Impact of endometriosis and its staging on assisted reproduction outcome: systematic review and meta-analysis

Clinical evaluation of laparoscopic surgery combined with triptorelin acetate in patients with endometriosis and infertility

Objective:

To investigate the effects of laparoscopic surgery combined with triptorelin acetate, gestrinone and mifepristone on pregnancy rate, pregnancy outcome, long-term recurrence and adverse reactions in patients with endometriosis (EMT) complicated with infertility.

Methods:

In this study, 150 patients with EMT and infertility were selected and randomly divided into triptorelin group (group A), gestrinone group (group B) and mifepristone group (group C), with 50 people in each group. Treatment was with gonadotropin-releasing hormone (GnRH-a) after laparoscopic surgery.

Results:

The success rate of pregnancy in group A was higher than that in group B and C. The incidence of adverse pregnancy outcome was lower than that in group B and C. Kupperman score and subjective symptom score were lower than those in group B and C before treatment. Sex hormone level and CA125 level were significantly better. In the B and C groups and before treatment; the long-term recurrence rate was significantly lower than the B and C groups; the incidence of adverse reactions was similar.

Conclusion:

Laparoscopic surgery combined with GnRH-a can improve the success and good rate of pregnancy in EMT patients, reduce clinical symptoms, avoid long-term recurrence, and increase the risk of adverse reactions. Triptorelin acetate is superior to gestrinone and mifepristone.

Endometriosis has no negative impact on outcomes of in vitro fertilisation in women with poor ovarian response

OBJECTIVE

To compare the in vitro fertilisation (IVF) outcomes of poor ovarian responders among women with laparoscopically diagnosed minimal-mild endometriosis (Group A), moderate-severe endometriosis (Group B) and those without endometriosis (Group C). The comparisons were made separately for age groups younger than 35 years and 35 years or older.

DESIGN

Retrospective study.

SETTING

A university-affiliated hospital in Guangzhou, China.

POPULATION

495 women younger than 35 years old and 543 women aged 35 or older who had poor ovarian response with or without laparoscopically diagnosed endometriosis.

METHODS

Poor ovarian response (POR) was diagnosed using the Bologna criteria. First cycle parameters were analysed over the same period of time from January 2011 to October 2014.

MAIN OUTCOME MEASURES

The primary endpoint was the live birth rate per embryo transfer cycle. Secondary outcome measures were clinical pregnancy rate, cycle cancellation rate and miscarriage rate.

RESULTS

In women aged 35 or older no differences were found among the three subgroups in terms of live birth rate, clinical pregnancy rate, cycle cancellation rate or miscarriage rate; in women aged younger than 35 years, the clinical pregnancy rates were 62.96, 45.45 and 43.27% for Groups A, B and C, respectively (P = 0.028). The live birth rate, cycle cancellation rate and miscarriage rate were not significantly different. Compared with the older group of women, the younger women had a significantly higher live birth rate (P < 0.001).

CONCLUSIONS

A woman's age is the most important factor governing the live birth rate with IVF. Endometriosis has no consistent impact on IVF outcomes in women with POR.

TWEETABLE ABSTRACT

Endometriosis has no negative impact on IVF outcomes in women with poor ovarian response.

Endometriosis and in vitro fertilisation

The aim of the present review was to discuss a matter of concern in the clinical field of obstetrics/gynecology, namely the potency of in vitro fertilization (IVF) in the management of endometriosis-associated infertility. Endometriosis is a medical condition affecting one tenth of women in their fertile years, and accounts for up to 50% of infertile women. Thus, such high prevalence has established the necessity for investigating the effectiveness of available techniques in eradicating the disease and constraining infertility as well as the accompanying pain symptoms of endometriosis. The underlying mechanisms connecting endometriosis with low fecundity have been extensively studied, both in terms of genetic alterations and epigenetic events that contribute to the manifestation of an infertility phenotype in women with the disease. Several studies have dealt with the impact of IVF in pregnancy rates (PRs) on patients with endometriosis, particularly regarding women who wish to conceive. Results retrieved from studies and meta-analyses depict a diverse pattern of IVF success, underlining the involvement of individual parameters in the configuration of the final outcome. The ultimate decision on undergoing IVF treatment should be based on objective criteria and clinicians' experience, customized according to patients' individual needs.

The deferred embryo transfer strategy improves cumulative pregnancy rates in endometriosis-related infertility: A retrospective matched cohort study

Background

Controlled ovarian stimulation in assisted reproduction technology (ART) may alters endometrial receptivity by an advancement of endometrial development. Recently, technical improvements in vitrification make deferred frozen-thawed embryo transfer (Def-ET) a feasible alternative to fresh embryo transfer (ET). In endometriosis-related infertility the eutopic endometrium is abnormal and its functional alterations are seen as likely to alter the quality of endometrial receptivity. One question in the endometriosis ART-management is to know whether Def-ET could restore optimal receptivity in endometriosis-affected women leading to increase in pregnancy rates.

