis-related infertility. For patients considering surgery, the risk of iatrogenic injury is among the most important factors in the context of fertility preservation, along with age and individual reproductive goals. In the case of endometrioma excision, evidence overwhelmingly demonstrates the negative impact of surgery on ovarian reserve, with significant reductions in antimullerian hormone (up to 30% in unilateral versus up to 44% in bilateral endometriomas). The surgical endometriosis patient should be thoroughly counseled regarding fertility preservation and discussion should include tissue, embryo, and oocyte cryopreservation options. For the latter, data support cryopreservation of 10-15 oocytes in women ≤35 years and over 20 for those >35 years for a realistic chance to achieve one or more live births. When performing surgical interventions for endometriosis, reproductive surgeons should employ fertility-conserving surgical methods to reduce the likelihood of postoperative iatrogenic diminished ovarian reserve.

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.

Combined effects of age and endometriosis on ovarian reserve in women with infertility

OBJECTIVE

To evaluate the combined effects of age and endometriosis on ovarian reserve in women with infertility.

METHODS

We conducted a cross-sectional study using an institutional database. Women with sonographic, laparoscopic, or histologic evidence of endometriosis were defined as the study group and the remaining women served as a control group. We evaluated demographic and clinical characteristics of the groups as a whole and stratified the patients into those aged 35 years or older and those younger than 35 years at the time of ovarian reserve testing.

RESULTS

Of a total of 656 women included in the final analysis, 71 women had a diagnosis of endometriosis. When compared with women without endometriosis, the median anti-Müllerian hormone (AMH) and antral follicular count (AFC) values were significantly lower in the group of women with endometriosis-median 2.1 ng/ml (interquartile range [IQR] 1.1-3.9) versus 1.2 ng/ml (IQR 0.6-2.4; P < 0.001) for AMH and 14 follicles (IQR 8-23) versus 7 follicles (IQR 5-14; P < 0.001) for AFC. When stratified into two age groups the association between a lower AFC and endometriosis remained significant for both age groups whereas the association between a lower AMH and endometriosis was significant only for the group of women aged 35 years oor older.

CONCLUSION

Our study highlights a detrimental effect by endometriosis and an age enhancement effect of endometriosis on ovarian reserve.

The Impact of Endometrioma on Embryo Quality in In Vitro Fertilization: A Retrospective Cohort Study

The influence of endometrioma on oocyte and embryo competence is inconclusive. Furthermore, the benefits of surgical treatment remain uncertain. This study aimed to investigate the effect of endometrioma on oocyte and embryo quality from a morphological perspective and further explore whether surgery could contribute to improving oocyte and embryo competence. A total of 664 IVF cycles with endometrioma (538 cycles underwent surgeries) and 3133 IVF cycles from the control group were included. The propensity score matching was used to balance the baseline differences between groups. There was a lower MII oocyte rate (85.0% versus 87.8%, p < 0.001; 84.9% versus 87.6%, p = 0.001) and a similar good-quality embryos rate in women with endometrioma (and those who underwent surgeries) compared with control group. For women with endometrioma, the rates of blastocyst development (67.1% versus 60.2%; p = 0.013) and good blastocyst development (40.7% versus 35.2%; p = 0.049) were significantly higher in those who had undergone surgical treatment compared with those who had not, but the rates of MII oocytes (79.9% versus 87.7%; p < 0.001) and normal fertilization (55.2% versus 66.2%; p < 0.001) were lower. The study indicates that endometrioma, including its surgical treatment, compromises the oocyte maturity not the embryo quality at the cleavage stage; however, the surgery seems to contribute to improving blastocyst development.

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.

