The clinical outcome of Dienogest treatment followed by in vitro fertilization and embryo transfer in infertile women with endometriosis.J Ovarian Res. 2019;12:123. [PMID: 31831028 DOI: 10.1186/s13048-019-0597-y]

Efficacy of hormone pre-treatment before ART to improve reproductive outcomes in infertile women with endometriosis: Network meta-analysis of randomized controlled trials

BACKGROUND

Hormone pre-treatment is still used before assisted reproductive technique (ART) in endometriotic women, but evidence supporting this recommendation is conflicting.

OBJECTIVES

To evaluate whether hormone pre-treatment with gonadotropin-releasing hormone (GnRH) agonists or progestogens could improve fertility in women with endometriosis undergoing ART.

SEARCH STRATEGY

MEDLINE, LILACS, EMBASE, Scielo.br, PROSPERO, Cochrane at the CENTRAL Register of Controlled Trials, conference abstracts, and international controlled trials registries were searched without temporal, geographic, and language limitations.

SELECTION CRITERIA

Randomized controlled trials that enrolled infertile women with endometriosis undergoing in vitro fertilization/intracytoplasmic sperm injection after the application of a stimulation protocol with hormone pre-treatment were selected and included.

DATA COLLECTION AND ANALYSIS

We conducted a network meta-analysis based on the random-effects model for mixed multiple treatment comparisons to rank the available hormone pre-treatment by the surface under the cumulative ranking curve area (SUCRA) following the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension statement for network meta-analyses. Quality assessment was carried out using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions. Egger test and funnel plot analysis were used for publication bias assessment. The primary outcome was clinical pregnancy rate (CPR). Secondary outcomes were live birth rate (LBR), pregnancy loss rate (PLR), and implantation rate (IR).

MAIN RESULTS

Nine studies with 2087 women were included. Ultralong (3 months GnRH agonist) (SUCRA 24.5%) and long protocols (1 month GnRH agonist) (SUCRA 24.9%) as well as progestins (SUCRA 28.8%) showed similar results to no treatment (SUCRA 21.8%) in terms of post-ART CPR. Regarding the LBR, no treatment (SUCRA 50.0%) showed highest rates relative to progestins (SUCRA 7.0%), and long (SUCRA 36.6%) and ultralong (SUCRA 6.4%) protocols. For PLR, no treatment (SUCRA 57.9%), followed by long protocol (SUCRA 18.4%), ultralong protocol (SUCRA 12.3%), and progestins (SUCRA 11.4%) showed the greatest degree of reduction. The long (SUCRA 45.0%) and ultralong (SUCRA 39.5%) protocols seemed more effective in increasing IR than did than progestins (SUCRA 15.5%).

CONCLUSIONS

The increased number of implanted pregnancies using a GnRH agonist protocol does not lead to higher clinical pregnancies or live births. Currently, there is no indication for hormone pre-treatment before ART in women with endometriosis as it does not increase fertility chances.

Fertility preservation in women with endometriosis: A retrospective non-Inferiority study comparing Dienogest in the PPOS protocol to antagonist and agonist protocols

BACKGROUND

Endometriosis is a common pathology that can lead to a decrease in fertility and is therefore a medical indication for preserving fertility. Traditionally, gonadotropin-releasing hormone (GnRH) antagonist and agonist protocols are used to stimulate the ovaries. However, the recent introduction of the progestin-primed ovarian stimulation (PPOS) protocol, using progestins to prevent LH surges, offers a new alternative. Dienogest, a progestin commonly used to treat endometriosis, could be incorporated into the PPOS protocol for patients with endometriosis, allowing them to maintain their background therapy during ovarian stimulation. The aim of this study was to assess the non-inferiority of using Dienogest in the PPOS protocol compared to antagonist and agonist protocols in terms of the number of mature oocytes retrieved from patients with endometriosis undergoing fertility preservation (FP).

METHODS

This retrospective, multicenter, non-inferiority study was conducted in patients with endometriosis, comparing the PPOS protocol with Dienogest, the antagonist protocol, and the agonist protocol. The primary endpoint was the number of mature oocytes retrieved. The secondary endpoint included ovarian response parameters, treatment complications, and tolerance assessed by validated questionnaires.

RESULTS

The study included 201 cycles performed in 130 patients. Non-inferiority of the PPOS-Dienogest protocol was demonstrated in pairwise comparisons against antagonist protocol (p = 0.0062) and agonist protocol (p = 0.0360) in the number of mature oocytes retrieved. Using Dienogest in the PPOS protocol was not associated with a smaller number of mature oocytes retrieved than with the GnRH antagonist or agonist conventional protocols. Additionally, no significant differences were found in ovarian response parameters, treatment tolerance, or complications between protocols.

CONCLUSION

The PPOS protocol with Dienogest appears to be a promising alternative for FP compared to traditional protocols for patients with endometriosis, without adversely affecting the number of mature oocytes retrieved. Larger prospective studies are required to confirm these results.

