New advances in the understanding of endometriosis related infertility

Extracellular vesicles-derived MicroRNA-145-5p is upregulated in the uterine fluid of women with endometriosis and impedes mouse and human blastocyst development

Previous work indicated that the implantation and pregnancy rates of women with endometriosis are lower than those of healthy women during in-vitro fertilisation and embryonic transfer. And there are numerous microRNAs (miRNAs) in human uterine luminal fluid (ULF), some of which are associated with early preimplantation development of embryos. In our study, we sought to determine whether miRNAs in the ULF are differentially expressed between women with and without endometriosis and to uncover the association of miRNAs with the development potential of blastocysts. The implantation and clinical pregnancy rates significantly decreased in women with endometriosis than in those without endometriosis. Notably, hsa-miR-145-5p was upregulated in ULF samples from women with endometriosis (fold change > 2, false discovery rate < 0.001). Moreover, the ratios of mouse/human early embryos that developed into blastocyst-staged embryos (P = 0.0065 and P = 0.0098, respectively) were significantly affected via miR-145-5p upregulation in mouse/human early embryos. Notch signalling pathway components had abnormal expression levels in the mouse/human blastocyst-stage embryos in the miR-145-5p mimic-enriched extracellular vesicles (EVs) group. In conclusions, our study revealed that human extracellular vesicle-derived miRNAs in ULF impacted the developmental potential of blastocysts in women with endometriosis. Moreover, the upregulation of miR-145-5p-enriched EVs in mouse and human embryos negatively affected blastocyst development by suppressing the expression of components of the NOTCH signalling pathway, which may contribute to elucidate the cause of infertility in women with endometriosis.

Oocyte cryopreservation for women with endometriosis: Justification, indications, and reproductive outcomes

Women with endometriosis often experience diminished ovarian reserve and a decreased number of oocytes retrieved. This reduction is exacerbated after surgery. Nevertheless, oocyte quality does not seem to be compromised in these patients. When embryos of good quality are obtained, in vitro fertilization outcomes are generally satisfactory. Oocyte cryopreservation may represent a fertility preservation option for women with planned and/or prior surgery, as it enables the collection of oocytes in advance. Given the diverse manifestations of endometriosis, which vary by type, age, and ovarian reserve, the decision to pursue oocyte cryopreservation should be weighed individually. Moreover, the potential benefits of this approach on future fertility must be carefully considered. Considering current guidelines, the most appropriate candidates for oocyte cryopreservation among women with endometriosis are: patients with bilateral endometriomas, typically larger than 3 cm; those with prior surgery for unilateral endometrioma who exhibit ipsilateral or contralateral recurrence; and those with unilateral endometrioma on a single ovary. However, the size criteria for endometrioma warrant further discussion. Conversely, oocyte cryopreservation is inadvisable for patients: with unilateral endometrioma smaller than 3 cm and good ovarian reserve; who have undergone surgery for bilateral endometriomas, regardless of recurrence; and who have diminished ovarian reserve. While consensus indicates that decisions regarding diminished ovarian reserve should be individualized, fertility preservation should often be considered for patients with serum anti-Müllerian hormone levels below 0.5 ng/mL. In such cases, a prolonged duration may be necessary to retrieve the desired 10 to 15 oocytes.

Exosomal microRNAs and long noncoding RNAs: as novel biomarkers for endometriosis

Endometriosis is a gynecological inflammatory disorder characterized by the development of endometrial-like cells outside the uterine cavity. This disease is associated with a wide range of clinical presentations, such as debilitating pelvic pain and infertility issues. Endometriosis diagnosis is not easily discovered by ultrasound or clinical examination. Indeed, difficulties in noninvasive endometriosis diagnosis delay the confirmation and management of the disorder, increase symptoms, and place a significant medical and financial burden on patients. So, identifying specific and sensitive biomarkers for this disease should therefore be a top goal. Exosomes are extracellular vesicles secreted by most cell types. They transport between cells' bioactive molecules such as noncoding RNAs and proteins. MicroRNAs and long noncoding RNAs which are key molecules transferred by exosomes have recently been identified to have a significant role in endometriosis by modulating different proteins and their related genes. As a result, the current review focuses on exosomal micro-and-long noncoding RNAs that are involved in endometriosis disease. Furthermore, major molecular mechanisms linking corresponding RNA molecules to endometriosis development will be briefly discussed to better clarify the potential functions of exosomal noncoding RNAs in the therapy and diagnosis of endometriosis.