Objective

To compare cumulative ART-outcomes between fresh versus Def-ET in endometriosis-infertile women.

Materials and methods

This matched cohort study compared def-ET strategy to fresh ET strategy between 01/10/2012 and 31/12/2014. One hundred and thirty-five endometriosis-affected women with a scheduled def-ET cycle and 424 endometriosis-affected women with a scheduled fresh ET cycle were eligible for matching. Matching criteria were: age, number of prior ART cycles, and endometriosis phenotype. Statistical analyses were conducted using univariable and multivariable logistic regression models.

Results

135 in the fresh ET group and 135 in the def-ET group were included in the analysis. The cumulative clinical pregnancy rate was significantly increased in the def-ET group compared to the fresh ET group [58 (43%) vs. 40 (29.6%), p = 0.047]. The cumulative ongoing pregnancy rate was 34.8% (n = 47) and 17.8% (n = 24) respectively in the Def-ET and the fresh-ET groups (p = 0.005). After multivariable conditional logistic regression analysis, Def-ET was associated with a significant increase in the cumulative ongoing pregnancy rate as compared to fresh ET (OR = 1.76, CI95% 1.06–2.92, p = 0.028).

Conclusion

Def-ET in endometriosis-affected women was associated with significantly higher cumulative ongoing pregnancy rates. Our preliminary results suggest that Def-ET for endometriosis-affected women is an attractive option that could increase their ART success rates. Future studies, with a randomized design, should be conducted to further confirm those results.

Endometriosis, endometrioma, and ART results: Current understanding and recommended practices

Endometriosis and infertility are linked in a complex relationship, and a number of different pathogenetic mechanisms may associate the two. Endometriosis is diagnosed in 6-8% of women undergoing ART. Women with endometriosis appear to have similar ART outcomes compared to controls in terms of live birth rates, despite a lower oocyte quality. Laparoscopy should not be routinely performed before ART with the only aim to diagnose mild or moderate endometriosis, but if the latter is found, surgical removal can be considered, as it might improve pregnancy rates. In case of more severe forms of the disease (endometrioma and deep infiltrating endometriosis), the benefits of surgery before ART are uncertain and must be balanced against risks. Management decisions should be individualized based on patient choice, age, associated symptoms, and the risk of repeat surgery.

Comparison of the symptoms and localisation of endometriosis involvement according to fertility status of endometriosis patients

This cross-sectional study aimed to assess the prevalence of endometriosis in women who were referred for Diagnostic Laparoscopy Unit due to infertility or pelvic pain between January 2012 and January 2013 and compare the symptoms and laparoscopic signs among the three groups according to the fertility status. Four hundred and thirteen women were evaluated; of these, 383 patients for infertility and 30 patients for pelvic pain and/or cyst. Endometriosis symptoms were compared between fertile and infertile women with primary and secondary infertility. There was no statistically significant difference in the overall prevalence of endometriosis between the three study groups (52.9%, 45% and 40.7%, respectively, in primary, secondary infertile and fertile women). The endometriosis stage was categorised as early- (I and II) or late- (III and IV) stages and the extent of endometriosis was divided into peritoneal, ovarian and ovarian coexisting with peritoneal. There is no relationship between the frequency of dysmenorrhoea or non-cyclic pelvic pain and the disease stage; although these pain symptoms are significantly more prevalent in cases with both ovarian and peritoneal endometriotic implants. Infertility was more prevalent among the patients with peritoneal endometriosis in comparison to the ones with ovarian endometriosis. Further studies with a larger sample size are required to confirm these findings. Impact statement What is already known on this subject? Few studies have been done in this area and only one study compared the localisation of endometriosis lesions between fertile and infertile endometriosis cases; however, more study is needed to confirm their results. What the results of this study add? A possible relationship between localisation of endometriosis involvement and infertility was found in the present study in agreement to result of a previous study performance in this area. Although the present study includes a greater number of cases than that of the previous reported study, further studies with a larger sample size are required for the confirmation or refusal of this finding. What are the implications of these findings for clinical practice and/or further research? The results of this study could have clinical application in the consultation and decision-making in infertile women with an endometriosis diagnosis.

Endometriosis, especially mild disease: a risk factor for miscarriages

OBJECTIVE

To investigate the prevalence of miscarriage in women with endometriosis (WwE) compared with disease-free control women (CW).

DESIGN

Cross-sectional analysis nested in a retrospective observational study (n = 940).

SETTING

Hospitals and associated private practices.

PATIENT(S)

Previously pregnant women (n = 268) within reproductive age in matched pairs.

INTERVENTION(S)

Retrospective analysis of surgical reports and self-administered questionnaires.

MAIN OUTCOME MEASURE(S)

Rate of miscarriage, subanalysis for fertility status (≤12 vs. >12 months' time to conception), endometriosis stages (revised American Society of Reproductive Medicine classification [rASRM] I/II vs. III/IV) and phenotypic localizations (superficial peritoneal, ovarian, and deep infiltrating endometriosis).