Effects and safety of propofol intravenous anesthesia in transvaginal oocyte retrieval on outcomes of in vitro fertilization and embryo transplantation

Purpose

Propofol, a widely utilized anesthetic, is employed to alleviate pain and anxiety in outpatient oocyte retrieval procedures. However, its potential impact and safety profile in the context of in vitro fertilization and embryo transfer (IVF-ET) remain unclear.

Methods

This retrospective study enrolled 1187 patients undergoing IVF-ET, and divided into two groups depending on whether they received propofol (propofol group, n=140) or not (control group, n=1047) for anesthesia during oocyte retrieval.

Results

The baseline characteristics were comparable between the groups. Compared with control group, the number of oocytes retrieved in propofol group was more (p=0.012), while both the estradiol (E2) level on the trigger day and the pre-ovulatory follicle count were higher in propofol group ((p<0.01). Additionally, the rate of preterm delivery was significantly higher in the propofol group (p<0.001). To further analyze the effect of propofol on the oocyte retrieval rate, patients were divided into three subgroups depending on the pre-ovulatory follicle count (≤10, 11-20, and >20) to eliminate the influence of inconsistency in the estimation of the pre-ovulatory follicle count between the two groups. Analysis revealed that the use of propofol during oocyte retrieval was particularly advantageous in the subgroup with a pre-ovulatory follicle count of 11-20, yielding a higher oocyte retrieval rate (p<0.001).

Conclusion

The use of propofol in oocyte retrieval did not adversely affect fertilization, embryo quality, or clinical outcomes. Moreover, it was found to increase the oocyte retrieval rate among patients with an estimated pre-ovulatory follicle count of 11-20. These findings offer valuable evidence supporting the clinical application of propofol in oocyte retrieval procedures.

Evidence based management of patients with endometriosis undergoing assisted conception: British fertility society policy and practice recommendations

Endometriosis is a chronic inflammatory condition in women of reproductive age, which can lead to infertility and pelvic pain. Endometriosis associated infertility is multifactorial in nature adversely affecting each step of the natural reproductive physiology and thereby processes and outcomes of Assisted Reproductive Technology (ART) cycles. These outcomes are further complicated by the subtype of endometriosis, being peritoneal, deep infiltrating and ovarian, which bear negative effects on ovarian reserve, response to stimulation, accessibility for oocyte retrieval, intraoperative safety and endometrial receptivity. There is still a lack of clear guidance about the role of surgery for ovarian endometriosis/endometriomas. This guideline evaluates the evidence of the impact of pelvic endometriosis and endometriomas on the outcome of ART and provides recommendations for management options before and during ART including intra-uterine insemination. Recommendations are made based on the current evidence for the management of patients with endometriosis across each step of ART with the primary aim of improving ART outcomes.

Improving reproductive outcomes in frozen embryo transfer over fresh embryo transfer in women with endometrioma: A historical cohort study

Background

Endometrioma, a common manifestation of endometriosis, often indicates the severity of the disease. In vitro fertilization and embryo transfer (ET) are key therapeutic strategies for infertility associated with endometriosis. However, the optimal type of ET (frozen or fresh) and its impact on pregnancy success rates remain debated, with limited studies available.

Objective

This historical cohort study aimed to compare fertility and neonatal outcomes, focusing on live birth rate (LBR), clinical pregnancy, and implantation rates in women with endometrioma-associated infertility, between fresh and frozen embryo transfer (FET).

Materials and Methods

In this historical cohort study, the medical records (files) of 289 women diagnosed with endometrioma-related infertility, who underwent in vitro fertilization/intracytoplasmic sperm injection treatment at Royan Institute, Tehran, Iran between March 2016-2021 were reviewed. Ultimately, 200 files that met the established criteria were selected for review. The extracted data was then compared between groups: FET (n = 121) and fresh ET (n = 79).

Results

No significant differences were observed between the groups in terms of demographic characteristics and endometrioma size. The only significant difference in fertility outcomes was the LBR, which was 36.4% for the FET group compared to 22.8% for the fresh ET group (p = 0.04). No significant differences were observed in neonatal outcomes between the groups. Overall, our study suggests that FET may lead to higher LBRs in women diagnosed with endometrioma.

Conclusion

Our study suggests that FET may lead to higher LBRs in women diagnosed with endometrioma.

Hormonal Therapies before in vitro fertilization in women with endometriosis: The Minotaur's Labyrinth and the Ariadne's Thread

Endometriosis-related infertility is one of the most debated topics in reproductive medicine. In recent years, prolonged pre-cycle hormonal regimens gained attention as a mean of improving the assisted reproduction technologies (ART) success rates in endometriosis patients. GnRH agonists, dienogest, medroxyprogesterone acetate, and aromatase inhibitors are the most studied medications. Conflicting results and a high risk of bias exist in almost all of the conducted studies in the field. However, current evidence suggests that pre-cycle treatment with GnRH agonists may be beneficial for patients with stage III/IV endometriosis. Dienogest and medroxyprogesterone acetate-based progestin-primed ovarian stimulation protocol was shown to be comparable to the prolonged GnRH agonists protocol. Finally, aromatase inhibitors seem to be of limited benefit to the assisted reproductive outcomes of endometriosis patients. Although it is challenging to draw any clinical conclusions, pre-cycle hormonal treatments seem to be best indicated in endometriosis patients who had previously failed ART treatment.