Expectant, Medical, and Surgical Management of Ovarian Endometriomas

Management options for ovarian endometriomas include expectant management, medical treatment, surgical treatment, in vitro fertilization (IVF), or a combination of the above. The choice of management depends on many clinical parameters that should be taken into consideration, the first of which is the main presenting symptom. Most patients are today referred to medical therapy as a first option in the case of associated pain, and to IVF in the case of associated infertility. When both symptoms are present, usually surgery is the preferred approach. Recently, however, surgical excision of an ovarian endometrioma has been associated with a postoperative reduction in the ovarian reserve, and recent guidelines suggest that the clinician should caution the patient as to the possible damage to the ovarian reserve in the case of surgery. However, evidence has been published as to a possible detrimental effect of the ovarian endometrioma on the ovarian reserve even if expectant management is followed. In this review, the current evidence on the conservative management of ovarian endometriomas, with particular focus on the issue of the ovarian reserve, is evaluated, and the different surgical techniques for the treatment of ovarian endometriomas are discussed.

Impacts of endometrioma on ovarian aging from basic science to clinical management

Endometriosis is a common reproductive disorder characterized by the presence of endometrial implants outside of the uterus. It affects ~1 in 10 women of reproductive age. Endometriosis in the ovary, also known as endometrioma (OMA), is the most frequent implantation site and the leading cause of reproductive failure in affected women. Ovarian aging is one of the characteristic features of OMA, however its underlying mechanism yet to be determined. Accumulated evidence has shown that pelvic and local microenvironments in women with OMA are manifested, causing detrimental effects on ovarian development and functions. Whilst clinical associations of OMA with poor ovarian reserve, premature ovarian insufficiency, and early menopause have been reported. Moreover, surgical ablation, fenestration, and cystectomy of OMA can further damage the normal ovarian reservoir, and trigger hyperactivation of primordial follicles, subsequently resulting in the undesired deterioration of ovarian functions. Nevertheless, there is no effective treatment to delay or restore ovarian aging. This review comprehensively summarised the pathogenesis and study hypothesis of ovarian aging caused by OMA in order to propose potential therapeutic targets and interventions for future studies.

Presence of Endometrioma Does Not Impair Embryo Quality and Assisted Reproductive Technology (ART) Cycle Outcome in Diminished Ovarian Reserve (DOR) Patients

This study aims to assess the impact of endometrioma on embryo quality and cycle outcome in patients who undergo assisted reproductive technology (ART) treatment due to diminished ovarian reserve (DOR). Retrospective case-control study was conducted in women ≤ 40 years of age who underwent ART treatment caused by DOR, defined according to POSEIDON criteria, at a university-based infertility clinic between January 2015 and December 2020. Three groups of patients were selected: group A included patients with an idiopathic DOR, group B included patients with endometrioma(s) who underwent ovarian cystectomy, and group C included patients with endometrioma(s) without surgical treatment. A total of 351 women with DOR were included in the final analysis. Demographic characteristics, including age and AMH, were similar between the groups. Significant differences were observed among groups on mean number of MII oocytes retrieved (1.88 ± 1.59 vs. 2.84 ± 2.89 vs. 2.78 ± 2.41, respectively; p < 0.001) and mean number of embryos (1.04 ± 1.18 vs. 1.87 ± 2.01 vs. 1.66 ± 1.81, respectively; p < 0.001). However, the mean number of top-quality embryos, cycle cancellation, and live birth rates were similar between the groups. Clinical pregnancy (35 (26.5%) vs. 8 (18.2%) vs. 18 (42.9%), respectively; p = 0.038) and miscarriage rates (12 (9.1%) vs. 0 vs. 8 (19.0%), respectively; p = 0.009) were higher in endometrioma group without surgery. Women with DOR appear to have similar ART cycle outcomes regardless of the etiology, in terms of live birth rates. Infertility of endometrioma patients might be related to altered endometrium rather than to decreased oocyte quality. Cystectomy for endometrioma before IVF did not seem to affect the LBR.