RESULT(S)

The miscarriage rate was higher in WwE (35.8% [95% confidence interval 29.6%-42.0%]) compared with CW (22.0% [16.7%-27.0%]); adjusted incidence risk ratio of 1.97 (95% CI 1.41-2.75). This remained significant in subfertile WwE (50.0% [40.7%-59.4%]) vs. CW (25.8% [8.5%-41.2%]) but not in fertile WwE (24.5% [16.3%-31.6%]) vs. CW (21.5% [15.9%-26.8%]). The miscarriage rate was higher in women with milder forms (rASRM I/II 42.1% [32.6%-51.4%] vs. rASRM III/IV 30.8% [22.6%-38.7%], compared with 22.0% [16.7%-27.0%] in CW), and in women with superficial peritoneal endometriosis (42.0% [32.0%-53.9%]) compared with ovarian endometriosis (28.6% [17.7%-38.7%]) and deep infiltrating endometriosis (33.9% [21.2%-46.0%]) compared with CW (22.0% [16.7%-27.0%]).

CONCLUSION(S)

Mild endometriosis, as in superficial lesions, is related to a great extent of inflammatory disorder, possibly leading to defective folliculogenesis, fertilization, and/or implantation, presenting as increased risk of miscarriage.

CLINICAL TRIAL REGISTRATION NUMBER

NCT02511626.

From Endometriosis to Pregnancy: Which is the “Road-Map”?

In the last decade, pregnancy was considered as a therapeutic period for patients affected by endometriosis and painful symptoms. However, several studies have taken into consideration how endometriosis affects pregnancy achievement and pregnancy development, including obstetric complications. The adverse effects of endometriosis on the development of pregnancy include miscarriage, hypertensive disorders and pre-eclampsia, placenta previa, obstetric hemorrhages, preterm birth, small for gestational age, and adverse neonatal outcomes. The aim of this review is to analyze the current literature regarding the relationship between different forms of endometriosis (endometrioma, peritoneal endometriosis, deep endometriosis) and infertility, and the impact of endometriosis on pregnancy outcomes.

[Bowel endometriosis and infertility: Do we need to operate?]

Endometriosis is a benign chronic inflammatory disease, whose pathogenesis is 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: superficial peritoneal, ovarian and/or deep infiltrating lesions). Bowel involvement constitutes one particularly severe form of the disease, affecting 8-12% of women with deep endometriosis. In case of associated infertility, bowel endometriosis constitutes a real therapeutic challenge for gynecologists. Indeed, while complete resection of the lesions alleviates pain and seems to improve spontaneous fertility, surgery remains technically challenging and may cause severe complications. Reverting to assisted Reproductive Technology (ART) is another valuable therapeutic option regarding pregnancy rates. Thus, the choice between surgical management or ART is still debated. Benefits and risks of these two options should be considered and discussed before planning treatment. In the present study, we aimed to answer the question: Bowel endometriosis and infertility: do we need to operate?

In Vitro Fertilization Success Rates after Surgically Treated Endometriosis and Effect of Time Interval between Surgery and In Vitro Fertilization

STUDY OBJECTIVE

To evaluate the impact of endometriosis staging and endometriomas on in vitro fertilization (IVF) outcome and to assess the optimal time interval between laparoscopy and IVF.

DESIGN

A retrospective clinical study (Canadian Task Force classification II1).

SETTING

A university-affiliated private infertility clinic.

PATIENTS

Two hundred sixteen infertile patients with endometriosis and 209 infertile patients without endometriosis.

INTERVENTIONS

Laparoscopy, IVF.

MEASUREMENTS AND MAIN RESULTS

Patients with endometriosis were classified according to American Society for Reproductive Medicine criteria; 58, 67, 63, and 28 patients had stages 1 through 4 disease, respectively. Patients with endometriosis had significantly lower estradiol on trigger day (9986 ± 6710 vs 12 220 ± 9414 pg/mL, respectively) and number of retrieved oocytes (12.7 ± 8.6 vs 14.0 ± 10, respectively) compared with controls. We found a consistent decline in clinical and ongoing pregnancy rates with increasing stage of endometriosis. The presence of endometrioma in patients with stages 3 and 4 endometriosis did not alter IVF outcome. Patients with a time interval of 7 to 12 and 13 to 25 months after surgery had a favorable outcome.

CONCLUSION

IVF pregnancy rate was negatively correlated with endometriosis severity. The presence of endometriomas had no impact on IVF clinical outcome. The optimal time to perform IVF appears to be between 7 and 25 months after endometriosis surgery.

Endometriosis and Infertility: A Systematic Review

Endometriosis is one of the most common gynaecological conditions affecting 6% to 12% of women in the reproductive age group. It can be found in 35% to 45% of women who are trying to conceive and are infertile. Infertility is one of the most common problems associated with endometriosis. This review will look at the evidence that endometriosis may lead to infertility and the data looking at whether surgical correction of endometriosis may improve fertility outcomes.