Fertility preservation in women with endometriosis: Oocyte cryopreservation and other techniques

In recent years, advancements in cryopreservation techniques for oocytes, embryos, and ovarian tissue have enabled offering fertility preservation (FP) options to women with endometriosis. It is recommended to always conduct specialized counselling on FP, especially before considering surgical interventions for endometriosis. The decision regarding the methods of FP, the timing, and to which women affected by endometriosis these techniques should be offered are still subjects of discussion. However, several studies suggest that it can be proposed before surgical interventions for endometriosis, particularly if the patient is undergoing mono or bilateral endometrioma surgery. The most recommended technique is ovarian stimulation, followed by oocyte cryopreservation. Nevertheless, the literature contains various studies describing FP through embryo cryopreservation or the retrieval and cryopreservation of ovarian tissue.

The Effects of Long-Term Dienogest Therapy on In Vitro Fertilization Outcomes in Women with Endometriosis: A Systematic Review and Meta-Analysis

OBJECTIVES

Assessing dienogest's efficacy in endometriosis patients undergoing in vitro fertilization (IVF).

DATA SOURCES

Systematic search in databases (PubMed, MEDLINE, Embase, Web of Science, Cochrane CENTRAL, Google Scholar) until 1 October 2022.

STUDY SELECTIONS

Randomized trials and observational studies comparing extended dienogest pre-treatment, no pre-treatment, or gonadotropin-releasing hormone (GnRH) agonist pre-treatment in endometriosis-linked IVF.

OUTCOME MEASURES

live birth, clinical pregnancy rates, oocytes collected, miscarriage rate, gonadotropin consumption.

DATA EXTRACTIONS AND SYNTHESES

Two authors independently assessed eligibility. Dichotomous variables were analyzed via a random-effect model and Mantel-Haenszel method to calculate weighted estimates and 95% confidence intervals (CI). I2 statistic gauged study heterogeneity; GRADE criteria evaluated evidence quality.

CONCLUSIONS

Out of 191 publications, five studies with 723 participants were included. Uncertainty persists on whether prolonged dienogest affects live birth (RR 1.42, 95% CI 0.29 to 6.84; 3 studies, n = 289; I2 86%) and clinical pregnancy rates (RR 1.33, 95% CI 0.31 to 5.65; 3 studies, n = 289; I2 86%) compared to conventional IVF. Moreover, uncertainty remains regarding intervention impact on live birth (RR 1.46, 95% CI 0.63 to 3.37; 1 study, n = 34) and clinical pregnancy rates (RR 1.32, 95% CI 0.78 to 2.23; 3 studies, n = 288; I2 0%) versus long-term GnRH agonist therapy before IVF. Given limited data and very low evidence quality, doubts arise about the benefits of long-term dienogest pre-treatment before conventional IVF in endometriosis patients.

NLRP3 concentration, oxidants, and antioxidants in plasma of endometriosis patients undergoing treatment with dienogest

OBJECTIVE

NOD-like receptor pyrin domain-containing 3 (NLRP3) is a cytosolic multi-protein complex that induces inflammation and is negatively regulated by progesterone. Previous researches have reported abnormal induction of reactive oxygen species (ROS) and progesterone resistance in endometriosis (EM). Since progesterone regulates ROS level and, consequently, inflammation, our objective is to investigate whether dienogest (DNG) regulates NLRP3 and whether the regulation of NLRP3 inflammasome by DNG in the blood plasma of patients with EM can affect oxidant and antioxidant markers.

METHODS

Plasma samples were obtained from control and EM patients experiencing pain symptoms to measure the level of NLRP3, oxidants, and antioxidants. Subsequently, these patients were given oral DNG 2 mg/day for six months for drug treatment. After six months, plasma samples were collected from the patients for re-examination.

RESULTS

The findings indicate that DNG reduced NLRP3 concentration and oxidant production while increasing antioxidant production in blood plasma. By reducing NLRP3, DNG was able to alleviate inflammation and pain caused by inflammation in EM patients.

CONCLUSION

In conclusion, the use of DNG in EM patients resulted in a decrease in NLRP3 concentration in the patient's plasma. Furthermore, this effect was enhanced by balancing oxidant/antioxidant levels, which may contribute to reducing inflammation associated with EM.

Transcriptome profiling reveals superovulation with the gonadotropin-releasing hormone agonist trigger impaired embryo implantation in mice

Introduction

Superovulation is a critical step in assisted reproductive technology, but the use of human chorionic gonadotropin (hCG) as a trigger for superovulation can result in ovarian hyperstimulation. Thus, the use of Gonadotropin-releasing hormone agonist (GnRHa) trigger has been increasingly adopted, although it has been associated with a higher rate of pregnancy failure compared to natural cycles. This study aimed to investigate the effect of GnRHa trigger on embryo implantation in a mouse model.