New treatment strategy for endometriosis using progestin-primed ovarian stimulation with dienogest: A prospective cohort study, comparison of dienogest versus dydrogesterone

Dienogest (DNG) is an oral progestin effective for the treatment of symptomatic endometriosis, such as reduction of endometrial lesion and control of pain intensity. Progestin-primed ovarian stimulation (PPOS) is a new controlled ovarian hyperstimulation (COH) regimen, and several reports have shown that dydrogesterone (DYG) is an appropriate progestin for PPOS. The purpose of this study was to evaluate the efficacy of DNG in patients undergoing PPOS during COH in comparison with DYG. This was a prospective, cohort, parallel-group, non-inferiority trial of 150 women with endometriosis undergoing assisted reproductive technology between February 2018 and May 2020 at the single fertility center. The assignment to each protocol was based on the optimal treatment for each patient. Patients taking DNG 2 mg continuously were assigned in the DNG group(n = 73). The other patients were allocated in DYG group(n = 77). All viable embryos were cryopreserved for subsequent transfer. The main outcome measures were the mature oocyte and fertilization rates. During this study, no premature LH surge was detected. A smaller number of oocytes were retrieved in the DNG group than in the DYG group (6.18 ± 3.60 vs. 9.85 ± 5.77); however, the rate of mature oocytes was significantly higher in the DNG group than in the DYG group (89.1 % vs. 78.9 %). The fertilization rate was comparable between two groups. Therefore, patients taking DNG for PPOS can continue endometriosis treatment and obtain good-quality embryos during COH. Further prospective randomized-controlled trial should be performed to confirm of this novel strategy of DNG.

Impaired implantation in endometriosis compared with couples with male subfertility after transfer of equal quality embryos: a matched cohort study

RESEARCH QUESTION

Is implantation impaired in patients with endometriosis undergoing IVF and intracytoplasmatic sperm injection (ICSI) cycles?

DESIGN

A retrospective matched cohort study was carried out on IVF/ICSI cycles with fresh single embryo transfer at the Department of Assisted Reproductive Medicine, Ghent University Hospital, Belgium, between July 2015 and August 2017 (n = 1053). A total of 118 endometriosis cases were matched 1:1 to 118 couples diagnosed with male subfertility and stratified by embryo quality (identical ALPHA grading categories), female age (±1 year) and parity (±1 delivery). Transvaginal ultrasound, magnetic resonance imaging or laparoscopy was used to diagnosed endometriosis, and the revised American Society for Reproductive Medicine score was used to classify the endometriosis into grade I/II versus grade III/IV. Male subfertility was defined in accordance with World Health Organization criteria (fifth edition).

RESULTS

Compared with endometriosis cases, control couples with male subfertility had significantly higher rates of positive HCG test on day 16 (P = 0.047, OR 2.077, CI 1.009 to 4.276), ongoing implantation (defined as a positive fetal heart rate on transvaginal ultrasound at a gestational age of at least 6.5-7 weeks) (P = 0.038, OR 2.265, CI 1.048 to 4.893), ongoing pregnancy (defined by a vital pregnancy at 11 weeks) (P = 0.046, OR 2.292, CI 1.016 to 5.173) and live birth (P = 0.043, OR 2.502, CI 1.029 to 6.087).

CONCLUSIONS

After matching for embryo quality, woman's age and parity, rates of positive HCG tests, ongoing implantation, ongoing pregnancy and live birth were more than twice as high in the control group compared with the endometriosis group.

MicroRNA22-5p targets ten-eleven translocation and regulates estrogen receptor 2 expression in infertile women with minimal/mild endometriosis during implantation window

Based on microRNA (miR) microarray analysis, we previously found that miR22-5p expression is decreased in the mid-luteal endometrium of women with minimal/mild endometriosis. Bioinformatics analysis predicted that miR22-5p targets ten-eleven translocation (TET2) 3'-untranslated region. This study aimed to determine the regulation and roles of miR22-5p in the pathogenesis of minimal/mild endometriosis-associated infertility. MiR22-5p and TET2 expression in the mid-luteal endometrium from women with or without minimal/mild endometriosis was analyzed. After transfection with miR22-5p mimics or inhibitor, TET2 expression was analyzed by quantitative reverse transcription (RT-q) PCR, western blotting and immunohistochemistry. 5-Hydroxymethylcytosine was determined by immunofluorescence and dot blotting. Expression and promoter methylation of estrogen receptor 2 (ESR2) was measured by RT-qPCR and western blotting, and by bisulfite sequencing, respectively. We first established that miR22-5p expression decreased and TET2 expression increased in minimal/mild endometriosis during implantation window. TET2 was found to be a direct target of miR22-5p. MiR22-5p regulated the expression of ESR2, but did not directly affect methylation of its promoter region (-197/+359). Our results suggest that an imbalance in miR22-5p expression in the mid-luteal endometrium may be involved in minimal/mild endometriosis-associated infertility.

Impacts of medroxyprogesterone acetate on oocytes and embryos: matched case-control study in women with stage III-IV ovarian endometriosis undergoing controlled ovarian hyperstimulation for in vitro fertilization

Background

This study investigated the effects of medroxyprogesterone acetate (MPA) on the oocytes and embryos in patients with advanced endometriosis who had a normal ovarian reserve and tubal infertility and received controlled ovarian hyperstimulation (COH) and explored the characteristics and pregnancy outcomes in subsequent frozen-thawed embryo transfer (FET) cycles.