[Endometriosis and miscarriage: Systematic review]

OBJECTIVES

In spontaneous pregnancies, endometriosis appears to be a risk factor of miscarriage. The aim of this study is to evaluate the association between endometriosis and miscarriage in spontaneous pregnancy.

METHODS

We searched the Cochrane Library, Medline of eligible studies from inception to December 2016, without any restriction. We selected studies that compared endometriosis-affected pregnant women to disease-free pregnant women. To ensure the quality of the methodology, the PRISMA criteria have been met at all stages of the development of this meta-analysis. The primary adverse pregnancy outcomes studied was miscarriage. Three reviewers independently extracted the studies' characteristics and outcome data.

RESULTS

Of 225 identified abstracts, 4 primary studies met our inclusion criteria by comparing spontaneous pregnant patients with endometriosis to disease-free women. Miscarriage rate was higher in the endometriosis group (OR 1.77 [CI 95% 1.13-2.78]).

CONCLUSION

In spontaneous pregnancies, endometriosis appears to be a risk factor of miscarriages (almost 80% increased risk). Further prospective studies are needed to confirm these results in order to establish the exact impact of endometriosis on spontaneous pregnancy course.

Is the oocyte quality affected by endometriosis? A review of the literature

Endometriosis is an estrogen-dependent chronic inflammatory condition that affects women in their reproductive period causing infertility and pelvic pain. The disease, especially at the ovarian site has been shown to have a detrimental impact on ovarian physiology. Indeed, sonographic and histologic data tend to support the idea that ovarian follicles of endometriosis patients are decreased in number and more atretic. Moreover, the local intrafollicular environment of patients affected is characterized by alterations of the granulosa cell compartment including reduced P450 aromatase expression and increased intracellular reactive oxygen species generation. However, no comprehensive evaluation of the literature addressing the effect of endometriosis on oocyte quality from both a clinical and a biological perspective has so far been conducted. Based on this systematic review of the literature, oocytes retrieved from women affected by endometriosis are more likely to fail in vitro maturation and to show altered morphology and lower cytoplasmic mitochondrial content compared to women with other causes of infertility. Results from meta-analyses addressing IVF outcomes in women affected would indicate that a reduction in the number of mature oocytes retrieved is associated with endometriosis while a reduction in fertilization rates is more likely to be associated with minimal/mild rather than with moderate/severe disease. However, evidence in this field is still far to be conclusive, especially with regards to the effects of different stages of the disease and to the impact of patients’ previous medical/surgical treatment(s).

Frozen embryo transfer cycles in women with deep endometriosis

OBJECTIVE

To compare the transfer pregnancy rates with frozen embryos from patients with deep endometriosis and non-endometriosis patients.

METHODS

We conducted a retrospective cohort study of review of medical records of 181 women aged 18-40 years, undergoing transfer of frozen embryos into a fertility center. The data collected was from January 2007 to December 2013.

RESULTS

Regarding the patients with endometriosis, there was no statistical difference in proportion to compare polycystic ovarian syndrome, male factor, tubal factor and unexplained infertility.

CONCLUSION

There was no difference between pregnancy rates obtained from frozen embryo transfer in deep endometriosis compared to other causes of infertility.

Abnormal Placentation Associated with Infertility as a Marker of Overall Health

Infertility and fertility treatments utilized are associated with abnormal placentation leading to adverse pregnancy outcomes related to placentation, including preterm birth, low birth weight, placenta accrete, and placenta previa. This may be due to the underlying genetics predisposing to infertility or the epigenetic changes associated with the fertility treatments utilized, as specific disease states leading to infertility are at increased risk of adverse outcomes, including placental abruption, fetal loss, gestational diabetes mellitus, and outcomes related to placentation, as well as the treatments utilized including in vitro fertilization (IVF) and non-IVF fertility treatment. Placentation defects, leading to adverse maternal and fetal outcomes, which are more pronounced in the infertile population, occur due to changes in trophoblast invasion, vascular defects, changes in the environmental milieu, chronic inflammation, and oxidative stress. These similar processes are recognized as major contributors to lifelong risk of cardiovascular and metabolic disease for both the mother and her offspring. Thus, abnormal placentation, found to be more prevalent in the infertile population, may be the key to better understand how infertility affects overall and long-term health.

Direct aspiration versus follicular flushing in poor responders undergoing intracytoplasmic sperm injection: a randomised controlled trial

OBJECTIVE

To compare follicle flushing three times with direct follicular aspiration in poor responders. Our hypothesis was that follicle flushing three times in poor responders would result in similar oocyte yield compared with direct aspiration in poor responders.

DESIGN

A randomised controlled trial performed between January 2015 and June 2015.

SETTING

University hospital.

POPULATION OR SAMPLE

Eighty eligible poor responders, who were defined as having five or fewer follicles ≥13 mm in average diameter with at least two follicles having maximum diameters >17 mm on the day of human chorionic gonadotrophin administration. Monofollicular cycles, including natural cycles, were excluded from the current trial.

METHODS

In the double-lumen needle group, oocyte retrieval was performed by flushing three times with 2 ml in each follicle and in the single-lumen group direct follicle aspiration was performed.

