The effect of endometriosis on implantation: results from the Yale University in vitro fertilization and embryo transfer program

Endometriotic Follicular Fluid Affects Granulosa Cells' Morphology and Increases Duplication Rate and Connexin-43 Expression

Endometriosis is a complicated condition characterized by inflammation, low oocyte quality, and decreased uterus receptivity, associated with fertility issues. This study aims to better understand the reduced pregnancy outcome in endometriosis by analyzing both the granulosa cells (GCs) and the follicular fluids (FFs) obtained during the assisted reproductive technology (ART)-related oocyte pick-up. Seventy patients, approaching our ART Center with the diagnosis of infertility for Age-Idiopathic Factor (AIF) (n = 36), endometriosis (ENDO) (n = 23), or male factor (MF) (n = 11), were enrolled in this study. GCs from each group were separately analyzed for morphology, replication, and expression of Connexin-43 and Follicle-Stimulating Hormone Receptor (FSHR) by microscopy, flow cytometry, and immunocytochemistry. Results show that FF in a culture medium allowed GCs to survive and replicate. Upon culturing GCs from each group with ENDO follicular fluid, increases were observed in both population doublings and in the development of fibroblast-like and muscle-like morphologies. Despite undergoing morphological changes, GCs consistently expressed FSHR. However, exposure to ENDO follicular fluid led to an upregulation of Connexin-43 expression across all GC groups. These findings suggest that in endometriosis, FF contains unidentified factors that can induce aberrant replication, morphological differentiation, and overexpression of Connexin-43, potentially contributing to follicular dysfunction.

Unraveling shared diagnostic genes and cellular microenvironmental changes in endometriosis and recurrent implantation failure through multi-omics analysis

Endometriosis and Recurrent Implantation Failure (RIF) are both pivotal clinical issues within the realm of reproductive medicine, sharing significant overlap in their pathophysiological mechanisms. However, research exploring the commonalities between these two conditions remains relatively scarce, and reliable shared diagnostic biomarkers have yet to be identified. In this study, we integrated transcriptomic and single-cell sequencing data from the Gene Expression Omnibus (GEO) database to identify shared diagnostic genes and alterations in the cellular microenvironment between EMs and RIF. Differential expression analysis and weighted gene co-expression network analysis (WGCNA) were employed to identify key genes. Machine learning algorithms, including Random Forest (RF) and XGBoost, were utilized to screen for shared diagnostic genes, which were subsequently validated through receiver operating characteristic (ROC) analysis and clinical prediction models. Single-cell analysis was conducted to investigate the expression patterns of these diagnostic genes across various cellular subpopulations. Additionally, gene set enrichment analysis (GSEA) and competing endogenous RNA (ceRNA) network analysis were employed to further elucidate the biological functions and regulatory mechanisms of these genes. A total of 16 key genes were identified, which were predominantly expressed in fibroblasts. Through machine learning, the optimal model combining RF and XGBoost was selected to identify the shared diagnostic genes PDIA4 and PGBD5. Single-cell analysis revealed significant differences in the expression of these diagnostic genes in fibroblasts between normal and disease states. ROC analysis showed that the Area Under the Curve (AUC) values for individual genes in disease diagnosis were all above 0.7. The constructed clinical prediction model demonstrated robust predictive capacity for the disease. Immune infiltration analysis indicated that M2 macrophages and γδ T cells play important roles in the pathogenesis of EMs and RIF. GSEA revealed that these genes are involved in immune responses, vascular function, and hormone regulation, and are regulated by miR-3121-3p. This study provides comprehensive insights into the shared cellular microenvironmental alterations and molecular mechanisms underlying EMs and RIF. The identification of PDIA4 and PGBD5 as shared diagnostic biomarkers offers new avenues for early diagnosis and targeted treatment of EMs-related RIF. Future work will focus on validating these findings in larger cohorts and exploring their therapeutic potential.

Untangling the independent effect of endometriosis, adenomyosis, and ART-related factors on maternal, placental, fetal, and neonatal adverse outcomes: results from a systematic review and meta-analysis

BACKGROUND

Women with endometriosis may constitute a group at a particularly increased risk of pregnancy-related complications. Furthermore, women selected for assisted reproductive technology (ART) are exposed to additional endocrinological and embryological factors that have been associated with adverse pregnancy outcomes.

OBJECTIVE AND RATIONALE

This study aimed to investigate the independent effect of endometriosis, adenomyosis, and various ART-related factors on adverse maternal, placental, fetal, and neonatal outcomes.

SEARCH METHODS

Published randomized controlled trials, cohort studies, and case-control studies were considered eligible. PubMed, MEDLINE, ClinicalTrials.gov, Embase, and Scopus were systematically searched up to 1 March 2024. This systematic review and meta-analysis was performed in line with the PRISMA and the MOOSE reporting guidelines. To thoroughly investigate the association between endometriosis/adenomyosis and adverse pregnancy outcomes, sub-analyses were conducted, whenever possible, according to: the method of conception (i.e. ART and non-ART conception), the endometriosis stage/phenotype, the coexistence of endometriosis and adenomyosis, any pre-pregnancy surgical treatment of endometriosis, and the form of adenomyosis. The odds ratio (OR) with 95% CI was used as effect measure. The quality of evidence was assessed using the GRADE approach.

OUTCOMES

We showed a higher risk of placenta previa in women with endometriosis compared to controls (34 studies, OR 2.84; 95% CI: 2.47, 3.26; I2 = 83%, moderate quality). The association was observed regardless of the method of conception and was particularly strong in the most severe forms of endometriosis (i.e. rASRM stage III-IV endometriosis and deep endometriosis (DE)) (OR 6.61; 95% CI: 2.08, 20.98; I2 = 66% and OR 14.54; 95% CI: 3.67, 57.67; I2 = 54%, respectively). We also showed an association, regardless of the method of conception, between endometriosis and: (i) preterm birth (PTB) (43 studies, OR 1.43; 95% CI: 1.32, 1.56; I2 = 89%, low quality) and (ii) cesarean section (29 studies, OR 1.52; 95% CI: 1.41, 1.63; I2 = 93%, low quality). The most severe forms of endometriosis were strongly associated with PTB. Two outcomes were associated with adenomyosis both in the main analysis and in the sub-analysis that included only ART pregnancies: (i) miscarriage (14 studies, OR 1.83; 95% CI: 1.53, 2.18; I2 = 72%, low quality) and (ii) pre-eclampsia (7 studies, OR 1.70; 95% CI: 1.16, 2.48; I2 = 77%, low quality). Regarding ART-related factors, the following associations were observed in the main analysis and confirmed in all sub-analyses conducted by pooling only risk estimates adjusted for covariates: (i) blastocyst stage embryo transfer (ET) and monozygotic twinning (28 studies, OR 2.05; 95% CI, 1.72, 2.45; I2 = 72%, low quality), (ii) frozen embryo transfer (FET) and (reduced risk of) small for gestational age (21 studies, OR 0.59; 95% CI, 0.57, 0.61; P < 0.00001; I2 = 17%, very low quality) and (increased risk of) large for gestational age (16 studies, OR 1.70; 95% CI, 1.60, 1.80; P < 0.00001; I2 = 55%, very low quality), (iii) artificial cycle (AC)-FET and pre-eclampsia (12 studies, OR 2.14; 95% CI: 1.91-2.39; I2 = 9%, low quality), PTB (21 studies, OR 1.24; 95% CI 1.15, 1.34; P < 0.0001; I2 = 50%, low quality), cesarean section (15 studies, OR 1.59; 95% CI 1.49, 1.70; P < 0.00001; I2 = 67%, very low quality) and post-partum hemorrhage (6 studies, OR 2.43; 95% CI 2.11, 2.81; P < 0.00001; I2 = 15%, very low quality).