Overexpression of ErbB-1 (EGFR) Protein in Eutopic Endometrium of Infertile Women with Severe Ovarian Endometriosis during the ‘Implantation Window’ of Menstrual Cycle

The strong association between endometriosis and infertility is of high clinical significance. High proliferative bias in eutopic endometrium during the secretory phase is a hallmark of endometriosis, which may result in high occurrence of implantation failure and resultant infertility in endometriosis. The ErbB family of proteins regulates the proliferation capacity in the endometrium, potentially causing endometrial hostility to the implantation process in endometriosis. However, our knowledge regarding the involvement of the ErbB family in human endometrium during the window of implantation (WOI) in endometriosis-associated infertility is scant. In the present study, the cellular profiles of immunopositive ErbBs-1 to -4 in the endometrium of endometriosis-free, infertile women (Group 1; n = 11) and in eutopic endometrium of infertile women diagnosed with stage IV ovarian endometriosis (Group 2; n = 13) during the mid-secretory phase were compared using standardized guidelines. Computer-aided standardized combinative analysis of immunoprecipitation in different compartments revealed an overexpression of ErbB-1 in the epithelial, stromal and vascular compartments, along with marginally higher ErbB-3 expression (p < 0.06) in the vascular compartment and ErbB-4 expression (p < 0.05) in the glandular epithelium and stroma in the endometrium during the WOI in women with primary infertility associated with stage IV ovarian endometriosis compared with disease-free endometrium of control infertile women. It appears that changes in ErbBs in the eutopic endometrium during WOI induce anomalous proliferative, inflammatory and angiogenic activities in it, which can antagonize endometrial preparation for embryo implantation in endometriosis. This knowledge appears usable in strategizing methods for the treatment of endometriosis-associated infertility, as well as preempting the oncogenic potential of endometriosis.

Predictive Value of Basal Serum Progesterone for Successful IVF in Endometriosis Patients: The Need for a Personalized Approach

The data regarding the role of progesterone (P4) in reproductive events of endometriosis patients are limited. This prospective study aimed to examine the predictive value of basal P4 serum levels for successful in vitro fertilization (IVF) in patients with primary infertility and endometriosis. The study included 73 patients divided according to endometriosis treatment (surgery vs. control—no treatment). The general data, basal hormonal status, and pregnancy rates were determined for every patient. Clinical pregnancy was achieved in 40.3% of patients, and more often in patients treated for endometriosis before IVF. The regression analysis showed that higher basal P4 serum levels were associated with achieving pregnancy through IVF. When regression was adjusted for the patient and IVF characteristics, higher basal P4 serum levels were associated with pregnancy achievement in both groups of women, along with the basal serum levels of FSH, LH, and AMH; EFI score; and stimulation protocol. The ROC analysis showed that the basal P4 serum level for successful IVF should be ≥0.7ng/mL. The basal P4 serum level cut-off for IVF success in endometriosis patients was determined for the first time. Constructed models for IVF success prediction emphasize the importance of determining the basal P4 serum levels for the personalized treatment of endometriosis-related infertility.

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.

Assisted reproductive treatment outcomes of women with endometriomas: Either with or without previous ovarian surgery

OBJECTIVE

The present study aimed to evaluate and compare the assisted reproductive technique (ART) outcomes of women with endometriomas either with or without prior endometrioma surgery.

MATERIALS AND METHODS

A total of 122 women with endometriomas underwent intracytoplasmic sperm injection-embryo transfer (ICSI-ET) at a tertiary IVF Center, between 2014 and 2019, were included in this retrospective study. Of this group, 38 patients had recurrent endometriomas and 84 patients had primary endometrioma without a previous endometrioma surgery. The outcomes of ART treatment including cancellation rates before ET, numbers of oocytes obtained, implantation, clinical pregnancy and live birth rates were compared between the groups. A logistic regression model including potential confounders as age and presence of male factor infertility was used to evaluate the possible effect of recurrent endometriomas on the live birth.

RESULTS

The baseline characteristics of the groups were similar. The poor ovarian response rate, defined as the harvest of fewer than four oocytes, was identified in 35.7% and 42.1% of primary and recurrent endometrioma groups, respectively. The implantation (27.2 ± 42.7% vs 24.1 ± 41.4%, P = .74), clinical pregnancy/ET (30.9% vs 27.6%, P = .93 ) and live birth rates/ET (22.1% vs 17.2%, P = .79) CONCLUSION: The ART outcomes of patients with primary and recurrent endometriomas do not seem different in terms of response to ovarian stimulation and live birth rates after ICSI. These results may indicate that the recurrence of the endometrioma might not have a further detrimental effect on ART outcome than the disease itself.