Methods

Mice in the superovulation (PG) group were administered 7.5 IU of PMSG, followed by the injection of 3.5 μg of GnRHa (Leuprorelin) 48 h later, while mice in the control group (CTR) mated naturally. We compared the number of oocytes, blastocysts, and corpus luteum between the two groups and the implantation sites after the transfer of natural blastocysts. Ovaries, uterus, and serum 2 and 4 days after mating were collected for qRT-PCR, transcriptome sequencing, and hormone assays.

Results

The PG group had more oocytes, blastocysts, and corpus luteum after superovulation than the CTR group. However, the mRNA expression of leukemia inhibitory factor (Lif) and the number of implantation sites were reduced in the PG group. The ELISA assay revealed that superovulation increased ovarian estrogen secretion. The transcriptome analysis showed that superphysiological estrogen led to a response of the uterus to a high estrogen signal, resulting in abnormal endometrium and extracellular matrix remodeling and up-regulation of ion transport and inflammation-related genes.

Conclusion

Our findings suggest that a combination of PMSG and GnRHa trigger impaired embryo implantation in mice, as the excessive uterine response to superphysiological estrogen levels can lead to the change of gene expression related to endometrial remodeling, abnormal expression of uterine ion transport genes and excessive immune-related genes.

Endometrial receptivity in women with endometriosis

As endometriosis is recognized as a contributing factor to infertility, prompting couples to embark on Assisted Reproductive Technology (ART) treatments, it becomes crucial to comprehend the extent and way this condition can affect success rates. Natural conception data reveal lower success rates for women with endometriosis, yet the same cannot be extrapolated to the outcomes of in vitro fertilization (IVF). In recent years, advancements in the ART process, particularly the distinct stages of the IVF pathway and investigations into embryo quality have shown a comparable rate of embryonic quality and chromosomal normalcy (euploidy) between embryos obtained from individuals with or without endometriosis. Thus, the primary question that lingers relates to the functionality of the endometrium. This review addresses whether endometriosis can influence endometrial receptivity and implantation rates.

IVF stimulation protocols and outcomes in women with endometriosis

Endometriosis is a complex medical condition with a high prevalence in women of reproductive age. Fertility is compromised in patients with endometriosis, and success in IVF treatments has been a challenge leading to evaluation of different stimulation protocols. The long-standing debate between GnRH agonist long protocols and short GnRH antagonist protocols is being resolved in favor of the latter, since in addition to presenting equivalent results with respect to the traditional option, they have the additional benefit of safety. The good results derived from vitrification techniques have led to the development of new stimulation strategies, such as progestin-primed ovarian stimulation (PPOS), with a greater degree of approval among patients. None of the stimulation protocols currently applied in women with endometriosis has been shown to be superior, so early intervention with an Assisted Reproduction treatment, regardless of the chosen protocol, can provide these women with good chances of motherhood. Women with endometrioma should be counseled for fertility preservation before planned ovarian endometrioma excision. The number of cryopreserved oocytes or embryos can be increased by repeated cycles.

Spatiotemporal Trends and Age-Period-Cohort Analysis for the Burden of Endometriosis-Related Infertility: An Analysis of the Global Burden of Disease Study 2019

BACKGROUND

Endometriosis is a common nonfatal gynecological disease, and infertility is one of its main dangers. Endometriosis-related infertility causes serious damage to women's health and places a burden on women of reproductive age. The aim of this study was to describe the current burden of endometriosis-associated infertility and to analyze its spatiotemporal trends.

METHODS

Age-standardized prevalence rate (ASPR) data from 1990 to 2019 for Endometriosis-related primary infertility (ERPI) and secondary infertility (ERSI) were obtained from the Global Burden of Disease Study (GBD) 2019. These data spanning three decades cover the global, sociodemographic index (SDI) regions, GBD regions, and 204 countries and territories. Spatiotemporal trends were analyzed by calculating the estimated annual percentage change (EAPC) and using a time-period-cohort model.

RESULTS

Globally, the ASPR of ERPI and ERSI showed a weak downward trend from 1990 to 2019, with EAPCs of -1.25 (95% CI: -1.39 to -1.11) and -0.6 (95% CI: -0.67 to -0.53), respectively. The spatiotemporal trends in ERPI and ERSI varied substantially between regions and age groups. When endometriosis-related infertility burden was linked to SDI values, a strong negative correlation was observed between the ASPR of ERSI and its EAPC and SDI values. When modeling with age-period-cohort, ERPI burden was found to be highest at ages 20-25 years, while ERSI burden was persistently higher at ages 20-45 years. Using 2000-2004 as the reference period, both ERPI and ERSI burden decreased with each year among women. Significant variability in burden between regions was found for the birth cohort factor.

CONCLUSIONS

The global burden of endometriosis-related infertility declined minimally from 1990 to 2019. However, this burden varied considerably across regions, age groups, periods, and birth cohorts. The results of this study reflect spatiotemporal trends in the burden of endometriosis-related infertility over the study period and may be used to help improve health management, develop timely and effective prevention and control strategies, and provide epidemiologic theoretical evidence for reducing the burden for endometriosis-related infertility.

