Poor response of ovaries with endometrioma previously treated with cystectomy to controlled ovarian hyperstimulation

Impact of cystectomy versus ablation for endometrioma on ovarian reserve: a systematic review and meta-analysis

OBJECTIVE

To investigate whether cystectomy or ablation for endometrioma has less impact on ovarian reserve as evaluated by antral follicle count (AFC) and antimüllerian hormone (AMH) levels.

DESIGN

Systematic review and meta-analysis.

SETTING

Not applicable.

PATIENT(S)

Patients with endometriomas undergoing cystectomy or ablation.

INTERVENTION(S)

All prospective studies comparing cystectomy with ablation for endometrioma in the PubMed, EMBASE, MEDLINE and Web of Science until April 3, 2022 were retrieved and reviewed. Medical treatment used as adjuvant therapy for the surgery was excluded. Two authors assessed eligibility and risk of bias independently. The statistical data were pooled using the Review Manager software.

MAIN OUTCOME MEASURE(S)

The changes of AMH levels and AFC values in cystectomy group and ablation group, including intergroup comparisons and intragroup comparisons.

RESULT(S)

Four randomized clinical trials and 2 prospective cohort studies were eligible for the meta-analysis, with a total of 294 patients. In the intergroup comparisons, preoperative AFC values were similar with low heterogeneity, but postoperative AFC values were significantly lower in cystectomy than ablation (mean differences [MD], -1.33; 95% credible interval, -2.15 to -0.51; I² = 57%). In the intragroup comparisons of AFC values, sensitivity analyses showed a significant decrease in cystectomy (MD, -1.93; 95% credible interval, -2.40 to -1.45; I² = 0%) at 6-month follow-up, compared with no reduction in ablation. The intragroup comparisons of AMH levels supported negative effects on ovarian reserve of both cystectomy (MD, -1.26; 95% credible interval, -1.64 to -0.88; I² = 45%) and ablation (MD, -0.70; 95% credible interval, -1.07 to -0.32; I² = 0%).

CONCLUSION(S)

Both ablation and cystectomy have significantly detrimental effects on ovarian reserve as evaluated by AMH, but the ablation causes relatively less damage to ovarian reserve as appraised by AFC.

CLINICAL TRIAL REGISTRATION NUMBER

CRD42020152823;PROSPERO (york.ac.uk).

Endometriosis and Infertility: A Long-Life Approach to Preserve Reproductive Integrity

Laparoscopic surgery was originally considered the gold standard in the treatment of endometriosis-related infertility. Assisted reproductive technology (ART) was indicated as second-line treatment or in the case of male factor. The combined approach of surgery followed by ART proved to offer higher chances of pregnancy in infertile women with endometriosis. However, it was highlighted how pelvic surgery for endometriosis, especially in cases of ovarian endometriomas, could cause iatrogenic damage due to ovarian reserve loss, adhesion formation (scarring), and ischemic damage. Furthermore, in the last few years, the trend to delay the first childbirth, recent technological advances in ultrasound diagnosis, and technological progress in clinical and laboratory aspects of ART have certainly influenced the approach to infertility and endometriosis with, ART assuming a more relevant role. Management of endometriosis should take into account that the disease is chronic and involves the reproductive system. Consequently, treatment and counselling should aim to preserve the chances of pregnancy for the patient, even if it is not associated with infertility. This review will analyse the evolution of the management of infertility associated with endometriosis and propose an algorithm for treatment decision-making based on the most recent acquisitions.

The Optimal Time of Ovarian Reserve Recovery After Laparoscopic Unilateral Ovarian Non-Endometriotic Cystectomy

Background

Laparoscopic ovarian cystectomy is established as the standard surgical approach for the treatment of benign ovarian cysts. However, previous studies have shown that potential fertility can be directly impaired by laparoscopic ovarian cystectomy, diminished ovarian reserve (DOR), and even premature ovarian failure. Therefore, fertility-preserving interventions are required for benign gynecologic diseases. However, there are still little data on the time period required for recovery of ovarian reserve after the laparoscopic unilateral ovarian cystectomy, which is very important for the individualization of treatment protocols. This study aimed at investigating the time needed for the ovarian reserve to recover after laparoscopic unilateral ovarian non-endometriotic cystectomy.

Materials and Methods

Sixty-seven patients with unilateral ovarian non-endometriotic cyst from Zhoupu and Punan Hospitals who underwent laparoscopic unilateral ovarian cystectomy were recruited as a postoperative observation group (POG). Also, 69 healthy age-matched women without ovarian cyst who did not undergo surgery were recruited as a referent group (RFG). Ovarian reserve with the serum anti-Müllerian hormone (AMH), follicle-stimulating hormone (FSH), estradiol (E2) levels, ovarian arterial resistance index (OARI), and antral follicle counts (AFCs) were measured on the third to fifth days of the same menstrual cycle. A postoperative 6-month follow-up of cases was performed.

Results

Compared with RFG, AFC of cyst side in the POG group showed no difference in the first, third, and sixth postoperative month (F = 0.03, F = 0.02, F = 0.55, respectively; p = 0.873, p = 0.878, p = 0.460, respectively). The OARI of cyst side in the POG group revealed no differences in the first, third, and sixth postoperative month (F = 0.73, F = 3.57, F = 1.75, respectively; p = 0.395, p = 0.061, p = 0.701, respectively). In the first month, the postoperative AMH levels significantly declined, reaching 1.88 ng/ml [interquartile range (IQR): 1.61-2.16 ng/ml] in POG and 2.57 ng/ml (IQR: 2.32-2.83 ng/ml) in RFG (F = 13.43, p = 0.000). For the data of AMH levels stratified by age, the same trend was observed between less than 25 and more than 26 years old. At this same time interval, the postoperative rate of decline was significantly lower compared to the preoperative one in POG (32.75%). The same trend was observed between the POG and RFG groups (26.67%).

Conclusions

The optimal time for recovery of ovarian reserve after laparoscopic unilateral ovarian cystectomy is estimated to be 6 months.