The Optimal Time of Ovarian Reserve Recovery After Laparoscopic Unilateral Ovarian Non-Endometriotic Cystectomy

Background

Laparoscopic ovarian cystectomy is established as the standard surgical approach for the treatment of benign ovarian cysts. However, previous studies have shown that potential fertility can be directly impaired by laparoscopic ovarian cystectomy, diminished ovarian reserve (DOR), and even premature ovarian failure. Therefore, fertility-preserving interventions are required for benign gynecologic diseases. However, there are still little data on the time period required for recovery of ovarian reserve after the laparoscopic unilateral ovarian cystectomy, which is very important for the individualization of treatment protocols. This study aimed at investigating the time needed for the ovarian reserve to recover after laparoscopic unilateral ovarian non-endometriotic cystectomy.

Materials and Methods

Sixty-seven patients with unilateral ovarian non-endometriotic cyst from Zhoupu and Punan Hospitals who underwent laparoscopic unilateral ovarian cystectomy were recruited as a postoperative observation group (POG). Also, 69 healthy age-matched women without ovarian cyst who did not undergo surgery were recruited as a referent group (RFG). Ovarian reserve with the serum anti-Müllerian hormone (AMH), follicle-stimulating hormone (FSH), estradiol (E2) levels, ovarian arterial resistance index (OARI), and antral follicle counts (AFCs) were measured on the third to fifth days of the same menstrual cycle. A postoperative 6-month follow-up of cases was performed.

Results

Compared with RFG, AFC of cyst side in the POG group showed no difference in the first, third, and sixth postoperative month (F = 0.03, F = 0.02, F = 0.55, respectively; p = 0.873, p = 0.878, p = 0.460, respectively). The OARI of cyst side in the POG group revealed no differences in the first, third, and sixth postoperative month (F = 0.73, F = 3.57, F = 1.75, respectively; p = 0.395, p = 0.061, p = 0.701, respectively). In the first month, the postoperative AMH levels significantly declined, reaching 1.88 ng/ml [interquartile range (IQR): 1.61-2.16 ng/ml] in POG and 2.57 ng/ml (IQR: 2.32-2.83 ng/ml) in RFG (F = 13.43, p = 0.000). For the data of AMH levels stratified by age, the same trend was observed between less than 25 and more than 26 years old. At this same time interval, the postoperative rate of decline was significantly lower compared to the preoperative one in POG (32.75%). The same trend was observed between the POG and RFG groups (26.67%).

Conclusions

The optimal time for recovery of ovarian reserve after laparoscopic unilateral ovarian cystectomy is estimated to be 6 months.

The Influence of Cesarean Delivery on Ovarian Reserve: a Prospective Cohort Study

To assess the association between cesarean delivery and ovarian reserve, as compared to vaginal delivery. A prospective case control study conducted at a single tertiary medical center between June 2018 and June 2019. Study population included women with singleton pregnancy that underwent first cesarean delivery that were compared to women undergoing normal vaginal delivery. Women with low ovarian reserve, endometriosis, previous pelvic surgery, chronic maternal disease, and active labor were excluded. Ovarian reserve was estimated by Anti-Mullerian hormone (AMH) levels that was determined twice for each participant: up to a week before and 3 months after delivery. Primary outcome was defined as the delta in AMH levels. Data were analyzed by non-parametric tests. During the study period, 135 women were enrolled, of them 63 (47%) underwent cesarean delivery and 72 (53%) had vaginal delivery. Women in the cesarean delivery group were older (34 (31-38) vs. 32 (29-35); p = 0.001); nevertheless, AMH levels measured before delivery were comparable between the two groups (0.92 (0.51-1.79) vs. 0.95 (0.51-1.79) pg/mL; p = 0.42). AMH levels measured after delivery were more than doubled in the study and control groups (2.15 (1.24-3.05) vs. 2.62 (1.05-5.09); p = 0.50), and delta AMH levels were also found comparable (1.25 (0.61-2.22) vs. 1.59 (0.63-3.41), respectively; p = 0.43). Linear regression analysis including age, mode of delivery, gestational age at delivery, and delta hemoglobin levels revealed that only maternal age was significantly associated with delta in AMH levels (B =  - 0.09, p = 0.04). Cesarean delivery does not decrease ovarian reserve as estimated by AMH.

