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Gazzo I, Moffa F, Ferrero S. Fertility preservation in women with endometriosis: Oocyte cryopreservation and other techniques. Best Pract Res Clin Obstet Gynaecol 2024:102503. [PMID: 38777734 DOI: 10.1016/j.bpobgyn.2024.102503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 05/02/2024] [Indexed: 05/25/2024]
Abstract
In recent years, advancements in cryopreservation techniques for oocytes, embryos, and ovarian tissue have enabled offering fertility preservation (FP) options to women with endometriosis. It is recommended to always conduct specialized counselling on FP, especially before considering surgical interventions for endometriosis. The decision regarding the methods of FP, the timing, and to which women affected by endometriosis these techniques should be offered are still subjects of discussion. However, several studies suggest that it can be proposed before surgical interventions for endometriosis, particularly if the patient is undergoing mono or bilateral endometrioma surgery. The most recommended technique is ovarian stimulation, followed by oocyte cryopreservation. Nevertheless, the literature contains various studies describing FP through embryo cryopreservation or the retrieval and cryopreservation of ovarian tissue.
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Affiliation(s)
- Irene Gazzo
- DINOGMI, University of Genova, Genova, Italy; IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | | | - Simone Ferrero
- DINOGMI, University of Genova, Genova, Italy; IRCCS Ospedale Policlinico San Martino, Genova, Italy.
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Goyri E, Kohls G, Garcia-Velasco J. IVF stimulation protocols and outcomes in women with endometriosis. Best Pract Res Clin Obstet Gynaecol 2024; 92:102429. [PMID: 38100935 DOI: 10.1016/j.bpobgyn.2023.102429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 11/10/2023] [Indexed: 12/17/2023]
Abstract
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.
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Choi YJ, Hong YH, Paik H, Kim SK, Lee JR, Suh CS. A Successful Live Birth From a Vitrified Oocyte for Fertility Preservation of a Patient With Borderline Ovarian Tumor Undergoing Bilateral Ovarian Surgery: A Case Report. J Korean Med Sci 2024; 39:e14. [PMID: 38193330 PMCID: PMC10782042 DOI: 10.3346/jkms.2024.39.e14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 11/03/2023] [Indexed: 01/10/2024] Open
Abstract
This article reports the live birth of a healthy newborn using vitrified-warmed oocytes from fertility preservation before ovarian surgery. The patient in our case underwent two cycles of controlled ovarian stimulation before laparoscopic bilateral ovarian cystectomy for endometriosis, and a total of 23 mature oocytes were vitrified. After surgery, her pathologic reports revealed a serous borderline tumor and endometrioma. Fifteen months after her second surgery of laparoscopic right salpingo-oophorectomy and left ovarian cystectomy owing to recurrence, she had been married by then, and three of the frozen oocytes were thawed for intracytoplasmic sperm injection. These oocytes were cryopreserved for 2.5 years. All three were fertilized, and two grade-A cleavage-stage embryos were transferred. A singleton pregnancy was achieved, resulting in the delivery of a healthy baby boy at 39.3 weeks of gestation. Oocyte cryopreservation is an effective method for fertility preservation prior to ovarian surgery when ovarian function decline is predictable.
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Affiliation(s)
- Yae Ji Choi
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
| | - Yeon Hee Hong
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
| | - Haerin Paik
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
| | - Seul Ki Kim
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
| | - Jung Ryeol Lee
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea.
| | - Chang Suk Suh
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
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Mifsud JM, Pellegrini L, Cozzolino M. Oocyte Cryopreservation in Women with Ovarian Endometriosis. J Clin Med 2023; 12:6767. [PMID: 37959232 PMCID: PMC10649633 DOI: 10.3390/jcm12216767] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 10/14/2023] [Accepted: 10/23/2023] [Indexed: 11/15/2023] Open
Abstract
Ovarian endometriosis is a gynecological condition that is closely associated with infertility-from its pathogenesis to treatment modalities, this condition presents a challenge both for patients and clinicians alike when seeking conception, due to low AMH levels, peritoneal inflammation, and the inadvertent removal of healthy ovarian parenchyma at surgery. In fact, around half of endometriosis patients seeking fertility require tertiary-level assisted reproduction techniques to achieve a live birth. Oocyte cryopreservation, a procedure initially designed for oncology patients, has emerged over recent years as a very promising treatment strategy for patients who have been diagnosed with ovarian endometriosis in order to preserve their fertility and obtain a live birth at a later stage in their lives. Counseling patients about oocyte preservation techniques at an early stage in the diagnosis, ideally before the age of 35 and especially prior to any surgical treatment, provides an excellent opportunity to discuss future fertility and the benefits associated with oocyte cryopreservation.
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Affiliation(s)
- Judith-Marie Mifsud
- IVIRMA Global Research Alliance, IVIRMA Roma, 00169 Rome, Italy; (J.-M.M.); (L.P.)
| | - Livia Pellegrini
- IVIRMA Global Research Alliance, IVIRMA Roma, 00169 Rome, Italy; (J.-M.M.); (L.P.)
| | - Mauro Cozzolino
- IVIRMA Global Research Alliance, IVIRMA Roma, 00169 Rome, Italy; (J.-M.M.); (L.P.)