Assisted reproductive technique outcomes in patients with endometrioma undergoing sclerotherapy vs laparoscopic cystectomy: Prospective cross-sectional study

PURPOSE

The authors compared assisted reproductive technique (ART) outcomes and the recurrence rate of endometrioma in the infertile patients undergoing sclerotherapy vs laparoscopic ovarian cystectomy.

METHODS

In this prospective cross-sectional study, a total of 101 infertile patients, with unilateral endometriomas, were divided into two groups. The first group (n = 57) underwent ART after 1 year of unsuccessful spontaneous pregnancy after laparoscopic ovarian cystectomy; the second group (n = 44) had ethanol sclerotherapy (EST) at the time of oocyte retrieval. The authors measured the number of oocytes, clinical pregnancy rate (CPR), live birth rate (LBR), complication, and recurrence of endometriomas as the primary and secondary outcomes.

RESULTS

The two groups had no significant differences in baseline characteristics and ovarian stimulation markers and also total number of oocytes. 42.1% and 34.1% of the patients (n = 24 and 15) had clinical pregnancy, and 38.6% and 29.5% (n = 22 and 13) had live birth following ART cycles in the surgery group and sclerotherapy group (P = .41, 0.34). The recurrence rates were 14.0% and 34.1% in the surgery and sclerotherapy groups (P = .017, X 2 = 5.67).

CONCLUSIONS

Ethanol sclerotherapy can be a good alternative to surgery concerning the treatment of endometrioma; however, the recurrence of the disease in this group is significantly higher.

Appropriate surgical management of ovarian endometrioma: excision or drainage?

Endometriosis negatively impacts the lives of countless women around the world. When medical management fails to improve quality of life often women are left making a decision whether or not to proceed with surgery. With endometriomas, patient's surgical options include complete surgical removal or drainage via laparoscopy. Here, we review the literature to discuss both techniques, excision and drainage of endometriomas, and what the research supports for endometrioma management.

Endometrioma and reproductive issues: a well-informed patient may be the driver for change

Endometriosis affects a great proportion of women during their reproductive years and may impair female fertility in several ways. Ovarian endometrioma (OE) is the most frequent phenotype and growing evidence suggest an endometrioma-mediated damage to the ovary, ovarian reserve and oocyte quality. Traditionally, surgery has been the first-line treatment in cases of OE. Great advances in assisted reproduction and fertility preservation techniques opened new possibilities towards a more conservative approach. Herein we discuss multiple mechanisms responsible for the deterioration of the reproductive capacity in cases of OE as well as the pros and cons of different treatment options. The management of endometrioma-related subfertility remains controversial and it will depend on patient's intentions and priorities. In the "internet era" patients tend to be hyper-informed and more participative, but they are often misguided and misinformed. Thus, doctors should be able to convert these individuals into well-informed patients in order to facilitate the process of shared decision making, which is extremely relevant in the context of OEs.

Oocyte vitrification for fertility preservation in women with endometriosis: an observational study

OBJECTIVE

To describe the outcome of fertility preservation (FP) using vitrified oocytes in patients with endometriosis and to determine the impact of ovarian surgery.

DESIGN

Retrospective observational study.

SETTING

University-affiliated private in vitro fertilization (IVF) center.

PATIENT(S)

Four hundred and eighty-five women with endometriosis who underwent FP from January 2007 to July 2018.

INTERVENTION(S)

Vitrification of metaphase II (MII) oocytes for future use.

MAIN OUTCOME MEASURE(S)

Oocyte survival rate and cumulative live-birth rate (CLBR).

RESULT(S)

Mean age at vitrification was 35.7 ± 3.7 years. The women undergoing operations were younger than the nonsurgical patients (33.4 ± 3.6 years vs. 36.7 ± 3.7 years). The survival rate and CLBR were 83.2% and 46.4%, respectively. The number of vitrified oocytes per cycle (6.2 ± 5.8) was higher for the nonsurgical patients compared with the unilateral (5.0 ± 4.5) or bilateral (4.5 ± 4.4) surgery groups, but was comparable among the surgical patients. The effect of age (adjusted odds ratio [OR] 0.904; 95% CI, 0.858-0.952), number of oocytes (adjusted OR 1.050; 95% CI, 1.025-1.091), and survival (adjusted OR 1.011; 95% CI, 1.001-1.020) on the CLBR was confirmed. However, the effect of surgery was not observed (adjusted OR 1.142; 95% CI, 0.778-1.677). Nonetheless, the ovarian response (vitrified oocytes = 8.6 ± 6.9 vs. 5.1 ± 4.8) and CLBR (72.5% vs. 52.8%) were higher in young (≤35 years) nonsurgical patient versus the surgical patients; older women showed similar outcomes.

CONCLUSION(S)

Fertility preservation gives patients with endometriosis a valid treatment option to help them increase their reproductive chances. We suggest performing surgery after ovarian stimulation for FP in young women. In older women, an individualized treatment should be considered.

"Delayed start" gonadotropin-releasing hormone antagonist protocol in Bologna poor-responders: A systematic review and meta-analysis of randomized controlled trials

To evaluate the effectiveness of delay start protocol in improving the success of in vitro fertilization (IVF) in poor responders according to Bologna's criteria. Only randomized controlled trial (RCT) of infertile women undergoing a single IVF/ICSI cycle with ovarian stimulation protocol based on daily injections with delay start protocol or a conventional antagonist protocol were included in this systematic review and meta-analysis. The review protocol was registered in PROSPERO before starting the data extraction (CRD42019128284). Primary outcome was clinical pregnancy rate. Ongoing pregnancy rate, miscarriage rate, number of oocytes, number of MII oocytes, stimulation length, gonadotropin amount and cancellation rate were considered as secondary outcomes. Four randomized controlled trials were included with a total number of 380 participants. 189 patients were included in the delayed start protocol and 191 were allocated to the comparison group. The results showed a significant higher clinical pregnancy rate (CPR) in patients allocated to the intervention. Data from all studies failed to detect a statistical difference between groups in terms of ongoing pregnancy rate (OPR), miscarriage rate (MR), Total-Oocyte, MII-Oocyte and Total-Embryos. Gonadotropin amount (GA) was significantly lower in the intervention group in comparison to controls, with no difference in stimulation length (SL) and cancelled cycle (CC). Delayed start GnRH-antagonist protocol may reduce GA and improve CPR in poor ovarian responder according to Bologna criteria.

