Is the dimension of ovarian endometriomas significantly modified by IVF–ICSI cycles?

Chapter 11. Endometriosis-related complications in women undergoing in-vitro fertilization

As a chronic inflammatory disease, endometriosis generates fibrosis and anatomic distortion, which add extra-challenges to assisted reproductive technology cycles and requires a personalized approach. Patients with endometriomas have significantly decreased ovarian reserve and the ultrasound examination tends to be challenging, possibly underestimating follicle counts. It is crucial to assess the feasibility of oocyte retrieval procedure during the initial examination of the patient, as the distortion of the pelvic anatomy, the presence of hydrosalpinges and endometriomas might render the procedure difficult and increase the risk of complications. Possible injury to adjacent organs and risk of infection must be considered. Assisted reproductive technology seems to have limited or no impact on endometriosis recurrence, pain symptom progression or the size of endometrioma.

Endometrioma and assisted reproductive technology: a review

PURPOSE

Endometriomas are a common cause of infertility necessitating assisted reproductive technology (ART). It had been previously thought that surgical removal of the endometriomas prior to ART would improve reproductive outcomes, but recent data suggests that surgical cystectomy might affect the ovarian reserve, decreasing the chances of ART success. The aim of this article is to review the literature on the effects of endometrioma surgery on ART outcomes providing an overview of the current evidence and assessing the need for further studies.

METHODS

A literature search was performed using PubMed and MEDLINE databases to identify studies that discuss endometriomas and assisted reproductive technology before versus after surgery.

RESULTS

In women with an endometrioma requiring ART, growing evidence suggests that surgery might result in damage to the ovarian reserve and further decrease chances of fertility. However, pregnancy rates, implantation rates, fertilization rates, and live birth rates seemed to be consistently similar across both groups.

CONCLUSION

The current evidence is inconclusive on whether endometriomas should be surgically removed prior to ART. Further large randomized controlled trials are needed for a definite answer, and until then, management should be individualized.

Endometriosis-associated infertility: surgery or IVF?

Endometriosis is a chronic disease frequently associated with female infertility. The choice of treatment in case of endometriosis is one of the most discussed topics in Reproductive Medicine. The approach to the patient with endometriosis and infertility should be tailored based on different parameters. The localization of the disease, the severity of symptoms and the age of the patient are just some of them. Management options include surgery, in-vitro fertilization (IVF), or a combination of both. Data, mostly uncontrolled, would favor surgery at any stage of endometriosis, increasing the chances of natural conception compared to expectant management. Laparoscopic excision of the ovarian endometrioma should be the treatment of choice when there is associated pain. Surgery should be performed following appropriate techniques to reduce the possible damage to the ovarian reserve. Pregnancy rates around 50% have been consistently reported after surgery, which compare favorably with those obtained with IVF. IVF, on the other hand, may be preferred in case of associated male or tubal factor, in case of a reduced ovarian reserve, or if previous surgery has failed, particularly if there is no associated pain, and when the ultrasonographic features of the ovarian cyst are reassuring. Sometimes IVF may be preceded by surgery, when a difficult access to follicles at pick-up, due to the size and location of the ovarian cyst, or to severe adhesions, is anticipated. Due to the lack of solid evidence in the scenario of endometriosis-associated infertility, robust data from randomized clinical trials (RCTs) are strongly needed.

Long-term Recurrence of Endometriosis in Women with Subfertility Caused by Endometriosis: A Comparison of the Efficacy of Surgery and Assisted Reproductive Technology as Fertilization Treatment Approaches

Background: The evolution of fertility treatment methods such as laparoscopic surgery and assisted reproductive technology (ART) leads to an increased chance for conception in women with endometriosis. However, it is still not clear which treatment is more likely to result in endometriosis recurrence. Objectives: The current study aimed at assessing the recurrence rate of endometriosis and its main determinants following fertility treatment with surgery or ART. Methods: The current historical cohort study was conducted on 51 consecutive women with endometriosis undergoing fertilization procedures, including laparoscopic surgery (n = 42) and ART (n = 9) in Tehran from 2006 to 2016. All patients with complete hospital records were enrolled in the study. The patients in the two groups were followed up for five years for endometriosis recurrence. Results: Within the follow-up time, the rate of endometriosis recurrence in patients of the surgery and ART groups was 28.6% and 44.4%, respectively, indicating no significant difference between the groups (P = 0.436). In this regard, the 1-, 2-, and 3-year recurrence-free survival rate in the ART group was 87.5%, 50.0%, and 50.0%, and in the surgery group was 96.9%, 90.6%, and 70.5%, respectively. Using the Cox proportional hazard modeling adjusted for baseline variables, the method of fertilization (ART or surgery) could not affect the rate of long-term recurrence of endometriosis (odds ratio = 1.428, 95% confidence interval: 0.177 - 9.900, P = 0.784). Conclusions: The method of fertilization treatment-e g, surgery, and ART- may not affect the rate of endometriosis recurrence in women with subfertility caused by endometriosis.

