Does the presence of endometriosis cause a challenge for transvaginal oocyte retrieval? A comparison between patients with and without endometriosis

Pain after oocyte retrieval in women with endometriosis undergoing fertility preservation or IVF

RESEARCH QUESTION

Do women with endometriosis undergoing oocyte retrieval for fertility preservation experience the same level of pain as women undergoing oocyte retrieval for IVF?

DESIGN

This retrospective cohort study included 796 cycles in women with endometriosis undergoing oocyte retrieval for fertility preservation (n = 401) or IVF (n = 395) between January 2020 and October 2022. Post-operative pain assessments were compared between the two groups using a numeric rating scale (NRS).

RESULTS

Women in the fertility preservation group were younger (32.1 ± 4.2 years versus 35.1 ± 4.1 years; P < 0.001), had a lower body mass index (22.8 ± 3.9 kg/m2 versus 24.6 ± 4.4 kg/m2; P < 0.001) and had a lower concentration of anti-Müllerian hormone (1.8 ± 1.5 ng/ml versus 2.15 ± 2.11 ng/ml; P = 0.026) in comparison with women in the IVF group. The oestrogen concentration on the day of ovulation trigger was higher in women in the fertility preservation group (2188 ± 1152 pg/ml versus 2081 ± 995 pg/ml; P = 0.004), and the prevalence rates of adenomyosis and digestive endometrial lesions were lower in women in the fertility preservation group (14% versus 29%, P < 0.001; 16% versus 25%, P = 0.003, respectively) compared with women in the IVF group. After oocyte puncture, more women in the fertility preservation group had an NRS pain score >3 (moderate to severe pain) compared with women in the IVF group (20% versus 14%; P = 0.018). The progestin-primed ovarian stimulation (PPOS) protocol was identified as an independent predictive factor of greater post-operative pain (adjusted OR 2.30, 95% CI 1.06-5.15; P = 0.039).

CONCLUSION

Women with endometriosis undergoing fertility preservation reported more intense post-operative pain in the recovery room than women undergoing IVF. The PPOS protocol was an independent risk factor of intense pain (NRS pain score >3) in women with endometriosis, but further studies are needed to confirm this result.

Fertility preservation in women with endometriosis: Oocyte cryopreservation and other techniques

In recent years, advancements in cryopreservation techniques for oocytes, embryos, and ovarian tissue have enabled offering fertility preservation (FP) options to women with endometriosis. It is recommended to always conduct specialized counselling on FP, especially before considering surgical interventions for endometriosis. The decision regarding the methods of FP, the timing, and to which women affected by endometriosis these techniques should be offered are still subjects of discussion. However, several studies suggest that it can be proposed before surgical interventions for endometriosis, particularly if the patient is undergoing mono or bilateral endometrioma surgery. The most recommended technique is ovarian stimulation, followed by oocyte cryopreservation. Nevertheless, the literature contains various studies describing FP through embryo cryopreservation or the retrieval and cryopreservation of ovarian tissue.

Oocyte Cryopreservation in Patients with Endometriosis: Current Knowledge and Number Needed to Treat

The rise of oocytes cryopreservation (OOC) in assisted reproductive techniques allows fertility preservation (FP) in an increasing number of indications. Endometriosis, a highly prevalent disease, potentially impairing ovarian reserve, seems, therefore, an interesting indication for it. The purpose of this study is to summarize the available evidence concerning FP by OOC in women with endometriosis and to calculate the number needed to treat (NNT). In total, 272 articles related to this topic were identified in PubMed. Eight studies were eligible for the review. In order to shed some light, a SWOT analysis was performed and the argument pros and cons were developed. The NNT calculated of OOC was 16, meaning that 16 women need to perform an OOC for one of them to have a child that she would not have had without this technique. In conclusion, OOC must be discussed with patients who suffer from endometriosis since it is an effective technique of FP, which can allow these patients to succeed a pregnancy that they otherwise would not have achieved. Nevertheless, it should not be performed in all patients as there is still a lack of robust socio-economic and risk–benefit data.

Safety of in-vitro fertilization in women with endometriosis

Management of women with endometriosis in general is complex. It requires a multidisciplinary and tailored approach. The time of in-vitro fertilization (IVF) may be particularly complicated because women with the disease face peculiar additional risks. In particular, oocytes retrieval may be more difficult and women with endometriomas are exposed to a low but consistent risk of infection and ovarian abscess development. There are also concerns regarding progression of deep invasive peritoneal lesions and misdiagnosis of an occult early ovarian cancer. However, evidence on these latter points is more controversial. Taken together, this body evidence is generally reassuring and does not justify prophylactic surgery prior to IVF to shrink these risks. However, given the uncertainties, women with endometriosis must be informed in depth of these peculiar additional risks.

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.

Abdominal wall endometriosis: experience of the General Surgery Service of the Antônio Pedro University Hospital of the Universidade Federal Fluminense

OBJECTIVE

to study the characteristics of women undergoing abdominal surgery with suspected abdominal wall endometriosis or abdominal wall tumor, and to assess the association with age, race and previous cesarean delivery.