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Endometriosis and ART: A prior history of surgery for OMA is associated with a poor ovarian response to hyperstimulation

Background

Many women whose fertility may have been impaired by endometriosis require assisted reproductive technology (ART) in order to become pregnant. However, the influence of ovarian endometriosis (OMA) on ovarian responsiveness to hyperstimulation has not been clearly established.

Objective

To evaluate the risk of a poor ovarian response (POR) to stimulation and ART outcomes in women with OMA.

Materials and methods

We conducted a large observational controlled matched cohort study in a tertiary care university hospital between 01/10/2012 and 31/12/2015. After matching by age and anti-Müllerian hormone (AMH) levels, 201 infertile women afflicted with OMA (the OMA group) and 402 disease-free women (the control group) undergoing an ART procedure were included in the study. The main outcomes that we measured were a POR to hyperstimulation (i.e., ≤ 3 oocytes retrieved, or cancelled cycles), the clinical pregnancy rate, and the live birth rate.

All of the women with endometriosis underwent a pre-ART work-up, in order to obtain an accurate diagnosis and staging of their disease. An OMA diagnosis was based on published imaging criteria (obtained by transvaginal sonography or magnetic resonance imaging) or on histological analysis for patients with a prior history of endometriosis surgery. The statistical analyses were conducted using univariate and multivariate logistic regression models.

Results

The incidence of a POR to hyperstimulation was significantly higher for the OMA group than for the control group [62/201 (30.8%) versus 90/402 (22.3%), respectively; p = 0.02]. However, no significant differences were found between the OMA and the control group in terms of the clinical pregnancy rate [53/151 (35%) versus 134/324 (41.3%), respectively; p = 0.23] and the live birth rate [39/151 (25.8%) versus 99/324 (30.5%), respectively; p = 0.33]. By multivariate analysis, a prior history of surgery for OMA was found to be an independent factor associated with a POR to stimulation [OR = 2.1; 95% CI: 1.1–4.0], unlike OMA without a prior history of surgery [OR: 1.5; 95% CI: 0.9–2.2].

Conclusion

The presence of OMA during ART treatment increased the risk of a POR to hyperstimulation, although the live birth rate was not affected. Furthermore, having OMA and having previously undergone surgery for OMA was identified as an independent risk factor for a POR.

The effect of surgical management of endometrioma on the IVF/ICSI outcomes when compared with no treatment? A systematic review and meta-analysis

Objective

To assess the impact of surgical management of endometrioma on the outcome of assisted reproduction treatment (ART).

Design

A systematic review and meta-analysis.

Setting

Department of reproductive medicine at teaching university hospital, UK.

Patients

Subfertile women with endometrioma undergoing ART.

Interventions

Surgical removal of endometrioma or expectant management.

Main outcome measures

Clinical pregnancy rate, pregnancy rate, live birth rate, number of oocytes retrieved and number of embryos available and ovarian response to gonadotrophins.

Results

An extensive search of electronic databases for articles published from inception to September 2016 yielded 11 eligible studies for meta-analysis. Meta-analysis was conducted comparing surgery versus no treatment of endometrioma. There were no significant differences in pregnancy rate per cycle, clinical pregnancy rate and live birth rate between women who underwent surgery for endometrioma and those who did not.

Conclusion

Current evidence suggests that women with endometriosis-related infertility have similar cycle outcomes to other patients going through ART. It is pertinent for clinicians to assess the risks of surgical intervention on ovarian reserve prior to initiating therapy.

Weigh the pros and cons to ovarian reserve before stripping ovarian endometriomas prior to IVF/ICSI: A meta-analysis

PURPOSE

To explore the effects of conservative surgery for endometriomas on ovarian responsiveness during assisted reproductive technology (ART) and provide reproductive and gynecological doctors with a more reliable reference program for the treatment of endometriomas.

METHODS

A literature search was performed by searching the PubMed, Embase, Cochrane Library, Web of Science and Science Direct databases. Studies with inter- and intra-patient comparisons of ovarian responses and oocyte quality between operated and unoperated ovaries and that met the inclusion criteria were retrieved, and the data from the outcome measures were extracted and pooled for this meta-analysis.

RESULTS

Twenty-one published studies (2649 ART cycles) were included. The total amount of gonadotropin (Gn) used (inverse variance (IV):0.48; 95% confidence interval (CI): [0.13, 1.82], P = 0.0007) was significantly increased in the women with endometriomas who had a history of cystectomy. The estrogen (E) level on the day of hCG administration (IV: -0.29; 95% CI: [-0.41, -0.17], P<0.00001), the number of mature or dominant follicles (IV: -1.17; 95% CI: [-1.51, -0.82], P<0.00001) and the total number of oocytes retrieved (IV: -1.78; 95% CI: [-2.38, -1.17], P<0.00001) were significantly decreased in the women with endometriomas who had a history of cystectomy. The duration of stimulation (IV: 0.02; 95% CI: [-0.09, 0.13], P = 0.77), the total number of formed embryos (IV: -0.06; 95% CI: [-0.17, 0.04], P = 0.25), the pregnancy rate(IV:0.98;95%CI[0.82,1.18], P = 0.83) and the live birth rate(IV:0.93;95%CI[0.70,1.23], P = 0.61)were not statistically different between the two groups. Similar intra-patient results were found in the number of mature or dominant follicles (IV: -0.88; 95% CI: [-1.25, -0.52], P<0.00001) and the total number of oocytes retrieved (IV: -3.48; 95% CI: [-4.77, -2.19], P<0.00001).

CONCLUSION

ART might be a better therapeutic method for ovarian endometrioma-related infertility than cystectomy.