Methods

In this prospective controlled study, 150 advanced endometriosis patients involving 150 in vitro fertilisation/intracytoplasmic sperm injection (IVF/ICSI) cycles and 163 FET cycles and 150 age-matched tubal infertility patients requiring 150 IVF/ICSI cycles and 115 FET cycles were recruited. Patients with endometriosis were sub-grouped into surgery group (n=102) (they were diagnosed with ovarian endometriomas and underwent 102 IVF/ICSI and 115FET cycles) and aspiration group (n=48) [they had ovarian "chocolate" cysts (>3 cm) that were aspirated and underwent 48 IVF/ICSI and 74 FET cycles].

Results

Lower oocyte retrieval rate was noted in the endometriosis group than in the control group. Similar oocyte yield and peak estrogen (E₂) level were found in two groups. The rates of mature oocyte, fertilization, cleavage, high-quality embryo, viable embryo, cancellation, implantation, and clinical pregnancy were similar between two groups. A higher oocyte yield was observed in the EMS cyst group than in the surgery group.

Conclusions

The ovary response, oocytes, embryos and pregnancy outcome were not influenced by the advanced endometriosis and the use of MPA and also independent of endometrioma or cyst surgery.

MicroRNA-451 is downregulated in the follicular fluid of women with endometriosis and influences mouse and human embryonic potential

BACKGROUND

Previous work demonstrated that there are numerous miRNAs in human follicular fluids, some of which are associated with reproductive diseases. In the current study, we sought to determine whether microRNAs (miRNAs) in the follicular fluid (FF) are differentially expressed between women with and without endometriosis and to uncover the association of miRNAs with the oocyte and embryonic development potential.

METHODS

FF was harvested from 30 women with endometriosis and 30 women without who underwent in vitro fertilization treatment at the University Hospital between February and December 2016. The FF samples were subjected to miRNA profiling and validation via quantitative reverse transcription polymerase chain reaction analysis. Mouse/human metaphase-I (MI) oocytes were harvested and micro-injected with an miR-451 inhibitor, and the effects of miR-451 knockdown on Wnt/WNT signalling genes were investigated.

RESULTS

Oocyte number, fertilization rate, and number of available embryos were decreased significantly in women with endometriosis relative to those without endometriosis. Hsa-miR-451 in FF was downregulated in endometriosis patients relative to control subjects (P < 0.01). Moreover, the proportions of mouse/human MI oocytes that developed into 2-pronuclei (2PN), 2-cell, 8-10-cell and blastocyst-stage embryos were affected by miR-451 knockdown in mouse/human oocytes. Components of the Wnt signalling pathway were aberrantly expressed in the mouse/human oocytes and embryos in the miR-451 inhibitor-injected group.

CONCLUSIONS

miR-451 was downregulated in FF samples from endometriosis patients and was modestly effective in distinguishing endometriosis patients from non-endometriosis patients. miR-451 downregulation in mouse and human oocytes affected pre-implantation embryogenesis by suppressing the Wnt signalling pathway. This miRNA might serve as a novel biomarker of oocyte and embryo quality in assisted reproductive treatment.

Endometriosis III and IV as a risk factor for tubal obstruction in infertile women

Objective:

A previous study carried out among infertile women with tubal obstruction identified a relative risk of 2.5 for Chlamydia trachomatis seropositivity. However, endometriosis may also be associated with increased risk. This study aimed to evaluate the risk of tubal obstruction associated with endometriosis III/IV among women submitted to assisted reproductive procedures.

Methods:

A case-control study was performed among 144 women with and without tubal obstruction. We calculated the odds ratio with 95% CI regarding the association of endometriosis III/IV and tubal obstruction. Calculations were performed using the SPSS v.17.0 package.

Results:

The mean age was 33.7 years (4.76 SD), and the mean infertility duration time was 66.7 months (120.6 SD). The total prevalence of endometriosis was 20/144 (13%). Among 144 women, the risk group with tubal obstruction and endometriosis III/IV comprised 7out of 20 (35%), compared with the group without such risk, that comprised 22 out of 124 (17%). The X² test was 3.19 with a p-value of 0.07. The odds ratio (OR) was 2.5 (95% CI: 0.647-9.639).

Conclusion:

Although the OR was 2.5, there was no significant difference between the groups with and without endometriosis III/IV. Further studies are needed to increase the sample size.

Investigating the impact of local inflammation on granulosa cells and follicular development in women with ovarian endometriosis

OBJECTIVE

To investigate the possible impact of local inflammation on granulosa cells (GCs) and follicular development in endometriosis patients.

DESIGN

Prospective study with related paired design.

SETTING

Reproductive medicine center.

PATIENT(S)

A total of 80 endometriosis patients and 104 controls, with cultured GCs collected from control participants younger than 35 years.

INTERVENTION(S)

Tumor necrosis factor-α (TNF-α) and nuclear factor κB (NF-κB) inhibitor.

