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

Why should we check the tubes in IVF patients with ovarian endometriosis before embryo transfer? a retrospective study

BACKGROUND

The endometrioma accompanying hydrosalpinx can affect the success rate of in vitro fertilization (IVF). We aimed to determine the incidence of hydrosalpinx in infertile patients with endometrioma and its effects on in vitro fertilization success.

METHODS

In our retrospective study, we performed hysterosalpingography (HSG) on patients diagnosed with endometrioma through ultrasound evaluation. Then, we performed diagnostic laparoscopy on patients with suspected tubal pathology and/or hydrosalpinx after HSG assessment. Laparoscopic tubal occlusion was performed for patients with hydrosalpinx.

RESULTS

HSG was performed on 760 patients diagnosed with ovarian endometriosis. After the assessment of HSG images, hydrosalpinx was detected in 184 of 760 patients (24.2%) and diagnostic laparoscopy was performed. Unilateral or bilateral hydrosalpinx were detected at 65 of 184 (35.3%) patients. Laparoscopy and proximal tubal occlusion were performed in these patients. Incidence of hydrosalpinx was found to be 8.5% in IVF patients with ovarian endometrioma.

CONCLUSION

Tubal patency screening may be considered for the patients with endometrioma before embryo transfer to prevent IVF failure due to hydrosalpinx.

Upregulated let-7 expression in the follicular fluid of patients with endometriomas leads to dysfunction of granulosa cells through targeting of IGF1R

STUDY QUESTION

What molecular mechanisms underlie the decline in ovarian reserve as the number and quality of oocytes decrease in patients with ovarian endometriomas (OEM)?

SUMMARY ANSWER

Elevated expression of the let-7 micro(mi)RNAs in the follicular microenvironment of OEM-affected ovaries targets the expression of type 1 insulin-like growth factor receptor (IGF1R) in granulosa cell (GC) and disrupts their proliferation, steroid hormone secretion levels, adenosine triphosphate (ATP) energy metabolism, and reactive oxygen species (ROS) oxidative stress levels.

WHAT IS KNOWN ALREADY

Patients with OEM exhibit diminished ovarian reserve, characterized by reduced oocyte quantity and quality. Fibrotic changes in the ovarian tissue surrounding the OEM create a disruptive microenvironment for follicular growth and development.

STUDY DESIGN, SIZE, DURATION

This is a cross-sectional study aimed to elucidate the molecular mechanisms underlying the impact of OEM on follicular development. Initially, miRNA expression profiles in follicular fluid (FF) samples were sequenced from patients with infertility related to OEM (N = 3) and male factor (MF) infertility (N = 3), with the latter serving as the control group. Differentially expressed miRNAs were validated in additional samples from each group (N = 55 in OEM group and N = 45 in MF group) to confirm candidate miRNAs. The study also investigated indicators associated with GCs dysfunction in vitro on rat GCs. Subsequently, rat models of OEM were established through endometrial allogeneic transplantation, and fertility experiments were conducted to assess the let-7/IGF1R axis response to OEM in vivo. Patient samples were collected between May 2018 and April 2019, and the mechanistic study was conducted over the subsequent three years.

PARTICIPANTS/MATERIALS, SETTING, METHODS

FF and GC samples were obtained from infertile patients undergoing IVF treatment for OEM and MF related infertility. miRNA expression profiles in FF samples were analyzed using second-generation high-throughput sequencing technology, and candidate miRNAs were validated through quantitative PCR (qPCR). In the in vitro experiments conducted with rat GCs, cell proliferation was assessed using the CCK-8 assay, while steroid hormone concentrations were measured using chemiluminescence. ATP content was determined with an ATP assay kit, and levels of ROS were quantified using flow cytometry. A dual luciferase reporter gene assay was employed to identify the target gene of let-7 based on the construction of a IGF1R reporter gene plasmid using 293T cells. Western blotting was utilized to evaluate the expression of IGF1R in GCs, as well as its downstream proteins, and changes in signaling pathways following let-7 agomir/antagomir transfection and/or Igf1r silencing. In the in vivo OEM rat models, alterations in ovarian structure and cyst morphology were observed using hematoxylin and eosin staining. The expressions of let-7 and Igf1r in GCs were evaluated through qPCR, while variations in IGF1R expression were investigated with immunohistochemistry.

MAIN RESULTS AND THE ROLE OF CHANCE

The cohort of patients with ovarian OEM in this study exhibited significantly decreased antral follicle counts, oocyte retrieval numbers, and normal fertilization rates compared to the control group with MF. The expression of the let-7 miRNA family was markedly upregulated in the FF and GCs of OEM patients. Transfection of rat GCs with let-7 agonists diminished the functions of GCs, including disrupted cell proliferation, mitochondrial oxidative phosphorylation, and steroid hormone secretion, while transfection of rat GCs with let-7 antagonists caused the opposite effects. Luciferase reporter gene experiments confirmed that let-7 complementarily bound to the 3'-untranslated regions of IGF1R. Stimulation of let-7 expression in rat GCs led to a significant decrease in IGF1R expression, while inhibition of let-7 increased IGF1R expression. The expression of IGF1R in the GCs of OEM patients was also significantly reduced compared to MF patients. Silencing of Igf1r led to the dysfunction of GCs, similar to the effects of let-7 agonization, as demonstrated by the downregulation of key proteins involved in cell proliferation (CCND2 and CCND3) and oestradiol synthesis, as well as an increase in progesterone synthesis (StAR), while implicating the PI3K-Akt and MAPK signaling pathways. The antagonistic effect of let-7 on GCs was ineffective when Igf1r was silenced. Conversely, the agonistic effect of let-7 on GCs could be reversed by stimulation with the IGF1R ligand IGF-1. These findings suggested that let-7 regulated the proliferation, differentiation, and ATP synthesis of GCs through targeting IGF1R. The OEM rat model demonstrated alterations in ovarian morphology and structure, along with reduced fertility. Let-7 expression was significantly upregulated in GCs of OEM rats compared to normal rats, while Igf1r and IGF1R expression in pre-ovulatory follicular GCs were notably downregulated, supporting the notion that elevated let-7 expression in the follicular microenvironment of OEM inhibited IGF1R, leading to abnormal GC function and impacting fertility at the molecular level.

LARGE SCALE DATA

N/A.

LIMITATIONS, REASONS FOR CAUTION

The synthesis and secretion mechanisms of steroid hormones are intricate and complex. Some enzymes that regulate oestrogen synthesis also play a role in progesterone synthesis. Moreover, certain receptors can respond to multiple hormone signals. Therefore, in this study, the expression patterns of key enzymes such as CYP17A, CYP11A1, HSD3B2, StAR, and receptors including AR, LHCGR, FSHR, ESR2, might be influenced by various factors and might not demonstrate complete consistency.

WIDER IMPLICATIONS OF THE FINDINGS

Future research will concentrate on investigating the potential impact of ovarian stromal cells on the external microenvironment of follicle growth. Additionally, screening for small molecule drugs that target let-7 and IGF1R actions can be conducted to intervene and modify the ovarian microenvironment, ultimately enhancing ovarian function.

STUDY FUNDING/COMPETING INTEREST(S)

This study received funding from the National Natural Science Foundation of China (grant number 82301851 to L.B.S., grant numbers U23A20403 and U20A20349 to S.Y.Z., and grant number 82371637 to Y.D.D.) and the Natural Science Foundation of Zhejiang Province (grant LTGY23H040010 to F.Z.). The authors have no conflicts of interest to declare.

Oocyte Quality in Women with Endometriosis

BACKGROUND

Endometriosis is a chronic gynecological condition that affects approximately 10% of women of reproductive age globally. It is associated with significant morbidity due to symptoms such as pelvic pain and infertility. Current knowledge suggests that endometriosis impacts oocyte quality, a critical factor for successful fertilization and pregnancy. Despite extensive research, the exact mechanisms remain unclear, and further updates are necessary to optimize treatment strategies.