Strategies to Preserve and Optimize Fertility for Patients with Endometriosis

Endometriosis is commonly associated with dysmenorrhea, chronic pelvic pain, and infertility. When medical therapy fails, surgery is often recommended; unfortunately, endometriosis surgery can adversely impact fertility and ovarian reserve in women desiring future childbearing. This review will focus on mechanisms of infertility in endometriosis patients as well as strategies for optimizing fertility in endometriosis patients when surgery is indicated. In addition, fertility preserving techniques such as oocyte and ovarian tissue cryopreservation as well as issues relevant to in vitro fertilization for patients with endometriosis are discussed.

Analyzing the risk factors for a diminished oocyte retrieval rate under controlled ovarian stimulation

Aim

To investigate which risk factors contribute to a lower oocyte retrieval ratio in women who are receiving controlled ovarian hyperstimulation.

Methods

The authors retrospectively analyzed 329 in vitro fertilization (IVF) cycles under controlled ovarian hyperstimulation by using a gonadotropin‐releasing hormone antagonist or agonist at Osaka Medical College, Japan. The patients were classified into five groups: advanced age, male infertility, severe endometriosis, tubal infertility, and unexplained infertility. The primary outcomes were the patients’ age, oocyte retrieval ratio, serum basal follicle‐stimulating hormone, total dose of gonadotropin, and the clinical outcome. A secondary outcome was the stepwise multivariate logistic regression analysis to assess the factors associated with the failure of oocyte retrieval.

Results

The oocyte retrieval ratio declined significantly with the patient's age. The ratio of endometriosis in unsuccessful cases was significantly higher than that in successful cycles. Advanced age and endometriosis were the factors that were significantly associated with a lowered oocyte retrieval rate.

Conclusion

Advanced age and endometriosis are high‐risk factors that contribute to oocyte retrieval failure in infertile patients who are receiving IVF treatment.

Effect of ovarian endometrioma on uterine and ovarian blood flow in infertile women

Background

Angiogenesis has been found to be among the most important factors in the pathogenesis of endometriosis. The formation of new blood vessels is critical for the survival of newly implanted endometriotic foci. The use of 3-D power Doppler allows for the demonstration of the dynamic vascular changes that occur during the process of in vitro fertilization (IVF). We aimed to evaluate the effect of ovarian endometrioma on uterine and ovarian blood flow in infertile women.

Materials and methods

In a case–control study at a university teaching hospital, 138 women with unilateral ovarian endometrioma scheduled for IVF were compared to 138 women with male-factor or unexplained infertility. In the mid-luteal (peri-implantation) phase of the cycle, endometrial thickness, uterine and ovarian artery pulsatility index and resistance index, endometrial and ovarian volume, 3-D power Doppler vascularization index (VI), flow index (FI), and vascularization FI (VFI) values were measured in both groups.

Results

There were no significant differences (P>0.05) in endometrial thickness, uterine ovarian artery pulsatility index and resistance index, endometrial and ovarian volume, or VI, FI, and VFI between the two groups. Furthermore, the endometrial and ovarian Doppler indices were not influenced by endometrioma size. No significant differences were observed in the ovarian Doppler indices between endometrioma-containing ovaries and contralateral ovaries.

Conclusion

Ovarian endometrioma is not associated with impaired endometrial and ovarian blood flows in infertile women scheduled for IVF, and it is not likely to affect endometrial receptivity or ovarian function through a vascular mechanism.

Poor ovarian reserve

Poor ovarian reserve (POR) is an important limiting factor for the success of any treatment modality for infertility. It indicates a reduction in quantity and quality of oocytes in women of reproductive age group. It may be age related as seen in advanced years of reproductive life or may occur in young women due to diverse etiological factors. Evaluating ovarian reserve and individualizing the therapeutic strategies are very important for optimizing the success rate. Majority or women with POR need to undergo in vitro fertilization to achieve pregnancy. However, pregnancy rate remains low despite a plethora of interventions and is associated with high pregnancy loss. Early detection and active management are essential to minimize the need for egg donation in these women.

Ovarian reserve may be compromised after adnexal surgery: Are we sufficiently fertility- focused in our surgical training?

There is a general trend towards delay in childbearing age amongst women. The ovarian reserve clearly falls with increasing age and the impact is greater with advancing age, particularly from late 30s. Presence of other risk factors can increase the risk of subfertility. A large number of women are exposed to pelvic surgery for various reasons, both elective and emergency. There is evidence that some of the pelvic surgery performed around ovaries and tubes has a negative impact on the ovarian reserve and in turn may cause a decline in woman's ability to conceive. A fertility-sparing focus on all pelvic surgery is likely to prevent further decline in ovarian reserve for women who are already at higher risk. Such focus seems to be currently lacking. It is proposed that integrating fertility-sparing focus to structured gynaecological surgical training will benefit women.

EFFECT OF PELVIC ENDOMETRIOSIS, ENDOMETRIOMAS AND RECURRENT ENDOMETRIOMAS ON IVF-ET/ICSI OUTCOMES

Introduction:

Endometriosis, the most common gynecological disorder, is a challenging disease observed in 20% - 40% of subfertile women.

Material and Methods:

380 women were divided into four groups. Group A consisted of 176 women with pelvic endometriosis. Group B consisted of 125 women who had previously undergone a laparoscopic endometrioma cystectomy. Group C consisted of 38 women with recurrent endometriomas without aspiration before IVF-ET/ICSI. Group D consisted of 41 women with recurrent endometriomas undergone aspiration before IVF-ET/ICSI.

Results:

Baseline FSH level (8.61 ± 3.42 mIU/mL) and total dose of Gn (2337.15 ± 853.00 IU) in Group A were the lowest (p < 0.05). The number of retrieved oocytes in Group B (7.98 ± 5.05) was significantly fewer than those in Group A and D (p < 0.05). The numbers of MII oocytes in Groups A, C and D were significantly larger than that in Group B. The number of retrieved oocytes, high-quality embryos, implantation and pregnancy rates were similar in Groups C and D.

Conclusions:

Pelvic endometriosis had a less adverse effect on ovarian reserve than endometrioma. No advantage was found in transvaginal aspiration for recurrent endometriomas before IVF-ET/ICSI.

When helping hurts: the effect of surgical interventions on ovarian reserve

This commentary reviews some of the major papers that have been published on the effect of ovarian reserve after surgical interventions. At the end, the authors outline a summary on the effect of these interventions, in terms of future fertility and menopause.