WIDER IMPLICATIONS

Severe endometriosis (i.e. rASRM stage III-IV endometriosis, DE) constitutes a considerable risk factor for placenta previa and PTB. Herein, we recommend against superimposing on this condition other exposure factors that have a strong association with the same obstetric adverse outcome or with different outcomes which, if coexisting, could determine the onset of an ominous obstetric syndrome. Specifically, we strongly discourage the use of AC regimens for FET in ovulatory women with rASRM stage III-IV endometriosis or DE. We also recommend single ET at the blastocyst stage in this high-risk population.

REGISTRATION NUMBER

CRD42023401428.

The Current Understanding of Molecular Mechanisms in Adenomyosis-Associated Infertility and the Treatment Strategy for Assisted Reproductive Technology

Adenomyosis, endometriosis of the uterus, is associated with an increased likelihood of abnormal endometrial molecular expressions thought to impair implantation and early embryo development, resulting in disrupted fertility, including the local effects of sex steroid and pituitary hormones, immune responses, inflammatory factors, and neuroangiogenic mediators. In the recent literature, all of the proposed pathogenetic mechanisms of adenomyosis reduce endometrial receptivity and alter the adhesion molecule expression necessary for embryo implantation. The evidence so far has shown that adenomyosis causes lower pregnancy and live birth rates, higher miscarriage rates, as well as adverse obstetric and neonatal outcomes. Both pharmaceutical and surgical treatments for adenomyosis seem to have a positive impact on reproductive outcomes, leading to improved pregnancy and live birth rates. In addition, adenomyosis has negative impacts on reproductive outcomes in patients undergoing assisted reproductive technology. This association appears less significant after patients follow a long gonadotropin-releasing hormone agonist (GnRHa) protocol, which improves implantation rates. The pre-treatment of GnRHa can also be beneficial before engaging in natural conception attempts. This review aims to discover adenomyosis-associated infertility and to provide patient-specific treatment options.

Endometriosis diagnosed by ultrasound is associated with lower live birth rates in women undergoing their first in vitro fertilization/intracytoplasmic sperm injection treatment

OBJECTIVE

To study the cumulative live birth rate (CLBR) after the first in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) treatment in women with or without deep-infiltrating endometriosis (DIE) and/or endometrioma diagnosed by transvaginal ultrasonography (TVUS), using the International Deep Endometriosis Analysis (IDEA) group definitions.

DESIGN

Prospective observational cohort study at a university hospital.

PATIENTS(S)

In total, 1,040 women with subfertility aged 25 to ≤39 years were undergoing their first IVF/ICSI treatment between January 2019 and October 2022. Of these, 234 (22.5%; 95% confidence interval [CI], 20.0-25.0) women were diagnosed with DIE and/or endometrioma at systematic TVUS before starting their treatment.

INTERVENTION(S)

All women underwent their first IVF or ICSI treatment. Fresh and/or frozen embryos from the first cycle were used until pregnancy was achieved or no embryos remained.

MAIN OUTCOME MEASURE(S)

Cumulative live birth rate after the first IVF/ICSI cycle in women with or without DIE and/or endometrioma.

RESULT(S)

The CLBR after the first IVF/ICSI treatment in the total cohort of women was 426/1,040 (41.0%; 95% CI, 38.0-44.0). Women with DIE and/or endometrioma had a lower CLBR (78/234, 33.3%; 95% CI, 27.3-39.4) than women without the disease (348/806, 43.2%; 95% CI, 39.8-46.6). The crude relative risk (RR) for cumulative live birth for women with DIE and/or endometrioma was 0.77; 95% CI, 0.63-0.94, and after adjustments were made for age, body mass index, s-antimüllerian hormone, stimulation protocol, and day for embryo transfer, the adjusted RR was 0.63; 95% CI, 0.48-0.82. There was no difference in the number of retrieved mature oocytes, fertilization rate, or good quality embryos between the 2 groups.

CONCLUSION

The presence of DIE and/or endometrioma diagnosed by TVUS lowers the chance of live birth in women undergoing their first IVF/ICSI treatment.

The definition of unexplained infertility: A systematic review

BACKGROUND

There is no consensus on tests required to either diagnose unexplained infertility or use for research inclusion criteria. This leads to heterogeneity and bias affecting meta-analysis and best practice advice.

OBJECTIVES

This systematic review analyses the variability of inclusion criteria applied to couples with unexplained infertility. We propose standardised criteria for use both in future research studies and clinical diagnosis.

SEARCH STRATEGY

CINAHL and MEDLINE online databases were searched up to November 2022 for all published studies recruiting couples with unexplained infertility, available in full text in the English language.

DATA COLLECTION AND ANALYSIS

Data were collected in an Excel spreadsheet. Results were analysed per category and methodology or reference range.

MAIN RESULTS

Of 375 relevant studies, only 258 defined their inclusion criteria. The most commonly applied inclusion criteria were semen analysis, tubal patency and assessment of ovulation in 220 (85%), 232 (90%), 205 (79.5%) respectively. Only 87/220 (39.5%) studies reporting semen analysis used the World Health Organization (WHO) limits. Tubal patency was accepted if bilateral in 145/232 (62.5%) and if unilateral in 24/232 (10.3%). Ovulation was assessed using mid-luteal serum progesterone in 115/205 (56.1%) and by a history of regular cycles in 87/205 (42.4%). Other criteria, including uterine cavity assessment and hormone profile, were applied in less than 50% of included studies.

CONCLUSIONS

This review highlights the heterogeneity among studied populations with unexplained infertility. Development and application of internationally accepted criteria will improve the quality of research and future clinical care.

Promising effects of exosomes from menstrual blood-derived mesenchymal stem cells on endometriosis

Endometriosis as a non-malignant gynecological disease leads to dysregulation of numerous cellular functions including apoptosis, angiogenesis, migration, proliferation, and inflammation. Accumulating evidence has shed light on the importance of endometrial stem cells within the menstrual blood which are involved in the establishment and progression of endometriotic lesions in a retrograde manner. According to the fact that the therapeutic benefits of mesenchymal stem cells are provided through paracrine functions, we used exosomes from menstrual blood-derived stem cells (MenSCs) for treating endometriotic stem cells to inhibit their lesion formation tendency. Menstrual blood samples from healthy and endometriosis women were collected. Isolated MenSCs by the density-gradient centrifugation method were characterized by flow cytometry. Secreted exosomes were isolated from healthy MenSCs (NE-MenSCs) and used to treat endometriotic cells (E-MenSCs). 72 h after treatment, different mechanisms and pathways including inflammation, proliferation, apoptosis, migration, and angiogenesis were analyzed using Real-Time PCR, ELISA, immunocytochemistry, annexin V/PI, and scratching assay. Exosome treatment significantly reduce the expression level of markers related to inflammation, proliferation, migration, and angiogenesis in E-MenSCs which are aberrantly expressed in endometriosis. Moreover, apoptosis was induced in E-MenSCs after treatment which was evaluated in both gene and protein levels. In this study, we give preliminary evidence for the potential of MenSCs-Exo in ameliorating endometriosis. Regarding our results, we suggest that after relevant clinical trial, MenSCs-derived exosomes can be considered as a better treatment option to improve endometriosis compared to common and conventional treatments and show their potential as a cell-free product in endometriosis repair.

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.

Implantation Failure in Endometriosis Patients: Etiopathogenesis

Embryo implantation requires adequate dialogue between a good quality embryo and a receptive endometrium. This implantation is still considered as the black box of reproductive medicine. Endometriosis is a highly prevalent chronic inflammatory disease, concerning about 10% of women of reproductive age and is one of the major causes of female infertility. The mechanisms involved in endometriosis-related infertility, an event not yet completely understood, are multifactorial and include anatomical changes, reduction in ovarian reserve, endocrine abnormalities, genetic profile, immunity markers, inflammatory mediators, or altered endometrial receptivity. In this article, we will focus on the impact of endometriosis on embryo quality and on endometrial receptivity. Results: Poor oocyte and embryo quality seem to promote a lower pregnancy rate, more than the endometrium itself in women with endometriosis. Other studies report the contrary. In addition, hormonal imbalance observed in the endometrium could also alter the embryo implantation. Conclusions: Controversial results in the literature add difficulties to the understanding of the mechanisms that lead to embryo implantation disorders. Furthermore, either oocyte/embryo impairment, altered endometrium, or both may cause impaired implantation. New prospective, randomized, and controlled studies are necessary to determine the origin of the defects that make conception more difficult in the case of endometriosis and adenomyosis.