Exploring the Impact of Endometrioma Aspiration and Dienogest Combination Therapy on Cyst Size, Inflammatory Cytokines in Follicular Fluid and Fertility Outcomes

Endometriomas (chocolate cysts) are cystic lesions that can develop on ovaries, and are characterized by the presence of ectopic endometrial tissue or similar tissue. Such lesions can cause a decline in the number and quality of oocytes, and lead to implantation failure. In this study, we retrospectively assessed the efficacy of repeated endometrioma aspiration and dienogest combination therapy in patients suffering endometriosis-associated infertility with endometriomas. A comparison was made between a treated group that underwent combination therapy followed by controlled ovarian hyperstimulation (COH) (n = 30) and a control group that did not undergo treatment (n = 40), at the IVF Osaka Clinic from September 2019 to September 2021. There were no differences in patient background between the two groups. A reduction in endometrioma size continued for 12 months after treatment. The numbers of follicles that developed to 15 mm or greater in size following COH and mature oocytes were significantly lower in the treated group compared to those in the control group. The levels of inflammatory cytokines in the follicular fluid significantly decreased in the treated group (p < 0.05). In patients in the treated group who underwent a second ova retrieval, the results were compared between those in the first ova retrieval (immediately after the end of treatment) and those in the second ova retrieval (four months after the first retrieval). The numbers of follicles following COH, retrieved, mature and fertilized ova were significantly increased in the second ova retrieval.

Impact of dienogest pretreatment on IVF-ET outcomes in patients with endometriosis: a systematic review and meta-analysis

BACKGROUND

To comprehensively evaluate the influence of dienogest (DNG) versus non-DNG pretreatment on in vitro fertilization and embryo transfer (IVF-ET) outcomes for patients with endometriosis.

METHODS

PubMed, Embase, Cochrane Library, Web of Science, CNKI, WanFang, and VIP were comprehensively searched for relevant publications until September 14, 2022. Primary outcomes included clinical pregnancy rate and live birth rate. Secondary outcomes included retrieved oocytes, mature oocytes, blastocysts, growing follicles, transferrable embryos, fertilization rate, implantation rate, and miscarriage rate. Subgroup analysis was performed according to different grouping methods and embryo types.

RESULTS

Five studies of 568 females with endometriosis were involved in this systematic review and meta-analysis. DNG treatment exhibited similar effects to non-DNG treatment on either the primary or the secondary outcomes (all P > 0.05). The DNG group had a significantly greater clinical pregnancy rate than the non-hormonal treatment group (pooled relative risk [RR]: 2.055, 95% confidence interval [CI]: 1.275, 3.312, P = 0.003), and exhibited a significantly lower clinical pregnancy rate than the long gonadotropin-releasing hormone agonist (GnRH-a) group (RR: 0.542, 95%CI: 0.321, 0.916, P = 0.022). For patients undergoing fresh embryo transfer, the DNG group displayed a significantly greater clinical pregnancy rate versus the non-DNG group (pooled RR: 1.848, 95%CI: 1.234, 2.767, P = 0.003). Patients receiving DNG had a significantly greater live birth rate than those with non-hormonal treatment (pooled RR: 2.136, 95%CI: 1.223, 3.734, P = 0.008), while having a significantly lower live birth rate than the long GnRH-a group (RR: 0.441, 95%CI: 0.214, 0.907, P = 0.026). While using fresh embryos, patients with DNG treatment had an increased live birth rate, compared with those without DNG treatment (pooled RR: 2.132, 95%CI: 1.090, 4.169, P = 0.027).

CONCLUSION

DNG treatment may have similar effects to non-DNG treatment on IVF-ET outcomes. The clinical pregnancy rate and live birth rate after DNG treatment may be significantly higher than those after non-hormonal treatment. More evidence is warranted to corroborate these findings.

A Lifelong Impact on Endometriosis: Pathophysiology and Pharmacological Treatment

Endometriosis is a chronic inflammatory disease associated with bothersome symptoms in premenopausal women and is complicated with long-term systemic impacts in the post-menopausal stage. It is generally defined by the presence of endometrial-like tissue outside the uterine cavity, which causes menstrual disorders, chronic pelvic pain, and infertility. Endometriotic lesions can also spread and grow in extra-pelvic sites; the chronic inflammatory status can cause systemic effects, including metabolic disorder, immune dysregulation, and cardiovascular diseases. The uncertain etiologies of endometriosis and their diverse presentations limit the treatment efficacy. High recurrence risk and intolerable side effects result in poor compliance. Current studies for endometriosis have paid attention to the advances in hormonal, neurological, and immunological approaches to the pathophysiology and their potential pharmacological intervention. Here we provide an overview of the lifelong impacts of endometriosis and summarize the updated consensus on therapeutic strategies.

Expectant, Medical, and Surgical Management of Ovarian Endometriomas

Management options for ovarian endometriomas include expectant management, medical treatment, surgical treatment, in vitro fertilization (IVF), or a combination of the above. The choice of management depends on many clinical parameters that should be taken into consideration, the first of which is the main presenting symptom. Most patients are today referred to medical therapy as a first option in the case of associated pain, and to IVF in the case of associated infertility. When both symptoms are present, usually surgery is the preferred approach. Recently, however, surgical excision of an ovarian endometrioma has been associated with a postoperative reduction in the ovarian reserve, and recent guidelines suggest that the clinician should caution the patient as to the possible damage to the ovarian reserve in the case of surgery. However, evidence has been published as to a possible detrimental effect of the ovarian endometrioma on the ovarian reserve even if expectant management is followed. In this review, the current evidence on the conservative management of ovarian endometriomas, with particular focus on the issue of the ovarian reserve, is evaluated, and the different surgical techniques for the treatment of ovarian endometriomas are discussed.

