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.

Endometriosis-associated infertility: From pathophysiology to tailored treatment

Despite the clinically recognized association between endometriosis and infertility, the mechanisms implicated in endometriosis-associated infertility are not fully understood. Endometriosis is a multifactorial and systemic disease that has pleiotropic direct and indirect effects on reproduction. A complex interaction between endometriosis subtype, pain, inflammation, altered pelvic anatomy, adhesions, disrupted ovarian reserve/function, and compromised endometrial receptivity as well as systemic effects of the disease define endometriosis-associated infertility. The population of infertile women with endometriosis is heterogeneous, and diverse patients' phenotypes can be observed in the clinical setting, thus making difficult to establish a precise diagnosis and a single mechanism of endometriosis related infertility. Moreover, clinical management of infertility associated with endometriosis can be challenging due to this heterogeneity. Innovative non-invasive diagnostic tools are on the horizon that may allow us to target the specific dysfunctional alteration in the reproduction process. Currently the treatment should be individualized according to the clinical situation and to the suspected level of impairment. Here we review the etiology of endometriosis related infertility as well as current treatment options, including the roles of surgery and assisted reproductive technologies.

Reproductive outcomes after laparoscopic surgery in infertile women affected by ovarian endometriomas, with or without in vitro fertilisation: results from the SAFE (surgery and ART for endometriomas) trial

We performed a retrospective cohort study, namely "Surgery and ART for Endometriomas" (SAFE) trial (Clinical Trial ID: NCT03717870), including women who underwent laparoscopic cystectomy for endometrioma before first IVF and compared their reproductive outcomes with the ones of women without endometriosis and with unexplained infertility, tubal factor or male factor infertility. We found that women who underwent previous laparoscopic cystectomy for endometrioma had higher FSH and LH levels between the 2nd and 5th day of the cycle before IVF, required higher doses of gonadotrophins for ovarian stimulation and had a lower number of retrieved oocytes compared with other types of infertility. Nevertheless, pregnancy and delivery rates remain comparable to other causes of infertility. In addition, differences in ovarian stimulation parameters between endometriosis and other types of infertility lost significance with the increase of women's age. These pieces of information can be considered useful to make adequate counselling about reproductive outcomes for infertile women with ovarian endometriomas and allow a proper decision-making approach shared with the patient.IMPACT STATEMENTWhat is already known on this subject? Although endometriomas are common findings in infertile women, whether they should be surgically removed before an in vitro fertilisation (IVF) is a long-lasting debate, and current evidence does not offer a robust background to draw firm recommendations.What do the results of this study add? Women who underwent previous laparoscopic cystectomy for endometrioma need higher doses of gonadotrophins for ovarian stimulation and have a lower number of retrieved oocytes, compared with other types of infertility. Pregnancy and delivery rates remain comparable to other causes of infertility.What are the implications of these findings for clinical practice and/or further research? These pieces of information can help to make adequate counselling about reproductive outcomes for infertile women with ovarian endometriomas and allow a proper decision-making approach shared with the patient.

Approaching ovarian endometrioma with medical therapy

Endometriosis is a chronic inflammatory gynecological disorder associated with pelvic pain symptoms and infertility. Ovarian cysts (endometriomas) are the most common localization of endometriosis in the pelvis. Considering non-invasive methods, transvaginal ultrasound has high sensitivity and specificity for endometrioma diagnosis. Laparoscopic removal of endometrioma is related to a damage to the ovarian reserve and should be limited to patients with suspicious cysts or unresponsive to medical treatment. The main goal of medical therapy of symptomatic endometrioma is the control of pain symptoms, while no benefits have been demonstrated in terms of improving fertility rates of women seeking pregnancy. The aim of medical treatment is the inhibition of ovulation, stop of menstruation and achievement of a stable hypo-hormonal milieu. Estroprogestins and progestins are indicated by guidelines as first line medications for symptomatic patients. Several hormonal treatments have been proposed for the treatment of symptomatic endometriomas. In particular, dienogest, a relatively new progestin, has shown promising results. Medical treatment should be conceived as a long-term treatment. Safety, tolerability, a low percentage of side effects and an easy route of administration are essential for patient acceptance and adherence to therapy.

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.

The impact of endometrioma size on ovarian responsiveness

RESEARCH QUESTION

Available evidence shows that the presence of ovarian endometriomas does not interfere with the ovarian response to ovarian stimulation. However, the mean size of the endometriomas in these studies is generally small, and two recent investigations suggested that follicular development could be impaired when focusing on larger endometriomas. However, these studies could not identify a clear threshold above which endometriomas could become detrimental.

