Does the anti-Müllerian hormone truly reflect ovarian response in women with endometrioma?

Surgical Management of Ovarian Endometrioma: Impact on Ovarian Reserve Parameters and Reproductive Outcomes

Ovarian endometriomas have a negative impact on a patient's reproductive potential and are likely to cause a reduction in ovarian reserve. The most commonly employed ovarian reserve parameters are anti-Müllerian hormone (AMH) and antral follicular count (AFC). Surgical management options of endometrioma include cystectomy, ablative methods, ethanol sclerotherapy and combined techniques. The optimal surgical approach remains a matter of debate. Our review aimed to summarize the literature on the impact of surgical management of endometrioma on AMH, AFC and fertility outcomes. Cystectomy may reduce recurrence rates and increase chances of spontaneous conception. However, a postoperative reduction in AMH is to be anticipated, despite there being evidence of recovery during follow-up. The reduction in ovarian reserve is likely multi-factorial. Cystectomy does not appear to significantly reduce, and may even increase, AFC. Ablative methods achieve an ovarian-tissue-sparing effect, and improved ovarian reserve, compared to cystectomy, has been demonstrated. A single study reported on AMH and AFC post sclerotherapy, and both were significantly reduced. AMH levels may be useful in predicting the chances of conception postoperatively. None of the aforementioned approaches has a clearly demonstrated superiority in terms of overall chances of conception. Surgical management of endometrioma may, overall, improve the probability of pregnancy. Evidence on its value before medically assisted reproduction (MAR) is conflicting; however, a combination of surgery followed by MAR may achieve the optimal fertility outcome. In view of the complexity of available evidence, individualization of care, combined with optimal surgical technique, is highly recommended.

Combined effects of age and endometriosis on ovarian reserve in women with infertility

OBJECTIVE

To evaluate the combined effects of age and endometriosis on ovarian reserve in women with infertility.

METHODS

We conducted a cross-sectional study using an institutional database. Women with sonographic, laparoscopic, or histologic evidence of endometriosis were defined as the study group and the remaining women served as a control group. We evaluated demographic and clinical characteristics of the groups as a whole and stratified the patients into those aged 35 years or older and those younger than 35 years at the time of ovarian reserve testing.

RESULTS

Of a total of 656 women included in the final analysis, 71 women had a diagnosis of endometriosis. When compared with women without endometriosis, the median anti-Müllerian hormone (AMH) and antral follicular count (AFC) values were significantly lower in the group of women with endometriosis-median 2.1 ng/ml (interquartile range [IQR] 1.1-3.9) versus 1.2 ng/ml (IQR 0.6-2.4; P < 0.001) for AMH and 14 follicles (IQR 8-23) versus 7 follicles (IQR 5-14; P < 0.001) for AFC. When stratified into two age groups the association between a lower AFC and endometriosis remained significant for both age groups whereas the association between a lower AMH and endometriosis was significant only for the group of women aged 35 years oor older.

CONCLUSION

Our study highlights a detrimental effect by endometriosis and an age enhancement effect of endometriosis on ovarian reserve.

An Online Tool Using Basal or Activated Ovarian Reserve Markers to Predict the Number of Oocytes Retrieved Following Controlled Ovarian Stimulation: A Prospective Observational Cohort Study

BACKGROUND

Predicting the number of oocytes retrieved (NOR) following controlled ovarian stimulation (COS) is the only way to ensure effective and safe treatment in assisted reproductive technology (ART). To date, there have been limited studies about predicting specific NOR, which hinders the development of individualized treatment in ART.

OBJECTIVE

To establish an online tool for predicting NOR.

MATERIALS AND METHODS

In total, 621 prospective routine gonadotropin releasing hormone (GnRH) antagonist COS cycles were studied. Independent variables included age, body mass index, antral follicle counts, basal FSH, basal and increment of anti-mullerian hormone, Luteinizing hormon, estradiol, testosterone, androstenedione, and inhibin B. The outcome variable was NOR. The independent variables underwent appropriate transformation to achieve a better fit for a linear relationship with NOR. Pruned forward selection with holdback validation was then used to establish predictive models. Corrected Akaike's information criterion, Schwarz-Bayesian information criterion, scaled -log[likelihood], and the generalized coefficient of determination (R²) were used for model evaluation.