Anti-Müllerian hormone levels after laparoscopic cystectomy for endometriomas as a possible predictor for pregnancy in infertility treatments

We assessed the associations between preoperative and postoperative serum anti-Müllerian hormone (AMH) levels and parameters of endometriosis and endometriomas surgery with the success of infertility treatments after cystectomy. Seventeen out of 54 patients got pregnant during the infertility treatments. In these patients, the median interval from surgery to conception was 16.3 months. The serum AMH levels 1-year postoperatively were significantly higher in the pregnant group compared to the non-pregnant group (3.44 ± 1.78 versus 2.17 ± 2.24 ng/ml, p = 0.049). The median interval from surgery to recurrence was 34.4 months, and no significant differences were found in the serum AMH levels at any time point between the recurrence and non-recurrence groups. Serum AMH levels 1 year after laparoscopic cystectomy for endometriomas may predict the success of postoperative infertility treatments, but not a recurrence of endometriomas.

Laparoscopic excision of ovarian endometrioma does not exert a qualitative effect on ovarian function: insights from in vitro fertilization and single embryo transfer cycles

PURPOSE

To evaluate whether laparoscopic excision of endometrioma exerts a qualitative effect on ovarian function.

METHODS

A retrospective analysis of oocytes retrieved in 25 cycles of 21 patients undergoing IVF treatment with controlled ovarian stimulation. The number of oocytes recovered from ovaries with a history of excision of endometrioma (E-Ov) were compared to those from contra-lateral healthy ovaries (H-Ov) as for the analysis of a quantitative effect of surgery. As for the analysis of a qualitative effect, 55 oocytes from E-Ov were compared to 128 oocytes from H-Ov in terms of normal fertilization rate and the rate of top-quality embryos per normally fertilized eggs. Furthermore, 10 embryos derived from oocytes recovered from E-Ov were compared to 24 embryos derived from oocytes from H-Ov in terms of clinical and on-going pregnancy rates per embryos in 34 single embryo transfer cycles.

RESULTS

Mean number of oocytes recovered from E-Ov was significantly smaller than that from H-Ov (2.2 ± 2.0 vs. 5.1 ± 3.3, P = 0.009). There was no difference between oocytes from E-Ov and H-Ov as for normal fertilization rate (63.6% vs. 69.5%, P = 0.43) and the rate of top-quality embryos (40.0% vs. 49.0%, P = 0.34). Clinical and on-going pregnancy rates per embryos were also similar in embryos derived from oocytes recovered from E-Ov and H-Ov (40.0% vs. 25.0%, P = 0.39 and 20.0% vs. 20.8%, P = 0.96).

CONCLUSIONS

The quality of oocytes recovered from the ovary with a history of laparoscopic excision of endometrioma is not inferior to the quality of oocytes from contra-lateral healthy ovary.

Surgical diminished ovarian reserve after endometrioma cystectomy versus idiopathic DOR: comparison of in vitro fertilization outcome

STUDY QUESTION

Does the live birth rate after IVF depend on the etiology of diminished ovarian reserve (DOR)?

SUMMARY ANSWER

IVF outcome and live birth rate are significantly impaired in women with DOR caused by a previous cystectomy for endometrioma compared with women with idiopathic DOR.

WHAT IS KNOWN ALREADY

The safety of the surgical treatment of endometriomas is being discussed in terms of damage to ovarian reserve. Several studies have reported a poor response to controlled ovarian stimulation and a significantly impaired IVF outcome in women with DOR consecutive to an endometrioma cystectomy compared with women with tubal factor infertility.

STUDY DESIGN, SIZE, DURATION

Retrospective case-control study conducted in women aged under 40 treated in our Reproductive Medicine Center between January 2010 and January 2014 for a DOR defined by anti-Müllerian hormone level <2 ng/ml. Two groups of patients were selected: group A included patients with a DOR diagnosed after cystectomy(s) for endometrioma(s), group B included patients with an idiopathic DOR. In each group, subgroups of patients 'poor ovarian responders', based on the ESHRE criteria ('Bologna criteria'), have been established.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A total of 51 patients in group A were matched to 116 patients in group B, representing respectively 125 and 243 IVF cycles. Among them, 39 patients in group A and 78 patients in group B validated strictly by the Bologna criteria, representing 99 and 189 IVF cycles, respectively. Each patient underwent a controlled ovarian hyperstimulation and IVF with fresh embryo transfer. Primary end-point was the live birth rate. Secondary end-points were the number of retrieved oocytes, fertilization rate, implantation rate, clinical pregnancy rate, spontaneous abortion rate and cycle cancelation rate.

MAIN RESULTS AND THE ROLE OF CHANCE

Significantly lower pregnancy (11.2% in group A versus 20.6% in group B, P = 0.02) and live birth (7.2 versus 16.9% respectively, P = 0.01) rates per cycle were assessed in women in group A compared with women in group B. The same results were obtained in the Bologna criteria subgroup analysis with a significantly lower pregnancy (9.1 versus 20.1%, P = 0.016) and live birth (5.1 versus 15.3%, P = 0.001) rates per cycle in women in subgroup A compared with women in subgroup B. Patients in group A required significantly higher gonadotrophins doses (2881 IU ± 1111 versus 2526 IU ± 795, P = 0.005), longer ovarian stimulation (10.6 Days ± 2.8 versus 9.9 Days ± 2.4, P = 0.019) and higher cancelation rate for poor response (12 versus 6.2%, P = 0.05). Despite a mean number of retrieved oocytes similar with the group B (5.4 ± 3.1 and 5.1 ± 3.2, NS), and a significantly higher fertilization rate (65.7 versus 47.2%, P < 0.001), women in group A showed a significantly lower implantation rate (7.2 versus 13.5%, P = 0.03). Abortion rate, ectopic pregnancy rate and multiple pregnancy rate were similar in both groups.

LIMITATIONS, REASONS FOR CAUTION

Data were collected retrospectively using the database of our Department. Sample size is relatively small but our study provides statistically significant evidence that the chances of IVF success are decreased in women with DOR after cystectomy for endometrioma. Further larger series are needed to confirm these findings.