MAIN OUTCOME MEASURE(S)

Intrafollicular concentrations of cytokines measured with ELISA, NF-κB binding levels with electrophoretic mobility shift assay (EMSA), and telomerase activity (TA) with quantitative-telomeric repeat amplification protocol (Q-TRAP) assay, and protein and mRNA expression with Western blot and polymerase chain reaction analyses, respectively.

RESULT(S)

Patients with endometriosis exhibited a statistically significantly lower antral follicle count (11.48 ± 8.11 vs. 15.68 ± 8.56), lower number of retrieved oocytes (8.28 ± 6.69 vs. 10.87 ± 6.26), and lower number of mature oocytes (6.67 ± 6.09 vs. 8.53 ± 5.69). The GCs from endometriosis patients showed higher NF-κB binding activity and increased expression of inhibitor of NF-κB kinase subunit β (IKKβ, 2.743-fold) and NF-κB inhibitor α (IκBα, 5.017-fold). Their NF-κB p65 expression was negatively associated with mature oocytes (bNF-κB' = -0.304, R² = 0.195, R = 0.442) but positively associated with intrafollicular TNF-α (r = 0.37); TA showed a negative relationship with NF-κB binding levels (r = -0.667). Tumor necrosis factor-α induced expression of IκBα (5.408-fold) and NF-κB p65 (1.400-fold) but lowered human telomerase reverse transcriptase (hTERT) and TA levels (0.0009 vs. 0.5619) in cultured GCs. However, inhibiting NF-κB obviously increased hTERT expression (1.988-fold).

CONCLUSION(S)

Endometriosis showed activated NF-κB pathways in GCs, which might negatively affect TA and oocyte quality. Intrafollicular TNF-α might down-regulate TA and hTERT via NF-κB pathway, but further studies are required.

The Role of Oxidative Stress and Membrane Transport Systems during Endometriosis: A Fresh Look at a Busy Corner

Endometriosis is a condition characterized by the presence of endometrial tissue outside the uterine cavity, leading to a chronic inflammatory reaction. It is one of the most widespread gynecological diseases with a 10-15% prevalence in the general female population, rising up to 30-45% in patients with infertility. Although it was first described in 1860, its etiology and pathogenesis are still unclear. It is now accepted that inflammation plays a central role in the development and progression of endometriosis. In particular, it is marked by an inflammatory process associated with the overproduction of an array of inflammatory mediators such as prostaglandins, metalloproteinases, cytokines, and chemokines. In addition, the growth and adhesion of endometrial cells in the peritoneal cavity due to reactive oxygen species (ROS) and free radicals lead to disease onset, its ensuing symptoms-among which pain and infertility. The aim of our review is to evaluate the role of oxidative stress and ROS in the pathogenesis of endometriosis and the efficacy of antioxidant therapy in the treatment and mitigation of its symptoms.

Use of medroxyprogesterone acetate in women with ovarian endometriosis undergoing controlled ovarian hyperstimulation for in vitro fertilization

This study investigated the use of medroxyprogesterone acetate (MPA) or a short protocol for controlled ovarian hyperstimulation (COH) in patients with advanced endometriosis who have normal ovarian function, and to compare cycle characteristics and pregnancy outcomes after frozen-thawed embryo transfer (FET). This was a retrospective case-control study of 244 patients with advanced endometriosis undering COH. The patients were allocated to three groups: the surgery group with MPA COH (62 patients, 71 IVF/ICSI cycles, 78 FET cycles); the aspiration group with MPA COH (85 patients had ovarian “chocolate” cysts (>3 cm) aspirated, 90 IVF/ICSI cycles, 76 FET cycles); and the short protocol group (97 patients, 101 IVF/ICSI cycles, 51 FET cycles). The results showed that higher rates of mature oocyte, D3 high quality embryo, hMG dose were observed in the two study groups using MPA compared with the short protocol. The number of >10–14 mm follicles on the trigger day, D3 top-quality embryos, viable embryos, rates of cancellation, fertilization, implantation, pregnancy outcomes were similar among the three groups. The oocytes, embryos, and pregnancy outcomes were not influenced by endometrioma surgery or presence of endometrioma. MPA COH could be effective for women with ovarian advanced endometriosis who had normal ovarian function.

CONTROLLED OVARIAN STIMULATION IN ENDOMETRIOSIS PATIENTS CAN BE INDIVIDUALIZED BY ANTI-MÜLLERIAN HORMONE LEVELS

CONTEXT

Anti-Mullerian hormone (AMH) assay is becoming the best indicator of successful IVF treatment response to fertility drugs and could be a useful marker of embryo implantation potential. Various protocols are being used for controlled ovarian stimulation (COS), but there is an uncertainty regarding the implementation of the best protocol for endometriosis patients and also little evidence is available concerning the clinical value of AMH levels in endometriosis.

OBJECTIVE

This study aimed to evaluate the prognostic value of serum AMH levels for pregnancy in COS using GnRH-agonist(GnRH-a) and GnRH-antagonist(GnRH-ant) protocols in endometriosis patients.