- IVIRMA Global Research Alliance, IVI Foundation, Instituto de Investigación Sanitaria La Fe (IIS La Fe), 46026 Valencia, Spain
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Kalaitzopoulos DR, Samartzis N, Eberhard M, Grigoriadis G, Miliaras D, Papanikolaou A, Daniilidis A. Co-Existence of Endometriosis with Ovarian Dermoid Cysts: A Retrospective Cohort Study. J Clin Med 2023; 12:6308. [PMID: 37834953 PMCID: PMC10574005 DOI: 10.3390/jcm12196308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 09/24/2023] [Accepted: 09/27/2023] [Indexed: 10/15/2023] Open
Abstract
Both endometriosis and ovarian dermoid cysts are benign conditions characterized by the presence of well-differentiated tissues in ectopic locations. The presence and surgical excision of these entities can potentially impact ovarian reserves, contributing to reduced chances of future pregnancy. The objective of our study is to investigate the bidirectional association between endometriosis and ovarian dermoid cysts, as well as to analyze the clinical characteristics of patients diagnosed with both conditions. A retrospective cohort study was conducted, including women who underwent laparoscopy and received histological diagnoses of endometriosis and/or dermoid cysts between 2011 and 2019 at the Cantonal Hospital of Schaffhausen. We identified 985 women with endometriosis and 83 women with ovarian dermoid cysts. Among these groups, 22 women presented with both endometriosis and ovarian dermoid cysts. The majority of the above patients had endometriosis stage rASRM I-II (72.7%), with peritoneal endometriosis being the most common phenotype of endometriosis (77.2%). Out of the 14 patients with a desire for future pregnancy, the majority (11/14, 78.5%) had an EFI score of 7-8. The prevalence of bilateral ovarian dermoid cysts was higher in women with both ovarian dermoid cysts and endometriosis in comparison to women with ovarian dermoid cysts without endometriosis (18% vs. 6.5%). Our study revealed that 26.5% of women with ovarian dermoid cysts also had endometriosis, a notably higher prevalence than observed in the general population. Clinicians should be aware of this co-existence, and preoperative counseling should be an integral part of the care plan for affected individuals, where the potential risks and the available options for fertility preservation should be discussed in detail.
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Affiliation(s)
| | - Nicolas Samartzis
- Department of Obstetrics and Gynecology, Cantonal Hospital of Schaffhausen, 8208 Schaffhausen, Switzerland; (N.S.); (M.E.)
| | - Markus Eberhard
- Department of Obstetrics and Gynecology, Cantonal Hospital of Schaffhausen, 8208 Schaffhausen, Switzerland; (N.S.); (M.E.)
| | - Georgios Grigoriadis
- 2nd University Department in Obstetrics and Gynecology, Hippokratio General Hospital, School of Medicine, Aristotle University of Thessaloniki, 54643 Thessaloniki, Greece; (G.G.)
| | - Dimosthenis Miliaras
- Laboratory of Histology and Embryology, School of Medicine, Aristotle University of Thessaloniki, 54643 Thessaloniki, Greece;
| | - Alexis Papanikolaou
- 2nd University Department in Obstetrics and Gynecology, Hippokratio General Hospital, School of Medicine, Aristotle University of Thessaloniki, 54643 Thessaloniki, Greece; (G.G.)
| | - Angelos Daniilidis
- 1st University Department in Obstetrics and Gynaecology, Papageorgiou General Hospital, School of Medicine, Aristotle University of Thessaloniki, 54643 Thessaloniki, Greece
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Chen LH, Lo WC, Huang HY, Wu HM. A Lifelong Impact on Endometriosis: Pathophysiology and Pharmacological Treatment. Int J Mol Sci 2023; 24:ijms24087503. [PMID: 37108664 PMCID: PMC10139092 DOI: 10.3390/ijms24087503] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 04/06/2023] [Accepted: 04/16/2023] [Indexed: 04/29/2023] Open
Abstract
Endometriosis is a chronic inflammatory disease associated with bothersome symptoms in premenopausal women and is complicated with long-term systemic impacts in the post-menopausal stage. It is generally defined by the presence of endometrial-like tissue outside the uterine cavity, which causes menstrual disorders, chronic pelvic pain, and infertility. Endometriotic lesions can also spread and grow in extra-pelvic sites; the chronic inflammatory status can cause systemic effects, including metabolic disorder, immune dysregulation, and cardiovascular diseases. The uncertain etiologies of endometriosis and their diverse presentations limit the treatment efficacy. High recurrence risk and intolerable side effects result in poor compliance. Current studies for endometriosis have paid attention to the advances in hormonal, neurological, and immunological approaches to the pathophysiology and their potential pharmacological intervention. Here we provide an overview of the lifelong impacts of endometriosis and summarize the updated consensus on therapeutic strategies.