Epigenetic Factors in Eutopic Endometrium in Women with Endometriosis and Infertility

Eutopic endometrium in patients with endometriosis is characterized by aberrant expression of essential genes during the implantation window. It predisposes to disturbance of endometrial receptivity. The pathomechanism of implantation failures in women with endometriosis remains unclear. This paper aims to summarize the knowledge on epigenetic mechanisms in eutopic endometrium in the group of patients with both endometriosis and infertility. The impaired DNA methylation patterns of gene promoter regions in eutopic tissue was established. The global profile of histone acetylation and methylation and the analysis of selected histone modifications showed significant differences in the endometrium of women with endometriosis. Aberrant expression of the proposed candidate genes may promote an unfavorable embryonic implantation environment of the endometrium due to an immunological dysfunction, inflammatory reaction, and apoptotic response in women with endometriosis. The role of the newly discovered proteins regulating gene expression, i.e., TET proteins, in endometrial pathology is not yet completely known. The cells of the eutopic endometrium in women with endometriosis contain a stable, impaired methylation pattern and a histone code. Medication targeting critical genes responsible for the aberrant gene expression pattern in eutopic endometrium may help treat infertility in women with endometriosis.

Effects of ovarian endometrioma aspiration on in vitro fertilization-intracytoplasmic sperm injection and embryo transfer outcomes: a systematic review and meta-analysis

PURPOSE

To evaluate the effect of ovarian endometrioma aspiration on IVF/ICSI outcomes.

METHODS

The PubMed, EMBASE, Web of Science, China National Knowledge Infrastructure, and Wanfang databases were searched to identify studies related to the treatment of endometrioma up to October 1, 2020, and the data of 1207 patients from 10 studies were analyzed using STATA.

RESULTS

The 10 studies in our analysis included 7 comparing aspiration and surgery and 6 comparing aspiration with no intervention. In the aspiration versus surgery groups, live birth rate [OR 0.97 (95% CI 0.51, 1.85), P = 0.925] and clinical pregnancy rate [OR 1.30 (95% CI 0.95, 1.80), P = 0.105] showed no significant difference between the two groups. Abortion rate [OR 4.26 (95% CI 1.38, 13.08), P = 0.011], the number of oocytes retrieved [mean difference 1.95 (95% CI 0.10, 3.81), P = 0.039], and the estradiol peak on hCG day [mean difference 392.16 (95% CI 230.14, 554.18), P < 0.001] were significantly higher in the aspiration group compared to the surgical group. In the aspiration versus the no intervention group, live birth rate [OR 0.84 (95% CI 0.45, 1.59), P = 0.602] and clinical pregnancy rate [OR 1.25 (95% CI 0.88, 1.77), P = 0.206] were not significantly different between the two groups. The abortion rate [OR 0.31 (95% CI 0.11, 0.88), P = 0.028] and the number of gonadotropin ampoules [mean difference - 3.13 ampoules (95% CI - 4.90, - 1.37), P < 0.001] were significantly lower in the aspiration group compared to the no intervention group.

CONCLUSION

Compared with surgical treatment or no intervention treatment, aspiration has less effect on ovarian response, ovarian reserve, and pregnancy outcomes.

Endometrial causes of recurrent pregnancy losses: endometriosis, adenomyosis, and chronic endometritis

Chronic inflammatory processes affecting the endometrium, as encountered in endometriosis, adenomyosis, and chronic endometritis, alter endometrial receptivity. These disorders are associated with early pregnancy losses and possibly recurrent pregnancy losses (RPL). In the cases of endometriosis, other factors associated with the disease also are susceptible of causing miscarriages and possibly RPL, such as an impact of intrapelvic inflammatory processes affecting the oocyte and embryo in case of natural conception. Conversely these latter effects obviously are bypassed in case of assisted reproductive technology. Chronic inflammation of the endometrium in the condition known as chronic endometritis also causes early pregnancy losses and RPL with beneficial effects achieved when specific treatment is undertaken.

Mesenchymal stem cells for restoring endometrial function: An infertility perspective

BACKGROUND

Mesenchymal stem cells (MSCs) can be derived from several tissues such as bone marrow, placenta, adipose tissue, or endometrial tissue. MSCs gain a lot of attention for cell-based therapy due to their characteristics including differentiation ability and immunomodulatory effect. Preclinical and clinical studies demonstrated that MSCs can be applied to treat female infertility by improving of the functions of ovary and uterus. This mini- review focuses on the current study of treatment of endometrial infertility by using MSCs.

METHODS

The present study performed a literature review focusing on the effect of MSCs for treatment of women infertility caused by endometrial dysfunction.

RESULTS

Bone marrow-, umbilical cord-, adipose-, amniotic-, and menstruation-derived MSCs enhance endometrial cell proliferation, injury repairs as well as reducing scar formation. The beneficial mechanism probably via immunomodulatory, cell differentiation, stimulates endometrial cell proliferation and down-regulation of fibrosis genes. The major advantage of using MSCs is to improve endometrial functions resulting in increased implantation and pregnancy.

CONCLUSIONS

MSCs exhibit a potential for endometrial infertility treatment. Adipose- and menstruation-derived stem cells show advantages over other sources because the cells can be derived easily and do not causes graft rejection after autologous transplantation.

Miscarriage on Endometriosis and Adenomyosis in Women by Assisted Reproductive Technology or with Spontaneous Conception: A Systematic Review and Meta-Analysis

Background

In the past several years, there has been an increasing concern on miscarriage caused by endometriosis or adenomyosis. However, the results reported by different studies remain controversial. The present study is aimed at assessing the impact of endometriosis and adenomyosis on miscarriage.

Materials and Methods

Searches were carried out in PubMed, Embase, and the Cochrane library for studies published from inception until February 29, 2020. The investigators included studies that evaluated miscarriage risk in pregnant women with endometriosis or adenomyosis by assisted reproductive technology (ART), or with spontaneous conception (SC). Miscarriage (<28 weeks) was the primary outcome. The secondary outcomes were antepartum hemorrhage (APH), postpartum hemorrhage (PPH), preterm birth, low birthweight, placenta praevia, placental abruption, ectopic pregnancy, stillbirth, gestational diabetes, preeclampsia, and intrauterine growth restriction (IUGR). Endnote was used for the study collection, and the data analyses were carried out by two authors using Review Manager version 5.2.

Results

Thirty-nine studies, which is comprised of 697,984 women, were included in the present study. Miscarriage risk increased in women with endometriosis in SC (OR: 1.81, 95% CI: 1.44-2.28, I² = 96%) compared with those without endometriosis, while women with endometriosis who underwent ART had a similar miscarriage risk, when compared to those with tubal infertility (OR: 1.03, 95% CI: 0.92-1.14, I² = 0%). Compared with those without adenomyosis, women with adenomyosis had an augmented miscarriage risk in ART (OR: 2.81, 95% CI: 1.44-5.47, I² = 64%). Compared with those without endometriosis, women with endometriosis had higher odds of APH, PPH, preterm birth, stillbirth, and placenta praevia. No difference was observed in the incidence of ectopic pregnancy, placental abruption, pre-eclampsia, gestational diabetes, low birthweight, and IUGR.

Conclusion

Women with endometriosis had an augmented miscarriage risk in SC and a similar miscarriage risk during ART. Adenomyosis was associated with miscarriage in pregnant women using ART.