Anti-Mullerian Hormone Changes Following Laparoscopic Ovarian Cystectomy: A Prospective Comparative Study

Purpose

To investigate whether laparoscopic ovarian cystectomy (LOC) affects ovarian reserve.

Patients and Methods

In 46 premenopausal women, who underwent either LOC (study group, n=26) or laparoscopic myomectomy (LM) (control group, n=20), serum anti-Mullerian hormone (AMH) levels were measured pre-operatively (AMH0), and postoperatively at 7 days (AMH1), 2 months (AMH2), and 6 months (AMH3). Changes in AMH from baseline level (AMH0) in each group were compared.

Results

AMH0 did not differ between the two groups (3.5 ± 3.33 in LOC vs 2.4 ± 2.72 in LM, P=0.250). AMH1, AMH2, and AMH3 in each group were also similar. However, a significant decline of AMH (ie more than 50% decrease compared to AMH0) at postoperative 6 months occurred more frequently in the LOC group than in the LM group. In the sub-analysis of the LOC group, a significant decline of AMH at postoperative 2 months and 6 months was highly correlated with bilateral ovarian tumors (P=0.001).

Conclusion

Compared to LM, serum AMH level showed a minimal decrease after 1 week following LOC, which did not revert to normal over 6 months of follow-up. In addition, a significant decline of ovarian reserve at postoperative 6 months was significantly more frequent in the LOC group, suggesting that LOC may have more adverse effects on ovarian reserve compared to the LM (control) group. Thus, care is required during the LOC procedure, specifically in women with bilateral tumors.

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.

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Correlation of Serum Anti-Mullerian Hormone (AMH) Level on Ovarian Volume in Women with Endometrioma

Background

The correlation between endometrioma and serum Anti-mullerian hormone (AMH) level is a benchmark in determining the prognosis and management of endometrioma. Endometrioma causes a decrease in ovarian reserve due to tissue damage that affects the formation of serum AMH. Serum AMH levels in daily practice are useful as a tool to determine ovarian reserve, markers for diagnosis and prognosis in infertility and reproductive abnormalities. The purpose of this study was to determine the relationship of serum AMH level in women with endometrioma and their correlation to ovarian volume.

Methods

This research was an analytical observational study with a cross-sectional design in women of reproductive age who were diagnosed with endometrioma within the period of August 2019–March 2020 at Hasan Sadikin Hospital, Bandung. Forty-four women who met the inclusion and exclusion criteria were then divided into endometrioma (n=22) and control (n=22) groups. In both groups, transvaginal ultrasound examination was performed to measure the volume of the ovary, then a laboratory examination of serum AMH level was carried out.

Results

Serum AMH levels in the endometrioma group were significantly lower than those in the control group (P<0.001). Serum AMH level did not differ significantly based on laterality of the observation group (P=1.000). There was a negative correlation between serum AMH level and the volume of ovarian endometrioma, although not statistically significant (r=−0.332; P=0.066).

Conclusion

There was a correlation between serum AMH level and endometrioma. Serum AMH levels were significantly lower in the endometrioma group but were not influenced by their laterality. We found a negative correlation between serum AMH level and ovarian volume containing endometrioma, but not statistically significant.

Ovarian Endometrioma Negatively Impacts Oocyte Quality and Quantity But Not Pregnancy Outcomes in Women Undergoing IVF/ICSI Treatment: A Retrospective Cohort Study

PURPOSE

To determine the impact of ovarian endometrioma per se on in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) outcomes.

METHODS

This retrospective study was conducted using two groups. The endometrioma group consisted of 862 women with infertility who had ovarian endometriomas and underwent their first ovarian stimulation for IVF/ICSI treatment between January 2011 to December 2019 at a public university hospital. A non-endometrioma comparison group, comprising 862 women with other infertility factors, was matched according to maternal age, body mass index (BMI), and infertility duration. Ovarian reserve and response and IVF/ICSI and pregnancy outcomes between the two groups were analyzed. Multivariate logistic regression (MLR) analysis was conducted on the basis of clinical covariates assessed for their association with live birth.