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Affiliation(s)
- Liang-Hsuan Chen
- Department of Obstetrics and Gynecology, Linkou Medical Center, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan 33305, Taiwan
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
| | - Wei-Che Lo
- Department of Obstetrics and Gynecology, Linkou Medical Center, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan 33305, Taiwan
| | - Hong-Yuan Huang
- Department of Obstetrics and Gynecology, Linkou Medical Center, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan 33305, Taiwan
| | - Hsien-Ming Wu
- Department of Obstetrics and Gynecology, Linkou Medical Center, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan 33305, Taiwan
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
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Fertility preservation for women with ovarian endometriosis: results from a retrospective cohort study. Reprod Biomed Online 2023; 46:332-337. [PMID: 36564221 DOI: 10.1016/j.rbmo.2022.11.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 11/22/2022] [Accepted: 11/23/2022] [Indexed: 12/03/2022]
Abstract
RESEARCH QUESTION What is the outcome of fertility-preservation treatments in women with endometrioma, especially those with endometrioma larger than 4 cm? DESIGN Retrospective cohort study. Women with definitive diagnosis of ovarian endometriosis (by histology or ultrasound), who underwent fertility-preservation treatment in two IVF units between 2016 and 2021, were included. As some women cryopreserved oocytes and other embryos, the primary outcome was the number of metaphase II (MII) oocytes retrieved. RESULTS Seventy-one women with ovarian endometriosis (OMA) underwent 138 fertility-preservation cycles. The median age of patients was 31 years. Forty out of 71 (56%) women underwent at least one surgery for OMA before fertility-preservation treatment. Multivariate analysis of each patient's first cycle was used. Women who underwent OMA surgery before fertility-preservation treatment had a 51.7% reduction (95% CI 26.1 to 68.5, P = 0.001) in the number of MII oocytes compared with women with OMA who did not undergo surgery. Among a subgroup who did not undergo surgery, those with an endometrioma larger than 4 cm had similar anti-Müllerian hormone concentration (2.6 ng/ml versus 2.1 ng/ml), number of oocytes retrieved (9 versus 9) and number of MII oocytes (7.6 versus seven 7) compared with women with an endometrioma of 4 cm or less. CONCLUSIONS Discussing fertility-preservation treatment options with patients with OMA is recommended, especially if surgery is planned.
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Bonavina G, Taylor HS. Endometriosis-associated infertility: From pathophysiology to tailored treatment. Front Endocrinol (Lausanne) 2022; 13:1020827. [PMID: 36387918 PMCID: PMC9643365 DOI: 10.3389/fendo.2022.1020827] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 10/06/2022] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Giulia Bonavina
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT, United States
| | - Hugh S Taylor
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT, United States
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Oocyte Cryopreservation in Patients with Endometriosis: Current Knowledge and Number Needed to Treat. J Clin Med 2022; 11:jcm11154559. [PMID: 35956174 PMCID: PMC9369629 DOI: 10.3390/jcm11154559] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 08/02/2022] [Accepted: 08/03/2022] [Indexed: 02/06/2023] Open
Abstract
The rise of oocytes cryopreservation (OOC) in assisted reproductive techniques allows fertility preservation (FP) in an increasing number of indications. Endometriosis, a highly prevalent disease, potentially impairing ovarian reserve, seems, therefore, an interesting indication for it. The purpose of this study is to summarize the available evidence concerning FP by OOC in women with endometriosis and to calculate the number needed to treat (NNT). In total, 272 articles related to this topic were identified in PubMed. Eight studies were eligible for the review. In order to shed some light, a SWOT analysis was performed and the argument pros and cons were developed. The NNT calculated of OOC was 16, meaning that 16 women need to perform an OOC for one of them to have a child that she would not have had without this technique. In conclusion, OOC must be discussed with patients who suffer from endometriosis since it is an effective technique of FP, which can allow these patients to succeed a pregnancy that they otherwise would not have achieved. Nevertheless, it should not be performed in all patients as there is still a lack of robust socio-economic and risk–benefit data.
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Endometriosis and Infertility: A Long-Life Approach to Preserve Reproductive Integrity. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19106162. [PMID: 35627698 PMCID: PMC9141878 DOI: 10.3390/ijerph19106162] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 05/01/2022] [Accepted: 05/06/2022] [Indexed: 02/04/2023]
Abstract
Laparoscopic surgery was originally considered the gold standard in the treatment of endometriosis-related infertility. Assisted reproductive technology (ART) was indicated as second-line treatment or in the case of male factor. The combined approach of surgery followed by ART proved to offer higher chances of pregnancy in infertile women with endometriosis. However, it was highlighted how pelvic surgery for endometriosis, especially in cases of ovarian endometriomas, could cause iatrogenic damage due to ovarian reserve loss, adhesion formation (scarring), and ischemic damage. Furthermore, in the last few years, the trend to delay the first childbirth, recent technological advances in ultrasound diagnosis, and technological progress in clinical and laboratory aspects of ART have certainly influenced the approach to infertility and endometriosis with, ART assuming a more relevant role. Management of endometriosis should take into account that the disease is chronic and involves the reproductive system. Consequently, treatment and counselling should aim to preserve the chances of pregnancy for the patient, even if it is not associated with infertility. This review will analyse the evolution of the management of infertility associated with endometriosis and propose an algorithm for treatment decision-making based on the most recent acquisitions.