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.

Long-term GnRH agonist therapy before in vitro fertilisation (IVF) for improving fertility outcomes in women with endometriosis

BACKGROUND

Endometriosis is known to have an impact on fertility and it is common for women affected by endometriosis to require fertility treatments, including in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI), to improve the chance of pregnancy. It has been postulated that long-term gonadotrophin-releasing hormone (GnRH) agonist therapy prior to IVF or ICSI can improve pregnancy outcomes. This systematic review supersedes the previous Cochrane Review on this topic (Sallam 2006).

OBJECTIVES

To determine the effectiveness and safety of long-term gonadotrophin-releasing hormone (GnRH) agonist therapy (minimum 3 months) versus no pretreatment or other pretreatment modalities, such as long-term continuous combined oral contraception (COC) or surgical therapy of endometrioma, before standard in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI) in women with endometriosis.

SEARCH METHODS

We searched the following electronic databases from their inception to 8 January 2019: Cochrane Gynaecology and Fertility Specialised Register of Controlled Trials, CENTRAL via the Cochrane CENTRAL Register of Studies ONLINE (CRSO), MEDLINE, Embase, PsycINFO, Cumulative Index to Nursing and Allied Health Literature (CINAHL). We searched trial registries to identify unpublished and ongoing trials. We also searched DARE (Database of Abstracts of Reviews of Effects), Web of Knowledge, OpenGrey, Latin American and Caribbean Health Science Information Database (LILACS), PubMed, Google and reference lists from relevant papers for any other relevant trials.

SELECTION CRITERIA

Randomised controlled trials (RCTs) involving women with surgically diagnosed endometriosis that compared use of any type of GnRH agonist for at least three months before an IVF/ICSI protocol to no pretreatment or other pretreatment modalities, specifically use of long-term continuous COC (minimum of 6 weeks) or surgical excision of endometrioma within six months prior to standard IVF/ICSI. The primary outcomes were live birth rate and complication rate per woman randomised.

DATA COLLECTION AND ANALYSIS

Two independent review authors assessed studies against the inclusion criteria, extracted data and assessed risk of bias. A third review author was consulted, if required. We contacted the study authors, as required. We analysed dichotomous outcomes using Mantel-Haenszel risk ratios (RRs), 95% confidence intervals (CIs) and a fixed-effect model. For small numbers of events, we used a Peto odds ratio (OR) with 95% CI instead. We analysed continuous outcomes using the mean difference (MD) between groups and presented with 95% CIs. We studied heterogeneity of the studies via the I2 statistic. We assessed the quality of evidence using GRADE criteria.

MAIN RESULTS

We included eight parallel-design RCTs, involving a total of 640 participants. We did not assess any of the studies as being at low risk of bias across all domains, with the main limitation being lack of blinding. Using GRADE methodology, the quality of the evidence ranged from very low to low quality. Long-term GnRH agonist therapy versus no pretreatment We are uncertain whether long-term GnRH agonist therapy affects the live birth rate (RR 0.48, 95% CI 0.26 to 0.87; 1 RCT, n = 147; I2 not calculable; very low-quality evidence) or the overall complication rate (Peto OR 1.23, 95% CI 0.37; to 4.14; 3 RCTs, n = 318; I2 = 73%; very low-quality evidence) compared to standard IVF/ICSI. Further, we are uncertain whether this intervention affects the clinical pregnancy rate (RR 1.13, 95% CI 0.91 to 1.41; 6 RCTs, n = 552, I2 = 66%; very low-quality evidence), multiple pregnancy rate (Peto OR 0.14, 95% CI 0.03 to 0.56; 2 RCTs, n = 208, I2 = 0%; very low-quality evidence), miscarriage rate (Peto OR 0.45, 95% CI 0.10 to 2.00; 2 RCTs, n = 208; I2 = 0%; very low-quality evidence), mean number of oocytes (MD 0.72, 95% CI 0.06 to 1.38; 4 RCTs, n = 385; I2 = 81%; very low-quality evidence) or mean number of embryos (MD -0.76, 95% CI -1.33 to -0.19; 2 RCTs, n = 267; I2 = 0%; very low-quality evidence). Long-term GnRH agonist therapy versus long-term continuous COC No studies reported on this comparison. Long-term GnRH agonist therapy versus surgical therapy of endometrioma No studies reported on this comparison.

AUTHORS' CONCLUSIONS

This review raises important questions regarding the merit of long-term GnRH agonist therapy compared to no pretreatment prior to standard IVF/ICSI in women with endometriosis. Contrary to previous findings, we are uncertain as to whether long-term GnRH agonist therapy impacts on the live birth rate or indeed the complication rate compared to standard IVF/ICSI. Further, we are uncertain whether this intervention impacts on the clinical pregnancy rate, multiple pregnancy rate, miscarriage rate, mean number of oocytes and mean number of embryos. In light of the paucity and very low quality of existing data, particularly for the primary outcomes examined, further high-quality trials are required to definitively determine the impact of long-term GnRH agonist therapy on IVF/ICSI outcomes, not only compared to no pretreatment, but also compared to other proposed alternatives to endometriosis management.

Implantation failures in women with infertility associated endometriosis

Endometriosis is currently considered as one of the most common diseases associated with infertility. A controversial issue is whether endometriosis per se exerts a detrimental effect on IVF outcomes. Failure of implantation due to endometriosis-associated infertility is a contradictory and widely discussed burden nowadays. The purpose of the study is to assess the quality of embryos and implantation rate in women with infertility associated with endometriosis. The study included infertile reproductive aged women, between 26 and 40 years who underwent IVF and ICSI procedures. The patients were divided into two groups: group I (n = 70) involved 70 patients with recurrent unilateral endometriomas, II control group (n = 50) with tubal factor infertility. The quality of the retrieved embryos was assessed according to the generally accepted classification of Gardner, indicating the rate of implantation in each group. Embryo transfer was performed in case of high quality embryos. Assessing the ovarian reserve indicators, in the group I patients with recurrent unilateral endometriomas the serum level of AMH was significantly lower (2.1 ± 1.75 vs. 3.2 ± 1.4, p < .005), as well as the number of retrieved oocytes (8.1 ± 3.9 and 10.1 ± 6.8, p < .005). The analysis of the results demonstrated that the duration of stimulation in the group patients with recurrent unilateral endometriomas was significantly higher in comparison with the group II (12.2 ± 1.8 and 10.2 ± 1.6 days, p < .001). Nevertheless, the number of good quality embryos retrieved was comparable in both groups (2.2 ± 1.5 and 2.8 ± 1.8). In the group I patients with recurrent unilateral endometriomas, there was a statistically significant decrease of implantation rate (17.1% vs. 24% p < .005). The results of the study revealed no statistical difference in embryo quality in the study cohort. However, it is important to note that a statistically significant difference in implantation rate in the group of endometriosis-associated infertility compared was obtained 1.5 times lower than in the control group (15.8% vs. 24.0% p < .005). The achieved results demonstrated an adverse IVF outcome in infertile women with recurrent endometrioma compared to the control group.

Effect of Prolonged GnRH Agonist Downregulation on ICSI Outcome in Patients With Endometriomas of Less Than 5 cm: A Randomized Controlled Trial

OBJECTIVE

To evaluate the effect of prolonged Gonadotropin releasing hormone (GnRH) agonist downregulation in patients with endometriomas of less than 5 cm on the outcome of the proceeding Intracytoplasmic sperm injection (ICSI) trial.

METHODS

In a randomized controlled trial at a university teaching hospital, 90 patients indicated for ICSI and having unilateral single endometrioma of less than 5 cm in diameter were randomized into 2 groups. Group A (45 patients) received the standard long protocol; whereas group B (45 patients) received 3 consecutive Intramuscular (IM) injections of triptorelin 3.75 mg 28 days apart followed by the standard long protocol 28 days after the last injection.