MLL1:EZH2 Ratio in Uterine Secretions and Endometrial Receptivity in Patients with Endometriosis

OBJECTIVE

To establish a novel approach for diagnosing endometriosis (EM) in patients with impaired endometrial receptivity.

METHOD

Mixed lineage leukemia 1 (MLL1) and enhancer of zeste homolog 2 (EZH2) levels were analyzed. The MLL1:EZH2 ratio in identifying impaired endometrial receptivity has been established and validated.

RESULTS

In normal endometrial tissue, the MLL1:EZH2 ratio increased significantly in the midsecretory phase, compared with that in the proliferative phase. In the midsecretory phase, the MLL1:EZH2 ratio in endometrial tissues and uterine secretions accurately identifies patients with EM who have impaired endometrial receptivity. In the validation group, the sensitivity and specificity of the MLL1:EZH2 ratio in the uterine secretions of the midsecretory phase, in diagnosing patients EM who have impaired endometrial receptivity, were 100% and 96.55%, respectively.

CONCLUSIONS

The MLL1:EZH2 ratio in uterine secretions of the midsecretory phase may serve as a marker to diagnose EM in patients with impaired endometrial receptivity.

Impact of Adenomyosis on Infertile Patients-Therapy Options and Reproductive Outcomes

Adenomyosis is associated with a negative impact on reproductive outcomes. Although adenomyosis is detected more frequently in women of late reproductive age, its impact on pregnancy rates is important because, in today's world, family planning has shifted towards the late reproductive phase of life for many women. Although the diagnostic indications for imaging studies are well-known, we lack strict diagnostic criteria and classification systems concerning the extent of the disease. Selecting the optimal evidence-based treatment option for adenomyosis is difficult because of the paucity of evidence concerning the association between fertility and the degree and composition of adenomyosis. Furthermore, the treatment of infertility might interfere with the treatment of adenomyosis due to the presence of pain. The aim of this review is to analyze the association between adenomyosis and infertility, and describe treatment options to enhance reproductive outcomes. The following aspects will be addressed in detail: (a) prevalence and causes of adenomyosis, (b) diagnostic tools with imaging techniques, (c) clinical symptoms, (d) proposed pathomechanism of adenomyosis and infertility, and (e) different treatment approaches (pharmacological, surgical, others) and their impact on reproductive outcomes.

Endometriosis-associated infertility: From pathophysiology to tailored treatment

Despite the clinically recognized association between endometriosis and infertility, the mechanisms implicated in endometriosis-associated infertility are not fully understood. Endometriosis is a multifactorial and systemic disease that has pleiotropic direct and indirect effects on reproduction. A complex interaction between endometriosis subtype, pain, inflammation, altered pelvic anatomy, adhesions, disrupted ovarian reserve/function, and compromised endometrial receptivity as well as systemic effects of the disease define endometriosis-associated infertility. The population of infertile women with endometriosis is heterogeneous, and diverse patients' phenotypes can be observed in the clinical setting, thus making difficult to establish a precise diagnosis and a single mechanism of endometriosis related infertility. Moreover, clinical management of infertility associated with endometriosis can be challenging due to this heterogeneity. Innovative non-invasive diagnostic tools are on the horizon that may allow us to target the specific dysfunctional alteration in the reproduction process. Currently the treatment should be individualized according to the clinical situation and to the suspected level of impairment. Here we review the etiology of endometriosis related infertility as well as current treatment options, including the roles of surgery and assisted reproductive technologies.

Impact of endometriosis on female fertility and the management options for endometriosis-related infertility in reproductive age women: a scoping review with recent evidences

Background

Endometriosis is a chronic inflammatory condition with varied presentation, which ultimately leads to chronic pelvic pain and infertility. It is a psychological and economic burden to the women and their families.

Main body of abstract

The literature search was performed on the following databases: MEDLINE, Google Scholar, Scopus, EMBASE, Global health, the COCHRANE library, and Web of Science. We searched the entirety of those databases for studies published until July 2020 and in English language. The literature search was conducted using the combination of the Medical Subject heading (MeSH) and any relevant keywords for “endometriosis related infertility and management” in different orders. The modalities of treatment of infertility in these patients are heterogeneous and inconclusive among the infertility experts. In this article, we tried to review the literature and look for the evidences for management of infertility caused by endometriosis. In stage I/II endometriosis, laparoscopic ablation leads to improvement in LBR. In stage III/IV, operative laparoscopy better than expectant management, to increase spontaneous pregnancy rates. Repeat surgery in stage III/IV rarely increases fecundability as it will decrease the ovarian reserve, and IVF will be better in these patients. The beneficial impact of GnRH agonist down-regulation in ART is undisputed. Dienogest is an upcoming and new alternative to GnRH agonist, with a better side effect profile. IVF + ICSI may be beneficial as compared to IVF alone. Younger patients planned for surgery due to pain or any other reason should be given the option of fertility preservation.