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Becker CM, Bokor A, Heikinheimo O, Horne A, Jansen F, Kiesel L, King K, Kvaskoff M, Nap A, Petersen K, Saridogan E, Tomassetti C, van Hanegem N, Vulliemoz N, Vermeulen N. ESHRE guideline: endometriosis. Hum Reprod Open 2022; 2022:hoac009. [PMID: 35350465 PMCID: PMC8951218 DOI: 10.1093/hropen/hoac009] [Citation(s) in RCA: 348] [Impact Index Per Article: 174.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Indexed: 12/14/2022] Open
Abstract
STUDY QUESTION How should endometriosis be diagnosed and managed based on the best available evidence from published literature? SUMMARY ANSWER The current guideline provides 109 recommendations on diagnosis, treatments for pain and infertility, management of disease recurrence, asymptomatic or extrapelvic disease, endometriosis in adolescents and postmenopausal women, prevention and the association with cancer. WHAT IS KNOWN ALREADY Endometriosis is a chronic condition with a plethora of presentations in terms of not only the occurrence of lesions, but also the presence of signs and symptoms. The most important symptoms include pain and infertility. STUDY DESIGN SIZE DURATION The guideline was developed according to the structured methodology for development of ESHRE guidelines. After formulation of key questions by a group of experts, literature searches and assessments were performed. Papers published up to 1 December 2020 and written in English were included in the literature review. PARTICIPANTS/MATERIALS SETTING METHODS Based on the collected evidence, recommendations were formulated and discussed within specialist subgroups and then presented to the core guideline development group (GDG) until consensus was reached. A stakeholder review was organized after finalization of the draft. The final version was approved by the GDG and the ESHRE Executive Committee. MAIN RESULTS AND THE ROLE OF CHANCE This guideline aims to help clinicians to apply best care for women with endometriosis. Although studies mostly focus on women of reproductive age, the guideline also addresses endometriosis in adolescents and postmenopausal women. The guideline outlines the diagnostic process for endometriosis, which challenges laparoscopy and histology as gold standard diagnostic tests. The options for treatment of endometriosis-associated pain symptoms include analgesics, medical treatments and surgery. Non-pharmacological treatments are also discussed. For management of endometriosis-associated infertility, surgical treatment and/or medically assisted reproduction are feasible. While most of the more recent studies confirm previous ESHRE recommendations, there are five topics in which significant changes to recommendations were required and changes in clinical practice are to be expected. LIMITATIONS REASONS FOR CAUTION The guideline describes different management options but, based on existing evidence, no firm recommendations could be formulated on the most appropriate treatments. Also, for specific clinical issues, such as asymptomatic endometriosis or extrapelvic endometriosis, the evidence is too scarce to make evidence-based recommendations. WIDER IMPLICATIONS OF THE FINDINGS The guideline provides clinicians with clear advice on best practice in endometriosis care, based on the best evidence currently available. In addition, a list of research recommendations is provided to stimulate further studies in endometriosis. STUDY FUNDING/COMPETING INTERESTS The guideline was developed and funded by ESHRE, covering expenses associated with the guideline meetings, with the literature searches and with the dissemination of the guideline. The guideline group members did not receive payments. C.M.B. reports grants from Bayer Healthcare and the European Commission; Participation on a Data Safety Monitoring Board or Advisory Board with ObsEva (Data Safety Monitoring Group) and Myovant (Scientific Advisory Group). A.B. reports grants from FEMaLE executive board member and European Commission Horizon 2020 grant; consulting fees from Ethicon Endo Surgery, Medtronic; honoraria for lectures from Ethicon; and support for meeting attendance from Gedeon Richter; A.H. reports grants from MRC, NIHR, CSO, Roche Diagnostics, Astra Zeneca, Ferring; Consulting fees from Roche Diagnostics, Nordic Pharma, Chugai and Benevolent Al Bio Limited all paid to the institution; a pending patent on Serum endometriosis biomarker; he is also Chair of TSC for STOP-OHSS and CERM trials. O.H. reports consulting fees and speaker's fees from Gedeon Richter and Bayer AG; support for attending meetings from Gedeon-Richter, and leadership roles at the Finnish Society for Obstetrics and Gynecology and the Nordic federation of the societies of obstetrics and gynecology. L.K. reports consulting fees from Gedeon Richter, AstraZeneca, Novartis, Dr KADE/Besins, Palleos Healthcare, Roche, Mithra; honoraria for lectures from Gedeon Richter, AstraZeneca, Novartis, Dr KADE/Besins, Palleos Healthcare, Roche, Mithra; support for attending meetings from Gedeon Richter, AstraZeneca, Novartis, Dr KADE/Besins, Palleos Healthcare, Roche, Mithra; he also has a leadership role in the German Society of Gynecological Endocrinology (DGGEF). M.K. reports grants from French Foundation for Medical Research (FRM), Australian Ministry of Health, Medical Research Future Fund and French National Cancer Institute; support for meeting attendance from European Society for Gynaecological Endoscopy (ESGE), European Congress on Endometriosis (EEC) and ESHRE; She is an advisory Board Member, FEMaLe Project (Finding Endometriosis Using Machine Learning), Scientific Committee Chair for the French Foundation for Research on Endometriosis and Scientific Committee Chair for the ComPaRe-Endometriosis cohort. A.N. reports grants from Merck SA and Ferring; speaker fees from Merck SA and Ferring; support for meeting attendance from Merck SA; Participation on a Data Safety Monitoring Board or Advisory Board with Nordic Pharma and Merck SA; she also is a board member of medical advisory board, Endometriosis Society, the Netherlands (patients advocacy group) and an executive board member of the World Endometriosis Society. E.S. reports grants from National Institute for Health Research UK, Rosetrees Trust, Barts and the London Charity; Royalties from De Gruyter (book editor); consulting fees from Hologic; speakers fees from Hologic, Johnson & Johnson, Medtronic, Intuitive, Olympus and Karl Storz; Participation in the Medicines for Women's Health Expert Advisory Group with Medicines and Healthcare Products Regulatory Agency (MHRA); he is also Ambassador for the World Endometriosis Society. C.T. reports grants from Merck SA; Consulting fees from Gedeon Richter, Nordic Pharma and Merck SA; speaker fees from Merck SA, all paid to the institution; and support for meeting attendance from Ferring, Gedeon Richter and Merck SA. The other authors have no conflicts of interest to declare. DISCLAIMER This guideline represents the views of ESHRE, which were achieved after careful consideration of the scientific evidence available at the time of preparation. In the absence of scientific evidence on certain aspects, a consensus between the relevant ESHRE stakeholders has been obtained. Adherence to these clinical practice guidelines does not guarantee a successful or specific outcome, nor does it establish a standard of care. Clinical practice guidelines do not replace the need for application of clinical judgement to each individual presentation, nor variations based on locality and facility type. ESHRE makes no warranty, express or implied, regarding the clinical practice guidelines and specifically excludes any warranties of merchantability and fitness for a particular use or purpose (Full disclaimer available at www.eshre.eu/guidelines.).