DESIGN

To identify this threshold, the study retrospectively selected women without a history of surgery for ovarian cysts who underwent IVF in the presence of unilateral endometriomas with a mean diameter between 20 and 49 mm. Selected women were divided into three categories of endometrioma size: 20-29 mm (group 1, n = 23), 30-39 mm (group 2, n = 2323), and 40-49 mm (group 3, n = 2321). Recruitment for each category was censored at about 21 women to ensure equal statistical power for each group.

RESULTS

The response to ovarian stimulation was equal or superior in the affected gonads in eight women (35%, 95% confidence interval [CI] 16-57%), seven women (30%, 95% CI 13-53%) and two women (10%, 95% CI 2-30%) in groups 1, 2 and 3, respectively. The median (interquartile range) number of developed follicles in the affected and intact ovaries was 6 (3-7) and 5 (4-9) in group 1 (P = 0.21), 4 (1-6) and 4 (3-7) in group 2 (P = 0.08), 5 (3-7), and 7 (4-8) in group 3 (P = 0.01), respectively.

CONCLUSIONS

The threshold to be used to distinguish between endometriomas that might and might not interfere with ovarian response is 4 cm in diameter.

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.

The Role of Fertility Preservation in Women with Endometriosis: A Systematic Review

OBJECTIVE

To summarize the available evidence concerning fertility preservation techniques in the context of women with endometriosis.

DATA SOURCES

We searched for studies published between 1984 and 2019 on endometriosis and Assisted Reproductive Technology outcomes. We searched MEDLINE and PubMed and performed a manual search of reference lists within identified studies.

METHODS OF STUDY SELECTION

A total of 426 articles were identified, and 7 studies were eligible to be included for the systematic review. We included all published studies, excluding reviews, case reports, and animal studies.

TABULATION, INTEGRATION, AND RESULTS

Despite a significant increase in the number of studies addressing fertility preservation over the study period, we found a relative lack of evidence addressing the use of fertility preservation techniques in women with endometriosis. The studies identified included 2 case reports, 1 histological science study, and 4 retrospective cohort studies.

CONCLUSION

Women with endometriosis may benefit from fertility preservation techniques. However, there currently is a paucity of data in this population, especially when compared with other indications for fertility preservation. Although much knowledge can be translated from the oncofertility discipline, we have identified and discussed endometriosis-related changes to ovarian reserve and oocyte health that justify further well-designed research to confirm that fertility preservation outcomes are similar for women with endometriosis.

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.

Which is worse? Comparison of ART outcome between women with primary or recurrent endometriomas

STUDY QUESTİON

Are live birth rates (LBR) different after ART cycles between women with primary or recurrent endometrioma?

SUMMARY ANSWER

Women with recurrent endometrioma have similar LBR as compared to patients with primary endometrioma.

WHAT IS ALREADY KNOWN

Recurrence rate can be as high as 29% after endometrioma excision. Prior studies on management of endometrioma before ART involve primary endometriomas. There is limited information regarding the prognosis of women with recurrent endometriomas.

STUDY DESIGN, SIZE, DURATION

A multicenter retrospective cohort study, including 76 women with primary and 82 women with recurrent endometriomas treated at the participating centers over a 6-year period.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Women with endometrioma who underwent ART at three academic ART centers. Couples with another indication for ART were excluded.

MAIN RESULTS AND THE ROLE OF CHANCE

Female age, median number of prior failed ART cycles, proportion of patients with bilateral endometrioma (28 versus 28.9%), ovarian stimulation protocols, and total gonadotropin consumption were similar between the study groups. Numbers of metaphase two oocytes (5 versus 6), number of embryos transferred, and the proportion of patients undergoing blastocyst transfer were similar across the study groups. Clinical pregnancy rates (36.6 versus 34.2%, absolute difference 2.4%, 95% CI: -12.5 to 17.3%, P = 0.83) and LBR (35.4 versus 30.3%, absolute difference 5.1%, 95% CI: -9.5 to 19.7%, P = 0.51) per started cycle in recurrent and primary endometrioma were similar. Comparable success rates were also confirmed with logistic regression analysis (OR: 1.14, 95% CI: 0.78-0.57, P = 2.3).

LIMITATIONS, REASONS FOR CAUTION

The retrospective design has inherent limitations. Some women with severely decreased ovarian reserve after primary endometrioma excision may not have pursued further treatment.