RESULTS

The results showed that significantly lower antral follicle count (AFC), anti-Müllerian hormone (AMH), ovarian sensitivity index (OSI), oocyte maturation and fertilization rates, blastocyst rate, number of oocytes retrieved, and available embryos were found in women with endometrioma compared with the control, respectively (P < 0.05). The cumulative live birth rate per patient in women with endometrioma was lower than that of women without endometrioma (39.32% vs. 46.87%, P = 0.002). In women with endometrioma, those who underwent surgical intervention prior to IVF/ICSI treatment had higher maturation (86.03% vs. 83.42%, P = 0.003), fertilization (78.16% vs. 74.93%, P = 0.004), and top-quality embryo rates (42.94% vs. 39.93%, P = 0.097) but had fewer oocytes retrieved (8.01 ± 5.70 vs. 9.12 ± 6.69, P = 0.013) than women without surgery. However, live birth rates were comparable between women with endometrioma and women in the control group, regardless of whether they had a prior history of ovarian surgery. MLR analysis showed no correlation between endometrioma per se and live birth after being adjusted for number of top-quality embryos transferred and stage of embryo transfer.

CONCLUSIONS

The data from this study supported the conclusion that ovarian endometrioma negatively impacts oocyte quality and quantity, but not overall pregnancy outcomes, in women undergoing IVF/ICSI treatment. Endometrioma lowers the cumulative live birth rate by decreasing the number of embryos. Surgical excision of endometrioma prior to IVF/ICSI can partly improve oocyte maturation and fertilization rates but not pregnancy outcomes.

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.

Analysis of factors associated with ovarian reserve in a group of poor responders to in vitro fertilization: A cross-sectional study

Background

Poor ovarian reserve and a high rate of pregnancy failure associated with low quality and quantity of oocytes are observed in poor responders to in vitro fertilization.

Objective

To assess the effect of age, body mass index (BMI), endometriosis, and history of ovarian surgery on ovarian reserve in a group of poor responders.

Materials and Methods

In this cross-sectional study 749 women who referred to Yasmin Clinic of Dr. Cipto Mangunkusumo National General Hospital from January 2013 to June 2017 were enrolled. Two definitions of poor responders and Poseidon criteria and consecutive sampling techniques were used. Participants were divided into good and poor responder groups based on the ovarian reserve test; participant with oocyte ≤ 3 was classified as a poor responder. Based on this, 188 participants with nine (4-47) oocytes were included in the poor responder group. While, good responder comprised of two (0-3) oocytes.

Results

Age and anti-Mullerian hormone level (AMH) were significantly associated with ovarian reserve in the poor-responder group (p < 0.001). However, in multivariate analyses, age was the only significant predictor of ovarian response in the poor-responder group (p = 0.004). While endometriosis was the significant predictor of Poseidon groups 1 and 4, surgical history was the significant predictor of Poseidon groups 2 and 3. Meanwhile, an increase in BMI decreased the risk of classification under Poseidon group 3.

Conclusion

Age, AMH, BMI, endometriosis, and history of ovarian surgery affected the risk of classification of the Poseidon group.

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.

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

OBJECTIVE

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

DATA SOURCES

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

TABULATION, INTEGRATION, AND RESULTS

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

CONCLUSION

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

Frozen blastocyst transfer improves the chance of live birth in women with endometrioma

Purpose: The existing literature is scarce regarding outcomes of fresh vs frozen embryo blastocyst transfers in women with endometrioma. The goal of the study was to compare outcomes between fresh and frozen blastocyst transfers (fresh-BT vs. frozen-BT) in endometrioma-affected women. Materials and methods: This study included 315 endometrioma-affected women aged between 20 and 39 years who underwent blastocyst transfer. Primary outcome was live birth rate (an alive birth after 24 completed weeks gestation). Results: The study groups did not differ in terms of patient characteristics and treatment variables. The live birth rate was 40.7% in fresh-BT group and 56.1% in frozen-BT group (OR:1.86, 95% CI:1.18-2.92 p = .007). The approach of frozen embryo transfer was an independent factor of live birth (adjusted OR:1.83, 95% CI:1.16-2.90, p = .009). Conclusion: The approach of frozen blastocyst transfer increases the chance of live birth in endometrioma-affected patients compared with fresh blastocyst transfer. Thus, a frozen embryo transfer may be the choice of strategy in these patients.