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Affiliation(s)
- Christian M Becker
- Nuffield Department of Women’s and Reproductive Health, Endometriosis CaRe
Centre, University of Oxford, Oxford, UK
| | - Attila Bokor
- Department of Obstetrics and Gynecology, Semmelweis University,
Budapest, Hungary
| | - Oskari Heikinheimo
- Department of Obstetrics & Gynecology, University of Helsinki and Helsinki
University Hospital, Helsinki, Finland
| | - Andrew Horne
- EXPPECT Centre for Endometriosis and Pelvic Pain, MRC Centre for Reproductive
Health, University of Edinburgh, Edinburgh, UK
| | - Femke Jansen
- EndoHome—Endometriosis Association Belgium, Belgium
| | - Ludwig Kiesel
- Department of Gynecology and Obstetrics, University Hospital
Muenster, Muenster, Germany
| | | | - Marina Kvaskoff
- Paris-Saclay University, UVSQ, Univ. Paris-Sud, Inserm, Gustave Roussy,
“Exposome and Heredity” Team, CESP, Villejuif, France
| | - Annemiek Nap
- Department of Gynaecology and Obstetrics, Radboudumc, Nijmegen,
The Netherlands
| | | | - Ertan Saridogan
- Department of Obstetrics and Gynaecology, University College London
Hospital, London, UK
- Elizabeth Garrett Anderson Institute for Women’s Health, University College
London, London, UK
| | - Carla Tomassetti
- Department of Obstetrics and Gynaecology, Leuven University Fertility Center,
University Hospitals Leuven, Leuven, Belgium
- Faculty of Medicine, Department of Development and Regeneration, LEERM (Lab of
Endometrium, Endometriosis and Reproductive Medicine), KU Leuven, Leuven,
Belgium
| | - Nehalennia van Hanegem
- Department of Reproductive Medicine and Gynecology, University Medical Center
Utrecht, Utrecht, The Netherlands
| | - Nicolas Vulliemoz
- Department of Woman Mother Child, Fertility Medicine and Gynaecological
Endocrinology, Lausanne University Hospital, Lausanne, Switzerland
| | - Nathalie Vermeulen
- European Society of Human Reproduction and Embryology,
Strombeek-Bever, Belgium
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Hong YH, Kim SK, Lee JR, Jee BC, Suh C. Clinical efficacy of dual trigger with human chorionic gonadotropin and a gonadotropin‐releasing hormone agonist for women undergoing fertility preservation. Reprod Med Biol 2022; 21:e12440. [PMID: 35386366 PMCID: PMC8967295 DOI: 10.1002/rmb2.12440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 01/04/2022] [Accepted: 01/12/2022] [Indexed: 11/28/2022] Open
Abstract
Purpose To determine the optimal maturation method to increase the yield of mature oocytes, especially for cancer patients with fewer chances of fertility preservation (FP) before gonadotoxic therapy. Methods A total of 373 cycles in 293 patients undergoing controlled ovarian stimulation (COS) for FP using a gonadotropin‐releasing hormone (GnRH) antagonist protocol were enrolled. The control group (n = 225) received 250 µg of recombinant human chorionic gonadotropin (rhCG) while the study group (n = 148) received 250 µg of rhCG and 0.2 mg of triptorelin for triggering. Subgroup analyses were performed for stimulation cycles with diminished ovarian reserve (DOR; anti‐Müllerian hormone (AMH) levels <1.1 ng/ml, n = 86), with endometrioma (n = 104), or with breast cancer and endometrial cancer using 5 mg of letrozole during the COS cycles (n = 84). Results There was no significant difference in the baseline characteristics or the number of total and mature oocytes between the two groups. Subgroup analyses for women with endometrioma or DOR showed similar results. However, the dual trigger group had a significantly higher number of mature oocytes than the rhCG trigger group in breast and endometrial cancer patients using letrozole during the COS cycles (6.9 ± 6.0 vs. 4.6 ± 3.6, p = 0.034). The maturation rate was higher in the dual trigger group, although the difference was not statistically significant (59.3 ± 26.7 vs. 50.0 ± 28.0, p = 0.124). Conclusions Dual triggering can be an efficient maturation method to maximize the yield of mature oocytes in breast or endometrial cancer patients using letrozole‐combined GnRH antagonist protocol for FP.