RESULTS

There were no significant differences in the clinical and hormonal characteristics between the 2 groups. All ICSI cycle characteristics including number of retrieved oocytes, fertilized oocytes, and transferred embryos were also not significantly different. However, patients who received prolonged GnRH agonist therapy showed significantly higher chemical ( P = .011), clinical ( P = .018), and ongoing ( P = .028) pregnancy rates.

CONCLUSION

Prolonged GnRH agonist downregulation improves the pregnancy rates in patients with small endometriomas undergoing ICSI.

Chronic Niche Inflammation in Endometriosis-Associated Infertility: Current Understanding and Future Therapeutic Strategies

Endometriosis is an estrogen-dependent inflammatory disease that affects up to 10% of women of reproductive age and accounts for up to 50% of female infertility cases. It has been highly associated with poorer outcomes of assisted reproductive technology (ART), including decreased oocyte retrieval, lower implantation, and pregnancy rates. A better understanding of the pathogenesis of endometriosis-associated infertility is crucial for improving infertility treatment outcomes. Current theories regarding how endometriosis reduces fertility include anatomical distortion, ovulatory dysfunction, and niche inflammation-associated peritoneal or implantation defects. This review will survey the latest evidence on the role of inflammatory niche in the peritoneal cavity, ovaries, and uterus of endometriosis patients. Nonhormone treatment strategies that target these inflammation processes are also included. Furthermore, mesenchymal stem cell-based therapies are highlighted for potential endometriosis treatment because of their immunomodulatory effects and tropism toward inflamed lesion foci. Potential applications of stem cell therapy in treatment of endometriosis-associated infertility in particular for safety and efficacy are discussed.

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

OBJECTIVE

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

DESIGN

Retrospective study.

SETTING

A university-affiliated hospital in Guangzhou, China.

POPULATION

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

METHODS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

TWEETABLE ABSTRACT

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

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

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

Decreased Concentrations of AMH in Follicular Fluid of Women with Endometriosis: A Hypothetical New Marker of Oocyte Quality

Introduction

Anti-müllerian hormone (AMH) has been recently introduced as a new marker of ovarian reserve with a high sensitivity and with the added value of being independent of cycle day. Some authors have claimed that it may also provide information regarding oocyte quality. As endometriosis is a disease that mainly affects the ovary and thus, egg quality, we decided to evaluate AMH follicular fluid concentrations in three clinical groups: a) women with endometriosis and a visible endometrioma at ultrasound in one of the ovaries, b) same women with endometrioma-free contralateral ovary, and c) women without endometriosis.

Material and Methods

From August to December 2007, 28 women undergoing an IVF/ICSI cycle in whom an endometrioma > 2cm was clearly visible at ultrasound in one of the ovaries and not in the other, and 28 fertile egg donors as controls entered the study. Follicular fluid from the largest follicle of each ovary (with endometrioma and without endometrioma) was individually collected prior to the rest of the follicular aspiration at the time of egg retrieval, and similarly in the control group. After cumulus identification and short centrifugation to remove cells, fluids were stored at -80°C until assayed. AMH was evaluated by a commercially available ELISA. Kolmorov-Smirnov test was performed to test for normality, as well as a one-way ANOVA with Tukey test to evaluate differences among groups. Significance was set at 0.05.

Results

AMH follicular fluid concentrations were significantly lower in women with endometriosis versus control (4.5 ± 2.6 vs 6.2 ± 3.0 ng/mL, p=0.02). Interestingly, when the three groups were evaluated individually, the concentration of AMH in follicular fluid obtained from the ovaries where a large endometrioma was present was significantly lower than in the other two groups – a) 4.1 ± 2.7 ng/mL in the ovaries with the endometrioma, b) 4.9 ± 2.6 ng/mL in the contralateral ovary in the same patients, and c) 6.2 ± 3.0 ng/mL in control patients; (p=0.039).

Conclusions

AMH concentration in follicular fluid is diminished in women with endometriosis. The presence of the endometrioma itself may reduce even further AMH concentration in the surrounding follicles. These results may reflect oocyte quality and could be useful when counselling patients regarding their reproductive outcome.

The Wnt/β-catenin signaling in endometriosis, the expression of total and active forms of β-catenin, total and inactive forms of glycogen synthase kinase-3β, WNT7a and DICKKOPF-1

OBJECTIVES

The cyclical changes in proliferation and differentiation of endometrial cells are regulated by estrogen and progesterone via modulating Wnt/β-catenin signaling. Imbalance in the expression of estrogen and progesterone receptors causes progesterone resistance in endometriosis patients. The aim of this study was to investigate the expression of some main components of Wnt/β-catenin signaling including WNT7a, DKK-1, β-catenin, and GSK-3β in eutopic endometrium and peritoneal endometriotic lesions of endometriosis patients compared to healthy endometrium in the mid-secretory phase of menstrual cycle.

STUDY DESIGN

This prospective study was performed, during a 12 months period from December 2015 to November 2016, on healthy women as the control group (n=14) and endometriosis patients (n=34). We used real-time polymerase chain reaction and Western blot techniques.

RESULTS

Protein and mRNA expression of DKK-1 were significantly down-regulated in both endometriotic lesions and eutopic endometrium of endometriosis group. We also demonstrated that the expression of non-phosphorylated β-catenin (active form) and phosphorylated GSK-3β (inactive form) were up-regulated in endometriosis patients. The mRNA levels of β-catenin, GSK-3β, and WNT7a, as well as the protein levels of total β-catenin, total GSK-3β, and WNT7a in endometriosis group, were not significantly different with those in control group. The patterns of mRNA and protein expression of all interested factors in the lesions were similar to those in the eutopic endometrium of same patients.

CONCLUSIONS

It seems that the aberrant activation of Wnt/β-catenin signaling in the secretory phase of the menstrual cycle in endometriosis has two essential elements: excessive inactivation of GSK-3β and suppression of the expression of Wnt signaling inhibitor DKK-1. Interventions in this signaling pathway may allow for the exploration of potential new targets for the control of development and progression of endometriosis.

Patients with endometriosis have aneuploidy rates equivalent to their age-matched peers in the in vitro fertilization population

OBJECTIVE

To determine whether endometriosis ultimately results in an increased risk of embryonic aneuploidy.

DESIGN

Retrospective cohort.

SETTING

Infertility clinic.

PATIENT(S)

Patients participating in an in vitro fertilization (IVF) cycle from 2009-2015 using preimplantation genetic screening (PGS) who had endometriosis identified by surgical diagnosis or by ultrasound findings consistent with a persistent space-occupying disease whose sonographic appearance was consistent with endometriosis.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Rate of aneuploidy in endometriosis patients undergoing IVF compared to controls without endometriosis undergoing IVF.

RESULT(S)

There were 305 patients with endometriosis who produced 1,880 blastocysts that met the criteria for inclusion in the endometriosis group. The mean age of the patients with endometriosis was 36.1 ± 3.9 years. When the aneuploidy rates in patients with endometriosis and aneuploidy rates in patients without endometriosis were stratified by Society for Assisted Reproductive Technology age groups and compared, there were no statistically significant differences in the rate of aneuploidy (odds ratio 0.85; 95% confidence interval, 0.84-0.85).

CONCLUSION(S)

Patients with endometriosis undergoing IVF have aneuploidy rates equivalent to their age-matched peers in IVF population who do not have endometriosis.

Effect of Endometriosis on IVF Outcomes in Cases of Single Embryo Transfer for first IVF Attempt in Patients under 35

Background

Implantation disorders are regarded differently in different groups undergoing in vitro fertilization (IVF) because of heterogeneous patient populations. To avoid this problem, this study was based solely on the first attempts of a single embryo transfer in patients under the age of 35.