Short conclusion

In women with endometriosis-related infertility, clinician should individualize management, with patient-centred, multi-modal, and interdisciplinary integrated approach.

Systematic review and Meta-analysis of efficacy and safety of dienogest in treatment of endometriosis

BACKGROUND

The quality of life of women with endometriosis is substantially adversely affected by the pelvic pain caused by this disease. However, the choice of medication for endometriosis remains controversial, and no drug has been clearly proven to be superior to others.

AIM

To assess the efficacy and safety of dienogest, a synthetic progestin, in the treatment of women with painful symptoms of endometriosis.

METHODS

PubMed, EMBASE, the Cochrane Library, and the Web of Science databases were searched from their inceptions to January 21, 2020 for randomized controlled trials (RCTs) that compared dienogest with other popular prescription drugs for the treatment of endometriosis. Two reviewers extracted the data. Mean difference (MD) values and risk ratios (RRs) with 95% confidence intervals (CIs) were calculated.

RESULTS

Ultimately, seven RCTs with a total of 1493 participants met the requirements for this review. Dienogest was found to more effective than placebo in alleviating endometriosis-related pain (MD = -32.93, 95%CI: -44.63 to -21.23), but led to a more significant decline in plasma estradiol concentrations than placebo (MD = -44.7, 95%CI: -62.24 to -24.69). Dienogest was superior to gonadotropin-releasing hormone analogues (GnRH-a) in relieving pain (MD = -2.41, 95%CI: -3.58 to -1.24). Moreover, compared with dienogest, GnRH-a were significantly more likely to lead to the loss of bone mineral density (MD = 2.77, 95%CI: 0.16 to 5.37) and were significantly associated with a higher incidence of headaches (RR = 0.68, 95%CI: 0.52 to 0.91) and hot flushes (RR = 0.43, 95%CI: 0.18 to 1.02).

CONCLUSION

This meta-analysis demonstrated that dienogest may be a better pain-relief treatment for endometriosis patients, due to its high efficacy and tolerability.

Novel therapeutic targets to improve IVF outcomes in endometriosis patients: a review and future prospects

BACKGROUND

Patients with endometriosis often experience infertility and have poor IVF outcomes, with low fertilization and pregnancy rates. Although many theories have tried to explain the mechanisms underlying infertility in these patients, none of them is conclusive.

OBJECTIVE AND RATIONALE

In this review, we discuss the pathologic mechanisms through which endometriosis likely leads to infertility along with the therapeutic options used to date to treat endometriosis-related infertility and, thereby, to improve IVF outcomes in patients with endometriosis.

SEARCH METHODS

We performed a comprehensive literature search of clinical outcomes in endometriosis and the molecular mechanisms contributing to oocyte quality using the PubMed database to identify human and animal studies published from 1992 until September 2020. In total, 123 manuscripts were included.

OUTCOMES

While some theories propose that endometriosis patients may have fertility problems as a result of decreased endometrial receptivity, others reinforce the idea that infertility could be associated with oocyte alterations and lower implantation rates. Single-cell RNA sequencing of oocytes from patients with endometriosis has identified dysregulated mechanisms involved in steroid metabolism and biosynthesis, response to oxidative stress and cell cycle regulation. Dysregulation of these mechanisms could result in the poor IVF outcomes observed in patients with endometriosis. Further, impaired steroidogenesis may directly affect oocyte and embryo quality. Increased oxidative stress in patients with endometriosis also has a detrimental effect on the follicular microenvironment, inducing cell cycle dysregulation in oocytes, poor oocyte quality, and infertility. Moreover, granulosa cells in the context of endometriosis undergo increased apoptosis and have an altered cell cycle that could adversely affect folliculogenesis, oocyte and embryo quality, and IVF outcomes. Endometriosis is also associated with inflammatory damage and impaired angiogenesis, which could be directly correlated with poor IVF outcomes. While therapeutic options using GnRH analogues, progestins and aromatase inhibitors do not improve endometriosis-related infertility, anti-inflammatory agents and antioxidant supplementation could improve oocyte quality as well as implantation and clinical pregnancy rates in patients with endometriosis.

WIDER IMPLICATIONS

Endometriosis is a heterogeneous disease whose pathogenesis is complex and could affect fertility by altering a collection of molecular mechanisms in oocytes. Thus, a single model is not sufficient to describe endometriosis-related infertility. Dysregulation of steroidogenesis, oxidative stress, cell cycle progression, inflammation and angiogenesis in the follicular environment and oocytes in individuals with endometriosis are all possible contributors to endometriosis-related infertility. Therefore, treatments targeting these mechanisms could be therapeutic alternatives to improve IVF outcomes for these patients.

Role of suppression of endometriosis with progestins before IVF-ET: a non-inferiority randomized controlled trial

BACKGROUND

Endometriosis affects the responsiveness to ovarian stimulation. This study aimed to assess the role of Dienogest pretreatment for endometriosis suppression as compared to Gonadotropin-releasing hormone agonist (GnRHa) in patients with endometriosis pursuing IVF treatment.