OBJECTIVES

This review aims to summarize current evidence regarding the impact of endometriosis on oocyte quality and its subsequent effects on fertility outcomes, particularly in the context of in vitro fertilization (IVF).

METHODS

A comprehensive search was conducted in PubMed using the terms "endometriosis AND oocyte quality," "endometriosis AND infertility, and "endometriosis AND IVF." The review included studies published up to July 2024.

OUTCOME

The review findings indicate that endometriosis may be associated with decreased oocyte quality, characterized by impaired morphological features and molecular abnormalities. These defects potentially lead to lower fertilization rates, impaired embryo development, and reduced pregnancy outcomes. However, some studies suggest that with controlled factors such as age and ovarian reserve, IVF outcomes may be comparable to those without endometriosis.

CONCLUSIONS AND OUTLOOK

For clinicians and scientists working in medically assisted reproduction, understanding the impact of endometriosis on oocyte quality is crucial for improving fertility treatment outcomes. Advances in assisted reproductive technologies and personalized treatment approaches may mitigate these adverse effects. The potential for using artificial intelligence to assess oocyte quality presents a promising avenue for future research, as currently there is no direct and objective measure to assess this parameter.

Indirect markers of oocyte quality in patients with ovarian endometriosis undergoing IVF/ICSI: a systematic review and meta-analysis

This systematic review and meta-analysis aimed to evaluate the impact of ovarian endometriomas (OMA) on indirect markers of oocyte quality in patients undergoing IVF, compared with women without anatomical or functional ovarian abnormalities. The search spanned original randomized controlled trials, case-control studies and cohort studies published in MEDLINE, the Cochrane Controlled Trials Register and the ClinicalTrials.gov database up to October 2023. Thirty-one studies were included in the meta-analysis, showing no significant differences in fertilization (OR 1.10, 95% CI 0.94-1.30), blastulation (OR 0.86, 95% CI 0.64-1.14) and cancellation (OR 1.06, 95% CI 0.78-1.44) rates. However, patients with OMA exhibited significantly lower numbers of total and mature (metaphase II) oocytes retrieved (mean difference -1.59, 95% CI -2.25 to -0.94; mean difference -1.86, 95% CI -2.46 to -1.26, respectively), and lower numbers of top-quality embryos (mean difference -0.49, 95% CI -0.92 to -0.06). The Ovarian Sensitivity Index was similar between the groups (mean difference -1.55, 95% CI -3.27 to 0.18). The lack of data published to date prevented meta-analysis on euploidy rate. In conclusion, although the presence of OMA could decrease the oocyte yield in patients undergoing IVF/intracytoplasmic sperm injection, it does not appear to have an adverse impact on oocyte quality.

Endometriosis and In Vitro Fertilization

In vitro fertilization (IVF) is an established option for the management of infertility in patients with endometriosis, though there remains ongoing debate around the extent to which endometriosis may compromise IVF treatment success, in which fertilization and preimplantation embryo development occur outside the pelvis. Whether endometriosis impacts oocyte and embryo quality and/or endometrial receptivity remains central to this debate. Here, we review the current literature relating to the impact of endometriosis on IVF outcomes and management strategies to consider when performing IVF treatment.

Impact of treatment interventions of endometriomas prior to in vitro fertilization: a systematic review and meta-analysis

Background

Treatment of endometrioma before in vitro fertilization (IVF) is challenging as it may affect ovarian response to induction.

Objective

A systematic review to search for the available optimal management of ovarian endometrioma before ovulation induction in IVF.

Search strategy

Screening of the MEDLINE, Web of Science, EMBASE, Cochrane database, and the clinical trial registration sites, covering the period from their inception up to June 2023 was done by two reviewers independently using the keywords ovarian endometrioma, ovarian endometriosis, endometrioma/surgery, endometrioma/hormonal treatment, randomized controlled trial(s), case-controlled studies, and cohort studies.

Selection criteria

All types of studies were included. Participants included were women with unilateral or bilateral ovarian endometriomas candidate for IVF/ICSI. We included 18 studies in the review. Three studies were randomized controlled parallel studies, six were prospective cohort, and nine were retrospective cohort studies.

Data collection and analysis

Data from all included studies were extracted by two authors (A. M., A. O.) independently. Data extracted included sample size, population characteristics including age, BMI, duration of infertility, ovarian reserve markers, cyst size, and bilaterality and induction protocol used.

Main results

We found 18 studies. Women with untreated endometrioma had significantly higher numbers of MII oocytes (the mean difference (MD) effect estimate was − 0.53 with [− 1.04, − 0.01] 95% CI and 0.04 P-value), higher number of obtained embryos (MD effect estimate was − 0.25 with [− 0.38, − 0.11] 95%CI and < 0.001 P-value), and required lower doses of gonadotropins for induction (MD effect estimate was 361.14 with [168.13, 5554.15] 95% CI and < 0.001 P-value) compared to those who had undergone surgical management of endometrioma. However, live birth (OR effect estimate was 0.79 with [0.54, 1.18] 95% CI and 0.25 P-value), clinical pregnancy (OR effect estimate was 0.95 with [0.72, 1.26] 95% CI and 0.73 P-value), miscarriage (OR effect estimate was 0.74 with [0.33, 1.63] 95% CI and 0.45 P-value), cancellation rates (OR effect estimate was 1.62 with [0.57, 4.66] 95% CI and 0.37 P-value), and the duration of stimulation (MD effect estimate was 0.19 with [− 0.42, − 0.81] 95% CI and 0.54 P-value) did not show any significant difference between the two groups of women. Hormonal treatment of endometrioma was associated with higher ongoing pregnancy rate (OR effect estimate was 3.39 with [1.83, 6.26] 95% CI and < 0.001 P-value), higher clinical pregnancy rate (OR effect estimate was 3.36 with [2.01, 5.63] 95% CI and < 0.001 P-value), and higher numbers of MII oocytes (MD effect estimate was 2.04 with [0.72, 3.36] 95% CI and 0.003 P-value) when compared to women who did not receive such therapy. These effects were evident in treatment with GnRH agonists, OCPs (oral contraceptive pills), and dienogest, while the miscarriage and cycle cancellation rates did not show these differences.

Conclusions

The optimal approach for treating endometrioma prior to IVF is not clear yet due to lack of well-designed randomized controlled trials.

Registration number

CRD42020151736.

Systematic review and meta-analysis on the effect of adjuvant gonadotropin-releasing hormone agonist (GnRH-a) on pregnancy outcomes in women with endometriosis following conservative surgery

BACKGROUND

Endometriosis frequently results in pain and infertility. While conservative surgery offers some relief, it often falls short of ensuring satisfactory pregnancy outcomes. Adjuvant GnRH-a is administered post-surgery to mitigate recurrence; however, its impact on pregnancy outcomes remains debated. This study endeavors to assess the efficacy of adjuvant GnRH-a in enhancing pregnancy outcomes post-conservative surgery in endometriosis patients.

METHODS

Databases including PubMed, Embase, the Cochrane Library, Medline (Ovid), Web of Science, and Scopus were rigorously searched up to 02 August 2023, without linguistic constraints. Identified articles were screened using strict inclusion and exclusion criteria. Evaluated outcomes encompassed pregnancy rate, live birth rate, miscarriage rate, ectopic pregnancy rate, multiple pregnancy rate, mean postoperative pregnancy interval, recurrence rate, and adverse reaction rate. The Cochrane risk of bias tool and the Jadad score evaluated the included studies' quality. Subgroup and sensitivity analysis were implemented to analyze the pooled results. A meta-analysis model expressed results as standardized mean difference (SMD) and Risk ratio (RR).