Methods

This was a retrospective comparative study with 2 groups of patients: a group with endometriosis (n = 288) and a group without endometriosis (n = 1,368), registered from January 2010 to December 2013 in the IVF center of the University Hospital of Clermont-Ferrand. This study compared the 2 groups and subgroups according to ovarian response and embryo quality, and analyzed oocyte number, embryo number, transfer rate, implantation rate and delivery rate per ovum pick-up and per transfer.

Results

In the cases of endometriosis, the number of collected oocytes (8.37 ± 7.01 vs. 10.13 ± 6.53 p<0.001), the transfer rate (81.4% vs. 86.1%, p = 0. 045) and the rate of cycles with a frozen embryo (48.9% vs. 57.3%, p<0.01) were lower. The probability of a satisfactory response to stimulation (70.7% vs. 81.0%, p<0.001) and of a good quality embryo cohort (45% vs. 52%, p = 0.003) was lower. However, the implantation and delivery rates per transfer were not distorted in the cases of endometriosis, either in the total group or in any subgroup. The cumulative live birth rate per attempt was similar (29.2% vs. 29.5%).

Conclusions

Endometriosis has no impact on the embryo transfer in IVF, particularly when the embryo quality is satisfactory.

In vitro fertilization for endometriosis-associated infertility

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

Stages of endometriosis: does it affect in vitro fertilization outcome

OBJECTIVE

Women with endometriosis often need in vitro fertilization (IVF) to conceive. There are conflicting data on the results of IVF in patients with endometriosis. The present study was undertaken to investigate whether or not the stage of endometriosis affects the IVF outcome in order to give the best patient counseling

MATERIALS AND METHODS

We compared IVF outcome measures between 40 patients with surgically confirmed minimal and mild endometriosis (American Society for Reproductive Medicine Stage I/II) and 38 patients with moderate and severe endometriosis (Stage III/IV). Each group was also compared with a control group of 157 patients with tubal factor infertility. Outcome measures included number of follicles, number of oocytes, mean number of ampoules of gonadotropins, cumulative pregnancy, and live birth rates

RESULTS

Higher cancelation rates, higher total gonadotropin requirements, and lower oocyte yield were found in women with endometriosis Stage III and IV compared with both the Stage I/II and control groups. The fertilization rate was higher in Stage III/IV endometriosis compared to Stage I/II. Clinical pregnancy and live birth rates were comparable between patients with endometriosis Stage I/II and control group, whereas they were significantly lower in patients with endometriosis Stage III/IV compared to other two groups.

CONCLUSION

The American Society for Reproductive Medicine classification of endometriosis is useful in predicting IVF outcome. Advanced endometriosis means a worse prognosis for IVF treatment compared to milder stages or tubal factor infertility. The decreased fertilization rate in Stage I/II endometriosis might be a cause of subfertility in these women, as a result of a hostile environment caused by the disease.

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

OBJECTIVE

To evaluate whether the presence or severity of endometriosis affects the outcome of assisted reproductive techniques (ART).

METHODS

In this systematic review, all studies comparing the outcome of ART in women with and those without endometriosis, or at different stages of the disease, were considered eligible. We used either risk ratio (RR) or mean difference (MD) and their 95%CIs for comparisons. The primary outcome was live birth; the secondary outcome was clinical pregnancy. Miscarriage and the number of oocytes retrieved were examined as additional outcomes.

RESULTS

We included 92 studies in the review and 78 in the meta-analysis: 20,167 women with endometriosis were compared with 121,931 women without endometriosis, and 1703 women with Stage-III/IV endometriosis were compared with 2227 women with Stage-I/II endometriosis. The following results were observed for the comparison of women with endometriosis vs women without endometriosis: live birth, RR = 0.99 (95%CI, 0.92-1.06); clinical pregnancy, RR = 0.95 (95%CI, 0.89-1.02); miscarriage, RR = 1.31 (95%CI, 1.07-1.59); number of oocytes retrieved, MD = -1.56 (95%CI, -2.05 to -1.08). The following results were observed for the comparison of women with Stage-III/IV vs Stage-I/II endometriosis: live birth, RR = 0.94 (95%CI, 0.80-1.11); clinical pregnancy, RR = 0.90 (95%CI, 0.82-1.00); miscarriage, RR = 0.99 (95%CI, 0.73-1.36); number of oocytes retrieved, MD = -1.03 (95%CI, -1.67 to -0.39).

CONCLUSIONS

Women with endometriosis undergoing ART have practically the same chance of achieving clinical pregnancy and live birth as do women with other causes of infertility. No relevant difference was observed in the chance of achieving clinical pregnancy and live birth following ART when comparing Stage-III/IV with Stage-I/II endometriosis. The quality of the evidence for the additional examined outcomes was very low, not allowing meaningful conclusions to be drawn.

Decreased expression of mucin-1 in endometriosis endometrium correlated with progesterone receptor B involved in infertility

PURPOSE

Mucin-1(MUC1), a type of glucoprotein, has various expression statuses on the endometrium at different menstrual phases. Normal expression of MCU1 is closely related to successful blastocyst implantation. MUC1 was synthesized and secreted by the glandular epithelium of the endometrium, which acts as a barrier to foreign bodies. The endometrium was able to recognize and accept the blastocyst implantation. Endometriosis has lower rates of successful implantation with in vitro fertilization and embryo transfer, which may involve the altered expression of MUC1 on eutopic endometrium. In vitro studies demonstrated that progesterone and its receptors affected MUC1 expression under different physiopathology conditions. Our study was designed to explore whether progesterone receptors alteration contributed to MUC1 varied expression on endometriosis endometrium.

METHODS

A total of 54 patients with different infertility reason were selected retrospectively from the First Affiliated Hospital of Soochow University and Kowloon Hospital, Suzhou, China. Endometrium samples were collected under operative procedures. The samples were assigned to two groups: endometriosis (n = 28) and oviduct block (control group, n = 26), on which we examined the expression of progesterone receptor B (PR-B) and MUC1, respectively, using immunohistochemistry and Western blotting.

RESULTS

Compared with the control group, the expression of MUC1 was significantly decreased in the mid-secretory phase of the menstrual cycle in endometriosis. There was relatively lower expression of MUC1 in different phases of the cycle in comparison with the control group. The varied expression of MUC1 was significantly related to PR-B variation in endometriosis endometrium (r = 0.763, P < 0.01).

CONCLUSION

Decreased expression of MUC1 may attribute to PR-B variation in the mid-secretory phase of endometriosis endometrium. It might be one of the factors resulted in infertility in endometriosis patients.

Endometrial nerve fibre density in patients undergoing IVF: a pilot study

The presence of nerve fibres in the functional layer of the endometrium has been strongly associated with endometriosis. Presence of nerve fibres in the endometrium of women undergoing IVF has not been previously assessed. This prospective pilot study assessed the presence of nerve fibres in endometrium of women undergoing IVF due to various causes and examined the correlation between the presence of nerve fibres and IVF success. A total of 32 IVF patients underwent endometrial biopsy during days 21-23 of the menstrual cycle. Nerve fibres were identified by immunohistochemical staining. Correlations between the presence and density of nerve fibres and aetiology of infertility and IVF success were measured. Nerve fibres were identified in the endometrium of 10/31 (32.3%) women with a satisfactory biopsy. Presence of nerve fibres was not correlated with cause of infertility. Clinical pregnancy was achieved in 12/32 (37.5%) patients, without correlation to presence of nerve fibres in the endometrium. Nerve fibres were identified in a substantial percentage of women undergoing IVF, possibly reflecting underdiagnosis of endometriosis in this population. The presence of nerve fibres does not appear to interfere with implantation. The significance of nerve fibres in the endometrium of IVF patients warrants further research. The presence of nerve fibres in the functional layer of the endometrium has been strongly associated with endometriosis. The presence of nerve fibres in the endometrium of women undergoing IVF has not been previously assessed. Our aim was to assess the presence of nerve fibres in endometrium of women with various causes of infertility undergoing IVF and to examine the association between the presence of nerve fibres in the endometrium and IVF success. In a prospective study, 32 IVF patients underwent endometrial biopsy during days 21-23 of the menstrual cycle. Nerve fibres were identified by immunohistochemical staining. Associations between the presence and density of nerve fibres and the aetiology of infertility and IVF success were measured. Nerve fibres were identified in the endometrium of 10/31 (32.3%) women with a satisfactory biopsy. No association was found between the presence of nerve fibres and the cause of infertility. Clinical pregnancy was achieved in 12/32 (37.5%) patients, without association with the presence of nerve fibres in the endometrium. Nerve fibres can be identified in a substantial percentage of women undergoing IVF, possibly reflecting underdiagnosis of endometriosis in this population. Their presence does not interfere with embryo implantation. The significance of nerve fibres in the endometrium of IVF patients warrants further research.