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Affiliation(s)
- Yeon Hee Hong
- Department of Obstetrics and Gynecology Seoul National University Bundang Hospital Seongnam Korea
- Department of Obstetrics and Gynecology Seoul National University College of Medicine Seoul Korea
| | - Seul Ki Kim
- Department of Obstetrics and Gynecology Seoul National University Bundang Hospital Seongnam Korea
- Department of Obstetrics and Gynecology Seoul National University College of Medicine Seoul Korea
| | - Jung Ryeol Lee
- Department of Obstetrics and Gynecology Seoul National University Bundang Hospital Seongnam Korea
- Department of Obstetrics and Gynecology Seoul National University College of Medicine Seoul Korea
| | - Byung Chul Jee
- Department of Obstetrics and Gynecology Seoul National University Bundang Hospital Seongnam Korea
- Department of Obstetrics and Gynecology Seoul National University College of Medicine Seoul Korea
| | - Chang Suk Suh
- Department of Obstetrics and Gynecology Seoul National University College of Medicine Seoul Korea
- Department of Surgical Oncology Sheikh Khalifa Specialty Hospital Ras Al Khaimah United Arab Emirates
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Can progesterone primed ovarian stimulation (PPOS) be introduced in elective fertility preservation? Results from vitrified oocytes from the oocyte donation program. Reprod Biomed Online 2022; 44:1015-1022. [DOI: 10.1016/j.rbmo.2022.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 02/03/2022] [Accepted: 02/04/2022] [Indexed: 11/22/2022]
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Younis JS, Shapso N, Izhaki I. Is ovarian reserve reduction following endometriotic cystectomy predicted? The implication for fertility preservation counseling. Front Endocrinol (Lausanne) 2022; 13:996531. [PMID: 36213292 PMCID: PMC9532518 DOI: 10.3389/fendo.2022.996531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 09/07/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- Johnny S. Younis
- Reproductive Medicine, Department of Obstetrics and Gynecology, Baruch-Padeh Medical Center, Poriya, Israel
- Azrieili Faculty of Medicine, Bar-Ilan University, Safed, Israel
- *Correspondence: Johnny S. Younis,
| | - Nora Shapso
- Reproductive Medicine, Department of Obstetrics and Gynecology, Baruch-Padeh Medical Center, Poriya, Israel
| | - Ido Izhaki
- Department of Evolutionary and Environmental Biology, University of Haifa, Haifa, Israel
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Younis JS. Is Oocyte Quality Impaired in Cases With Ovarian Endometriosis? A Second Look Into the Clinical Setting. Front Endocrinol (Lausanne) 2022; 13:921032. [PMID: 35846314 PMCID: PMC9279608 DOI: 10.3389/fendo.2022.921032] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 06/06/2022] [Indexed: 11/24/2022] Open
Affiliation(s)
- Johnny S. Younis
- Reproductive Medicine, Department of Obstetrics and Gynecology, Baruch-Padeh Medical Center, Poriya, Israel
- Azrieili Faculty of Medicine in Galilee, Safed, Bar-Ilan University, Safed, Israel
- *Correspondence: Johnny S. Younis,
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Legrand C, Keller L, Collinet P, Barbotin AL, Béhal H, Rubod C, Decanter C. Oocyte accumulation for fertility preservation in women with benign ovarian tumours with a history of previous surgery, multiple or large cysts. Reprod Biomed Online 2021; 43:205-214. [PMID: 34247989 DOI: 10.1016/j.rbmo.2021.04.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 04/23/2021] [Accepted: 04/27/2021] [Indexed: 10/21/2022]
Abstract
RESEARCH QUESTION What are ovarian stimulation cycle outcomes and acceptance rates of an oocyte accumulation programme in young women with benign ovarian tumour (BOT)? DESIGN Retrospective cohort study conducted at the Academic Assisted Reproductive Technology and Fertility Preservation Centre, Lille University Hospital, between January 2016 and December 2019. The number of metaphase II oocytes per cycle and per patient after accumulation were evaluated. Two groups were identified for the analysis: endometrioma ('endometrioma') and dermoid, mucinous or serous cyst ('other cysts'). RESULTS A total of 113 fertility-preservation cycles were analysed in 70 women aged 27.9 ± 4.8 years. Almost all women had undergone previous ovarian surgery before fertility preservation (89%). Mean anti-Müllerian hormone levels before ovarian stimulation was 12.5 ± 8.7 pmol/l. A total of 6.4 ± 3.4 oocytes were retrieved, and 4.3 ± 3.4 metaphase II (MII) oocytes were vitrified per cycle. All agreed to the oocyte accumulation programme and all underwent at least one cycle. To date, 36 (51%) patients achieved two or three fertility- preservation cycles. After accumulation, 7.0 ± 5.23 MII oocytes were vitrified per patient. No difference was found in ovarian response and oocyte cohort between the 'endometrioma' and 'other cysts' groups. Questionnaires completed after oocyte retrieval revealed abdominal bloating and pelvic pain in most patients, with no difference according to the type of cyst. No serious adverse events occurred. CONCLUSIONS Oocyte accumulation should be systematically offered to young women with BOT irrespective of histological type, as it seems to be well-tolerated. Long-term follow-up is needed to assess the efficiency of oocyte accumulation to optimize the chances of subsequent pregnancies.