DESIGN

This is a cross-sectional study between March 2012 and November 2015.

SUBJECTS AND METHODS

Data were collected from 249 COS cycles of endometriosis patients, including 129 cycles with GnRH-a and 120 cycles with GnRH-ant. Patients in each group were classified into three subgroups based on their serum AMH levels. The outcomes of ICSI program were evaluated.

RESULTS

The ROC curve analysis showed that embryo and oocyte counts and AMH were equally predictive for pregnancy, as demonstrated by a similar area under the curve (AUC) of 0.69, 0.66 and 0.64, respectively. The sensitivity and specificity for prediction of positive pregnancy were 70.91% and 67.01% for embryo counts, 70.91% and 67.53% for oocyte counts at the cutoff values of 5 and 7, respectively, and 83.64% and 52.58% for AMH levels at the cutoff values of 1.3ng/mL.

CONCLUSIONS

This study demonstrates that AMH as a single test has substantial accuracy in the prediction of pregnancy using the GnRH antagonist protocol for patients with endometriosis. In other words, AMH assay prior to ovarian stimulation initiation guides the clinicians to choose the antagonist stimulation protocol for the patients with two extreme AMH levels. AMH levels can be used to individualize control ovarian stimulation in endometriosis patients.

The effects of surgery for endometriosis on pregnancy outcomes following in vitro fertilization and embryo transfer: a systematic review and meta-analysis

PURPOSE

To review the literature about the effect of endometriosis on in vitro-fertilization and embryo-transfer (IVF-ET).

METHODS

A search in EMBASE, MEDLINE, ClinicalTrial.gov, reference lists from 2000 to 2013 was conducted. Inclusion criteria were: endometriosis confirmed with histologic examination, women undergoing IVF-ET, endometriosis treated or diagnosed by surgery. Women undergoing IVF-ET after surgical removal of endometriosic implants, or a surgical diagnosis of endometriosis without its removal, were compared to women without endometriosis. Main outcomes were clinical pregnancy and delivery rates.

RESULTS

Thirteen studies were selected, including 980 women with endometriosis and 5934 controls. Clinical pregnancy rate was lower in women with endometriosis than in controls (OR 0.65; 95 % CI 0.44-0.96), but delivery rate was similar (OR 1.17; 95 % CI 0.69-1.98). When surgery was operative, clinical pregnancy rate after IVF-ET was lower in endometriosis than controls (OR 0.54; 95 % CI 0.34-0.85), but delivery rate was similar (OR 1.12; 95 % CI 0.60-2.07). When surgery was diagnostic, clinical pregnancy (OR 1.15; 95 % CI 0.46-2.84) and delivery rates (OR 1.65; 95 % CI 0.36-7.45) did not differ between the groups. Site of endometriosis was not related to IVF-ET outcomes. Clinical pregnancy rates were similar between stage I-II and controls (OR 0.99; 95 % CI 0.63-1.56) but lower in stage III-IV than controls (OR 0.45; 95 % CI 0.29-0.70), whereas delivery rate was not associated with stage.

CONCLUSIONS

In the presence of endometriosis, the clinical pregnancy rate after IVF-ET is lower than in controls. The prognosis is better for mild endometriosis compared with more advanced stages. Even after surgical removal of endometriosis, IVF-ET results remain worse than in controls.

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.

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.

T helper (Th)1, Th2, and Th17 interleukin pathways in infertile patients with minimal/mild endometriosis

In the present study, interleukin (IL)-10, IL-12, IL-17, and IL-23 levels were measured in serum and peritoneal fluid of women with minimal or mild endometriosis and compared with levels in controls without endometriosis. Higher IL-23 levels were encountered in the peritoneal fluid of women with endometriosis, suggesting a possible role of this cytokine in these women's infertility.

Intraperitoneal inflammation decreases endometriosis in a mouse model

BACKGROUND

The role of the immune system in the pathogenesis of endometriosis remains elusive. It has been shown that patients have an altered peritoneal environment with increased levels of inflammatory cytokines, activated macrophages and reduced clearance of retrogradely transported endometrial fragments. However, it is not known if this unique inflammatory situation is cause or consequence of endometriosis. This study investigates the impact of a pre-existing peritoneal inflammation on endometriosis establishment in a mouse model.

METHODS

Endometriosis was induced by intraperitoneal injection of enhanced green fluorescent protein (EGFP)-expressing endometrium in mice. In parallel, a peritonitis model was established via intraperitoneal injection of thioglycolate medium (TM). Finally, endometriosis was induced in the inflamed peritoneal cavity and lesion establishment as well as morphological and histological characteristics were analysed.

RESULTS

Induction of endometriosis in an inflamed peritoneal cavity resulted in fewer lesions and significantly lower sum of lesion surface area per mouse in the TM-treated group. Additionally, a higher amount of non-attached debris could be detected in the peritoneal cavity of TM-treated mice.

