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Women with endometrioma-related infertility face a dilemma when choosing the appropriate therapy: surgery or in vitro fertilization

2018; Elsevier BV; Volume: 110; Issue: 7 Linguagem: Inglês

10.1016/j.fertnstert.2018.10.002

1556-5653

Jacques Donnez,

Gynecological conditions and treatments

Endometriosis, particularly ovarian endometriosis, is a disease detrimental to fertility. The exact pathophysiology of endometrioma-related infertility is still a source of debate, however, and a number of mechanisms have been suggested. It has been postulated that it distorts the tubo-ovarian anatomy or induces an inflammatory reaction followed by the so-called burn-out effect, which impacts the follicle reserve (1Kitajima M. Dolmans M.M. Donnez O. Masuzaki H. Soares M. Donnez J. Enhanced follicular recruitment and atresia in cortex derived from ovaries with endometriomas.Fertil Steril. 2014; 101: 1031-1037Abstract Full Text Full Text PDF PubMed Scopus (119) Google Scholar) and causes oxidative stress (2Donnez J. Binda M.M. Donnez O. Dolmans M.M. Oxidative stress in the pelvic cavity and its role in the pathogenesis of endometriosis.Fertil Steril. 2016; 106: 1011-1017Abstract Full Text Full Text PDF PubMed Scopus (109) Google Scholar) resulting in poorer quality oocytes. Indeed, toxic content from an endometrioma may result in local inflammation, elevated oxidative stress levels, increased fibrosis, loss of cortex-specific stroma, smooth muscle cell metaplasia, and a diminished follicle reserve due to greater follicle atresia (1Kitajima M. Dolmans M.M. Donnez O. Masuzaki H. Soares M. Donnez J. Enhanced follicular recruitment and atresia in cortex derived from ovaries with endometriomas.Fertil Steril. 2014; 101: 1031-1037Abstract Full Text Full Text PDF PubMed Scopus (119) Google Scholar, 2Donnez J. Binda M.M. Donnez O. Dolmans M.M. Oxidative stress in the pelvic cavity and its role in the pathogenesis of endometriosis.Fertil Steril. 2016; 106: 1011-1017Abstract Full Text Full Text PDF PubMed Scopus (109) Google Scholar). According to a recent review, the presence of endometriomas does not adversely affect IVF outcomes in terms of live births (3Hamdan M. Dunselman G. Li T.C. Cheong Y. The impact of endometrioma on IVF/ICSI outcomes: a systematic review and meta-analysis.Hum Reprod Update. 2015; 21: 809-825Crossref PubMed Scopus (175) Google Scholar). Women with endometriomas have similar live birth rates but a lower oocyte yield per cycle and a higher cancellation rate than those without endometriomas. The latter finding may nevertheless influence cumulative live birth rates. Women with endometrioma-related infertility face a dilemma when choosing the appropriate therapy: surgery or IVF. According to European Society of Human Reproduction and Embryology guidelines reported by Dunselman et al. (4Dunselman G.A. Vermeulen N. Becker C. Calhaz-Jorge C. D'Hooghe T. De Bie B. et al.for the European Society of Human Reproduction and Embryology. ESHRE guideline: management of women with endometriosis.Hum Reprod. 2014; 29: 400-412Crossref PubMed Scopus (1316) Google Scholar), surgical treatment of endometriomas before IVF/intracytoplasmic sperm injection (ICSI) is widely practiced, even though there is very little robust evidence to provide adequate guidance to clinicians. Numerous recent studies have generated concerns that managing endometriomas surgically could be detrimental to the ovarian reserve and subsequently adversely affect IVF/ICSI reproductive outcomes. However, the risks of surgery and its potential damage to the ovarian reserve need to be balanced against complications associated with the persistence of endometriomas during IVF/ICSI (Fig. 1). It should be stressed that the ovarian reserve may well be depleted even before surgery in some women with endometriomas (1Kitajima M. Dolmans M.M. Donnez O. Masuzaki H. Soares M. Donnez J. Enhanced follicular recruitment and atresia in cortex derived from ovaries with endometriomas.Fertil Steril. 2014; 101: 1031-1037Abstract Full Text Full Text PDF PubMed Scopus (119) Google Scholar) and that, if indicated, an appropriate surgical strategy should be undertaken to decrease the risk of removing healthy ovarian cortex containing follicles during cystectomy (5Donnez J. García-Solares J. Dolmans M.M. Ovarian endometriosis and fertility preservation: a challenge in 2018.Minerva Ginecol. 2018; 70: 408-414PubMed Google Scholar). The pros and cons of surgical management have now been debated for almost 15 years, but the debate rages on in 2018, calling for a “fertile battle” on this topic between world experts in the field in an attempt to solve this clinical conundrum for health care practitioners. Hamdan et al. (3Hamdan M. Dunselman G. Li T.C. Cheong Y. The impact of endometrioma on IVF/ICSI outcomes: a systematic review and meta-analysis.Hum Reprod Update. 2015; 21: 809-825Crossref PubMed Scopus (175) Google Scholar) speculated that the diminished number of oocytes retrieved and higher baseline levels of FSH in women with endometriomas compared with those without endometriosis was related to a direct impact on the ovary. Kitajima et al. (1Kitajima M. Dolmans M.M. Donnez O. Masuzaki H. Soares M. Donnez J. Enhanced follicular recruitment and atresia in cortex derived from ovaries with endometriomas.Fertil Steril. 2014; 101: 1031-1037Abstract Full Text Full Text PDF PubMed Scopus (119) Google Scholar) demonstrated this detrimental effect in two studies with the burn-out hypothesis and suggested that endometriomas are a progressive condition. The disease may not only affect oocyte numbers but, more importantly, oocyte quality. Some studies have found the follicular microenvironment of women with endometriosis to be deleterious to the integrity and intrinsic functions of the oocyte and subsequent embryo development. By contrast, other studies examining the morphology of oocytes and embryo development in women with and without endometriosis have not identified any differences between the two groups. Dunselman et al. (4Dunselman G.A. Vermeulen N. Becker C. Calhaz-Jorge C. D'Hooghe T. De Bie B. et al.for the European Society of Human Reproduction and Embryology. ESHRE guideline: management of women with endometriosis.Hum Reprod. 2014; 29: 400-412Crossref PubMed Scopus (1316) Google Scholar) and Hamdan et al. (3Hamdan M. Dunselman G. Li T.C. Cheong Y. The impact of endometrioma on IVF/ICSI outcomes: a systematic review and meta-analysis.Hum Reprod Update. 2015; 21: 809-825Crossref PubMed Scopus (175) Google Scholar) have both highlighted the lack of clinical studies investigating complications associated with the surgical management of endometriomas as well as complications encountered over the course of IVF treatment and oocyte pick-up, such as pain, infection, or fever. It is therefore important to consider individualizing the care of women with endometriomas before IVF/ICSI and adopting a more conservative approach in those who are asymptomatic, older, or known to have a low ovarian reserve before IVF/ICSI. Ovarian endometriosis and infertility: in vitro fertilization (IVF) or surgery as the first approach?Fertility and SterilityVol. 110Issue 7PreviewIVF is commonly applied to all indications for infertility, but increasingly unexplained causes predominate ( www.sart.org ). Specifically, endometriosis is listed as the primary diagnosis in less than 4% of cases in the United States, primarily because laparoscopy is not performed for the basic infertility workup, as it once was (1). Unexplained cases of infertility show a high prevalence of endometriosis (2, 3). Visible endometriosis such as endometriomas present a special challenge, especially since ovarian reserve may be compromised when ovarian surgery is performed. Full-Text PDF