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Affiliation(s)
- Charlotte Legrand
- Centre d'Assistance Médicale à la Procréation et de Préservation de la Fertilité, Hôpital Jeanne de Flandre, Centre Hospitalier Universitaire de Lille, Lille F-59000, France.
| | - Laura Keller
- Institut de Biologie de la Reproduction-Spermiologie-CECOS, Hôpital Jeanne de Flandre, Centre Hospitalier Universitaire de Lille, Lille F-59000, France
| | - Pierre Collinet
- Service de Chirurgie Gynécologique, Centre Hospitalier Universitaire de Lille, Lille F-59000, France; Université Lille Nord de France, Faculté de Médecine, Lille F-59000, France
| | - Anne Laure Barbotin
- Institut de Biologie de la Reproduction-Spermiologie-CECOS, Hôpital Jeanne de Flandre, Centre Hospitalier Universitaire de Lille, Lille F-59000, France
| | - Hélène Béhal
- Université Lille Nord de France, Faculté de Médecine, Lille F-59000, France; ULR 2694 - METRICS, Évaluation des technologies de santé et des pratiques médicales, Centre Hospitalier Universitaire de Lille, Lille F-59000, France
| | - Chrystele Rubod
- Service de Chirurgie Gynécologique, Centre Hospitalier Universitaire de Lille, Lille F-59000, France; Université Lille Nord de France, Faculté de Médecine, Lille F-59000, France
| | - Christine Decanter
- Centre d'Assistance Médicale à la Procréation et de Préservation de la Fertilité, Hôpital Jeanne de Flandre, Centre Hospitalier Universitaire de Lille, Lille F-59000, France; UE 4308 'Gamétogénèse et qualité du gamète'
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Ohata K, Ezoe K, Miki T, Kouraba S, Fujiwara N, Yabuuchi A, Kobayashi T, Kato K. Effects of fatty acid supplementation during vitrification and warming on the developmental competence of mouse, bovine and human oocytes and embryos. Reprod Biomed Online 2021; 43:14-25. [PMID: 34049810 DOI: 10.1016/j.rbmo.2021.03.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 03/25/2021] [Accepted: 03/31/2021] [Indexed: 02/05/2023]
Abstract
RESEARCH QUESTION Does fatty acid supplementation in vitrification and warming media influence developmental competence in oocytes after vitrification and warming? DESIGN Mouse oocytes and four-cell embryos were vitrified and warmed with solutions supplemented with fatty acid and cultured to the blastocyst stage. To study lipid metabolism after vitrification, quantitative real-time polymerase chain reaction was used to analyse the expression of genes related to beta oxidation in mouse embryos vitrified and warmed with or without fatty acids. The effects of fatty acid supplementation in the warming solutions on the developmental competence of bovine and human embryos were analysed. Blastocyst outgrowth assay was used to evaluate the potential of human blastocysts for adhesion to fibronectin. RESULTS The neutral lipid content of mouse oocytes in the fatty acid 1% supplementation group was significantly higher than in the fatty acid 0% group (P = 0.0032). The developmental rate to the blastocyst stage was significantly higher in the fatty acid 1% group than in the fatty acid 0% group in mice (P = 0.0345). Fatty acid supplementation in warming solution upregulated Acaa2 and Hadha in mouse embryos. Fatty acids significantly improved the developmental ability of bovine embryos to the blastocyst stage (P = 0.0048). Warming with 1% fatty acid supplementation significantly increased the proportion of human blastocysts with morphological grade A inner cell mass (P = 0.0074) and trophectoderm (P = 0.0323). CONCLUSIONS Fatty acid supplementation in the warming solutions improved the developmental competence of vitrified-warmed mouse oocytes by activating the beta-oxidation pathway. Fatty acid supplementation enhanced the developmental rate of bovine embryos to the blastocyst stage and improved morphological characteristics of human embryos vitrified at the cleavage stage.
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Affiliation(s)
- Kazuki Ohata
- Kato Ladies Clinic, 7-20-3 Nishishinjuku, Tokyo Shinjuku-ku 160-0023, Japan
| | - Kenji Ezoe
- Kato Ladies Clinic, 7-20-3 Nishishinjuku, Tokyo Shinjuku-ku 160-0023, Japan.
| | - Tetsuya Miki
- Kato Ladies Clinic, 7-20-3 Nishishinjuku, Tokyo Shinjuku-ku 160-0023, Japan
| | - Shizu Kouraba
- Towako Medical Research Center, 2-5-2 Asahidai, Ishikawa Nomi-shi 923-1211, Japan
| | - Nanoha Fujiwara
- Kato Ladies Clinic, 7-20-3 Nishishinjuku, Tokyo Shinjuku-ku 160-0023, Japan
| | - Akiko Yabuuchi
- Kato Ladies Clinic, 7-20-3 Nishishinjuku, Tokyo Shinjuku-ku 160-0023, Japan
| | - Tamotsu Kobayashi
- Kato Ladies Clinic, 7-20-3 Nishishinjuku, Tokyo Shinjuku-ku 160-0023, Japan
| | - Keiichi Kato
- Kato Ladies Clinic, 7-20-3 Nishishinjuku, Tokyo Shinjuku-ku 160-0023, Japan.