CONCLUSIONS

An intraperitoneal inflammation decreases endometriosis establishment in this mouse model. Thus, a pre-existing peritoneal inflammation might not be a factor favouring the development of endometriosis.

Endometriosis and infertility: epidemiology and evidence-based treatments

Endometriosis is an estrogen-dependent disorder defined as the presence of endometrial tissue outside of the uterine cavity. A leading cause of infertility, endometriosis has a prevalence of 0.5-5% in fertile and 25-40% in infertile women. The optimal choice of management for endometriosis-associated infertility remains obscure. Removal or suppression of endometrial deposits by medical or surgical means constitutes the basis of endometriosis management. Current evidence indicates that suppressive medical treatment of endometriosis does not benefit fertility and should not be used for this indication alone. Surgery is probably efficacious for all stages of the disease. Controlled ovarian hyperstimulation with intrauterine insemination is recommended in early-stage and surgically corrected endometriosis when pelvic anatomy is normal. In advanced cases, in vitro fertilization is a treatment of choice, and its success may be augmented with prolonged gonadotropin-releasing hormone analog treatment. Further randomized clinical trials focusing on diverse etiopathogenic mechanisms and therapeutic innovation are necessary to find more conclusive, evidence-based answers regarding this enigmatic disease.

GnRH agonist and antagonist protocols for stage I–II endometriosis and endometrioma in in vitro fertilization/intracytoplasmic sperm injection cycles

OBJECTIVE

To investigate the outcomes of intracytoplasmic sperm injection (ICSI) cycles after controlled ovarian hyperstimulation (COH) with GnRH antagonist or GnRH agonist (GnRH-a) in mild-to-moderate endometriosis and endometrioma.

DESIGN

Prospective randomize trial.

SETTING

A private IVF center.

PATIENT(S)

A total of 246 ICSI cycles in 246 patients were divided into three groups: women with mild-to-moderate endometriosis (n = 98); women who had ovarian surgery for endometrioma (n = 81); women with endometrioma and no history of previous surgery (n = 67).

INTERVENTION(S)

Patients in each group were randomized to COH with either triptrolein or cetrorelix.

MAIN OUTCOME MEASURE(S)

Clinical parameters, characteristics of COH, and ICSI results were analyzed.

RESULT(S)

Outcomes of COH with both GnRH antagonist and GnRH-a were similar in patients with mild-to-moderate endometriosis. Implantation rates were 15.9% vs. 22.6% and clinical pregnancy rates were 27.5% vs. 39% with GnRH antagonist and GnRH-a protocols, respectively, in patients who had ovarian surgery for endometrioma. Implantation rates were 12.5% vs. 14.8% and clinical pregnancy rates were 20.5% vs. 24.2% with GnRH antagonist and GnRH-a protocols, respectively, in patients with endometrioma and no history of ovarian surgery.

CONCLUSION(S)

Considering the implantation and clinical pregnancy rates, COH with both GnRH antagonist and GnRH-a protocols may be equally effective in patients with mild-to-moderate endometriosis and endometrioma who did and did not undergo ovarian surgery.

La stérilité par endométriose

From the literature, the crucial knowledge were drawn among endometriosis related infertility. Endometriosis is an important factor of infertility in minimal or light stages and a major one in mild or moderate stages. Thus, a laparoscopy must be performed to confirm endometriosis when suggestive clinical or biological signs exist. In absence of them, laparoscopy can be delayed after intra-uterine inseminations (IUI). The first line treatment is laparoscopic surgery. Its efficacy is proven. It is useless to prescribe a post-operative medical treatment (GnRH analogues). Surgery leads to 25 to 40% of deliveries. It is dependant on age, infertility duration, tubo-ovarian adhesion and tubes involvement. But, surgery can be avoided and the patient is directly referred to In Vitro Fertilization (IVF) when the lesions extension is so important that surgery exposes to complications or when there is a permanent other indication for IVF (severe male infertility). When infertility persists 6 to 12 months after surgery and without patent recurrence, ovulation stimulations and IUI are performed as the second line treatment. After IUI failure, or in case of recurrence, IVF must be applied. A second surgery is not recommended. The IVF results are not impaired by the presence of endometriosis and even of endometriomas. Thus, it is useless to operate again endometriosis before IVF. In opposition, in severe stages or in cases of recurrence, a pre-IVF medical treatment (GnRH analogues) improves the results. IVF do not increased the risk of endometriosis acute growth. In case of infertility and pain, infertility is considered as the first target. But medical treatment can be prescribed between the IVF attempts.

Women with advanced-stage endometriosis and previous surgery respond less well to gonadotropin stimulation, but have similar IVF implantation and delivery rates compared with women with tubal factor infertility

OBJECTIVE

To investigate the response to controlled ovarian hyperstimulation and ART outcomes in women with advanced-stage endometriosis and previous surgeries at the Yale IVF program between 1996 and 2002.

DESIGN

Retrospective case control study.

