Endometriosis and in vitro fertilisation

What is the impact of endometriosis and the AFS stage on cumulative pregnancy rates in IVF programs?

BACKGROUND

Endometriosis is commonly observed in infertile women and can be staged with regard to severity [e.g. according to the American Fertility Society (AFS) classification]. This condition can cause infertility through impaired oocyte quality, fertilization disorders, tubal lesions, adhesions, deep infiltration, and adenomyosis. Although women with endometriosis often turn to in vitro fertilization (IVF) programs, the literature data on IVF outcomes are sometimes contradictory (i.e. the same as in other etiologies of infertility, or worse). The objective of the present study was to assess and compare pregnancy rates in women with and without endometriosis and according to the endometriosis stage.

METHODS

We retrospectively studied clinical and ongoing pregnancy rates in IVF and the cumulative pregnancy rates after frozen/thawed embryo transfers, in women without endometriosis (group A) or with endometriosis (group B). We further compared groups in which endometriosis was staged according to the revised AFS classification: stage 1/2 (group C), stage 3/4 (group D, without endometrioma), and endometrioma alone (group E).

RESULTS

We documented 430 cycles in group A and 460 in group B (including 56 in group C, 88 in group D and 316 in group E). After fresh or frozen/thawed embryo transfers, the differences in ongoing pregnancy rates between groups A and B were not significant. However the cumulative rates per couple were significantly lower (p < 0.05) in group D.

CONCLUSIONS

We recommend IVF for women with endometriosis because the pregnancy rates are similar to those observed for women with other types of infertility. This approach is in line with the international guidelines issued by assisted reproductive technology societies. These results again raise the question of whether surgical resection of deep infiltrating endometriosis (stage 3/4) should be recommended before admission to an IVF program. Trial registration This study was approved by an institutional review board (CPP Ouest VI, Brest, France): reference: B2020CE.43.

The Impact of Endometriosis on In Vitro Fertilization Outcome

Introduction:Endometriosis is a common inflammatory disease and a major cause of infertility through various mechanisms. Materials and method: We conducted a retrospective study in infertile women with endometriosis who underwent in vitro fertilization (IVF) in order to evaluate the particularities and outcome of ovarian stimulation. Results:A total of 59 patients aged 24-40 years were included. Clinical characteristics of the studied group revealed dysmenorrhea in 66.66% of cases, previous ovarian surgery in 57.89% and primary infertility in 78.94%. The most used protocol was the short one with antagonist (64.91%), followed by the long protocol with agonist (22.80%), and Dual-stim protocol (12.28%). The number of ovarian stimulation days varied between 8-14 days. The total number of oocytes obtained ranged between 0-12. Standard IVF was performed in 40.35% of cases and FIV-ICSI in 59.64% of cases; 78.94% of patients were able to obtain an embryo and blastocysts were obtained in 42.10% of cases. All patients aged under 35 obtained at least one viable embryo. Fresh or frozen single embryo transfer was furtherly performed with a day 3 embryo or a blastocyst. Fresh embryo transfer was mainly performed with day 3 embryos (60.46%). The overall biochemical pregnancy rate in the studied lot was 35.59%. The biochemical pregnancy rate was 40% in the group of patients aged under 35 and 35.13% in the group aged over 35 years. Conclusion:Women with endometriosis are a special category of poor ovarian response mainly due to the decline in ovarian reserve and inferior IVF results are expected due to a lower number of retrieved oocytes, lower fertilization rates, poor embryo quality and altered endometrial receptivity.

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.