MAIN OUTCOME MEASURE

Number of metaphase II oocytes retrieved.

RESULTS

The mean number of metaphase II oocytes was similar in both groups (1.9 ± 0.1 versus 2.1 ± 0.1, respectively). The clinical pregnancy and live birth rates were similar in both groups (32.5% versus 25% and 25% versus 22.5%, respectively). The only significant difference between the two groups was the duration of oocyte retrieval (178.4 ± 13.4 versus 236.3 ± 24.1 seconds, respectively, P = 0.01).

CONCLUSION

Follicular flushing is time consuming and has similar results compared with direct follicle aspiration in poor responders.

TWEETABLE ABSTRACT

Direct follicle aspiration versus flushing in poor responders yields similar metaphase II oocytes.

Prognostic factors for assisted reproductive technology in women with endometriosis-related infertility

BACKGROUND

Assisted reproductive technology is one of the therapeutic options offered for managing endometriosis-associated infertility. Yet, published data on assisted reproductive technology outcome in women affected by endometriosis are conflicting and the determinant factors for pregnancy chances unclear.

OBJECTIVE

We sought to evaluate assisted reproductive technology outcomes in a series of 359 endometriosis patients, to identify prognostic factors and determine if there is an impact of the endometriosis phenotype.

STUDY DESIGN

This was a retrospective observational cohort study, including 359 consecutive endometriosis patients undergoing in vitro fertilization or intracytoplasmic sperm injection, from June 2005 through February 2013 at a university hospital. Endometriotic lesions were classified into 3 phenotypes-superficial peritoneal endometriosis, endometrioma, or deep infiltrating endometriosis-based on imaging criteria (transvaginal ultrasound, magnetic resonance imaging); histological proof confirmed the diagnosis in women with a history of surgery for endometriosis. Main outcome measures were clinical pregnancy rates and live birth rates per cycle and per embryo transfer. Prognostic factors of assisted reproductive technology outcome were identified by comparing women who became pregnant and those who did not, using univariate and adjusted multiple logistic regression models.

RESULTS

In all, 359 endometriosis patients underwent 720 assisted reproductive technology cycles. In all, 158 (44%) patients became pregnant, and 114 (31.8%) had a live birth. The clinical pregnancy rate and the live birth rate per embryo transfer were 36.4% and 22.8%, respectively. The endometriosis phenotype (superficial endometriosis, endometrioma, or deep infiltrating endometriosis) had no impact on assisted reproductive technology outcomes. After multivariate analysis, history of surgery for endometriosis (odds ratio, 0.14; 95% confidence ratio, 0.06-0.38) or past surgery for endometrioma (odds ratio, 0.39; 95% confidence ratio, 0.18-0.84) were independent factors associated with lower pregnancy rates. Anti-müllerian hormone levels <2 ng/mL (odds ratio, 0.51; 95% confidence ratio, 0.28-0.91) and antral follicle count <10 (odds ratio, 0.27; 95% confidence ratio, 0.14-0.53) were also associated with negative assisted reproductive technology outcomes.

CONCLUSION

The endometriosis phenotype seems to have no impact on assisted reproductive technology results. An altered ovarian reserve and a previous surgery for endometriosis and/or endometrioma are associated with decreased pregnancy rates.

The impact of endometriosis on the outcome of Assisted Reproductive Technology

BACKGROUND

Endometriosis has been described to impair fertility through various mechanisms. However, studies evaluating the reproductive outcomes of women undergoing assisted reproductive technologies show controversial results. The aim of this study is to assess whether the reproductive outcome is impaired among women with endometriosis-associated infertility undergoing IVF.

METHODS

A retrospective cohort study was performed, including women undergoing IVF reported by the Red Latinoamericana de Reproduccion Asistida (Redlara) registry, between January 2010 and December 2012. The study group included women with endometriosis-associated infertility, and the control group women with tubal factor, endocrine disorders or unexplained infertility. Women above 40 years, severe male factor and premature ovarian failure were excluded. The reproductive outcomes of between both groups were compared. The primary outcome was live birth. Secondary outcomes included clinical pregnancy, miscarriage, number of oocytes retrieved and number of fertilized oocytes. Outcomes were assessed after the first fresh IVF cycle, and were adjusted for age and number of embryos transferred.

RESULTS

A total of 22.416 women were included (3.583 with endometriosis and 18.833 in the control group). Mean age of patients in the endometriosis group and control group was 34.86 (3.47) and 34.61 (3.91) respectively, p = 0.000. The mean number of oocytes retrieved were 8.89 (6.23) and 9.86 (7.02) respectively, p = 0.000. No significant differences were observed between groups in terms of live birth (odds ratio (OR) 1.032, p = 0.556), clinical pregnancy (OR 1.044, p = 0.428) and miscarriage rates (OR 1.049, p = 0.623). Women with endometriosis had significantly lower number of oocytes retrieved (incidence risk ratio (IRR) 0.917, 95% CI 0.895-0.940), however, the number of fertilized oocytes did not differ among the two groups when adjusting for the number of oocytes retrieved (IRR 1.003, p = 0.794). An age-stratified analysis was performed, and no differences were observed in the reproductive outcomes between groups for women aged under 35 and 35 to 40.