SETTING

Academic medical center.

PATIENT(S)

The study group consisted of 68 women who previously undergone laparoscopic surgery for advanced-stage endometriosis. The control group included 106 women with tubal-factor infertility. The women with endometriosis underwent 133 IVF-ET cycles and the control group 208 cycles.

INTERVENTION(S)

Controlled ovarian hyperstimulation and IVF-ET.

MAIN OUTCOME MEASURE(S)

Response to gonadotropins, fertilization, cleavage, implantation, pregnancy, miscarriage, and live birth rates.

RESULT(S)

Lower peak E(2) levels, higher total gonadotropin requirements, lower oocyte yield, and higher cancellation rates were found in women with endometriosis compared with tubal-factor control subjects. However, no differences were found in fertilization, cleavage, implantation, pregnancy, miscarriage, and delivery rates between the endometriosis and tubal-factor groups.

CONCLUSION(S)

Women with advanced-stage endometriosis who have undergone previous surgery respond less well to gonadotropins than women with tubal-factor infertility. However, implantation, pregnancy, and delivery rates are similar, suggesting that embryo quality and uterine receptivity remains unaffected despite diminished ovarian reserve in women with endometriosis.

Effect of endometrioma cystectomy on IVF outcome: a prospective randomized study

The study was conducted to investigate the effect of conservative surgery of ovarian endometriomas before an ICSI cycle. Ninety-nine patients with endometriomas who were referred to an intracytoplasmic sperm injection (ICSI) cycle were enrolled in the study. The patients were prospectively randomized into two groups; group I (49 patients) underwent conservative ovarian surgery before the ICSI cycle and group II (50 patients) underwent the ICSI cycle directly. The stimulation was started 3 months after the operation in group I and directly in group II. In the ovarian surgery group, stimulation was significantly longer (14.0 days in group I and 10.8 days in group II; P = 0.001), total recombinant FSH dose was significantly higher (4575 IU in group I and 3675 IU in group II; P = 0.001), and mean number of mature oocytes was significantly lower (7.8 in group I and 8.6 in group II; P = 0.032). There was no difference in terms of fertilization (86% in group I and 88% in group II), implantation (16.5% in group I and 18.5% in group II) and pregnancy rates (34% in group I and 38% in group II). Ovarian surgery resulted in longer stimulation, higher FSH requirement and lower oocyte number, but fertilization, pregnancy and implantation rates did not differ between the groups.

Nonsteroidal antiinflammatory drugs differentially suppress endometriosis in a murine model

OBJECTIVE

To determine whether nonsteroidal antiinflammatory drugs (NSAIDs) affect the establishment and progression of endometriotic lesions in a murine model.

DESIGN

Pharmacologic intervention in a surgically induced murine model of abdominal/peritoneal endometriosis.

SETTING

Animal research facility.

PATIENT(S)

Eight-week-old, female C57BL/6 mice.

INTERVENTION(S)

After implantation of autologous endometrium, mice were randomized into groups and treated with one of several NSAIDs or the vehicle-matched control for 4 weeks.

MAIN OUTCOME MEASURE(S)

Establishment, growth, and total burden of endometriotic lesions.

RESULT(S)

The NSAIDs differentially inhibited lesion establishment and growth, resulting in significantly reduced disease burden. Compared with controls (5.7 +/- 2.3 mm(2)), lesion burden was reduced by celecoxib (1.3 +/- 1.2 mm(2)), indomethacin (1.4 +/- 1.4 mm(2)), naproxen (2.7 +/- 1.2 mm(2)), sulindac (3.1 +/- 1.5 mm(2)), rofecoxib (3.4 +/- 3.0 mm(2)), and ibuprofen (4.1 +/- 1.4 mm(2)). In contrast, aspirin (5.9 +/- 1.2 mm(2)) had no statistically significant effect. Uninterrupted estrus cycling was confirmed by vaginal exams and smears in celecoxib-treated mice.

CONCLUSION(S)

Chronic administration of certain NSAIDs limits the progression of endometriosis in this murine model. The data suggest that NSAID selection in the treatment of endometriosis should be extended beyond pain management to maximize the inhibitory effect on disease burden.

Endometriosis affects sperm–endosalpingeal interactions

BACKGROUND

The interaction between spermatozoa and the epithelium of the isthmic region of the uterine tube is thought to be an important part of the mechanisms of sperm transport to the site of fertilization and in preparing them for fertilization. However, it is unclear whether a dysfunction of this mechanism may contribute to subfertility in some individuals.

METHODS

The sperm-binding characteristics of the epithelium from the uterine tubes of three groups of women were examined: (i) eight with pelvic endometriosis (not involving the uterine tubes); (ii) five women who had been receiving zoladex injections to control their symptoms; and (iii) as controls 10 women undergoing an elective procedure for benign gynaecological problems but with no other pathology of the reproductive tract.

RESULTS

Significantly more spermatozoa bound per unit area to the ampullary epithelium of the uterine tubes taken from women with a previous diagnosis of endometriosis.