RESULTS

A total of 17 studies about 2485 patients were assimilated. Meta-analysis revealed that post-surgery, the GnRH-a cohort experienced a marginally elevated pregnancy rate (RR = 1.20, 95% CI = 1.02-1.41; P = 0.03) and a reduced mean time to conceive (RR = -1.17, 95% CI = -1.70- -0.64; P < 0.0001). Contrarily, other evaluated outcomes did not exhibit notable statistical differences.

CONCLUSIONS

Incorporating adjuvant GnRH-a following conservative surgery may be deemed beneficial for women with endometriosis, especially before Assisted Reproductive Technology (ART). Nonetheless, owing to pronounced heterogeneity, subsequent research is warranted to substantiate these potential advantages conclusively.

REGISTRATION NUMBER

CRD42023448280.

Epidemiology of infertility in women with endometriosis

Endometriosis is a benign, chronic, inflammatory condition affecting up to 10 % of women and characterised by the presence of glands and stroma tissue outside the uterus. Epidemiological and clinical studies demonstrate a consistent association between endometriosis and infertility. However, this relationship is far to be clearly understood and several mechanisms are involved. Available data show that patients with endometriosis have an increased estimated risk of infertility between two and four times compared with the general population. On the other hand, the probability of patients with infertility to have endometriosis is reported up to about 50 % of the cases. Future studies should aim to better elucidate the mechanisms behind endometriosis-associated infertility in order to offer the more appropriate and tailored management for the patients.

IVF stimulation protocols and outcomes in women with endometriosis

Endometriosis is a complex medical condition with a high prevalence in women of reproductive age. Fertility is compromised in patients with endometriosis, and success in IVF treatments has been a challenge leading to evaluation of different stimulation protocols. The long-standing debate between GnRH agonist long protocols and short GnRH antagonist protocols is being resolved in favor of the latter, since in addition to presenting equivalent results with respect to the traditional option, they have the additional benefit of safety. The good results derived from vitrification techniques have led to the development of new stimulation strategies, such as progestin-primed ovarian stimulation (PPOS), with a greater degree of approval among patients. None of the stimulation protocols currently applied in women with endometriosis has been shown to be superior, so early intervention with an Assisted Reproduction treatment, regardless of the chosen protocol, can provide these women with good chances of motherhood. Women with endometrioma should be counseled for fertility preservation before planned ovarian endometrioma excision. The number of cryopreserved oocytes or embryos can be increased by repeated cycles.

Impact of moderate-to-severe endometriosis on IVF cumulative live birth rate: a retrospective matched cohort study

RESEARCH QUESTION

Does moderate-to-severe endometriosis have an impact on cumulative live birth rates (cLBR) and IVF outcomes?

DESIGN

In this retrospective matched cohort study, women with moderate-to-severe endometriosis undergoing IVF or intracytoplasmic sperm injection treatment from January 2015 to December 2020 were matched 1:2 to women with other causes of infertility (control group). The main outcome was cLBR per cycle and per woman, and secondary outcomes were number of oocytes retrieved and number of mature oocytes, fertilization rate, total number of embryos and usable embryos, implantation rate, clinical pregnancy rate and miscarriage rate per cycle.

RESULTS

In total, 195 women with endometriosis were matched with 390 women without endometriosis (323 and 646 cycles, respectively). Women with endometriosis had significantly fewer oocytes retrieved than women in the control group (P=0.003) despite higher doses of gonadotropins, but had a similar number of mature oocytes, fertilization rate, and total number of embryos and usable embryos. cLBR per cycle and per women did not differ significantly between the endometriosis group and the control group (19.8% versus 24.3%, P = 0.12; 32.3% versus 37.2%, P = 0.24, respectively). In women with endometrioma, a history of cystectomy did not impact cLBR per cycle (28.3% versus 31.9%, P = 0.68). We did not observe any significant impact of tobacco use in the endometriosis group compared with the control group (16.4% versus 25.9%, P = 0.13).

CONCLUSION

This matched cohort study did not observe a significant impact of moderate-to-severe endometriosis on cLBR among women undergoing IVF. These data are reassuring for the counselling of infertile women with endometriosis before IVF.

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.

Evaluation of endometrioma size effect on ovarian reserve, embryo quality and pregnancy outcome after in vitro fertilization cycle; a cross-sectional study

INTRODUCTION

Investigation of endometrioma size and its laterality on the quality of the embryo in patients with endometrioma compared to healthy subjects.

MATERIALS AND METHODS

In this retrospective and cross-sectional study, 70 patients with unilateral and bilateral endometrioma were recruited and compared with 70 age-matched infertile patients as the control group in terms of AMH before ovum pick-up, embryo quality as well as pregnancy outcome. Additionally, in the case group, we divided both unilateral (n = 32) and bilateral endometrioma patients (n = 38) into three groups based on the size of endometrioma. (1-3 cm, 3-6 cm, 6-10 cm) RESULTS: There was no difference in terms of age, BMI, parity, and age of menarche between the case and control groups. Moreover, no significant difference was observed in the baseline level of AMH between the case 2.96 ± 2.72 ng/dl (0.21-11.3) and control 2.73 ± 2.39 (0.21-12.8) groups. (P = 0.59) There was also no significant difference concerning AMH level between unilateral 3.58 ± 3.20 ng/dl (0.21-12.8) and bilateral endometrioma 2.45 ± 2.14 (0.21 - 0.20) groups. In terms of the quality and number of embryos, there was no significant difference between the case and control groups. (P = 0.30) Although the AMH level decreased with the increase in endometrioma size, this difference was not statistically significant. (P = 0.07) There was no significant difference in terms of the embryo quality between the groups based on the size of endometrioma. (P = 0.77) In addition, no significant difference was observed between the case and control groups in the terms of birth weight and pregnancy complications, such as premature delivery, cesarean section rate, neonatal respiratory distress, jaundice, as well as hospitalization rate. Head circumference of the newborns was higher in the endometrioma group while their Apgar score was lower in the case compared to the control group.

CONCLUSION

The presence of endometrioma by itself does not affect the main result of IVF procedures, including the number and quality of embryos and pregnancy outcome. Thus, IVF and embryo preservation and even pregnancy before surgery seem to be reasonable for endometriotic patients.

Endometriosis, Oocyte, and Embryo Quality

Endometriosis is a common finding among women with infertility, and women who are diagnosed with endometriosis are almost twice as likely to experience infertility. Mechanisms by which endometriosis causes infertility remain poorly understood. In this review, we evaluate the current literature on the impact of endometriosis on oocyte and embryo quality. The presence of endometriosis evidently reduces ovarian reserve, oocyte quality, and embryo quality; however, this does not appear to translate to a clear clinical impact. Analysis of data from large assisted reproduction technology registries has shown that women with endometriosis have a lower oocyte yield but no reduction in reproductive outcomes. There is a need for future studies in the form of well-designed randomized controlled trials to further evaluate the role of surgical and medical treatment options in women with endometriosis undergoing assisted conception.

Current Understanding of and Future Directions for Endometriosis-Related Infertility Research with a Focus on Ferroptosis

BACKGROUND

To date, the development of therapy for endometriosis and disease-related infertility remains a major challenge. Iron overload caused by periodic bleeding is a hallmark of endometriosis. Ferroptosis is an iron- and lipid-reactive oxygen species-dependent type of programmed cell death that is distinct from apoptosis, necrosis, and autophagy. This review summarizes the current understanding of and future directions for the research and treatment of endometriosis and disease-related infertility, with the main focus on the molecular basis of ferroptosis in endometriotic and granulosa cells.

METHODS

Papers published between 2000 and 2022 in the PubMed and Google Scholar databases were included in this review.

RESULTS

Emerging evidence suggests that ferroptosis is closely linked to the pathophysiology of endometriosis. Endometriotic cells are characterized by ferroptosis resistance, whereas granulosa cells remain highly susceptible to ferroptosis, suggesting that the regulation of ferroptosis is utilized as an interventional target for research into the treatment of endometriosis and disease-related infertility. New therapeutic strategies are urgently needed to efficiently kill endometriotic cells while protecting granulosa cells.