WIDER IMPLICATIONS OF THE FINDINGS

The management of endometrioma prior to ART is controversial but a different management strategy is not required for recurrent endometriomas. Since recurrent endometriomas do not have a worse impact on ART outcome than primary endometriomas, and repeat surgery has a higher risk for complications, conservative management without surgery can be justified.

STUDY FUNDING/COMPETING INTEREST(S)

No funding or competing interests to declare.

TRIAL REGISTRATION NUMBER

None.

Detrimental effects of endometriosis on oocyte morphology in intracytoplasmic sperm injection cycles: a retrospective cohort study

While an association can be addressed among endometriosis and subfertility, the causal relationship has not been elucidated yet. Impaired oocyte quality in endometriosis patients has been accused for the unsuccessful outcomes of assisted reproductive techniques. There are limited studies in literature evaluated association between endometriosis and oocyte morphology. We conducted this retrospective study to evaluate whether morphological abnormalities of oocytes are more common in women with endometriosis than women with diagnosis of male factor infertility as a source of healthy oocytes. Totally 1568 oocytes, 775 (49.4%) in endometriosis groups and 793 (50.6%) in control group were evaluated for morphological parameters before ICSI cycles. Abnormal oocyte morphology was detected in 352 (22.4%) of 1568 oocytes. Of the abnormal oocytes, 208 (59.1%) were in endometriosis group and 144 (40.9%) in control group (p < .001). The following dysmorphisms were significantly higher in oocytes retrieved from endometriosis group: dark cytoplasm; dark, large or thin zona pellucida; and flat or fragmented polar body (p <  .05 for all). When morphological parameters for oocytes of endometriosis patients evaluated, the oocyte defects has increased significantly in endometriosis patients. These findings are thought to be useful to clarify the subfertility in endometriosis patient, which needs to be confirmed with further studies.

Weigh the pros and cons to ovarian reserve before stripping ovarian endometriomas prior to IVF/ICSI: A meta-analysis

PURPOSE

To explore the effects of conservative surgery for endometriomas on ovarian responsiveness during assisted reproductive technology (ART) and provide reproductive and gynecological doctors with a more reliable reference program for the treatment of endometriomas.

METHODS

A literature search was performed by searching the PubMed, Embase, Cochrane Library, Web of Science and Science Direct databases. Studies with inter- and intra-patient comparisons of ovarian responses and oocyte quality between operated and unoperated ovaries and that met the inclusion criteria were retrieved, and the data from the outcome measures were extracted and pooled for this meta-analysis.

RESULTS

Twenty-one published studies (2649 ART cycles) were included. The total amount of gonadotropin (Gn) used (inverse variance (IV):0.48; 95% confidence interval (CI): [0.13, 1.82], P = 0.0007) was significantly increased in the women with endometriomas who had a history of cystectomy. The estrogen (E) level on the day of hCG administration (IV: -0.29; 95% CI: [-0.41, -0.17], P<0.00001), the number of mature or dominant follicles (IV: -1.17; 95% CI: [-1.51, -0.82], P<0.00001) and the total number of oocytes retrieved (IV: -1.78; 95% CI: [-2.38, -1.17], P<0.00001) were significantly decreased in the women with endometriomas who had a history of cystectomy. The duration of stimulation (IV: 0.02; 95% CI: [-0.09, 0.13], P = 0.77), the total number of formed embryos (IV: -0.06; 95% CI: [-0.17, 0.04], P = 0.25), the pregnancy rate(IV:0.98;95%CI[0.82,1.18], P = 0.83) and the live birth rate(IV:0.93;95%CI[0.70,1.23], P = 0.61)were not statistically different between the two groups. Similar intra-patient results were found in the number of mature or dominant follicles (IV: -0.88; 95% CI: [-1.25, -0.52], P<0.00001) and the total number of oocytes retrieved (IV: -3.48; 95% CI: [-4.77, -2.19], P<0.00001).

CONCLUSION

ART might be a better therapeutic method for ovarian endometrioma-related infertility than cystectomy.

[Conservative management of endometrioma in women undergoing in vitro fertilization]

Endometriosis is a chronic disease. The pathogenesis is actually still unclear. Endometriosis is responsible for infertility and/or pelvic pain. One of the most important features of the disease is the heterogeneity (clinical and anatomical). Among the different phenotypes of endometriosis, the ovarian endometrioma seems to most important lesion in the management of endometriosis-related infertility. Surgical treatment is associated to a decrease of the ovarian reserve and a potential detrimental effect on in vitro fecondation (IVF) outcomes. Thus, the choice between conservative or surgical management of endometrioma before IVF is actually debated. The advantages and drawback of surgical and conservative management should be discussed before to plan the treatment. In the present review, we aimed at assessing the risks of a conservative management of endometrioma as compared to surgery before IVF.

