Pregnancy Rate after Controlled Ovarian Hyperstimulation and Intrauterine Insemination for the Treatment of Endometriosis following Surgery

Impact of endometriosis on female fertility and the management options for endometriosis-related infertility in reproductive age women: a scoping review with recent evidences

Background

Endometriosis is a chronic inflammatory condition with varied presentation, which ultimately leads to chronic pelvic pain and infertility. It is a psychological and economic burden to the women and their families.

Main body of abstract

The literature search was performed on the following databases: MEDLINE, Google Scholar, Scopus, EMBASE, Global health, the COCHRANE library, and Web of Science. We searched the entirety of those databases for studies published until July 2020 and in English language. The literature search was conducted using the combination of the Medical Subject heading (MeSH) and any relevant keywords for “endometriosis related infertility and management” in different orders. The modalities of treatment of infertility in these patients are heterogeneous and inconclusive among the infertility experts. In this article, we tried to review the literature and look for the evidences for management of infertility caused by endometriosis. In stage I/II endometriosis, laparoscopic ablation leads to improvement in LBR. In stage III/IV, operative laparoscopy better than expectant management, to increase spontaneous pregnancy rates. Repeat surgery in stage III/IV rarely increases fecundability as it will decrease the ovarian reserve, and IVF will be better in these patients. The beneficial impact of GnRH agonist down-regulation in ART is undisputed. Dienogest is an upcoming and new alternative to GnRH agonist, with a better side effect profile. IVF + ICSI may be beneficial as compared to IVF alone. Younger patients planned for surgery due to pain or any other reason should be given the option of fertility preservation.

Short conclusion

In women with endometriosis-related infertility, clinician should individualize management, with patient-centred, multi-modal, and interdisciplinary integrated approach.

Ovulation induction with clomiphene citrate or letrozole following laparoscopy in infertile women with minimal to mild endometriosis: a prospective randomised controlled trial

We conducted a prospective randomised controlled trial to explore the efficacy of clomiphene citrate (CC) and Letrozole (LTZ) for improving fecundity in infertile women with minimal to mild endometriosis after operative laparoscopy. We found that the ovulation rate of LTZ (88.7%) and CC (84.5%) were significantly higher than that of Control (70.5%) (p < .001). However, there was no significant difference in cumulative clinical pregnancy rates at 3, 6, 12 months after laparoscopy among the three groups (LTZ: 30%, 34.3%, 38.6% vs CC: 28.6%, 42.9%, 50.0% vs Control: 18.6%, 24.3%, 31.4%, respectively). No significant difference was observed in live-birth rate among the three groups (p = 1.125). For infertile women with minimal to mild endometriosis, ovulation induction with letrozole or clomiphene citrate after laparoscopy significantly increases ovulation rate, which are comparable between them; but does not demonstrate a significant advantage on improving pregnancy rate and live-birth rate when compared to laparoscopy alone.Impact statementWhat is already known on this subject? Endometriosis significantly decreases fecundity of women. Operative laparoscopy was recommended as an effective option to increase spontaneous pregnancy rate in infertile women with minimal to mild endometriosis. However, there is still no optimum treatment strategy for improving fertility of women with endometriosis.What do the results of this study add? For infertile women with minimal to mild endometriosis, ovulation induction with letrozole or clomiphene citrate after laparoscopy significantly increases ovulation rate, which are comparable between them; but does not demonstrate a significant advantage on improving pregnancy rate and live-birth rate when compared to laparoscopy alone.What are the implications of these findings for clinical practice and/or further research? Our results suggest that operative laparoscopy in conjunction with ovulation induction may improve fertility of women with minimal to mild endometriosis. Further research could focus on prolonging cycles of ovulation induction or choosing alternative ovarian stimulation protocols. More RCTs are still needed to compare the efficacy of letrozole with CC in ovulation induction.

Impact of surgery for endometriomas on pregnancy outcomes following in vitro fertilization-intracytoplasmic sperm injection. Who should be the preferred laparoscopists: gynecologists or reproductive surgeons?

OBJECTIVE

To investigate whether laparoscopic excision of ovarian endometriomas pretreated with operation by gynecologists or reproductive surgeons exerts different effects on in vitro fertilization-intracytoplasmic sperm injection results.

MATERIALS AND METHODS

Retrospective case control study. Relevant information was collected from the electronic records of women who underwent IVF/ICSI from 01/01/2013 to 30/12/2015 in our unit. The study group consisted of 35 women who previously had laparoscopic endometrioma excision by reproductive surgeons in our unit; the control group included 36 patients who underwent surgery for endometriomas by gynecologists in our hospital.

RESULT(S)

There were slightly higher numbers of AFC and higher pregnancy rate in the study group, although differences did not reach statistical significance. For patients over 35 years old, there were more oocyte retrieved, mature oocytes and two pronucei (2PN) in the study group than the control group although observed differences did not reach statistical significance.

CONCLUSION(S)

Electrocautery is more deleterious on ovarian reserve than hemostatic suture. In procedure of patients who wish to conceive, surgeons should use hemostatic suturing technique preferentially.

Post-laparoscopy predictive factors of achieving pregnancy in patients treated for infertility

Introduction

Laparoscopy is a long-established diagnostic and therapeutic method for treating women suffering from infertility. The application of this method of treatment can help achieve pregnancy only if there is correct classification of patients and evaluation of their partner’s reproductive capacity. The main predictors of achieving pregnancy in a couple treated for infertility are the woman’s age, her ovarian reserve, tubal patency, the presence of endometriosis and quality of sperm parameters.

Aim

To evaluate the effect of endometriosis, ovarian reserve and selected parameters of semen on the effect of achieving pregnancy in patients undergoing laparoscopy.

Material and methods

The most significant predictor of pregnancy in patients undergoing laparoscopy due to infertility was found to be anti-Mullerian hormone (AMH) level after laparoscopy, and the main parameters of semen partners were density, motility and morphology. The number of achieved pregnancies after the laparoscopic treatment of infertility was lower in patients diagnosed with endometriosis, and depended on the severity of the condition.

Results

As a result of laparoscopic treatment of endometriosis, we found a decrease in ovarian reserve measured by means of AMH.

Conclusions

The most important predictors of pregnancy in patients who underwent laparoscopy due to infertility are post-laparoscopy AMH levels and the main parameters of the partner’s semen: density, motility and morphology. The number of pregnancies after laparoscopic treatment is lower in patients diagnosed with endometriosis, and depends on the severity of the conditio.