CONCLUSIONS

Reproductive outcomes among women undergoing IVF and diagnosed with endometriosis-associated infertility do not differ significantly from women without the disease. Although women with endometriosis generate fewer oocytes, fertilization rate is not impaired and the likelihood of achieving a live birth is also not affected.

Follicular fluid lipid peroxidation levels in women with endometriosis during controlled ovarian hyperstimulation

This observational study aimed to establishing a relationship between lipid peroxidation and endometriosis in women undergoing controlled ovarian hyperstimulation. A total of 79 women were divided into two groups: (i) controls (tubal or male factor); and (ii) endometriosis (stages III/IV). The endometriosis diagnosis was confirmed by videolaparoscopy and the controlled ovarian stimulation protocol was similar to all patients. Follicular fluid (FF) lipid peroxidation levels were determined through the quantification of malondialdehyde. Statistical analysis was performed using parametric and non-parametric tests, logistic regression was performed to estimate the chance of achieving a pregnancy in each group and a moving average was calculated for the endometriosis group. Peroxidation levels in the endometriosis group were significantly higher when compared to controls. The moving average showed a decrease of MDA levels in the endometriosis group with increasing female age. Moreover, women with endometriosis who were under 33 years of age were 4.3 times more likely to achieve a pregnancy than women above that age. In conclusion, endometriosis is associated with increased FF oxidative stress (OS) in patients undergoing in vitro fertilization (IVF). Also, increasing age is associated with a decrease in severity of the oxidative status, but a decreased chance of pregnancy.

Women's Reproductive History Before the Diagnosis of Incident Endometriosis

BACKGROUND

Endometriosis is a gynecologic disease reported to be associated with infertility and, possibly, adverse pregnancy outcomes. While considerable research focuses on pregnancy outcomes following diagnosis and/or treatment, few data actually describe women's reproductive history before diagnosis for a more complete understanding of endometriosis and reproduction.

MATERIALS AND METHODS

The study sample comprised 473 women (aged 18-44 years) undergoing laparoscopies or laparotomies, irrespective of surgical indication at 14 clinical sites, during the period 2007-2009. Upon enrollment and before surgery, women were queried about pregnancy intentions and the time required to become pregnant for planned pregnancies. Endometriosis was defined as surgically visualized disease. Using discrete time survival analysis, we estimated fecundability odds ratios (FORs) and 95% confidence intervals (CIs) to assess time to pregnancy (TTP) after adjusting for potential confounders (age, body composition, cigarette smoking, site). Generalized estimating equations accounted for multiple pregnancy attempts per woman. FORs <1.0 denote a longer TTP or diminished fecundity.

RESULTS

Approximately 66% and 69% of women with and without endometriosis, respectively, reported having a planned pregnancy before surgery, respectively. After adjustment, an endometriosis diagnosis was associated with ≈29% reduction in fecundity or a longer TTP across all pregnancy-trying attempts (adjusted FOR = 0.71; 95% CI 0.46-1.10). While FORs were consistently <1.0, irrespective of endometriosis staging, CIs included 1.

CONCLUSIONS

Women with endometriosis had a longer TTP than unaffected women, irrespective of disease severity, although the findings did not achieve significance. Prior reproductive history may be informative for predicting fecundity and pregnancy outcomes following diagnosis/treatment.

Pregnancy complications in spontaneous and assisted conceptions of women with infertility and subfertility factors. A comprehensive review

In the literature, there is growing evidence that assisted reproductive techniques increase the risk of pregnancy complications in subfertile couples. Moreover, many concomitant preconception risk factors for subfertility are frequently present in the same subject and increase the risk of pregnancy complications. This review aimed to summarize in a systematic fashion the best current evidence regarding the effects of preconception maternal factors on maternal and neonatal outcomes. A literature search up to March 2016 was performed in IBSS, SocINDEX, Institute for Scientific Information, PubMed, Web of Science and Google Scholar. An evidence-based hierarchy was used to determine which articles to include and analyse. Available data show that the risk of pregnancy complications in spontaneous and assisted conceptions is likely multifactorial, and the magnitude of this risk is probably very different according specific subgroups of patients. Notwithstanding the only moderate level and quality of the available evidence, available data suggest that the presence and the treatment of specific preconception cofactors of subfertility should be always taken into account both in clinical practice and for scientific purposes.

Clinical management of endometriosis-associated infertility

Endometriosis is a common chronic benign disease that affects reproductive age women and causes chronic pelvic pain and infertility. Despite its prevalence, the exact mechanisms of the pathogenesis of endometriosis-associated infertility are unknown, and precise standards of management have not yet been established. Medical and surgical treatments for endometriosis have different effects on the chance of conception, either spontaneously or via assisted reproductive technologies (ART). In this manuscript, we review the literature from years 1979 to 2015 to report on the proposed mechanism of endometriosis-associated infertility, the staging system of endometriosis for pregnancy outcomes and the current management of patients with endometriosis-associated infertility.