Do endometriomas grow during ovarian stimulation for assisted reproduction? A three-dimensional volume analysis before and after ovarian stimulation

Whether endometriomas grow because of supraphysiological oestradiol levels attained during ovarian stimulation for assisted reproduction techniques is a concern. In this prospective study, 25 women with 28 endometriomas underwent three-dimensional ultrasound using sono-automated volume calculation software. Endometrioma volume was measured on the first day of gonadotrophin injection (V1) and the day of ovulation trigger (V2). Nine (36%) women were stimulated in a gonadotrophin releasing hormone antagonist protocol (GnRH), 13 (52%) in a long, and three (12%) in an ultra-long GnRH agonist protocol. Mean duration of stimulation was 10.3 days with median total gonadotrophin dose of 4500 IU/day. Median number of cumulus oocyte complexes was five, and metaphase-two oocytes was four. None of the endometriomas were punctured during oocyte retrieval. Median V1 was 22.2 ml (12-30 ml) and median V2 was 24.99 ml (11.2-37.4 ml) with P = 0.001. Twenty-three out of 28 endometriomas (82%) grew to some extent during ovarian stimulation. Endometrioma growth was positively correlated with prestimulation cyst volume (Correlation coefficient 0.664; P < 0.01). Although the 3-ml average growth was statistically significant, it could be regarded as clinically insignificant.

[Conservative management of endometrioma in women undergoing in vitro fertilization]

Endometriosis is a chronic disease. The pathogenesis is actually still unclear. Endometriosis is responsible for infertility and/or pelvic pain. One of the most important features of the disease is the heterogeneity (clinical and anatomical). Among the different phenotypes of endometriosis, the ovarian endometrioma seems to most important lesion in the management of endometriosis-related infertility. Surgical treatment is associated to a decrease of the ovarian reserve and a potential detrimental effect on in vitro fecondation (IVF) outcomes. Thus, the choice between conservative or surgical management of endometrioma before IVF is actually debated. The advantages and drawback of surgical and conservative management should be discussed before to plan the treatment. In the present review, we aimed at assessing the risks of a conservative management of endometrioma as compared to surgery before IVF.

Analysis of Adherence, Persistence, and Surgery Among Endometriosis Patients Treated with Leuprolide Acetate Plus Norethindrone Acetate Add-Back Therapy

BACKGROUND

Endometriosis affects over 10 million women in the United States. Depot leuprolide acetate (LA), a gonadotropin-releasing hormone agonist, has been used extensively for the treatment of women with endometriosis but is associated with hypoestrogenic symptoms and bone mineral density loss. The concomitant use of add-back therapies, specifically norethindrone acetate (NETA), can alleviate these adverse effects.

OBJECTIVE

To compare adherence to and persistence with LA treatment and time to endometriosis-related surgery among women treated with NETA and women treated with LA plus other add-back therapies or LA only.

METHODS

This retrospective analysis was conducted using Truven Health MarketScan Commercial Claims and Encounters Database. Women with a diagnosis of endometriosis (ICD-9-CM code 617.xx) who initiated LA (index date) in 2005-2011 were selected for inclusion. Additional requirements were 12 months of continuous enrollment pre- and post-index and no evidence of endometriosis-related surgeries pre-index or up to 30 days post-index; no pre-index use of estrogen or noncontraceptive hormones; and no diagnoses of uterine fibroids, malignant neoplasms, infertility, or pregnancy. Patients were characterized as using NETA; other add-back therapies (estrogens, progestins, or estrogen-progestin combinations); or no add-back therapy. Adherence to and persistence with LA were measured over the 6 months following the index date using outpatient medical and pharmacy claims. Patients were considered adherent if their proportion of days covered was greater than or equal to 0.80. Persistence was operationalized as time to discontinuation, defined as a continuous gap of > 60 days without LA on hand. Time to endometriosis-related surgery (laparotomy, laparoscopy, excision/ablation/fulguration, oophorectomy, and hysterectomy) was measured over the 12 months following the index date. Surgeries were identified from inpatient and outpatient medical claims using procedure codes. Outcomes were compared among cohorts using multivariable logistic and Cox proportional hazards regression models controlling for demographics and baseline clinical characteristics.