CONCLUSIONS

An analysis of the ferroptosis pathway in in vitro, in vivo, and animal research enhances our understanding of the pathogenesis of this disease. Here, we discuss the role of ferroptosis modulators as a research approach and potential novel treatment for endometriosis and disease-related infertility.

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

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

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

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

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.

The effect of endometriosis on fertility in an animal model

The present experimental model aimed to investigate the possible effect of endometriosis on ovarian function by altering follicular maturation and development. This single-blind, randomized study included twenty-four female Sprague Dawley mice, 2.5 months old, weighing 160-200 grams. The animals were randomly separated into four groups on the day of the surgery. Each group consisted of 6 mice. The first group (A) consisted of healthy female mice (control group). The second group (B) consisted of mice subjected to surgical insertion of ovarian endometrioma. The third group (C) consisted of mice subjected to surgically induced diffuse intraperitoneal endometriosis, and the fourth group (D) consisted of mice subjected to surgically induced extraperitoneal endometriosis. According to our experimental model, endometriosis may affect ovarian function by increasing the number of luteinized unruptured follicles (follicles that have undergone luteinization without prior rupture).

Does current ovarian endometrioma increase the time for DOR patients to reach live birth in IVF?

BACKGROUND

The contents of ovarian endometrioma (OMA) such as inflammatory mediators, reactive oxygen species, and iron may disrupt normal folliculogenesis and result in subsequent oocyte apoptosis. Therefore, women with OMA have a potential risk of diminished ovarian reserve (DOR). The purpose of this study is to compare the in vitro fertilization (IVF) outcomes and efficiency between DOR patients with and without current OMA.

METHODS

This retrospective case-control study included a total of 493 women with DOR (serum anti-Müllerian hormone level < 1.1 ng/mL). Ninety patients with OMA (Group A) underwent 191 IVF cycles and 403 patients without ovarian OMA (Group B) underwent 888 IVF cycles in our center between January 2014 and December 2018. Basal characteristics and IVF outcomes were compared between Group A and Group B. Time to achieve live birth were compared between patients with live birth in two groups (Group A1, 31 patients; Group B1, 132 patients).

RESULTS

Clinical and demographic characteristics of patients were similar respectively between groups (A vs. B, A1 vs. B1). There were no statistically significant differences in implantation rate, live birth rate per OPU and per ET cycle and the cumulative live birth rate per patient and per patient with good-quality embryos between Group A and Group B (P > 0.05). Total time to achieve live birth has no statistically significant difference between Group A1 and Group B1 (P > 0.05).

CONCLUSION

For DOR women, presence of endometrioma did not affect the IVF outcomes. Even the time to get live birth was not prolonged by current OMA.

Treating Deep Endometriosis in Infertile Patients before Assisted Reproductive Technology

Deep endometriosis (DE) causes infertility and pelvic pain. Surgical management of DE has become a topic of increasing interest in gynecological surgery. In women desirous of pregnancy, optimal management such as surgery versus first-line assisted reproductive technology (ART) for patients with severe endometriosis is strongly debated. Current guidelines and literature including retrospective and prospective studies in English available on DE surgery, infertility, and pregnancy outcomes following surgery were searched in Cochrane Library with DE, DIE, Infertility, "DE surgery and pregnancy outcomes," and "Deep infiltrating endometriosis and assisted reproduction" as keywords. The purpose was to find evidence to answer the following clinical questions: How does DE affect fertility and pregnancy? What are the possible benefits of primary surgery for DIE before in vitro fertilization (IVF)? Several studies have recently concluded that surgical removal of DE nodules might actually have a favorable impact on IVF outcomes. This is in contradiction to European Society of Human Reproduction and Embryology statement which stated that there was no evidence supporting surgical management of DE prior to ART to improve pregnancy rate; several studies have suggested that the surgical removal of DE nodules might actually have a favorable impact on IVF outcomes. Treatment of DE affecting the rectovaginal septum or bowel requires complex surgery with considerable risk of complications. This review article tries to analyze the rationale of surgical treatment of DE before ART. A balance must be struck between exposing the patient to surgical risk and improvement in pain and fertility potential. Decisions should be tailored according to the individual needs of each woman and most importantly on the ability of the surgeons.

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

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

Impact of endometriosis on oocyte morphology in IVF-ICSI: retrospective study of a cohort of more than 6000 mature oocytes

BACKGROUND

Infertility associated with endometriosis can be explained by several non-exclusive mechanisms. The oocyte plays a crucial role in determining embryonic competence and this is particularly relevant for in vitro fertilization (IVF) outcomes. According to some authors, the morphology of oocytes could also be a non-invasive marker of oocyte quality. The aim of this study was to evaluate the relationship between endometriosis and oocyte morphology after controlled ovarian stimulation for intracytoplasmic sperm injection (ICSI) on a large oocyte cohort.

METHODS

Single-center comparative retrospective study in the academic In Vitro Fertilization (IVF) unit of the Lille University Hospital. A total of 596 women treated for IVF-ICSI with ejaculated spermatozoa for sperm alterations were included. They were classified as endometriosis (n = 175) or control groups (n = 401). The morphological evaluation of 2,016 mature oocytes from 348 cycles of patients with endometriosis was compared with that of 4,073 mature oocytes from 576 control cycles. The main outcome measures were Average Oocyte Quality Index (AOQI) and metaphase II oocyte morphological scoring system (MOMS). Comparison of groups was carried out by a mixed linear model and by a generalized estimation equation model with a "patient" random effect to consider that a patient might have several attempts.

RESULTS

No difference in AOQI and MOMS scores was found between endometriosis and control women (adjusted p = 0.084 and 0.053, respectively). In case of endometriosis, there were significantly fewer metaphase II oocytes retrieved, embryos obtained, grade 1 embryos and number of cumulative clinical pregnancies compared to controls. In the endometriosis group, endometriosis surgery was associated with a reduced number of mature oocytes retrieved, and the presence of endometrioma(s) was associated with some abnormal oocyte shapes. Nevertheless, no difference concerning the AOQI and MOMS scores was found in these subgroups.

CONCLUSION

Endometriosis does not have a negative impact on oocytes' morphology in IVF-ICSI.

TRIAL REGISTRATION

On December 16, 2019, the Institutional Review Board of the Lille University Hospital gave unrestricted approval for the anonymous use of all patients' clinical, hormonal and ultrasound records (reference DEC20150715-0002).

Analysis of 2438 cycles for the impact of endometrioma and its surgery on the IVF outcomes

OBJECTIVE

Management of ovarian endometrioma before IVF treatment is still challenging. We aimed to assess the effect of the pre-cycle surgical removal of endometriomas on IVF outcomes in a large number of cycles in patients undergoing IVF/ICSI treatment. Besides this, we also proposed to compare the cycle outcomes within both normo and poor responder patients to evaluate the impact of endometrioma and its surgery.

STUDY DESIGN

A retrospective cohort study was conducted in a private IVF clinic between September 2014 and December 2018. A total of 2438 IVF/ICSI cycles of 1936 patients were reviewed. Patients who had previous endometrioma surgery (Group 1), patients with non-operated endometrioma (Group 2), and patients without endometriosis, including tubal factor infertility confirmed by laparoscopy and unexplained infertility without endometrioma (Group 3) were analyzed in this study.