CONCLUSIONS

These findings suggest that the characteristics of sperm binding to tubal epithelium may be disrupted in women with a gynaecological pathology such as endometriosis. It is suggested that this may have the potential to interfere with the availability of freely motile spermatozoa, of the appropriate physiological status, to take part in fertilization. This may be a newly described mechanism by which endometriosis can cause infertility.

Aspiration of ovarian endometriomas before intracytoplasmic sperm injection

OBJECTIVE

To investigate whether aspiration of ovarian endometriomas before controlled ovarian stimulation (COH) improves intracytoplasmic sperm injection (ICSI) outcomes.

DESIGN

Prospective study.

SETTING

University hospital.

PATIENT(S)

A prospective analysis of 171 patients with ovarian endometriosis and tubal factor infertility were divided into four groups: aspiration of endometriomas at the beginning of COH in patients with ovarian endometriomas and no history of previous surgery (n = 41) (group 1); nonaspirated endometriomas (n = 40) (group 2); history of ovarian surgery for endometriomas in patients without ovarian endometriomas at the beginning of COH (n = 44) (group 3); and tubal factor infertility (n = 46) (control group 4).

INTERVENTION(S)

Aspiration of endometriomas.

MAIN OUTCOME MEASURE(S)

Clinical parameters, characteristics of COH, and ICSI results were analyzed.

RESULT(S)

We observed higher levels of E(2) on the day of hCG injection after aspiration of endometriomas compared with nonaspirated endometriomas. When we compared all endometriomas and tubal factor (control) groups, we observed a lower number of total follicles (>17 mm) and metaphase II (MII) oocytes in nonaspirated and resected endometrioma groups and a longer duration of COH in the nonaspirated endometrioma group compared with the tubal factor group. Implantation and clinical pregnancy rates were similar among all groups.

CONCLUSION(S)

In the current study, all patients with endometriomas had significantly lower numbers of MII oocytes compared with those in patients with tubal factor infertility. We propose that aspiration of endometriomas before COH neither reduces the amount of gonadotropins nor increases the number of follicles >17 mm, the number of MII oocytes retrieved, the implantation rates, or the clinical pregnancy rates. Resection of small endometriomas (1-6 cm) may not present any additional benefits to the IVF-ICSI cycle outcomes.

Removal of endometriomas before in vitro fertilization does not improve fertility outcomes: a matched, case–control study

OBJECTIVE

To investigate whether conservative surgery on ovarian endometriomas before an IVF cycle improves fertility outcomes.

DESIGN

Retrospective, matched case-control study.

SETTING

Two academic IVF programs.

PATIENT(S)

One hundred eighty-nine women with endometriomas who underwent IVF treatment: 56 women proceeded directly to IVF, and 133 first underwent conservative ovarian surgery.

INTERVENTION(S)

Controlled ovarian hyperstimulation and IVF-ET.

MAIN OUTCOME MEASURE(S)

Response to gonadotropins, fertilization, implantation, and pregnancy rates.

RESULT(S)

Aside from lower peak E(2) levels on the day of hCG and a higher total FSH dose in women previously operated for an endometrioma, no significant differences were found between the two groups in the different IVF variables analyzed.

CONCLUSION(S)

Laparoscopic cystectomy for endometriomas before commencing an IVF cycle does not improve fertility outcomes. Proceeding directly to controlled ovarian hyperstimulation in women with asymptomatic ovarian endometriomas might reduce the time to pregnancy, the costs of treatment, and the hypothetical complications of laparoscopic surgery. Conversely, conservative surgical treatment of ovarian endometriomas in symptomatic women does not impair IVF or intracytoplasmic sperm injection success rates.

Interleukin-1 inhibits interleukin-15 production by progesterone during in vitro decidualization in human

Interleukin (IL)-15 is a novel cytokine that plays important roles in uterine natural killer cell function and one of the candidate genes that is upregulated during the window of implantation for human endometrium. IL-15 expression and production by human endometrial stromal cells (ESCs) is elevated during in vitro decidualization by progesterone (P). In the present study, we evaluated the effects of IL-1beta, a proinflammatory cytokine, on IL-15 production in ESCs. By enzyme-linked immunosorbent assay (ELISA), IL-1beta had no effect on IL-15 production from ESCs in short-term culture (for 24 h), whereas IL-1beta stimulated production of IL-8. However, using ELISA and Northern blot analyses we found that IL-1beta significantly inhibited P-induced IL-15 production and mRNA expression in long-term culture (for 12 days) of ESCs in vitro (P<0.01). This inhibition was not due to IL-1beta-mediated cytotoxicity, as ESCs cultured in the presence of IL-1beta showed no evidence of significant change in their viability. These results suggest that ovarian steroid hormones and IL-1beta regulate IL-15 mRNA expression and protein production in long-term culture, and that IL-1beta plays a role as a negative regulator of IL-15 production during decidualization in human endometrium.