WIDER IMPLICATIONS OF THE FINDINGS

To our knowledge, this is the first study evaluating IVF outcome in patients with DOR after cystectomy(s) for endometrioma(s) versus in patients with an idiopathic DOR. In addition to the risk of damaging ovarian reserve, we hypothesize that endometrioma surgery would not have qualitative benefits on results in IVF in patients with DOR.

STUDY FUNDING/COMPETING INTERESTS

The authors have no competing interests to declare.

Side of ovarian endometrioma does not affect the outcome of in vitro fertilization/intracytoplasmic sperm injection in infertile women after laparoscopic cystectomy

AIM

The aim of this study was to assess the impact of the laterality of ovarian endometrioma on pregnancy outcome of in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) in infertile patients undergoing laparoscopic cystectomy.

MATERIAL AND METHODS

A total of 103 IVF/ICSI cycles in patients who had undergone laparoscopic cystectomy for unilateral endometriomas were reviewed retrospectively from January 2005 through December 2009. There were 41 cycles where laparoscopic cystectomy had been carried out for right endometriomas and 62 cycles after left-side surgery. Primary outcome measures were ovarian reserve and ovarian response. Secondary outcome measures were the implantation rate, clinical pregnancy rate, and live birth rate.

RESULTS

There was no difference among the two groups with regard to antral follicle count, number of oocytes retrieved, the dosage of gonadotrophin, estradiol level on human chorionic gonadotrophin day, good-quality embryos for transfer, and fertilization rate. The clinical pregnancy rate and live birth rate were similar between the two groups; however, the implantation rate was significantly lower in the cycles with left-side ovarian endometrioma compared to the right counterpart (10.1% vs 20.2%; P = 0.015).

CONCLUSION

There were no associations among the laterality of ovarian endometrioma, ovarian reserve and ovarian response in IVF/ICSI cycles. However, left ovarian endometrioma after laparoscopic cystectomy may impair implantation rate as compared to right ovarian endometrioma.

Ovarian reserve markers and assisted reproductive technique (ART) outcomes in women with advanced endometriosis

BACKGROUND

The role of ovarian reserve markers as predictors of the controlled ovarian stimulation (COS) response in intracytoplasmic sperm injection (ICSI) cycles in women with endometriosis has been much debated. The aim of the present study is to assess the predictability of ovarian reserve markers for the number of mature oocytes (MII) retrieved and to assess the pregnancy rate and live birth rate in women with advanced endometriosis.

METHODS

Two hundred eighty-five infertile women who had laparoscopy followed by a first ICSI cycle were recruited in this prospective study. One hundred ten patients were diagnosed with endometriosis stage III-IV (group 1), and 175 patients had no endometriosis (group II). Sixty-three patients in group 1 had no history of previous endometrioma surgery (group Ia), and 47 patients had a history of previous endometrioma surgery (group Ib).

RESULTS

The number of mature oocytes retrieved was significantly lower in women with advanced endometriosis than in women with no endometriosis. The number of mature oocytes retrieved in women with and without endometriosis was best predicted by antral follicle count (AFC) and age, whereas only AFC was a predictor in women with previous endometrioma surgery (odds ratio: 0.49; 95% confidence interval: 0.13-0.60). Women with endometriosis had a lower rate of live births than the control group, but this difference was not statistically significant; the number of live births was significantly lower in those with previous endometrioma surgery.

CONCLUSIONS

The best predictor of the COS response in ICSI was AFC, followed by age. Women receiving ICSI following surgery for ovarian endometrioma had a poorer clinical outcome and lower rate of live births compared with those with endometriosis but no previous surgery and the control group.

Effect of endometriosis on implantation rates when compared to tubal factor in fresh non donor in vitro fertilization cycles

OBJECTIVE:

The objective of the following study is to compare the outcome of in vitro fertilization and embryo transfer (IVF-ET) in women with endometriosis and tubal-factor infertility.

DESIGN:

Retrospective study.

SETTING:

Tertiary referral hospital, assisted reproductive technologies unit.

MATERIALS AND METHOD:

The study group consisted of 78 women diagnosed with advanced stage endometriosis. The control group included 100 women with tubal-factor infertility. These groups were retrospectively analyzed regarding stimulation, fertilization, embryo development, implantation and pregnancy outcome.

INTERVENTION (S):

Controlled ovarian hyperstimulation and IVF-ET.

RESULTS:

Lower oocyte yield with lower fertilization rate were found in women with endometriosis compared with tubal-factor control subjects. However, no differences were found in cleavage, implantation and clinical pregnancy rates between the endometriosis and tubal-factor groups.

CONCLUSIONS:

Our results showed that women with endometriosis have a lower oocyte yield and lower fertilization rate compared with women with tubal-factor infertility. However, once the oocyte is fertilized, it seems that the embryo has a normal chance of implantation, leading to similar pregnancy rates and adequately treated women with endometriosis have equal chances of conception as seen with tubal-factor infertility.

In vitro fertilization outcome in women with endometriosis & previous ovarian surgery

BACKGROUND & OBJECTIVES

Women with endometriosis often need in vitro fertilization (IVF) to concieve. There are conflicting data on the results of IVF in patients with endometriosis. This study was undertaken to elucidate the influence of endometriosis on IVF outcome to give the best counselling for infertile patient with this problem.

METHODS

The outcome measures in 78 patients with surgically confirmed endometriosis were compared with 157 patients with tubal factor infertility, all of whom have undergone IVF. The groups were matched for age and follicle stimulating hormone (FSH) levels. Outcome measures included number of follicles, number of oocytes, peak oestradiol (E2) concentrations and mean number of ampoules of gonadotropins. Cumulative pregnancy, miscarriage and live birth rates were calculated in both the groups.

RESULTS

Higher cancelation rates, higher total gonadotropin requirements, lower peak E2 levels and lower oocyte yield were found in women with endometriosis and previous surgery compared with those with tubal factor infertility. However, no differences were found in fertilization, implantation, pregnancy, miscarriage, multiple births and delivery rates between the endometriosis and tubal factor infertility groups.