A systematic review on endometriosis during pregnancy: diagnosis, misdiagnosis, complications and outcomes

BACKGROUND

Traditionally, pregnancy was considered to have a positive effect on endometriosis and its painful symptoms due not only to blockage of ovulation preventing bleeding of endometriotic tissue but also to different metabolic, hormonal, immune and angiogenesis changes related to pregnancy. However, a growing literature is emerging on the role of endometriosis in affecting the development of pregnancy and its outcomes and also on the impact of pregnancy on endometriosis. The present article aims to underline the difficulty in diagnosing endometriotic lesions during pregnancy and discuss the options for the treatment of decidualized endometriosis in relation to imaging and symptomatology; to describe all the possible acute complications of pregnancy caused by pre-existing endometriosis and evaluate potential treatments of these complications; to assess whether endometriosis affects pregnancy outcome and hypothesize mechanisms to explain the underlying relationships.

METHODS

This systematic review is based on material searched and obtained via Pubmed and Medline between January 1950 and March 2015. Peer-reviewed, English-language journal articles examining the impact of endometriosis on pregnancy and vice versa were included in this article.

RESULTS

Changes of the endometriotic lesions may occur during pregnancy caused by the modifications of the hormonal milieu, posing a clinical dilemma due to their atypical appearance. The management of these events is actually challenging as only few cases have been described and the review of available literature evidenced a lack of formal estimates of their incidence. Acute complications of endometriosis during pregnancy, such as spontaneous hemoperitoneum, bowel and ovarian complications, represent rare but life-threatening conditions that require, in most of the cases, surgical operations to be managed. Due to the unpredictability of these complications, no specific recommendation for additional interventions to the routinely monitoring of pregnancy of women with known history of endometriosis is advisable. Even if the results of the published studies are controversial, some evidence is suggestive of an association of endometriosis with spontaneous miscarriage, preterm birth and small for gestational age babies. A correlation of endometriosis with placenta previa (odds ratio from 1.67 to 15.1 according to various studies) has been demonstrated, possibly linked to the abnormal frequency and amplitude of uterine contractions observed in women affected. Finally, there is no evidence that prophylactic surgery would prevent the negative impact of endometriosis itself on pregnancy outcome.

CONCLUSIONS

Complications of endometriosis during pregnancy are rare and there is no evidence that the disease has a major detrimental effect on pregnancy outcome. Therefore, pregnant women with endometriosis can be reassured on the course of their pregnancies although the physicians should be aware of the potential increased risk of placenta previa. Current evidence does not support any modification of conventional monitoring of pregnancy in patients with endometriosis.

Ovarian response is a better predictor of clinical pregnancy rate following embryo transfer than is thin endometrium or presence of an endometrioma

OBJECTIVES

To examine whether endometrial thickness and the presence of endometrioma are independent predictors of clinical pregnancy rate or simply associated with poor ovarian response (POR).

METHODS

This was a retrospective cohort study assessing the first cycle of all women undergoing in-vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) in a university hospital in Brazil between January 2011 and December 2012. Only the first cycle of each woman within the study period was considered. Women over 40 years of age and those who used clomiphene citrate during controlled ovarian stimulation (COS) or did not undergo embryo transfer were excluded from analysis. POR was defined as ≤ three oocytes retrieved and a thin endometrium was defined as endometrial thickness ≤ 7.0 mm on the day of human chorionic gonadotropin (hCG) administration. We performed a multiple regression analysis to identify which of the following parameters were independent predictors of clinical pregnancy: age, number of oocytes retrieved, endometrial thickness or the presence of endometrioma.

RESULTS

Within the study period, 787 women began COS, but 270 were excluded from analysis. Among the 517 women analyzed, those who achieved pregnancy were younger and yielded more oocytes. The proportion of POR was higher in women with a thin endometrium (17/57 (29.8%) vs 80/460 (17.4%); P = 0.03) and in women with endometrioma (15/39 (38.5%) vs 82/478 (17.2%); P = 0.002). The results of regression analysis showed that only age and the number of oocytes retrieved were independent predictors of pregnancy. Additionally, we observed higher clinical pregnancy rates in women with a thin endometrium from whom ≥ seven oocytes were retrieved (11/25 (44.0%)) compared to women with normal endometrial thickness (99/241 (41.1%)). Considering only women from whom ≥ four oocytes were retrieved, we observed reasonable pregnancy rates in those with a thin endometrium (14/40 (35.0%)) and in those with endometrioma (9/24 (37.5%)).

CONCLUSION

Both a thin endometrium and the presence of endometrioma are associated with POR but are not important independent predictors of clinical pregnancy. Good pregnancy rates can be observed when these conditions are present in women with a good ovarian response.