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Hong YH, Lee HK, Kim SK, Lee JR, Suh CS. The Significance of Planned Fertility Preservation for Women With Endometrioma Before an Expected Ovarian Cystectomy. Front Endocrinol (Lausanne) 2021; 12:794117. [PMID: 34975763 PMCID: PMC8715896 DOI: 10.3389/fendo.2021.794117] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 11/25/2021] [Indexed: 01/21/2023] Open
Abstract
Endometrioma is known to reduce the ovarian reserve and the extent of the decrease is more severe when ovarian surgery is performed. Therefore, to prevent this decline in fertility, patients with endometrioma are considered candidates for preoperative fertility preservation (FP). In this study, we evaluate the efficacy of FP in women with endometrioma before planned ovarian surgery. A total of 95 cycles in 62 patients with endometrioma, undergoing controlled ovarian stimulation (COS) for FP using a gonadotropin-releasing hormone (GnRH) antagonist protocol before an expected ovarian surgery, were enrolled retrospectively. COS outcomes were compared according to endometrioma laterality. Additionally, first COS cycle outcomes in patients with endometrioma were compared with those in infertile patients, or in patients with a benign ovarian cyst using propensity score matching. When multiple COS cycles were performed, the results of cumulative cycles were analyzed. Embryo quality was worse in the bilateral endometrioma group. Compared with the infertile patient group, the patients with endometrioma had significantly lower Anti-Müllerian Hormone (AMH) and fewer numbers of oocytes retrieved (median, 3.3 vs. 1.2, p<0.001; 7.0 vs. 4.0, p=0.009, respectively). Compared with mature oocytes in infertile patients or patients with a benign cyst, mature oocytes were fewer in patients with endometrioma, but this was not statistically significant (median, 4.0 vs. 3.0, p=0.085; 5.5 vs. 3.0, p=0.052, respectively). The median value of the cumulative number of cryopreserved oocytes or embryos was 14.5 up to the fourth cycle compared to 3 up to the first cycle, with cumulative effect. Women with endometrioma should be counseled for FP before planned ovarian cystectomy. The number of cryopreserved oocytes or embryos can be increased by repeated cycles.
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Affiliation(s)
- Yeon Hee Hong
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam, South Korea
- Health Promotion Center, Seoul National University Bundang Hospital, Seongnam, South Korea
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, South Korea
| | - Hyun Kyoung Lee
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Seul Ki Kim
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam, South Korea
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, South Korea
| | - Jung Ryeol Lee
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam, South Korea
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, South Korea
- *Correspondence: Jung Ryeol Lee,
| | - Chang Suk Suh
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, South Korea
- Department of Surgical Oncology, Sheikh Khalifa Specialty Hospital, Ras Al Khaimah, United Arab Emirates
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Cecchino GN, Cozzolino M, Roque M, García-Velasco JA. Endometrioma and reproductive issues: a well-informed patient may be the driver for change. ACTA ACUST UNITED AC 2020; 72:149-156. [PMID: 33000615 DOI: 10.23736/s0026-4784.20.04595-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Endometriosis affects a great proportion of women during their reproductive years and may impair female fertility in several ways. Ovarian endometrioma (OE) is the most frequent phenotype and growing evidence suggest an endometrioma-mediated damage to the ovary, ovarian reserve and oocyte quality. Traditionally, surgery has been the first-line treatment in cases of OE. Great advances in assisted reproduction and fertility preservation techniques opened new possibilities towards a more conservative approach. Herein we discuss multiple mechanisms responsible for the deterioration of the reproductive capacity in cases of OE as well as the pros and cons of different treatment options. The management of endometrioma-related subfertility remains controversial and it will depend on patient's intentions and priorities. In the "internet era" patients tend to be hyper-informed and more participative, but they are often misguided and misinformed. Thus, doctors should be able to convert these individuals into well-informed patients in order to facilitate the process of shared decision making, which is extremely relevant in the context of OEs.
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Affiliation(s)
- Gustavo N Cecchino
- Department of Gynecology, Federal University of São Paulo, São Paulo, Brazil - .,Department of Gynecology and Obstetrics, Rey Juan Carlos University, Madrid, Spain - .,Department of Reproductive Medicine, Mater Prime, São Paulo, Brazil -
| | - Mauro Cozzolino
- Department of Gynecology and Obstetrics, Rey Juan Carlos University, Madrid, Spain.,Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT, USA.,IVIRMA, IVI Foundation, Health Research Institute La Fe, Valencia, Spain
| | - Matheus Roque
- Department of Reproductive Medicine, Mater Prime, São Paulo, Brazil
| | - Juan A García-Velasco
- Department of Gynecology and Obstetrics, Rey Juan Carlos University, Madrid, Spain.,Department of Reproductive Medicine and Infertility, IVIRMA Madrid, Madrid, Spain
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