Improving the diagnostic recognition of thoracic endometriosis: Spotlight on a new histo-morphological indicator

The diagnosis of thoracic endometriosis (TE) is challenging, hence resulting in under-diagnosis as well as long delays before arriving at a correct definitive diagnosis. Our aim is to review the histopathological findings in TE, summarise the diagnostic features, identify any major histo-morphological indicator(s) hitherto unrecognised as such, suggest diagnostic criteria; all with the aim of improving the diagnostic capacity and reducing observer error even where the clinical suspicion is low. A case-control study in which a search in the pathology archives of a referral hospital over a 10-year period was conducted. Twenty-six cases of TE were identified, reviewed, and compared with a control population of 48 cases taken from common benign thoracic diseases. Nine notable histological features were identified in varying permutations in the test group, namely: endometrioid glands, lymphoid clusters, ceroid macrophages, siderophages, cholesterol crystals, capillary congestion, multinucleated giant cells, smooth muscle bundles and fibrosis. The first 6 features were frequent; each being present in over 13 (13/26; 50%) test cases. The first 8 features showed significant association with TE by the Chi-squared test (P<0.05). In this group, the strength of association is high for the first 4 features (Cramér's V≥0.5). The presence of ceroid macrophages is shown to be a novel key feature, previously unrecognised as such, for the identification of TE. The presence of any three of four features including endometrioid glands, lymphoid clusters, ceroid macrophages and siderophages is a suggested criterion for the definitive diagnosis of TE.

Insufficient Cumulus Expansion and Poor Oocyte Retrieval in Endometriosis-Related Infertile Women

Endometriosis (EMs) is a common cause for female infertility, leading to the need for in vitro fertilization (IVF). In clinics, we found the operative oocyte retrieval to be more or less difficult in women with EMs. We hypothesized that EMs may be involved in the insufficient cumulus expansion that partially explained the lower oocyte retrieval in EMs-related infertile women undergoing assisted reproductive technology (ART). To explore whether the insufficient cumulus expansion exists in EMs-related infertile women and whether there is a possible relationship between the insufficient cumulus expansion and the clinical phenomenon of difficulty in oocyte retrieval. Those infertile women undergoing IVF recorded in our database between January 2013 and October 2017 were included. The expression levels of cumulus expansion-related genes (HAS2/PTGS2/PTX3/TNFAIP6) in the cumulus cells (CCs) from 19 infertile women with EMs and 24 controls were analyzed by real-time PCR. After that, 635 women with EMs-associated infertility (the EMs group) and 4634 women with male factor-associated infertility (the control group) were included in the retrospective analysis. The clinical outcomes were compared between the two groups. The relative mRNA levels of cumulus expansion-related genes were significantly decreased in the CCs from those infertile women with EMs when compared to the control group (all p < 0.05), especially the expression of PTGS2. The mean oocyte retrieval rates (proportion of obtained oocytes in punctured follicles) were (76.33 ± 2.58)% and (71.80 ± 0.58)% (p < 0.01). The mean numbers of flushing times per follicle were 1.11 ± 0.65 and 3.86 ± 1.53 (p < 0.001). The lower expression of cumulus expansion-related genes in CCs suggests the insufficient cumulus expansion in EMs-related infertile women, which partially explains a possible mechanism related to poor oocyte retrieval.

Defining the genetic profile of endometriosis

Endometriosis is a pathological condition which has been extensively studied, since its pathophysiology stems from a broad spectrum of environmental influences and genetic factors. Familial studies aim at defining inheritance trends, while linkage analysis studies focus on the identification of genetic sites related to endometriosis susceptibility. Genetic association studies take into account candidate genes and single nucleotide polymorphisms, and hence target at unraveling the association between disease severity and genetic variation. The common goal of various types of studies is, through genetic mapping methods, the timely identification of therapeutic strategies for disease symptoms, including pelvic pain and infertility, as well as efficient counselling. While genome-wide association studies (GWAS) play a primary role in depicting genetic contributions to disease development, they entail a certain bias as regards the case-control nature of their design and the reproducibility of the results. Nevertheless, genetic-oriented studies and the implementation of the results through clinical tests, hold a considerable advantage in proper disease management. In this review article, we present information about gene-gene and gene-environment interactions involved in endometriosis and discuss the effectiveness of GWAS in identitying novel potential therapeutic targets in an attempt to develop novel therapeutic strategies for a better management and treatment of patients with endometriosis.