RESULTS

The final sample included 3,114 women, with a mean age of 36.9 years. The majority of women used LA only with no add-back therapy (n = 1,963, 63.0%), while 15.1% (n = 470) used NETA, and 21.9% (N = 681) used other add-back therapies. During the 6-month follow-up, more patients in the LA plus NETA cohort were adherent to LA therapy compared with LA only (47.2% vs. 31.5%, P < 0.001), and fewer patients discontinued (37.9% vs. 59.6%, P < 0.001). Additionally, fewer patients underwent endometriosis-related surgery in the 12 months after LA initiation in the LA plus NETA cohort (12.6% vs. 16.9%, P = 0.021). In multivariable models, women who initiated LA plus NETA or LA plus other add-back therapies had a higher likelihood of being adherent to LA than LA only patients (OR = 1.91, 95% CI = 1.55-2.36 and OR = 1.95, 95% CI = 1.63-2.34) and lower likelihood of LA discontinuation (HR = 0.54, 95% CI = 0.46-0.63 and HR = 0.59, 95% CI = 0.52-0.68). NETA patients had a lower surgery rate in the 12-month post-index period compared with other add-back patients (HR = 0.68, 95% CI = 0.50-0.93) or LA only patients (HR = 0.69, 95% CI = 0.52-0.92).

CONCLUSIONS

For women with endometriosis, treatment with LA and concomitant add-back therapies was associated with better adherence to and persistence with LA over the 6 months following initiation, compared with treatment with LA only. The increased adherence and persistence to LA may translate into decreased need for surgical intervention, although fewer endometriosis-related surgeries were only observed in the 12 months following LA initiation for patients using concomitant NETA add-back therapy. These results support an increased and earlier use of NETA add-back therapy among women who initiate LA.

DISCLOSURES

This study was funded by AbbVie, which also markets the endometriosis drugs Lupron and Lupaneta Pack. AbbVie participated in the study design, research, data collection, analysis and interpretation, writing, review, and approval of this publication. Soliman and Castelli-Haley are employees of AbbVie and may own AbbVie stock or stock options. Bonafede and Farr are employees of Truven Health Analytics, which received a research contract to conduct this study with and on behalf of AbbVie. Winkel is a clinical professor in the Department of Obstetrics and Gynecology at Georgetown University in Washington, DC, and has served in a consulting role on research to AbbVie for this project. An earlier version of the current research was presented at the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) 20th Annual International Meeting; Philadelphia, PA; May 2015. All authors participated in data analysis and interpretation and contributed to the development of the manuscript.

Impaired uterine artery flow associated with the presence of ovarian endometrioma: preliminary results of a prospective study

BACKGROUND

Aim of this prospective, case-control study was to evaluate uterine arteries' blood flow before and after laparoscopic surgery in patients with ovarian endometriosis and its possible correlation with infertility.

METHODS

We prospectively enrolled 110 women of reproductive age; 69 with ovarian endometriomas and scheduled for surgery, and 41 controls. At enrolment, a detailed medical, gynecologic and obstetric history was collected. Fertility and pregnancy desire were assessed. All patients underwent complete physical and gynecologic examination. Transvaginal ultrasound with Doppler color flow was performed to evaluate Resistance Index (RI) of uterine arteries during the secretory phase, at enrolment (T0) and 3 months after laparoscopic surgery (T1).

RESULTS

Among cases, 27 patients were excluded because they did not meet the inclusion criteria. At enrolment (T0) unilateral or bilateral flow alterations (RI ≥ 0.8) were found in 38 out of 42 patients with ovarian endometriosis (90%), whereas in the control group only 17 women (41%) had Doppler alterations. The difference in uterine artery RI values between cases and controls was statistically significant (P < 0.0001). A statistically significant improvement in uterine artery flow (P <0.0001) was found 3 months after surgical treatment of endometriosis. Nineteen patients with endometriosis (45%) were infertile before surgery; all of them presented uterine artery Doppler alterations at T0. After surgery the pregnancy rate was significantly higher in patients who presented uterine artery flow normalization than in those with persistent uterine artery flow alterations (p = 0.002).