The effect of endometriosis on in vitro fertilisation outcome: a systematic review and meta-analysis

BACKGROUND

Endometriosis is found in 0.5-5% of fertile women and 25-40% of infertile women. It is known that endometriosis is associated with infertility, but there is uncertainty whether women with endometriosis have adverse pregnancy outcomes in in vitro fertilisation (IVF) treatment.

OBJECTIVES

To explore the association between endometriosis and IVF outcome.

SEARCH STRATEGY

Searches were conducted on MEDLINE, EMBASE, Cochrane Library and Web of Science (inception, December 2012) in all languages, together with reference lists of retrieved papers.

SELECTION CRITERIA

Studies comparing IVF outcome in women with endometriosis with women without endometriosis. Patients were classified by stage of endometriosis. The outcomes were fertilisation, implantation, clinical pregnancy and live birth rates. Study selection was conducted independently by two reviewers. The Newcastle-Ottawa Quality Assessment Scale was used for quality assessment.

DATA COLLECTION AND ANALYSIS

Data extraction was conducted independently by two reviewers. Relative risks from individual studies were meta-analysed.

MAIN RESULTS

Twenty-seven observational studies were included, comprising 8984 women. Meta-analysis of these studies showed that fertilisation rates were reduced in stage I/II of endometriosis (relative risk [RR] = 0.93, 95% confidence interval [95% CI] 0.87-0.99, P = 0.03). There was a decrease in the implantation rate (RR = 0.79, 95% CI 0.67-0.93, P = 0.006) and clinical pregnancy rate (RR = 0.79, 95% CI 0.69-0.91, P = 0.0008) in women with stage III/IV endometriosis undergoing IVF treatment.

CONCLUSION

The presence of severe endometriosis (stage III/IV) is associated with poor implantation and clinical pregnancy rates in women undergoing IVF treatment.

Preoperative serum anti-mullerian hormone level in women with ovarian endometrioma and mature cystic teratoma

PURPOSE

To investigate whether preoperative serum anti-mullerian hormone (AMH) levels are lower in women with ovarian endometrioma and in women with mature cystic teratoma of the ovaries.

MATERIALS AND METHODS

In a tertiary university hospital, a retrospective case-control study was performed. Serum AMH levels between an advanced (stage III and IV) endometrioma group (n=102) and an age- and body mass index (BMI)-matched control group were compared. Serum AMH levels between an ovarian mature cystic teratoma group (n=48) and age- and BMI-matched controls were also compared.

RESULTS

Absolute serum AMH and multiples of the median for AMH (AMH-MoM) relevant to Korean standards were lower in the endometrioma group than controls, but this was not statistically significant (mean±SEM, 2.9±0.3 ng/mL vs. 3.3±0.3 ng/mL, p=0.28 and 1.3±0.1 vs. 1.6±0.1, p=0.29, respectively). Specifically, the stage IV endometriosis group (n=51) exhibited significantly lower serum AMH and AMH-MoM (2.1±0.3 vs. 3.1±0.4 ng/mL, p=0.02 and 1.1±0.1 vs. 1.7±0.2, p=0.03, respectively). Serum AMH and AMH-MoM levels were similar between stage III endometriosis and controls (3.7±0.5 vs. 3.4±0.5 ng/mL and 1.6±0.2 vs. 1.5±0.2, respectively), as well as between the mature cystic teratoma group and controls (4.0±0.5 ng/mL vs. 4.0±0.5 ng/mL and 1.6±0.2 vs. 1.6±0.3, respectively). Interestingly, AMH-MoM level was negatively correlated with endometriosis score with statistical significance (r²=0.13, p<0.01).

CONCLUSION

In women with advanced ovarian endometrioma, preoperative serum AMH values tended to be lower than those for age and BMI-matched controls. Notably, stage IV endometrioma appeared to be closely associated with decreased ovarian reserve, even before operation. Clinicians should keep this information in mind before undertaking surgery of ovarian endometrioma.

Cellular and molecular basis for endometriosis-associated infertility

Endometriosis is a gynecological disease characterized by the presence of endometrial glandular epithelial and stromal cells growing in the extra-uterine environment. The disease afflicts 10%–15% of menstruating women causing debilitating pain and infertility. Endometriosis appears to affect every part of a woman’s reproductive system including ovarian function, oocyte quality, embryo development and implantation, uterine function and the endocrine system choreographing the reproductive process and results in infertility or spontaneous pregnancy loss. Current treatments are laden with menopausal-like side effects and many cause cessation or chemical alteration of the reproductive cycle, neither of which is conducive to achieving a pregnancy. However, despite the prevalence, physical and psychological tolls and health care costs, a cure for endometriosis has not yet been found. We hypothesize that endometriosis causes infertility via multifaceted mechanisms that are intricately interwoven thereby contributing to our lack of understanding of this disease process. Identifying and understanding the cellular and molecular mechanisms responsible for endometriosis-associated infertility might help unravel the confounding multiplicities of infertility and provide insights into novel therapeutic approaches and potentially curative treatments for endometriosis.

Krüppel-like factor 9 and progesterone receptor coregulation of decidualizing endometrial stromal cells: implications for the pathogenesis of endometriosis

CONTEXT

Endometriosis is characterized by progesterone resistance and associated with infertility. Krüppel-like factor 9 (KLF9) is a progesterone receptor (PGR)-interacting protein, and mice null for Klf9 are subfertile. Whether loss of KLF9 expression contributes to progesterone resistance of eutopic endometrium of women with endometriosis is unknown.

OBJECTIVE

The aims were to investigate 1) KLF9 expression in eutopic endometrium of women with and without endometriosis, 2) effects of attenuated KLF9 expression on WNT-signaling component expression and on WNT inhibitor Dickkopf-1 promoter activity in human endometrial stromal cells (HESC), and 3) PGR and KLF9 coregulation of the stromal transcriptome network.

METHODS

Transcript levels of KLF9, PGR, and WNT signaling components were measured in eutopic endometrium of women with and without endometriosis. Transcript and protein levels of WNT signaling components in HESC transfected with KLF9 and/or PGR small interfering RNA were analyzed by quantitative RT-PCR and Western blot. KLF9 and PGR coregulation of Dickkopf-1 promoter activity was evaluated using human Dickkopf-1-luciferase promoter/reporter constructs and by chromatin immunoprecipitation. KLF9 and PGR signaling networks were analyzed by gene expression array profiling.

RESULTS

Eutopic endometrium from women with endometriosis had reduced expression of KLF9 mRNA together with those of PGR-B, WNT4, WNT2, and DKK1. KLF9 and PGR were recruited to the DKK1 promoter and modified each other's transactivity. In HESC, KLF9 and PGR coregulated components of the WNT, cytokine, and IGF gene networks that are implicated in endometriosis and infertility.

CONCLUSION

Loss of KLF9 coregulation of endometrial stromal PGR-responsive gene networks may underlie progesterone resistance in endometriosis.

In vitro fertilization is a successful treatment in endometriosis-associated infertility

OBJECTIVE

To assess success rates of IVF and intracytoplasmic sperm injection in women with various stages of endometriosis.