RESULTS

Total dose of gonadotropins was significantly higher in group 1 than others (p < 0.05). However, antral follicle counts, estradiol levels on the day of hCG trigger, the number of retrieved and metaphase II oocytes were significantly lower in group 1 than in other groups (p < 0.05). Poor response to gonadotropins was more frequent in group 1 as compared to other groups (47.9%, 34.3%, 35.5%, respectively) (p < 0.05). Cycle cancellation rates were significantly higher in group 1 than in other groups (6.7%, 1.4%, and 2.8%, respectively) (p < 0.05). Clinical pregnancy (CPR) and live birth rates (LBR) per cycle and embryo transfer were not different among groups. However, CPR per cycle and embryo transfer were significantly higher in the operated endometrioma group within unexpected poor responders (p = 0.023, p = 0.010, respectively). CPR and LBR per cycle and per embryo transfer were similar within normo-responder patients. Multiple logistic regression analysis revealed that female age and poor response to gonadotropins were the significant variables in predicting live birth (OR: 0.946, CI: 0.926-0.966, p < 0.001 and OR: 3.294, CI: 2.336-4.645, p < 0.001, respectively).

CONCLUSION

Pre-cyle removal of endometrioma may have an adverse impact on ovarian reserve, and pregnancy outcomes seem to be similar with or without surgery in patients undergoing IVF treatment. However, endometrioma surgery may be considered in the subsequent IVF cycles of patients with lower than expected ovarian response.

The Impact of Endometriosis on Embryo Quality in in-vitro Fertilization/Intracytoplasmic Sperm Injection: A Systematic Review and Meta-Analysis

Background: The association between endometriosis and embryological outcomes remains uncertain. The meta-analysis aimed to evaluate the impact of endometriosis on embryo quality.

Methods: A systematic review and meta-analysis was conducted to investigate the association between the endometriosis and embryo quality. Searches were performed on the three electronic databases: PubMed, EMBASE, and Web of Science. The detailed characteristics and data of the included studies were extracted. The risk ratio with 95% confidence intervals were calculated using the random and fixed effects model. The main outcome measures were high-quality embryo rate, cleavage rate, and embryo formation rate.

Results: A total of 22 studies included were analyzed. Compared with the control group, women with endometriosis had a similar high-quality embryo rate (RR = 1.00; 95% CI, 0.94–1.06), a comparable cleavage rate (RR = 1.00; 95% CI, 0.97–1.02), and a similar embryo formation rate (RR = 1.10; 95% CI, 0.97–1.24). In women with stage III-IV endometriosis, there was no statistically significantly difference in high-quality embryo rate (RR = 1.02; 95% CI, 0.94–1.10), cleavage rate (RR = 1.00; 95% CI, 0.98–1.02), and embryo formation rate (RR = 1.05; 95% CI, 0.97–1.14), compared with those without endometriosis. For women with unilateral endometrioma, pooling of results from the affected ovaries did not show a statistically significantly difference in high-quality embryo rate (RR = 0.99; 95% CI, 0.60–1.63) in comparison to the normal contralateral ovaries.

Conclusions: Our results seem to indicate that endometriosis does not compromise embryo quality from the perspective of morphology.

The impact of endometriosis on the outcome of assisted reproductive techniques: role of fertility preservation

Endometriosis is one of the most common diseases associated with infertility. It requires different therapeutic approaches, depending on the type, whether superficial, ovarian or deep endometriotic nodules, clinical presentation, age or origin of infertility. Patients with endometriosis should be considered a group of high-risk for infertility and any intervention should be planned taking this consideration into account. For many years, surgery was the only tool in improving fertility outcomes. Nowadays, it remains the gold standard for the treatment of endometriosis, but it should be carefully used because of its harmful potential, leading to premature ovarian insufficiency and further infertility. With the development of modern assisted reproductive techniques (ART), which can offer better results in terms of fertility, the role of surgery progressively decreased. Nowadays, therapeutic approach is complex and multidisciplinary teams should be guiding individual treatment for each woman. Options include medical treatment, surgery, in vitro fertilization (IVF) or oocytes/embryo/ovarian tissue cryopreservation. There is a constant effort in developing diagnostic scores, in order to predict risk of infertility and create standard of practice, offering a long-term approach in terms of fertility preservation and quality of life.

Early Pregnancy Outcomes in Fresh Versus Deferred Embryo Transfer Cycles for Endometriosis-Associated Infertility: A Retrospective Cohort Study

Given the estrogen-dependence associated with endometriosis, hyper-stimulation associated with assisted reproduction treatment may exacerbate the disease process and adversely affect endometrial receptivity and subsequent implantation. In this way, a freeze-all deferred embryo transfer (ET) approach may benefit patients with endometriosis, although controversy exists regarding the mechanism of endometriosis-associated infertility and benefits of deferred ET on endometrial receptivity. Hence, the purpose of this study was to compare in vitro fertilization (IVF) outcomes in women with endometriosis, diagnosed by histology, undergoing fresh versus deferred-ET after elective cryopreservation. Of the 728 women included, no significant differences were observed in baseline patient characteristics and response to gonadotrophin stimulation between fresh and deferred ET groups. Furthermore, no significant differences in implantation rate (49.7 vs. 49.9%, p = 0.73), clinical pregnancy rate (40.9 vs. 39.9%, p = 0.49), and miscarriage rate (9.4 vs. 9.9%, p = 0.63) were observed between fresh and deferred ET groups, respectively. Hence, contrary to previous studies, our results suggest that a deferred ET “freeze-all” IVF strategy does not improve early pregnancy outcomes among women with endometriosis. However, prospective studies are required to validate these findings and further insight into the etiology and pathogenesis of endometriosis-associated infertility are necessary to optimize IVF protocols in this population.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Analysis of IVF/ICSI Outcomes in Endometriosis Patients With Recurrent Implantation Failure: Influence on Cumulative Live Birth Rate

OBJECTIVE

To study the influence of endometriosis activity on the pregnancy outcomes of patients with recurrent implantation failure (RIF) in in-vitro fertilization/intra-cytoplasmic sperm injection (IVF/ICSI) cycles. The pregnancy outcomes were compared between RIF patients with endometriosis who received treatment at different occasions to explore the appropriate treatment plan for these patients and to optimize the pregnancy-support strategies.

DESIGN

Ambispective cohort study.

METHODS

A total of 330 patients with endometriosis were enrolled from 2008 to 2018 and included 1043 IVF/ICSI cycles. All patients were diagnosed with RIF after IVF/ICSI. Patients were assigned to three subtypes according to different control states of endometriosis, including the untreated, early-treatment, and late-treatment groups. The clinical pregnancy rate, live birth rate, and cumulative live birth rate of endometriosis patients with RIF were the main outcomes; additionally, the fertilization rate, available embryonic rate, and high-quality embryonic rate were also compared.

RESULTS

The early-treatment and late-treatment groups showed higher cumulative live birth rate than the untreated group (early-treated 43.6% vs. late-treated 46.3% vs. untreated 27.7%, P<0.001), though patients in the two treatment groups had higher rates of adenomyosis and ovarian surgery. The two treatment group showed a better laboratory result than the untreated and especially, the early-treatment group. The untreated group (46.24%) had a lower IVF fertilization rate than the treated group (early-treated [64.40%] and late-treated [60.27%] (P<0.001). In addition, the rates of available embryos and high-quality embryos in the early-treated group were much higher those that in the untreated group (90.30% vs. 85.20%, 76.50% vs. 64.47%). Kaplan-Meier curve showed that patients in the untreated group needed a mean of 23.126 months to achieve one live birth; whereas those in the treated group needed a comparatively shorter duration (early-treated: 18.479 ± 0.882 months and late-treated: 14.183 ± 1.102 months, respectively).

CONCLUSION

Endometriosis has a negative influence on IVF/ICSI outcome. The control of endometriosis activity can result in a higher cumulative live birth rate in patients. It is necessary for endometriosis patients to receive medical treatment to achieve a better prognosis especially for those with RIF.

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

OBJECTIVE

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

DATA SOURCES

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

TABULATION, INTEGRATION, AND RESULTS

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

CONCLUSION

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

The impact of endometrioma on in vitro fertilisation/intra-cytoplasmic injection IVF/ICSI reproductive outcomes: a systematic review and meta-analysis

Background

Assisted reproductive technologies (ART) such as in vitro fertilisation (IVF) and intra-cytoplasmic sperm injection (ICSI) are often used to aid fertility in women with endometrioma; however, the implications of endometrioma on ART are unresolved.