Effects of Supplementation of Human Endometriotic Fluids on In Vitro Mouse Preantral Follicle Culture

This study aimed to investigate the potential detrimental effect of human endometriotic fluids (EFs) on in vitro growth of mouse preantral follicles. Preantral follicles (isolated from ovaries of 7- to 8-week-old mice) were cultured in growth medium for 10 days and then in maturation medium for 2 days. During in vitro culture, EF supernatants (0%, 2.5%, 5%, and 10%) were supplemented. Meiotic spindle integrity of metaphase II (MII) oocytes was analyzed. Hormone (17β-estradiol and anti-Müllerian hormone [AMH]) levels in the final spent media were measured by enzyme-linked immunosorbent assay. The survival rates of follicles at day 10 were significantly lower in 3 EF-supplemented groups (56.1%, 30.6%, and 6.2%; 83.6% in the nonsupplemented group). The production of total oocytes per initiated follicle was also significantly lower in the 3 EF-supplemented groups (34.7%, 18.4%, and 4.1%; 68.1% in the nonsupplemented group). Proportions of the oocyte with normal spindles were significantly lower in the 3 EF-supplemented groups (10%, 0% and 0%; 52% in the nonsupplemented group). In the final spent media, the level of 17β-estradiol was significantly lower only in the 10% EF-supplemented group, and the level of AMH was significantly lower in all 3 EF-supplemented groups, when compared with the nonsupplemented group. During in vitro culture of mouse preantral follicles, the survival rate, oocyte acquisition, spindle integrity of MII oocytes, and AMH production were greatly affected by EF supplementation. These findings suggest a possibility of detrimental effects of endometriotic cysts on folliculogenesis in adjacent ovarian tissues.

Value of in situ ovarian volume measured during cesarean delivery to assess the potential of diminished ovarian reserve

OBJECTIVE

We aimed to determine the value of mean ovarian volume (OV) determined by three-dimensional in situ measurement of ovaries during cesarean delivery (CD) to assess the potential of diminished ovarian reserve (DOR) evaluated by hormonal and ultrasonographic parameters 3 months after the cesarean delivery.

METHODS

Each ovary was measured underwent CD in three dimensions, and three months after CD, the mean OV, serum AMH, FSH, LH, and estradiol levels, and antral follicle count (AFC) values were recorded as well as other demographic and obstetric parameters.

RESULTS

After categorizing the study subjects as having a potential of DOR by the criteria of serum AMH <1 pg/mL and AFC value ≤6, in patients with a potential of DOR, the mean intra-operative and post-operative OVs were significantly decreased (p < 0.05). Considering the correlation coefficients obtained by the correlations of post-operative AMH level and AFC value with the mean intra-operative and post-operative OV values, the mean intra-operative OV provided significantly higher correlation coefficients (p < 0.05).

CONCLUSIONS

These findings, overall, support the diagnostic value of mean OV determined by the in situ measurement of three dimensions of left and right ovaries during cesarean delivery for the screening of potential for the DOR.

The Presence of Endometrioma Does Not Impair Time-Lapse Morphokinetic Parameters and Quality of Embryos: A Study On Sibling Oocytes

OBJECTIVE

To see whether the oocytes retrieved from an ovary with an endometrioma would develop into embryos with aberrant timings of cleavage as assessed using time-lapse monitoring (TLM) and poorer morphologic quality compared with sibling oocytes from the contralateral ovary with no endometrioma in the same patient after intracytoplasmic sperm injection.

METHODS

This was an observational prospective study at an in vitro fertilization (IVF) center of a private hospital. It included analysis and comparison of 128 embryos (69 embryos developed from the ovary with endometrioma and 59 embryos from the contralateral ovary without endometrioma serving as controls from a total of 20 women with infertility). Morphology of the embryo was assessed twice (days 3 and 5), again by capturing images with the TLM system. Morphokinetic parameters of embryos and clinical pregnancy rates were recorded separately from ovaries with and without endometrioma and were the primary outcomes of the study. Secondary outcomes included number of retrieved oocytes, number of metaphase II (MII) oocytes, fertilization rates, and conventional morphological classification of embryos.