Assessment of ovarian reserve by antral follicle count in ovaries with endometrioma

OBJECTIVE

To evaluate whether the antral follicle count (AFC) is underestimated in the presence of an endometrioma.

METHODS

This was a retrospective cohort study assessing all women undergoing in-vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) at our clinic between January 2011 and December 2012 who had both ovaries and unilateral endometrioma. The primary outcome of the study was the difference between AFC and the number of oocytes retrieved per ovary.

RESULTS

Within the study period 787 women underwent IVF/ICSI at our clinic. Sixty of these women had at least one endometrioma, but 23 were excluded from the analysis as six had only one ovary and 17 had bilateral endometriomas. Therefore a total of 37 women were included in this study and analysis. Compared with the contralateral ovaries, ovaries with an endometrioma were significantly larger in volume (median, 10.3 (interquartile range (IQR), 4.7-18.9)  cm(3) vs median, 3.6 (IQR, 2.7-6.5)  cm(3); P < 0.001) and presented a significantly lower AFC (median, 3.0 (IQR, 1.0-6.0) vs median, 5.0 (IQR, 2.0-6.5); P = 0.001). However, the median number of oocytes retrieved was similar (P = 0.60) between ovaries with an endometrioma (2.0 (IQR, 0.5-5.0)) and the contralateral ovaries (2.0 (IQR, 0.0-4.0)). Accordingly, the median difference between AFC and number of oocytes retrieved was significantly smaller (P = 0.005) for ovaries with an endometrioma (0.0 (IQR, -1.0 to 1.5) than for those without (2.0 (IQR, 0.0-4.0)).

CONCLUSIONS

Although the AFC is reduced in ovaries with an endometrioma, the number of oocytes retrieved is similar, suggesting that the AFC is underestimated in such ovaries. We believe that this is a consequence of an impaired ability to detect small follicles in the presence of an endometrioma.

Endometriosis and assisted reproductive technology: United States trends and outcomes 2000-2011

OBJECTIVE

To assess endometriosis-associated infertility trends among assisted reproductive technology (ART) cycles, and to compare cancellation and hyperstimulation risks and pregnancy and live birth rates among women using ART for endometriosis-associated vs. male factor infertility.

DESIGN

Descriptive and multivariable analyses of Centers for Disease Control and Prevention (CDC) National ART Surveillance System data.

SETTING

Fertility centers.

PATIENT(S)

All reported fresh autologous ART cycles in the United States between 2000 and 2011 (n = 1,589,079).

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Oocyte yield, hyperstimulation, cancellation, implantation, pregnancy, live birth.

RESULT(S)

The absolute number of ART cycles with an endometriosis diagnosis fell in recent years, from 16,751 (2000) to 15,311 (2011); the percentage fell over time, from 17.0% (2000) to 9.6% (2011) of all cycles. Compared with male factor (n = 375,557), endometriosis-associated cycles (n = 112,475) yielded fewer oocytes (50.5% vs. 42.5% of cycles with only 0-10 oocytes retrieved), lower risk of hyperstimulation (1.1% vs. 1.3%, adjusted risk ratio [aRR] 0.82, 95% confidence interval [CI] 0.74-0.91), and an increased risk of cancellation (12.9% vs. 10.1%, aRR 1.30, 95% CI 1.25-1.35). Endometriosis was associated with a statistically decreased but likely clinically insignificant difference in the following outcomes: chance of pregnancy per transfer (43.7% vs. 44.8%, aRR 0.96, 95% CI 0.95-0.98) among couples who did not also have tubal factor infertility and live birth per transfer (37.2% vs. 37.6%, aRR 0.96, 95% CI 0.94-0.98).

CONCLUSION(S)

The percentage of endometriosis-associated ART cycles has decreased over time. As compared with male factor infertility, endometriosis is associated with increased cancellation and decreased hyperstimulation risks. Despite decreased oocyte yield and higher medication dose, the difference in pregnancy and live birth rates may be of limited clinical significance, suggesting comparable pregnancy outcomes per transfer.

Down-regulation of the CYP19A1 gene in cumulus cells of infertile women with endometriosis

Aromatase plays a fundamental role in the establishment of oocyte quality, which might be compromised in infertile women with endometriosis. The expression of the CYP19A1 gene (that encodes aromatase) was compared in cumulus cells and oestradiol concentrations in the follicular fluid of infertile women with and without endometriosis submitted to ovarian stimulation for intracytoplasmic sperm injection. Cumulus cells were isolated and the expression of the CYP19A1 was quantitated through real-time polymerase chain reaction. Oestradiol concentrations in follicular fluid were measured by chemiluminescence immunoassay. A lower expression of the CYP19A1 in the cumulus cells of infertile women with endometriosis was observed compared with controls (0.17 ± 0.13 and 0.56 ± 0.12, respectively), and no significant difference in the follicular fluid oestradiol concentrations was observed between groups. Our results show reduced expression of the CYP19A1 in cumulus cells of infertile women with endometriosis, which may play a role in the pathogenesis of endometriosis-related infertility.