Objective

To determine the effect of endometrioma on reproductive outcomes in women undergoing IVF or ICSI.

Methods

A systematic review and meta-analysis was conducted to identify articles examining women who had endometrioma and had undergone IVF or ICSI. Electronic searches were performed in PubMed, BIOSIS and MEDLINE up to September 2019. The primary outcome was live birth rate (LBR). Secondary outcomes included clinical pregnancy rate (CPR), implantation rate (IR), number of oocytes retrieved, number of metaphase II (MII) oocytes retrieved, number of embryos and top-quality embryos and the duration of gonadotrophin stimulation and dose.

Results

Eight studies were included. Where significant heterogeneity between studies was identified, a random-effects model was used. The number of oocytes (weighted means difference; WMD-2.25; 95% CI 3.43 to − 1.06, p = 0.0002) and the number of MII oocytes retrieved (WMD-4.64; 95% CI 5.65 to − 3.63, p < 0.00001) were significantly lower in women with endometrioma versus controls. All other outcomes, including gonadotrophin dose and duration, the total number of embryos, high-quality embryos, CPR, IR and LBR were similar in women with and without endometrioma.

Conclusion

Even though women with endometriomas had a reduced number of oocytes and MII oocytes retrieved when compared to women without, no other differences in reproductive outcomes were identified. This implies that IVF/ICSI is a beneficial ART approach for women with endometrioma.

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

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

Reproductive, obstetric, and perinatal outcomes of women with adenomyosis and endometriosis: a systematic review and meta-analysis

BACKGROUND

The reproductive impact of adenomyosis and endometriosis is widely researched but the extent of these impacts remains elusive. It has been demonstrated that endometriosis, in particular, is known to result in subfertility but endometriosis and adenomyosis are increasingly linked to late pregnancy complications such as those caused by placental insufficiency. At the molecular level, the presence of ectopic endometrium perturbs the endometrial hormonal, cellular, and immunological milieu, negatively influencing decidualization, placentation, and developmental programming of the embryo. It is unclear if and how such early aberrant reproductive development relates to pregnancy outcomes in endometriosis and adenomyosis.

OBJECTIVE AND RATIONALE

The aims of this systematic review and meta-analysis were to (i) investigate the association of adenomyosis and endometriosis with fertility, obstetric, and neonatal outcomes of women through both assisted reproduction and natural conception and (ii) determine whether endometriosis disease subtypes have specific impacts on different stages of the reproductive process.

SEARCH METHODS

A systematic literature review of NHS evidence electronic databases and the Cochrane database identified all comparative and observational studies between 1980 and December 2018 in any language on adenomyosis and endometriosis with fertility, obstetric, and neonatal outcomes (23 search terms used). A total of 104 papers were selected for data extraction and meta-analysis, with use of Downs and Black standardized checklist to evaluate quality and bias.

OUTCOMES

We found that endometriosis consistently leads to reduced oocyte yield and a reduced fertilization rate (FR), in line with current evidence. Milder forms of endometriosis were most likely to affect the fertilization (FR OR 0.77, CI 0.63-0.93) and earlier implantation processes (implantation rate OR 0.76, CI 0.62-0.93). The more severe disease by American Society for Reproductive Medicine staging (ASRM III and IV) influenced all stages of reproduction. Ovarian endometriosis negatively affects the oocyte yield (MD -1.22, CI -1.96, -0.49) and number of mature oocytes (MD -2.24, CI -3.4, -1.09). We found an increased risk of miscarriage in both adenomyosis and endometriosis (OR 3.40, CI 1.41-8.65 and OR 1.30, CI 1.25-1.35, respectively), and endometriosis can be associated with a range of obstetric and fetal complications including preterm delivery (OR 1.38, CI 1.01-1.89), caesarean section delivery (OR 1.98 CI 1.64-2.38), and neonatal unit admission following delivery (OR 1.29, CI 1.07-1.55).

WIDER IMPLICATIONS

Adenomyosis and the subtypes of endometriosis may have specific complication profiles though further evidence is needed to be able to draw conclusions. Several known pregnancy complications are likely to be associated with these conditions. The complications are possibly caused by dysfunctional uterine changes leading to implantation and placentation issues and therefore could potentially have far-reaching consequences as suggested by Barker's hypothesis. Our findings would suggest that women with these conditions should ideally receive pre-natal counselling and should be considered higher risk in pregnancy and at delivery, until evidence to the contrary is available. In order to expand our knowledge of these conditions and better advise on future management of these patients in reproductive and maternal medicine, a more unified approach to studying fertility and reproductive outcomes with longer term follow-up of the offspring and attention to the subtype of disease is necessary.

Elevated Levels of Monocyte Chemotactic Protein-1 in the Follicular Fluid Reveals Different Populations among Women with Severe Endometriosis

To determine if a modification of the cytokine profile occurs in the follicular fluid (FF) of women with endometriosis undergoing in vitro fertilization (IVF), we performed a prospective observational study from January 2018 to February 2019. In total, 87 women undergoing IVF were included: 43 for severe endometriosis-related infertility and 40 controls with other causes of infertility. The cytokine profile of the FF was determined by multiplex fluorescent-bead-based technology allowing the measurement of 59 cytokines. Monocyte Chemoattractant Protein 1 (MCP-1) was the only variable retained in the multivariate analysis. We identified two subgroups of patients in the endometriosis group: MCP-1-low group (n = 23), which had FF MCP-1 levels comparable to the control group, and MCP-1-high (n = 20), which had significantly higher FF levels. Only patients in the MCP-1-high group had a significantly altered cytokine profile in the FF, and had a significantly higher serum estradiol level (p = 0.002) and a significantly lower number of oocytes recovered (p = 0.01) compared to the MCP-1-low and the control group. Our study has shown an alteration of the oocyte microenvironment in women with endometriosis associated with high follicular fluid levels of MCP-1, allowing the identification of a subgroup of endometriosis patients with a potentially worse prognosis.

Do ovarian endometriomas affect ovarian response to ovarian stimulation for IVF/ICSI?

RESEARCH QUESTION

Does the presence of ovarian endometriomas affect ovarian response to ovarian stimulation after adjusting for age and ovarian reserve markers?

DESIGN

This retrospective cross-sectional study compared the ovarian response between patients with ovarian endometriomas and women with other infertility factors undergoing their first ovarian stimulation for IVF/intracytoplasmic sperm injection (ICSI). An age-specific nomogram model for the number of oocytes retrieved was built for both groups, and ovarian response was compared after adjusting for age, gonadotrophin dose, anti-Mullerian hormone (AMH) concentration and antral follicle count (AFC).

RESULTS

A total of 923 patients were included: 101 women with at least one ovarian endometrioma, and 822 patients with other infertility factors. Comparisons of the nomograms for the number of oocytes retrieved demonstrated that response was significantly lower for women with endometrioma when the results were adjusted for age the z-score for the number of oocytes retrieved (-0.49 ± 0.71 versus -0.20 ± 0.86; 95% confidence interval [CI] -0.47 to -0.12) and also after adjustment for the total dose of gonadotrophins and AMH values (z-score mean difference -0.338; 95% CI -0.54, -0.14). When the z-score was adjusted for gonadotrophin dose and AFC, the number of oocytes retrieved was comparable between the two groups (z-score mean difference -0.038; 95% CI -0.34 to 0.27).

CONCLUSIONS

Ovarian response after ovarian stimulation for IVF/ICSI in women with endometriomas is significantly lower than in controls after adjusting for age, gonadotrophin dose and AMH. Dose and protocol selection for ovarian stimulation in patients with endometrioma should be based on AFC rather than AMH, as the latter may be overestimated.