INTERPRETATION & CONCLUSIONS

The present findings showed that women with endometriosis and previous surgery responded less well to gonadotropins during ovarian stimulation and hence the cost of treatment to achieve pregnancy was higher in this group compared with those with tubal factor infertility. However, the outcome of IVF treatment in patients with endometriosis was as good as in women with tubal factor infertility.

Ovarian cystectomy in endometriomas: Combined approach

Endometrioma is one of the most frequent adnexal masses in the premenopausal population, but the recommended treatment is still a subject of debate. Medical therapy is inefficient and can not be recommended in the management of ovarian endometriomas. The general consensus is that ovarian endometriomas larger than 4 cm should be removed, both to reduce pain and to improve spontaneous conception rates. The removal of ovarian endometriomas can be difficult, as the capsule is often densely adherent. While the surgical treatment of choice is surgical laparoscopy, for conservative treatment, the preferred method is modified combined cystectomy. Cystectomy can be destructive for the ovary, whereas ablation may be incomplete, with a greater risk of recurrence. To the best of our knowledge, the modified combined technique seems to be more efficient in the treatment of endometriomas.

Comparing long term impact on ovarian reserve between laparoscopic ovarian cystectomy and open laprotomy for ovarian endometrioma

Objective

To compare the long term impact on ovarian reserve between laparoscopic ovarian cystectomy with bipolar electrocoagulation and laparotomic cystectomy with suturing for ovarian endometrotic cyst.

Patient and method(s)

121 patients with benign ovarian endometroitic cysts were randomised to either laparoscopic ovarian cystectomy using bipolar electrocoagulation (61 patients) or laparotomic ovarian cystectomy using sutures (60 patients). Serum follicle-stimulating hormone, Antimullerian hormon, Basal antral follicle Count, mean ovarian diameter, and ovarian stromal blood flow velocity were measured at 6, 12 and 18 months after surgery and compared in both groups.

Result(s)

A statistically significant increase of serum FSH was found in the laproscopic bipolar group at 6-, 12 and 18-month postoperativly compared to open laparotomy suture group. Also, a statistically significant decrease of the mean AMH value occurred in laproscopic bipolar group at 6-, 12 and 18-month follow- up compared to open laparotomy suture group. Basal antral follicle number, mean ovarian diameter and peak systolic velocity were significantly decreased during the 6-, 12,18 -month follow-up in laproscopic bipolar group compared to open laparotomy suture group.

Conclusion(s)

After laproscopic ovarian cystecomy for endometrioma all pareameter of ovarian reseve are significantly decreased on long term follow up as compared to open laprotomy.

Influence of endomeriotic cyst diameter and the severity of endometriosis on the ovarian parenchyma excised during laparoscopic cystectomy

INTRODUCTION

Endometrioma is a common form of endometriosis and it is represented by endometriotic deposits within the ovaries which accounts for upto 17-44% of cases. Laparoscopic stripping of ovarian endometriotic cysts is an accepted technique owing to low recurrence rates. Decrease in residual ovarian tissue volume was noted in many studies followed cystectomy. This study aims at estimating whether the size of endometriotic cyst is related to ovarian parenchyma excised along with cyst wall.

MATERIAL AND METHODS

Prospective study was done at University teaching hospital for one year. A total of 56 women underwent laparoscopic endometriotic cystectomy. Cystectomy was done by stripping method and endometriosis was staged according to revised American Society of Reproductive Medicine classification (rASRM). The endometrioma wall was evaluated histologically and were categorised into 2 groups based on semi- quantitative scale of 0-4. Group 1 and 2 showed grade 0, 1, 2 and 3, 4 in the cyst wall respectively.

RESULTS

Mean age of patients was 31.4 years, duration of infertility was 4.1 years and cyst diameter measured 6.3 cm. 73.2% (n=41) were in Group 1 and 26.8% (n=15) were in Group 2 , mean cyst diameter was being 4.3 cm and 5.0 cm respectively. There was no significant statistical correlation between preoperative cyst diameter and ovarian parenchyma removed (p=0.15). 93.3% (n=14) of group 2, and only 65.8% (n=27 ) of group 1 were found to have moderate to severe endometriosis, indicating there is correlation between disease severity and loss of ovarian tissue (p= 0.04).

CONCLUSION

Endometriotic cystectomy when performed with accurate surgical technique leads to no significant ovarian tissue removal. However, disease severity significantly determines the loss of normal ovarian parenchyma.

Congenital factor XIII deficiency in women: a systematic review of literature

Factor XIII (FXIII) deficiency is a rare congenital bleeding disorder. There is a paucity of data in the literature about obstetrics and gynaecological problems in women affected by FXIII deficiency. The aim of this study was to examine gynaecological problems and obstetric complications and outcome in women with congenital FXIII deficiency. An electronic search was performed to identify the published literature on PUBMED, MEDLINE, EMBASE, Journals @OVID and CINAHL Plus databases using the following keywords: 'congenital factor XIII deficiency' AND 'women OR Pregnancy'. A total of 39 relevant articles were found and included in this systematic review; 27 case reports and 12 case series dating from 1964 to 2012. A total of 121 women were identified. Menorrhagia (26%) was the second most common bleeding reported after umbilical bleeding. Ovulation bleeding reported in 8% of women. Among 63 women, 192 pregnancies were reported; of these, 127 (66%) resulted in a miscarriage and 65 (34%) reached viability stage. In 136 pregnancies without prophylactic therapy, 124 (91%) resulted in a miscarriage and 12(9%) progressed to viability stage. Antepartum haemorrhage occurred in 5/65 (8%) pregnancies reaching viability stage while postpartum haemorrhage (PPH) seen in 16 (25%) cases. Women with congenital FXIII deficiency suffer significant bleeding complications. Menorrhagia and ovulation bleeding are common gynaecological problems and more prevalent than reported. Pregnancies in women with FXIII deficiency have a significant risk of miscarriage, placental abruption and PPH if not on prophylaxis treatment.