RESULTS

There were no differences in terms of the following time-lapse morphokinetic parameters of embryos. The mean numbers of oocytes and MII oocytes collected from the ovary with the endometrioma were similar to those collected from the contralateral ovary without endometrioma. Fertilization rates and the percentage of embryos with top morphologic quality were also similar.

CONCLUSIONS

According to the morphokinetic parameters, this study further strengthens the notion that removal of endometriomas before IVF is not a necessity in terms of better oocyte quality and development.

Impact of endometriomas and their removal on ovarian reserve

PURPOSE OF REVIEW

The effect of endometrioma on ovulatory function and ovarian reserve was unclear. Conflicting opinions exist regarding effect of endometrioma excision on ovarian reserve.

RECENT FINDINGS

Endometriomas do not seem to affect ovulatory function. Women with endometrioma have lower antral follicle count and serum anti-Müllerian hormone levels than age-matched healthy controls. There is high-quality evidence suggesting a significant decline in serum anti-Müllerian hormone levels following endometrioma excision. However, a similarly significant decline in antral follicle count is not demonstrated. Cauterization seems to be a contributing factor to ovarian damage and suturing the cyst bed could perhaps be a better alternative.

SUMMARY

It seems prudent to warn patients regarding loss of ovarian reserve following endometrioma excision. Surgeons should cautiously limit the use of cauterization following stripping of endometrioma. Well designed studies comparing effect of various haemostatic measures on ovarian reserve are needed.

In vitro fertilization for endometriosis-associated infertility

Endometriosis is an enigmatic disease affecting 10-15% of reproductive aged women and is encountered in 25-35% of women suffering from infertility. IVF is an effective tool to overcome endometriosis-associated infertility when expectant management or surgery fails. Direct IVF should be envisioned if the female age is greater than 38 year and infertility is long lasting. Likewise, semen characteristics or tubal status that is incompatible with natural conception mandates going straight to IVF. IVF, not only bypasses the distortion of pelvic anatomy associated with advanced stage endometriosis, but also removes gametes from a hostile peritoneal environment. In this article, we address the impact, if any, of endometriosis and endometriomason IVF outcome, whether surgical treatment of early-stage disease, endometriomas or deep infiltrating endometriosis would enhance pregnancy rates in IVF, which protocol to employ for controlled ovarian hyperstimulation for IVF and finally the impact, if any, of controlled ovarian hyperstimulation for IVF on progression of endometriosis.

Fertility preservation in women with endometriosis: for all, for some, for none?

The increasing confidence with the techniques of oocyte and ovarian cortex freezing has prompted their potential use for patient categories other than those at risk of early menopause due to cancer treatments. Women affected by every iatrogenic or pathologic condition known to compromise ovarian function severely have been considered as potential candidates for fertility preservation. Among them, women with endometriosis may represent a particularly suitable group since they are at increased risk of premature ovarian exhaustion and about half of them will experience infertility. Based on the currently available notions on the intricate relationships between endometriosis, infertility and damage to the ovarian reserve, we speculate that fertility preservation may be of interest for women with endometriosis, in particular for those with bilateral unoperated endometriomas and for those who previously had excision of unilateral endometriomas and require surgery for a contralateral recurrence. Young age at diagnosis may be an independent but pivotal additional factor to be taken into consideration in the balance of the pros and cons of fertility preservation. On the other hand, we argue against the introduction of fertility preservation for endometriosis in routine clinical practice. To date, only few cases have been reported and there are insufficient data for robust cost-utility analyses. It is noteworthy that endometriosis is a relatively common disease and systematically including affected women in a fertility preservation program would have profound clinical, logistic and financial effects. More clinical data and in-depth economic analysis are imperative prior to recommending its routine use.

Impact of ovarian endometrioma on ovarian responsiveness and IVF: a systematic review and meta-analysis

In this systematic review and meta-analysis, the effect of ovarian endometrioma on ovarian responsiveness to stimulation and on assisted reproduction outcomes was evaluated. Nine published studies (1039 cases) were included. The number of oocytes retrieved (mean difference [MD] -1.50; 95% CI, -2.84 to -0.15, P = 0.03), metaphase II (MII) oocytes retrieved (MD -3.61; 95% CI -4.44 to -2.78, P < 0.00001) and total embryos formed (MD -0.66; 95% CI -1.13 to -0.18, P = 0.007) were significantly lower in women with ovarian endometrioma than the control group. Gonadotrophin dose, duration of stimulation, number of good-quality embryos, implantation rate, clinical pregnancy rate and live birth rate were similar. Comparisons between ovaries with endometriomas and healthy ovaries of the same individuals were also made. Number of oocytes retrieved, MII oocytes retrieved and total embryos formed were not statistically significantly different between the affected ovaries and contralateral normal ovaries. Observational studies showed that ovarian endometrioma was associated with fewer oocytes retrieved, fewer MII oocytes retrieved and fewer total formed embryos. Clinical pregnancy rate and live birth rates were not affected. Intra-patient comparisons in women with unilateral endometrioma suggested the number of oocytes retrieved, MII oocytes retrieved and total embryos formed were similar.