Peripheral Estrogens in Women with Endometriosis Undergoing IVF

A consistent body of in vitro evidence supports a detrimental effect of endometriosis on ovarian steroidogenesis, in particular the synthesis of estrogens. However, clinical evidence is scanty and methodologically weak. This study aimed at clarifying whether peripheral 17-β-estradiol during IVF are influenced by the presence of endometriosis. Women undergoing IVF were retrospectively reviewed. Cases were women with a diagnosis of endometriosis. Controls were matched to cases in a 1:1 ratio by study period, age, total number of developed follicles on the day of hCG administration, protocol of hyperstimulation, gonadotropin used, and starting dose. The primary outcome was the ratio between serum levels of 17-β-estradiol and the total number of developed follicles. Fifty-three women with endometriosis and 53 controls were selected. The median ratio (interquartile range) between serum 17-β-estradiol and the total number of developed follicles in the two groups was 207 (164-282) and 201 (144-268) pg/ml, respectively (p = 0.46). Sensitivity analyses on the magnitude of the follicular response, the history of surgery for endometriomas, and the presence of endometriomas did not show any subgroup at increased risk of peripheral estrogens impairment. Endometriosis does not influence peripheral levels of 17-β-estradiol during IVF. Our findings argue against a biologically relevant effect of the disease on ovarian estrogen-synthesis.

Metformin induces lipid changes on sphingolipid species and oxidized lipids in polycystic ovary syndrome women

Metformin is one of the treatments used for PCOS pathology decreasing body weight, plasma androgen, FSH and glucose levels. Unfortunately, there is little known about metformin's effects on lipid metabolism, a crucial process in PCOS pathology. We have employed a lipidomic approach to explore alterations in the plasma lipid profile of patients with PCOS following metformin treatment. The aim is to offer new insights about the effect of metformin in PCOS patients. Plasma samples were obtained from 27 subjects prior to and following 12 weeks of metformin treatment. A detailed biochemical characterization and lipidomic profile was performed. Metformin reduces BMI, HOMA-IR, FSH and androstenedione and increases DHEA-S but no changes were found in glucose levels after treatment. Multivariate statistics revealed a specific lipidomic signature due to the effect of 12 weeks of metformin treatment in PCOS patients. This signature includes changes in sphingolipid metabolism suggesting a crosstalk between these lipid species and the androgenic metabolism and a decrease in oxidized lipids reinforcing that metformin treatment improves oxidative stress status. Our study confirms the specific effect of metformin in lipid metabolism on women with PCOS after 12 weeks of treatment.

Rethinking mechanisms, diagnosis and management of endometriosis

Endometriosis is a chronic inflammatory disease defined as the presence of endometrial tissue outside the uterus, which causes pelvic pain and infertility. This disease should be viewed as a public health problem with a major effect on the quality of life of women as well as being a substantial economic burden. In light of the considerable progress with diagnostic imaging (for example, transvaginal ultrasound and MRI), exploratory laparoscopy should no longer be used to diagnose endometriotic lesions. Instead, diagnosis of endometriosis should be based on a structured process involving the combination of patient interviews, clinical examination and imaging. Notably, a diagnosis of endometriosis often leads to immediate surgery. Therefore, rethinking the diagnosis and management of endometriosis is warranted. Instead of assessing endometriosis on the day of the diagnosis, gynaecologists should consider the patient's 'endometriosis life'. Medical treatment is the first-line therapeutic option for patients with pelvic pain and no desire for immediate pregnancy. In women with infertility, careful consideration should be made regarding whether to provide assisted reproductive technologies prior to performing endometriosis surgery. Modern endometriosis management should be individualized with a patient-centred, multi-modal and interdisciplinary integrated approach.

Effect of Endometrioma cystectomy on cytokines of follicular fluid and IVF outcomes

Background

Endometriosis patients undergoing in vitro fertilization-embryo transfer (IVF-ET) treatment suffer from lower success rates. The success of IVF-ET is related to the receptivity of the uterus and the quality of embryos, and it is well known a patient’s endometriosis does not impair the receptivity. Whether endometrioma should be removed surgically before IVF remains controversial. Studies have shown that endometrioma removal decreases peritoneal inflammation, but little information is available regarding the alteration in the cytokines of follicular fluid. The objective of this study was to examine the impact of endometrioma cystectomy on the outcome of IVF and the levels of intrafollicular inflammatory cytokines and to investigate correlations between cytokine concentrations and IVF outcomes.

Method

A total of 41 women with endometriosis-associated infertility undergoing IVF were recruited; 13 patients (surgery group, S group) had surgery to remove the endometrioma before enrollment, and 28 patients (non-surgery group, NS group) were untreated before IVF. The follicular fluid from a dominant follicle was collected during oocyte retrieval, and the concentrations of sixteen soluble cytokines known to be involved in ovarian function were measured.

Results

Among the soluble molecules examined in this study, chemokines and growth factors and a few are inflammatory cytokines were found in the follicular fluid of patients with endometriosis. In addition, the expression levels of chemokines, growth factors, and most inflammatory cytokines did not differ between the S and NS groups, but interleukin (IL)-18 levels were significantly lower in the NS group. However, the levels of IL-18 in the FF did not correlate with IVF cycle parameters. The implantation and clinical pregnancy rates were similar between the two groups, but the anti-Müllerian hormone (AMH) level was lower in the S group than in the NS group.

Conclusions

These findings suggest that endometrioma surgery may potentially reduce the ovarian reserve and has little impact on the success rate of IVF. Ovarian endometriomas are not associated with cytokine profiles in FF from infertile women, and they are not likely to affect the quality of the oocyte and embryo as a result of an inflammatory mechanism.

Endometriosis and cumulative live birth rate after fresh and frozen IVF cycles with single embryo transfer in young women: no impact beyond reduced ovarian sensitivity-a case control study

Purpose

To investigate the impact of symptomatic and surgically confirmed endometriosis on ovarian sensitivity index (OSI) and cumulative live-birth rates (LBR) using predominantly single embryo transfer (SET).

Methods

Cross-sectional case-control study in a University-based ART program. Women with symptomatic and surgically confirmed endometriosis (N = 172), who underwent IVF/ICSI at Karolinska University Hospital were compared to controls without clinically suspected endometriosis (N = 2585). Two thousand seven hundred fifty-seven patients underwent 8236 treatment cycles (4598 fresh and 3638 frozen cycles). Primary outcome measures included Ovarian Sensitivity Index (OSI) estimated as collected oocytes/FSH dose and cumulative LBR/oocyte pickup (OPU). Generalized estimated equation (GEE) model accounting for dependencies between consecutive treatments were applied. Secondary outcomes included number of oocytes, pregnancy rate per OPU and per ET, LBR per ET, and miscarriage rate.

Results

Patients diagnosed with endometriosis had significantly fewer oocytes collected (8.47 vs. 9.54, p = 0.015) and lower OSI (p = 0.011) than controls. There were no differences in cycle cancelations (p = 0.59) or miscarriages (p = 0.95) between the two groups. Cumulative LBR/OPU did not differ between women with endometriosis and controls (35.6% vs. 34.7%, respectively, p = 0.83). In both groups, more than 60% of women had consecutive FETs after fresh ETs (p = 0.49) with SET in > 70% of cases. The results were similar whether ovarian endometrioma was present or not.

Conclusions

Our data support that a diagnosis of endometriosis, with or without present endometrioma, does not negatively affect ART cumulative results. The impact of endometriosis was discernible on OSI but not on clinical relevant outcomes including pregnancy and LBR.

Does the anti-Müllerian hormone truly reflect ovarian response in women with endometrioma?