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.

Antral follicle count is reduced in the presence of endometriosis: a systematic review and meta-analysis

Studies suggest that the presence of endometriosis may lead to impaired ovarian reserve, while results evaluating the changes in antral follicle count (AFC) in endometriosis remain controversial. A systematic search returned 15 studies, of which nine compared AFC between patients with and without endometriosis, five articles reported differences in AFC between affected and unaffected ovaries in patients with unilateral ovarian endometriosis and one reported both of the above two situations. Overall results showed a significant decrease in AFC and anti-Müllerian hormone (AMH) and increase in serum FSH concentrations in patients with endometriosis when compared with controls. Additionally, the AFC for the ovary with the endometrioma was also significantly lower than that of the contralateral ovary in patients with unilateral ovarian endometriosis. Moreover, it appears that the AFC in patients with endometriosis where the ovaries are not affected or in early stage were not significantly different in the control group. These findings demonstrate that endometriosis is associated with reduced AFC and AMH and elevated serum concentrations of FSH, suggesting a reduction in ovarian reserve in patients with endometriosis, especially in those with ovarian endometrioma and advanced stage.

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

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

Practical Recommendations for the Management of Benign Adnexal Masses

OBJECTIVE

 To perform a comprehensive review to provide practical recommendations regarding the diagnosis and treatment of benign adnexal masses, as well as information for appropriate consent, regarding possible loss of the ovarian reserve.

METHODS

 A comprehensive review of the literature was performed to identify the most relevant data about this subject.

RESULTS

 In total, 48 studies addressed the necessary aspects of the review, and we described their epidemiology, diagnoses, treatment options with detailed techniques, and perspectives regarding future fertility.

CONCLUSIONS

 Adnexal masses are extremely common. The application of diagnosis algorithms is mandatory to exclude malignancy. A great number of cases can be managed with surveillance. Surgery, when necessary, should be performed with adequate techniques. However, even in the hands of experienced surgeons, there is a significant decrease in ovarian reserves, especially in cases of endometriomas. There is an evident necessity of studies that focus on the long-term impact on fertility.

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.

Management of endometriosis-related infertility: Considerations and treatment options

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.

Pelvic endometriosis: Refer to the surgeon at the right moment: Pelvic endometriosis: When refer to the surgeon?

BACKGROUND

As endometriosis is not a single condition but different morphological types, it is easy to conceive that its management allow for a diversity of approaches. The objective of this literature review is about a simplified pathway through care for patients with endometriosis, and to target the right time for surgical treatment.

METHODS

Through a literature and references review, the different surgical care arrangements according to attainment, to symptoms and to the patients demands and expectations are reviewed.

RESULTS

An existing literature and recommendations synthesis has been done, and it was found that an optimum medical or surgical care rely on a multidisciplinary approach. Asymptomatic patients should not have surgery, and the medical treatment precede surgical treatment in numerous indications. In case of a surgical need, the right moment is determined by the recommendations, as noted in this article. Different aspects are necessary, the symptomatology, the intend to be pregnant and the recurrence of lesions in particular, but also the use of medically assisted reproduction or not.

CONCLUSION

In order to optimize the surgical treatment of patients with endometriosis, it is advisable to not refer these patients to the surgeon not too soon and not too late, furthermore if he's an expert. In all cases the treatment is multidisciplinary, and the most difficult cases are referred to multidisciplinary consultative reunion. The surgical treatment relies on "centre of expertise's" existence for some specific forms of deep endometriosis. The surgical treatment is a question of both pathology and timing.

BRIEF SUMMARY

In order to optimize the surgical treatment of endometriosis, it is advisable to refer patients to the surgeon at the right moment.