RESULTS

A multiple negative binomial regression model was used for predicting NOR because it fitted a negative binomial distribution. We established Model 1, using basal ovarian reserve markers, and Model 2, using both basal and early dynamic markers for predicting NOR following COS. The generalized R² values were 0.54 and 0.51 for Model 1 and 0.64 and 0.62 for Model 2 in the training and validation sets, respectively.

CONCLUSION

Models 1 and 2 could be applied to different scenarios. For directing the starting dose of recombinant follicle stimulation hormone (rFSH), Model 1 using basic predictors could be used prior to COS. Model 2 could be used for directing the adjustment of rFSH dosages during COS. An online tool (http://121.43.113.123:8002/) based on these two models is also developed. We anticipate that the clinical application of this tool could help the ART clinics to reduce iatrogenic ovarian under- or over-responses, and could reduce costs during COS for ART.

Antral follicle count is reduced in the presence of endometriosis: a systematic review and meta-analysis

Studies suggest that the presence of endometriosis may lead to impaired ovarian reserve, while results evaluating the changes in antral follicle count (AFC) in endometriosis remain controversial. A systematic search returned 15 studies, of which nine compared AFC between patients with and without endometriosis, five articles reported differences in AFC between affected and unaffected ovaries in patients with unilateral ovarian endometriosis and one reported both of the above two situations. Overall results showed a significant decrease in AFC and anti-Müllerian hormone (AMH) and increase in serum FSH concentrations in patients with endometriosis when compared with controls. Additionally, the AFC for the ovary with the endometrioma was also significantly lower than that of the contralateral ovary in patients with unilateral ovarian endometriosis. Moreover, it appears that the AFC in patients with endometriosis where the ovaries are not affected or in early stage were not significantly different in the control group. These findings demonstrate that endometriosis is associated with reduced AFC and AMH and elevated serum concentrations of FSH, suggesting a reduction in ovarian reserve in patients with endometriosis, especially in those with ovarian endometrioma and advanced stage.

Do ovarian endometriomas affect ovarian response to ovarian stimulation for IVF/ICSI?

RESEARCH QUESTION

Does the presence of ovarian endometriomas affect ovarian response to ovarian stimulation after adjusting for age and ovarian reserve markers?

DESIGN

This retrospective cross-sectional study compared the ovarian response between patients with ovarian endometriomas and women with other infertility factors undergoing their first ovarian stimulation for IVF/intracytoplasmic sperm injection (ICSI). An age-specific nomogram model for the number of oocytes retrieved was built for both groups, and ovarian response was compared after adjusting for age, gonadotrophin dose, anti-Mullerian hormone (AMH) concentration and antral follicle count (AFC).

RESULTS

A total of 923 patients were included: 101 women with at least one ovarian endometrioma, and 822 patients with other infertility factors. Comparisons of the nomograms for the number of oocytes retrieved demonstrated that response was significantly lower for women with endometrioma when the results were adjusted for age the z-score for the number of oocytes retrieved (-0.49 ± 0.71 versus -0.20 ± 0.86; 95% confidence interval [CI] -0.47 to -0.12) and also after adjustment for the total dose of gonadotrophins and AMH values (z-score mean difference -0.338; 95% CI -0.54, -0.14). When the z-score was adjusted for gonadotrophin dose and AFC, the number of oocytes retrieved was comparable between the two groups (z-score mean difference -0.038; 95% CI -0.34 to 0.27).

CONCLUSIONS

Ovarian response after ovarian stimulation for IVF/ICSI in women with endometriomas is significantly lower than in controls after adjusting for age, gonadotrophin dose and AMH. Dose and protocol selection for ovarian stimulation in patients with endometrioma should be based on AFC rather than AMH, as the latter may be overestimated.