CONCLUSIONS

A strong correlation was found between uterine artery flow abnormalities and ovarian endometriosis. Uterine artery flow improvement following surgery seems to increase the probabilities of achieving pregnancy.

The vanishing endometrioma: the intriguing impact of pregnancy on small endometriotic ovarian cysts

There is a general belief that pregnancy has a beneficial effect on endometriosis but evidence is scanty. Moreover, some recent warning reports documented progression-growth of ovarian endometriomas during pregnancy. To further elucidate this aspect, we set up a prospective cohort study. We recruited 24 women carrying endometriomas at the time of in vitro fertilization who got pregnant. Selected women were contacted about 12-18 months after oocyte retrieval and invited to refer for ultrasound. The primary aim was to evaluate the modifications of endometriotic cysts after pregnancy. Twenty-four women carrying 40 endometriomas accepted to participate. The number of cysts per patient was significantly reduced following pregnancy (p = 0.003). It was unchanged in eight cases (33%), increased in two cases (8%) and reduced in three cases (13%). In the remaining 11 women (46%), no cyst could be detected. A comparison of the size of the endometrioma could be done in 21 cysts; the mean ± SD diameter before and after pregnancy was 20 ± 9 and 18 ± 7 mm, respectively (p = 0.27). In conclusion, pregnancy has a beneficial effect on endometriomas. A consistent proportion of cysts becomes undetectable after delivery. Further studies are warranted to clarify the mechanisms determining the disappearance of these cysts.

Gonadotrophin-releasing hormone analogues and endometriosis: current strategies and new insights

BACKGROUND

Endometriosis is an estrogen-dependent chronic inflammatory disease affecting 5% to 10% of women in reproductive age and has been reported also in adolescents. Its main clinical presentations are chronic pelvic pain and infertility.

OBJECTIVE

To provide a comprehensive review of the recently published data concerning the mechanism of action of gonadotrophin-releasing hormone analogues (GnRHas) as well as to analyze their role in the management of endometriosis-associated pain and infertility in addition to its value in adolescent cases. Furthermore, to provide practical recommendations and new insights based on the best available information.

METHODS

Systematic search was performed of the Cochrane Library and Medical Literature Analysis and Retrieval System Online database looking for the different trials, reviews and various guidelines relating to GnRHas usage in the management of endometriosis-associated pain, infertility and in adolescent cases.

RESULTS

From a pathophysiological perspective, there is a growing scientific evidence that GnRHas exert its therapeutic effects by their classical pituitary downregulation and via a direct effect on the endometrial cells themselves. Accordingly, they represent an important medical option for the management of different aspects of this enigmatic disease.

CONCLUSION

GnRHas have a valuable strategic role in treatment of endometriosis-associated pain and infertility as well as in adolescents above 16 years.

Endometrioma and ART: Does the Needle Work?

Aim and Objectives

The aim of this study was to see if the fertility outcome improved when IVF/ICSI was done after administration of GnRH analogs and cyst aspiration in comparison with patients in whom either only cyst aspiration or only GnRh analogs were administered.

Materials and methods

This was a prospective study done in a tertiary level ART center which included 30 patients over a span of 5 years from 2004 to 2009. All of them had endometriomas and underwent assisted reproductive techniques (ART) either after cyst aspiration with or without GnRH analog pretreatment or only GnRH analog pretreatment.

Depending on the pretreatment received, they were classified into three groups:

• Group B: Both GnRH analog and cyst aspiration

• Group C: Only cyst aspiration

• Group G: Only GnRH analog.

The patients were not randomized.

The number of days required for stimulation, total dose of stimulation required, number of oocytes obtained, quality of embryos, and the pregnancy rates for each group were tabulated for comparison.

Statistical analysis

The significance of the difference in ART outcome after the different modalities of pretreatment, which was estimated in terms of pregnancy rates was evaluated by calculating the p-value.

Observations and results

Significant difference was observed between the pregnancy rates in the three groups, with the maximum pregnancy rate in group B, followed by the group G and then the group C. The p-value showed a trend, though not statistically significant, indicating the need for larger prospective studies with greater number of subjects.

Conclusion

Pretreating endometriomas by aspirating the cysts and administering three doses of GnRH analog depot preparation prior to IVF/ICSI seems to be better than administering GnRH analog depot preparation alone or aspirating the cysts alone in terms of the number of days required for stimulation, the number of oocytes obtained, and the clinical pregnancy rates.