METHODS

In this randomized controlled trial, 134 women with endometriosis-related infertility were randomly allocated to group A (n = 67) who had monthly depot GnRHa for 3 months before ovarian stimulation in IVF treatment (Ultra-long protocol), and Group B (n = 67) who had daily oral Dienogest 2 mg/d for 3 months before starting standard long protocol for IVF. The primary outcome measure was the number of oocytes retrieved. The secondary outcome measures included the number of mature oocytes, fertilization rate, quality of life assessed by FertiQoL scores, cost of treatment, and pregnancy outcomes.

RESULTS

Although there was no statistically significant difference between both groups regarding ovarian stimulation, response parameters, and pregnancy outcomes, the Dienogest group had a lower cost of treatment (2773 vs. 3664 EGP, P < 0.001), lower side effects (29.9% vs. 59.7%, P < 0.001), higher FertiQoL treatment scores (33.2 vs. 25.1, P < 0.001) and higher tolerability scores (14.1 vs. 9.4, P < 0.001 < 0.001).

CONCLUSION

Our study indicates that Dienogest is a suitable and safe substitute for GnRHa pretreatment in endometriosis patients.

TRIAL REGISTRATION

NCT04500743 "Retrospectively registered on August 5, 2020".

Assisted reproductive technology for women with endometriosis, a clinically oriented review

PURPOSE OF REVIEW

To discuss optimal management of an assisted reproductive technology (ART) cycle in women with endometriosis.

RECENT FINDINGS

New studies involving euploid embryo transfers provide more insight on the etiology of endometriosis-associated infertility. Oocyte competence to reach live birth seems unlikely to be affected by the disease. Routine medical or surgical treatment prior to an ART cycle does not appear beneficial. Short gonadotropin releasing hormone (GnRH) antagonist or progestin primed ovarian stimulation protocols seem to be proper first choices, depending on the intention for a fresh embryo transfer. Low-quality evidence supports frozen thawed over fresh embryo transfer. Ovarian stimulation for ART does not seem to be associated with symptom progression or recurrence.

SUMMARY

How endometriosis affects fertility is still unclear, but ART is an effective pragmatic treatment. Each woman with endometriosis must be assessed with a holistic approach, and in the absence of an indication for otherwise, ART cycles can be kept simple with patient-friendly protocols. Whether a frozen embryo transfer is better than a fresh one should be investigated.

Ovarian reserve after three-step laparoscopic surgery for endometriomas utilizing dienogest: A pilot study

Purpose

Surgery for endometriomas may cause detrimental effects on ovarian reserve. We evaluated the safety of three‐step laparoscopic surgery for endometriomas utilizing dienogest in terms of post‐surgical ovarian reserve.

Methods

Twelve women received first look laparoscopy (FLL) with fenestration and drainage. Immediately after the surgery, they took oral dienogest 2 mg for three months; then, they received second look laparoscopy (SLL) with cystectomy. We compared serum AMH levels between women had three‐step management with dienogest, and another twelve women had conventional one‐step surgery without medications. In women had three‐step procedures, the changes in concentration of proinflammatory cytokines and chemokines in peritoneal fluids were evaluated.

Results

Serum AMH levels were significantly decreased after three months of dienogest following FLL. AMH levels were also significantly decreased 3‐6 months both after SLL and after one‐step surgery; however, recovery of serum AMH levels at 9‐12 months after surgery was evident in women had three‐step surgery comparing to those of one‐step surgery. Proinflammatory cytokines and chemokines in peritoneal fluids were downregulated at the time of SLL comparing to those of FLL.

Conclusions

Three‐step surgery with dienogest may be a beneficial approach to protect ovarian reserve. Dienogest may exert its effects in part by lowering proinflammatory cytokines and chemokines.

The role of pharmacotherapy in the treatment of endometriosis across the lifespan

INTRODUCTION

Endometriosis is estimated to affect 10% of reproductive-aged women. The gold standard for treatment is surgery; however, surgery carries a significant morbidity and cost burden. There is an ongoing need for safe, effective medical therapies for endometriosis patients, both in conjunction with and independent of surgical interventions. Most conventional therapies for endometriosis work by a similar mechanism, and efficacy is variable. In recent years, there has been increased interest in the development and testing of novel pharmacotherapies for endometriosis.

AREAS COVERED

This review discusses both conventional and emerging treatments for endometriosis. The authors present the application of these drugs in different presentations of endometriosis across the lifespan and discuss how emerging therapies might fit into future medical management of endometriosis. Conventional therapies include nonsteroidal anti-inflammatory drugs, combined oral contraceptives, progestins, GnRH agonists/antagonists, and aromatase inhibitors. Emerging therapies are focused on disease-specific targets such as endothelial growth factor receptors.

EXPERT OPINION

The field of endometriosis therapy is moving toward modifying the immune and inflammatory milieu surrounding endometrial implants. If these drugs show efficacy in clinical trials, combining them with current medical treatment is expected to result in a profound impact on symptom and disease burden for patients who suffer from endometriosis worldwide.