DESIGN

Retrospective cohort study.

SETTING

Reproductive medicine unit in a university hospital.

PATIENT(S)

Infertile women (n = 2,245) with various stages of endometriosis or tubal factor infertility.

INTERVENTION(S)

IVF or intracytoplasmic sperm injection.

MAIN OUTCOME MEASURE(S)

Dose of FSH, number of oocytes retrieved, fertilization rate, implantation rate, pregnancy rate (PR), live birth/ongoing PR.

RESULT(S)

Women with endometriosis had similar pregnancy and live birth/ongoing PR as did women with tubal factor infertility, but the American Society for Reproductive Medicine (ASRM) stage I and II endometriosis patients had a lower fertilization rate, and stage III and IV patients required more FSH and had fewer oocytes retrieved. Splitting the stage III and IV groups into patients with and without endometriomas showed that the endometrioma group required more FSH and had a significantly lower pregnancy and live birth/ongoing PR.

CONCLUSION(S)

With the exception of patients with endometrioma, infertile women with various stages of endometriosis have the same success rates with IVF and intracytoplasmic sperm injection as patients with tubal factor. This contrasts with the systematic review on which the European Society of Human Reproduction and Embryology bases its recommendations.

Implantation Rate Remains Unaffected in Women with Endometriosis Compared to Tubal Factor Infertility

Purpose

To reconsider the implantation and delivery rates which occurred six years later in women with endometriosis from the Yale IVF Programme.

Methods

Five hundred and ninety-seven consecutive IVF and ICSI treatment cycles were analyzed retrospectively. Patients with endometriosis (n=130; 258 cycles) were compared with an age-matched control group with tubal infertility (n=104; 206 cycles) and also with a group with male infertility (n=59; 133 cycles). Data from the endometriosis group were analyzed further in minimal-mild (144 cycles) and moderate-severe (114 cycles) subgroups. All the patients underwent laparoscopy prior to IVF treatment.

Results

Fewer oocytes were retrieved and similar fertilization (59% vs. 61%), implantation (12.3% vs. 16%), and delivery (23.7% vs. 26.3%) rates were found in patients with endometriosis compared to tubal infertility. A trend towards reduced pregnancy rate per transfer (17.5%) in the male infertility vs. endometriosis or tubal infertility groups (34% and 37.8% respectively) was observed. The number of embryos transferred in each group was comparable. Analysis of first cycles only across all groups revealed that the implantation rate did not have any statistically significant differences in the endometriosis versus the tubal or male infertility groups. Within the endometriosis group, the implantation, pregnancy, and delivery rates were similar in subgroups.

Conclusions

We conclude that in patients with endometriosis, implantation, pregnancy, and delivery rates are similar with tubal factor infertility, and higher compared to male infertility. Our results suggest that embryo quality and uterine receptivity remain unaffected in women with endometriosis.

Inflammatory pathways in endometrial disorders

Complex interactions between the endocrine and immune systems govern the key endometrial events of implantation and menstruation. In contrast to other tissue sites, cyclical endometrial inflammation is physiological. However, dysregulation of this inflammatory response can lead to endometrial disorders. This review examines the inflammatory processes occurring in the normal endometrium during menstruation and implantation, highlighting recent advances in our understanding and gaps in current knowledge. Subsequently, the role of inflammatory pathways in the pathology of various common endometrial conditions is discussed, including heavy menstrual bleeding, dysmenorrhoea (painful periods), uterine fibroids, endometriosis and recurrent miscarriage.

Does advanced-stage endometriosis affect the gene expression of estrogen and progesterone receptors in granulosa cells?

OBJECTIVE

To evaluate how endometriosis affects the expression of estrogen and progesterone receptors mRNA in granulosa cells.

DESIGN

Prospective study.

SETTING

IVF-ET program at Osaka Medical College.

PATIENT(S)

Eighteen patients with revised American Fertility Society stage IV endometriosis and 23 patients with tubal infertility without endometriosis.

INTERVENTION(S)

Granulosa cells obtained from patients with endometriosis were examined for estrogen (ER-β, ER-α) and progesterone (PR-A, PR-B) receptor mRNA expression ratio against GAPDH.

MAIN OUTCOME MEASURE(S)

Hormonal environment and clinical outcome were investigated. Expression of ER and PR mRNA were evaluated by StepOne real-time polymerase chain reaction (PCR) analysis.

RESULT(S)

Total hMG/FSH levels were statistically higher in patients with endometriosis; however, high-quality embryo rates and pregnancy rates were lower in patients with endometriosis than in patients with tubal infertility. Expression of PR-A and ER-α in patients with endometriosis was statistically higher than in patients with tubal infertility. The expression of PRs and ERs in patients with tubal infertility showed a positive correlation; however, it was not identified in the endometriosis group.

CONCLUSION(S)

The higher PR-A and ER-α gene expression in granulosa cells in patients with endometriosis, compared with patients with tubal infertility, might be a leading cause of ovarian dysfunction due to endometriosis.

A possible mechanism of autoimmune-mediated infertility in women with endometriosis

PROBLEM

Endometriosis has been proposed to be an autoimmune disease because of the presence of a variety of autoantibodies specific for endometrial or ovarian antigens. The object of the present study is to characterize binding specificity of anti-laminin-111 autoantibodies in infertile patients with endometriosis and to investigate whether these autoantibodies affect the in vitro embryo development.

METHOD OF STUDY

An ELISA analysis using overlapping synthesized peptides that covered the entire G domain of laminin-α1 chain was performed in infertile patients with endometriosis (n = 45). Mouse blastocysts were cultured in media containing the purified IgG from one antibody-positive serum on laminin-111-coated dishes.

RESULTS

Anti-laminin-111 autoantibodies were directed to several particular biologically functional peptide sequences in laminin-α 1 chain G domain. The tested IgG significantly inhibited the extent of in vitro trophoblast outgrowth.

CONCLUSION

Anti-laminin-111 autoantibodies may have major pathogenic roles on early reproductive failure including endometriosis-associated infertility.

Human papillomavirus infection in couples undergoing in vitro fertilization procedures: impact on reproductive outcomes

A prospective study was performed to assess the relationship between human papillomavirus (HPV) infection in 199 infertile couples and outcome of assisted reproductive technologies (ARTs). A highly statistically significant correlation between pregnancy loss rate (proportion of pregnancies detected by β-hCG that did not progress beyond 20 weeks) and positive HPV DNA testing in the male partner of infertile couples, compared with HPV negatives, was observed (66.7% vs. 15%).

The role of the Hoxa10/HOXA10 gene in the etiology of endometriosis and its related infertility: a review

PURPOSE

endometriosis and its associated infertility have been the object of continuous research for over a century. To understand the molecular mechanisms underlying the disease, it has become necessary to determine the aspects of its etiology that are not explained by the retrograde menstruation theory. This could in turn elucidate how various clinical and surgical treatments might affect the evolution and remission of the disease.

METHODS

this review is focused on the most recent clinical and laboratory findings regarding the association of HOXA10 with endometriosis and infertility.

RESULT

the homebox (Hox/HOX) proteins are highly conserved transcription factors that determine segmental body identities in multiple species, including humans. Hoxa10/HOXA10 is directly involved in the embryogenesis of the uterus and embryo implantation via regulation of downstream genes. Cyclical endometrial expression of Hoxa10/HOXA10, with a peak of expression occurring during the window of implantation, is observed in the adult in response to estrogen and progesterone. Women with endometriosis do not demonstrate the expected mid-luteal rise of HOXA10 expression, which might partially explain the infertility observed in many of these patients. Recent studies also demonstrated HOXA10 expression in endometriotic foci outside the Müllerian tract.

CONCLUSIONS

multiple lines of evidence suggest that the actions of the homeobox A10 (Hoxa10/HOXA10) gene could account for some aspects of endometriosis.