METHOD

retrospective and analytical study carried out from January 2000 to December 2019, at the General Surgery Service of Hospital Universitário Antônio Pedro (HUAP) at Universidade Federal Fluminense (UFF). Medical records of 100 patients with abdominal wall endometriosis and other types of abdominal wall tumors were analyzed. Age, color, previous history of cesarean section or abdominal surgery and histopathological data were verified. The patients were classified as young adults (aged between 18 and 28 years and 11 months) and adults. The SPSS program was used for data analysis, Fisher's test with a significance level of 0.05.

RESULTS

abdominal wall endometriosis with histopathological confirmation was found in 22%, the mean age was 52.28 ± 18.66 which was lower when compared to other diagnoses. There was an association between previous cesarean section and abdominal wall endometriosis (p <0.005).

CONCLUSION

the women with a diagnosis of abdominal wall endometriosis had undergone previous cesareans (the majority) and were in an active reproductive age. Although the brown skin women were the most frequent, there was no statistical difference.

Recommendations for good practice in ultrasound: oocyte pick up†

STUDY QUESTION

What is good practice in ultrasound (US), and more specifically during the different stages of transvaginal oocyte retrieval, based on evidence in the literature and expert opinion on US practice in ART?

SUMMARY ANSWER

This document provides good practice recommendations covering technical aspects of US-guided transvaginal oocyte retrieval (oocyte pick up: OPU) formulated by a group of experts after considering the published data, and including the preparatory stage of OPU, the actual procedure and post-procedure care.

WHAT IS KNOWN ALREADY

US-guided transvaginal OPU is a widely performed procedure, but standards for best practice are not available.

STUDY DESIGN SIZE DURATION

A working group (WG) collaborated on writing recommendations on the practical aspects of transvaginal OPU. A literature search for evidence of the key aspects of the procedure was carried out. Selected papers (n = 190) relevant to the topic were analyzed by the WG.

PARTICIPANTS/MATERIALS SETTING METHODS

The WG members considered the following key points in the papers: whether US practice standards were explained; to what extent the OPU technique was described and whether complications or incidents and how to prevent such events were reported. In the end, only 108 papers could be used to support the recommendations in this document, which focused on transvaginal OPU. Laparoscopic OPU, transabdominal OPU and OPU for IVM were outside the scope of the study.

MAIN RESULTS AND THE ROLE OF CHANCE

There was a scarcity of studies on the actual procedural OPU technique. The document presents general recommendations for transvaginal OPU, and specific recommendations for its different stages, including prior to, during and after the procedure. Most evidence focussed on comparing different equipment (needles) and on complications and risks, including the risk of infection. For these topics, the recommendations were largely based on the results of the studies. Recommendations are provided on equipment and materials, possible risks and complications, audit and training. One of the major research gaps was training and competence. This paper has also outlined a list of research priorities (including clarification on the value or full blood count, antibiotic prophylaxis and flushing, and the need for training and proficiency).

LIMITATIONS REASONS FOR CAUTION

The recommendations of this paper were mostly based on clinical expertise, as at present, only a few clinical trials have focused on the oocyte retrieval techniques, and almost all available data are observational. In addition, studies focusing on OPU were heterogeneous with significant difference in techniques used, which made drafting conclusions and recommendations based on these studies even more challenging.

WIDER IMPLICATIONS OF THE FINDINGS

These recommendations complement previous guidelines on the management of good laboratory practice in ART. Some useful troubleshooting/checklist recommendations are given for easy implementation in clinical practice. These recommendations aim to contribute to the standardization of a rather common procedure that is still performed with great heterogeneity.

STUDY FUNDING/COMPETING INTERESTS

The meetings of the WG were funded by ESHRE. The other authors declare that they have no conflict of interest.

TRIAL REGISTRATION NUMBER

NA.ESHRE Pages content is not externally peer reviewed. The manuscript has been approved by the Executive Committee of ESHRE.

Effect of Body Mass Index on the Efficacy of Paracervical Block for Ultrasound-Guided Transvaginal Oocyte Retrieval as assessed by Requirement of Rescue Propofol

Background and Aims:

Oocyte retrieval is the only vital aspect of in vitro fertilization requiring anesthesia. Previous studies have shown the inconclusive role of paracervical block (PCB) in transvaginal oocyte retrieval (TVOR) under ultrasound guidance. This study was planned to observe the role and efficacy of PCB as measured by the amount of propofol used as rescue in patients undergoing TVOR and grading it on the basis of body mass index (BMI).

Methods:

This prospective, comparative study, conducted over 1 year, recruited 140 American Society of Anesthesiologists I and II patients and divided into two groups as follows: Group A received PCB with 20 ml of 1% lignocaine and Group B received no PCB. Total propofol consumed, BMI, time taken, oocytes retrieved, postprocedure visual analog scale score, and complications were noted. In both the groups, patients were then divided into underweight, normal, overweight, and obese according to BMI. Statistical analysis was done using Statistical Package Mini Tab Version 17.0. The primary objective was to study the efficacy of PCB as estimated by amount of propofol required during the procedure. The secondary aim was to assess the effect of BMI on the efficacy of PCB.

Results:

Propofol requirement was found to be significantly more (P < 0.05) in Group B patients (172.14 ± 64.15) in comparison to Group A (132.14 ± 66.11). Amount of propofol required in normal BMI and overweight patients was significantly higher in Group B. No significant difference was observed in underweight, and obese patients in both the groups.

Conclusion:

PCB reduces the consumption of propofol in normal BMI patients. Underweight and obese population do not benefit from PCB.