Lateralization of ovarian follicles

BACKGROUND/AIM

To evaluate a possible lateralization of antral follicle count (AFC) based on the finding that endometriosis, if present, is more commonly found in the left hemipelvis.

METHODS

We evaluated the records of 6,617 baseline ultrasounds conducted at our Reproductive Center between 2007 and 2011 in a university teaching hospital setting. We included all ultrasounds with an AFC of 1 or greater and excluded those with incomplete documentation or with ovarian cyst, including endometriotic cysts (n = 909). The main outcome measure was the comparison of the number of antral follicles between the right and left ovary.

RESULTS

The number of antral follicles in the right ovary (median 18, range 15-22) was significantly higher than in the left ovary (median 16, range 13-20) among women with polycystic ovaries (PCO, AFC ≥24). Similarly, the number of antral follicles in the right ovary (median 8, range 6-10) was significantly higher than in the left ovary (median 7, range 5-9) in women with no PCO but normal ovarian reserve (AFC 10-23).

CONCLUSIONS

In women with PCO and non-PCO with normal ovarian reserve, the right ovary contains a higher number of antral follicles than the left ovary.

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

STUDY QUESTION

Do the presence of endometriomas and their laparoscopic excision lead to a decrease in ovarian reserve as assessed by serum anti-Müllerian hormone (AMH) levels?

SUMMARY ANSWER

Both the presence and excision of endometriomas cause a significant decrease in serum AMH levels, which is sustained 6 months after surgery.

WHAT IS KNOWN ALREADY

No previous comparison of serum AMH levels between women with and without endometrioma has been reported. However, studies have suggested a decline in serum AMH levels 1-3 months after endometrioma excision but long-term data are needed.

STUDY DESIGN, SIZE, DURATION

A prospective cohort study including 30 women with endometrioma >2 cm were age matched with 30 healthy women without ovarian cysts.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Women with endometrioma underwent laparoscopic excision with the stripping technique. Serum AMH level and antral follicle count (AFC) were determined preoperatively, 1 and 6 months after surgery. Correlation analyses were undertaken in order to identify determinants of surgery-related change in ovarian reserve.

MAIN RESULTS AND THE ROLE OF CHANCE

Compared with controls at baseline, women with endometrioma had lower AMH levels (4.2 ± 2.3 versus 2.8 ± 2.2 ng/ml, respectively, P = 0.02) and AFC (14.7 ± 4.1 versus 9.7 ± 4.8, respectively, P < 0.01). Serum AMH levels were further decreased 6 months after surgery (2.8 ± 2.2 versus 1.8 ± 1.3 ng/ml, P = 0.02), while AFC remained unchanged (9.7 ± 4.8 versus 10.4 ± 4.2, P = 0.63). The rate of decline in AMH was not correlated with age, laterality of endometrioma, cyst diameter or the number of primordial follicles on the surgical specimens. The preoperative serum AMH level was positively correlated with the rate of decline in serum AMH after surgery (r = 0.47, P = 0.02).

LIMITATIONS, REASONS FOR CAUTION

The absence of a non-treated group of women with endometriomas as a further control prevents comment on the presence of a progressive decline in ovarian reserve related to endometrioma per se. The sample size may be too small for detection of factors correlated with the extent of ovarian damage.

WIDER IMPLICATIONS OF THE FINDINGS

While the findings are mostly in agreement with previous studies, the present study is the first to show that the presence of endometrioma per se is associated with a decrease in ovarian reserve. The extent of surgery-related decline in ovarian reserve is not predictable using preoperative or perioperative factors. It may be prudent to measure AMH levels preoperatively and delay/avoid surgical excision as far as is possible if subsequent fertility is a concern. Additional studies are required to further investigate whether the endometrioma-related decline in ovarian reserve per se is progressive in nature and whether it exceeds the surgery-related decline.

STUDY FUNDING/COMPETING INTEREST(S)

This study was funded by the Research Fund of the Uludag University School of Medicine. The authors have no conflict of interest associated with this study.