Removal of unilateral endometriomas is associated with immediate and sustained reduction in ovarian reserve

Endometrioma surgery by stripping the cyst capsule has been associated with a reduction in ovarian reserve. It is still not clear whether the inflicted damage is immediate, sustained over time or associated with the use of electrocautery, nor which marker is more accurately reflects the post-operative reduction in ovarian reserve. This observational study assessed the damage inflicted by endometrioma removal with anti-Müllerian hormone (AMH) concentration and antral follicle count (AFC) pre and post-operatively. Twenty-five women with unilateral endometrioma underwent laparoscopic stripping of the endometrioma cyst capsule. There was a significant decrease both in AMH concentration (24%) and in AFC (11%) 1 month following surgery (P<0.01). At 6months post-operatively, the respective values were 24% and 15% less than preoperatively. AMH concentration and AFC showed no correlation with the use of bipolar electrocautery during surgery. Primordial follicles embedded adjacent to the cyst capsule were found in 61.5% of the specimens. Endometrioma surgery by stripping of the cyst capsule is associated with a significant reduction in ovarian reserve. The reduction is immediate and sustained over time. AMH appears to be a better indicator for post-operative quantification of the ovarian reserve.

The impact of excision of ovarian endometrioma on ovarian reserve: a systematic review and meta-analysis

CONTEXT

Endometriomas are mainly treated surgically. However, there has been concern over the potential damaging effect of this surgery on ovarian reserve.

OBJECTIVE

The aim of this meta-analysis was to investigate the impact of surgery for endometriomas on ovarian reserve as determined by serum anti-müllerian hormone (AMH).

DATA SOURCES

MEDLINE, PubMed, and Embase were searched electronically.

STUDY SELECTION

All prospective cohort studies that analyzed changes of serum AMH concentrations after surgical treatment of endometriomas were eligible. Twenty-one studies were identified, of which eight were selected for meta-analysis.

DATA EXTRACTION

Two reviewers performed the data extraction independently.

DATA SYNTHESIS

Pooled analysis of 237 patients showed a statistically significant decrease in serum AMH concentration after ovarian cystectomy (weighted mean difference -1.13 ng/ml; 95% confidence interval -0.37 to -1.88), although heterogeneity was high. Sensitivity analysis for studies with a preoperative serum AMH level of 3.1 ng/ml or greater improved heterogeneity but also still showed a significant postoperative fall in serum AMH (weighted mean difference -1.52 ng/ml, 95% confidence interval -1.04 to -2).

CONCLUSION

The results of this study suggest a negative impact of excision of endometriomas on ovarian reserve as evidenced by a significant postoperative fall in circulating AMH.

Minimally invasive gynecologic procedures

PURPOSE OF REVIEW

To evaluate different surgical options for the treatment of endometriomas. A heated debate is currently under way between advocates of excisional surgery and the ablative approach. With papers increasingly focusing on ovarian reserve after endometrioma surgery, a review was mandatory.

RECENT FINDINGS

Excisional and ablative surgery are well known procedures. This paper describes a combined technique that allows preservation of ovarian volume and antral follicle count. The question of postoperative ovarian reserve is widely discussed and the risk of malignancy is addressed.

SUMMARY

Some previously published reviews have probably too hastily concluded that excision is a better option than ablation. They failed to analyze the ovarian reserve, which is often significantly decreased after excisional surgery.This manuscript clearly explains the crucial importance of preserving the ovarian blood supply, as well as the ovarian cortex containing all primordial follicles, during surgery.

Impact of endometriosis on in vitro fertilization and embryo transfer cycles in young women: a stage-dependent interference

OBJECTIVE

Endometriosis is a frequent indication for in vitro fertilization and embryo transfer (IVF-ET). Its influence on IVF-ET cycles remains controversial. We evaluated the impact of the severity of endometriosis on IVF-ET cycles in young women.

DESIGN

Retrospective cohort study.

SETTING

Academic tertiary referral centre.

SAMPLE AND METHODS

In a retrospective cohort analysis, 164 IVF-ET cycles in 148 women with endometriosis-associated infertility were analyzed. Eighty cycles performed during the same period on 72 consecutive women with tubal infertility were considered as controls. All patients were younger than 35 years old.

MAIN OUTCOME MEASURES

Response to controlled ovarian hyperstimulation (COH), number of oocytes retrieved, fertilization, implantation and pregnancy rate (PR).

RESULTS

Clinical PR was lower in the group with endometriosis (all stages) in comparison with the tubal factor group. Higher total gonadotropin requirements, lower response to COH and lower oocyte yield were also found in the endometriosis group. Stage-stratified analysis showed a lower fertilization rate in stage I-II (52.6% stage I-II, 70.5% stage III-IV and 71.9% tubal factor). In stage III-IV endometriosis there was a higher cycle cancellation rate, a reduced response to COH and a lower PR compared with both the stage I-II and the tubal infertility groups (PR 9.7, 25 and 26.1%, respectively).

CONCLUSIONS

Stage III-IV was strongly associated with poor IVF outcome. A decreased fertilization rate in stage I-II might be a cause of subfertility in these women, owing to a hostile environment caused by the disease.

Effects of laparoscopic surgery on serum anti-Müllerian hormone levels in reproductive-aged women with endometrioma

A few studies have investigated the effects of laparoscopic cystectomy for endometrioma on ovarian reserve using serum anti-Müllerian hormone (AMH) levels and have shown inconsistent results. This prospective study was performed to estimate early changes in serum AMH after laparoscopic surgery for endometrioma. In 27 women aged 21-46 years who underwent laparoscopic unilateral cystectomy (n = 13) or oophorectomy (n = 14) for endometrioma, we measured pre- and postoperative serum AMH levels at baseline and 1 week, 1 month, and 3 months after surgery. Serial changes in serum AMH levels were analyzed according to the operation type using analysis of variance. Mean levels of serum AMH decreased significantly immediately after surgery and remained for up to 3 months in both operation types (P = 0.002 for cystectomy group and P <0.001 for oophorectomy group). In addition, the serum AMH levels showed similar patterns of change after cystectomy or oophorectomy. In conclusion, laparoscopic ovarian cystectomy for endometrioma appears to decrease serum AMH levels immediately after surgery.