In this study, our aim was to determine which factor is more correlated with the number of oocytes retrieved in patients with endometrioma compared with controls undergoing in vitro fertilisation-intracytoplasmic sperm injection (IVF-ICSI) cycles: antral follicle count (AFC) or anti-Müllerian hormone (AMH). A total of 60 women with endometrioma and a control population of 60 women without endometrioma in the same period were randomly selected underwent the injection IVF-ICSI treatment. No significant differences were found between the groups in terms of age (28.78 ± 3.49 vs. 29.52 ± 2.47, p = .187), body mass index (23.62 ± 2.05 vs. 23.91 ± 2.11, p = .449), duration of infertility [(3 (2-4) vs. 3 (2-3), p = .139)], AMH level (1.52 ± 0.51 vs. 1.32 ± 0.92, p = .133), duration of stimulation [(9 (9-10) vs. 10 (9-10), p = .135)], total gonadotropin dose [(2750 (2262.5-3337.5) vs. 2770 (2680-3562.5), p = .125)], endometrial thickness [(10 (10-11) vs. 10 (9-11), p = .463)], fertilisation rates (67.20 ± 18.04 vs. 62.28 ± 17.13, p = .123), grade I embryo (43.3% vs. 30%, p = .185), clinical pregnancy rates (40% vs. 26.7%, p = .123), and the perinatal outcomes between the groups. The AFC was higher in the controls than in those with endometrioma (9.20 ± 1.80 vs. 6.32 ± 2.04, p < .001). The number of oocytes retrieved was also higher in the controls than in those with endometrioma [(7 (6-8) vs. 4 (4-5.75), p < .001)]. We found that women with endometrioma had a significantly lower number of oocytes retrieved than the controls despite the same AMH levels in both groups. AFC is a better marker of ovarian response than AMH in women with endometrioma undergoing IVF-ICSI. Impact statement What is already known on this subject? Utilising the ovarian reserve is important in the success of ovarian stimulation and in evaluating the success of assisted reproductive technologies. The anti-Müllerian hormone (AMH) level and the antral follicle count (AFC) are widely used in the prediction of ovarian functional reserve and response. However, no perfect marker exists in the evaluation of ovarian reserve and ovarian response. What do the results of this study add? Our study demonstrated that women with endometrioma have a significantly lower number of oocytes retrieved than the controls, despite the same AMH levels in both groups; which strongly suggests that AFC is a better reflection of ovarian response than AMH in women with endometrioma undergoing an in vitro fertilisation-intracytoplasmic sperm injection (IVF-ICSI). What are the implications of these findings for clinical practice and/or further research? This important issue has been reviewed and discussed for years, however, the conclusions are still controversial. Additional research is needed to understand which ovarian reserve test could better predict ovarian response outcome?

Endometrioma, fertility, and assisted reproductive treatments: connecting the dots

PURPOSE OF REVIEW

Surgery has traditionally been the primary treatment option for endometriosis-related infertility of any phenotype. However, advances and refinements of assisted reproductive technologies (ART) permit a more conservative approach in many scenarios. This review summarizes the latest findings in the field of reproductive medicine, which have supported a paradigm shift towards more conservative management of ovarian endometrioma.

RECENT FINDINGS

The presence of ovarian endometrioma per se is likely to impair ovarian reserve and alter ovarian functional anatomy. Conventional laparoscopic surgery is associated with significant risk of additional damage, and less invasive treatment approaches require further evaluation. With regard to infertile women with ovarian endometrioma who are scheduled for ART treatment, current data indicate that prior surgical intervention does not improve ART outcomes, and that controlled ovarian hyperstimulation (COH) does not affect quality of life or pain symptoms.

SUMMARY

Reproductive medicine physicians frequently encounter patients with ovarian endometrioma. The current evidence does not support the postponement of infertility treatment in favour of surgery, except in cases with severe symptoms or to improve follicle accessibility. Although these patients may exhibit diminished ovarian response to COH, their endometrial receptivity, aneuploidy rates, and fertility outcomes are similar to healthy controls. Surgery for ovarian endometrioma provides no benefits in ART treatments.

Fertility After Ovarian Cystectomy: How Does Surgery Affect IVF/ICSI Outcomes?

Introduction For patients considering undergoing assisted reproductive techniques (ART), many concerns arise when persistent ovarian cysts are found. This large study aimed to determine how ovarian cyst removal affects success rates of IVF/ICSI therapies.

Methods 550 patients who underwent an IVF/ICSI treatment between 2002 and 2011 with a persistent ovarian cyst ≤ 5 cm before treatment were analyzed retrospectively. 328 patientsʼ preference was to undergo a laparoscopic cystectomy and 222 patients opted for a conservative management. Control subjects included 13 552 patients undergoing IVF/ICSI at the same period of time without an ovarian cyst.

Results After adjusting for age, patients with ovarian cysts without surgery needed a significant higher stimulation dose than the control group (2576.4 vs. 2207.5 IU, p < 0.001). However, on average, they had 1.13 (− 0.25 – 2.01) higher oocyte number retrieved compared to the operated patients (9.0 ± 5.5 vs. 8.2 ± 5.0) (p = 0.012). Patients after surgical cyst removal had a significant lower number of oocytes retrieved (MNOR) in comparison to the control group (8.2 ± 5.0 vs. 9.5 ± 5.4) (p = 0.00). Compared to controls, operated patients had similar clinical pregnancy rate (CPR) (34.2 vs. 33.5%) OR 1.031 (95% CI 0.817 – 1.302) (p = 0.815). Compared to controls, patients without surgery showed significant lower pregnancy rate (34.2 vs. 25,7%) OR 1.428 (95% CI 1.054 – 1.936) (p = 0.002) and lower live birth rate (LBR) (21.9 vs. 13.5%) OR 1.685 (95% CI 1.143 – 2.485) (p = 0.008).

Conclusions Ovarian cystectomy did not negatively impact the pregnancy rate or the live birth rate compared to controls.

Risk factors for inadequate response to ovarian stimulation in assisted reproduction cycles: systematic review

PURPOSE

Controlled ovarian stimulation is a fundamental part of a successful assisted reproduction treatment, and recognizing patients at risk of a poor response allows the development of targeted research to propose new treatment strategies for this specific group. The objective of this systematic review was to determine risk factors for poor ovarian response (POR) to controlled stimulation in assisted reproduction cycles described in the literature.

METHODS

The primary databases MEDLINE, Cochrane, LILACS, and SciELO were consulted, using specific terms with a restriction for articles in English or Portuguese published in the last 10 years.

RESULTS AND CONCLUSION

Our data suggest that environmental endocrine disruptors, tobacco, genetic mutations, endometriomas, ovarian surgery, chemotherapy, and short menstrual cycles are factors that influence stimulation in assisted reproduction cycles. Further studies are necessary for characterizing patients with prior risk factors.

Could surgical management improve the IVF outcomes in infertile women with endometrioma?: a review

Endometriosis is a chronic inflammatory condition that affects fertility and could be toxic to the ovary. Endometrioma per se and surgical interventions for endometrioma significantly reduce the ovarian reserve. Therefore, to prepare for surgical intervention for endometrioma, the high-risk group with decreased ovarian reserve must be considered. There is no evidence to support the use of surgical intervention before in vitro fertilization (IVF) to improve the reproductive outcomes of subsequent IVF in infertile women with advanced-stage endometriosis or endometrioma. As surgical treatment has few benefits, IVF could be recommended immediately for aiding conception in these women. However, the reproductive prognosis of IVF may be worse in the more advanced stages of endometriosis. When dysmenorrhea is severe or when cancer is suspected, surgery prior to IVF may be necessary and justified. When the size of the endometrioma is very large, surgery could be required prior to IVF to facilitate access to follicles during oocyte retrieval or to improve the ovarian response to controlled ovarian stimulation. Prolonged pituitary downregulation in women with surgically diagnosed endometriosis may be helpful to increase the clinical pregnancy rate in subsequent IVF cycles. The purpose of this paper was to review the efficiency and clinical application of the surgical intervention and IVF for infertile women with advanced-stage endometriosis or endometrioma.

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.