Endometriosis, ART, fertility preservation

Individualized management of endometriosis and fertility preservation are important.

Key Points

Importance:

• Infertility caused by endometriosis affects oocyte quality, ovarian reserve, tubal-ovarian dysfunction, endometrial receptivity, and folliculogenesis.

Highlights:

• The therapeutic approach for endometriosis is complex, necessitates patient-specific individualized therapy by a multidisciplinary team.

What's done here:

• This article reviews the recent therapeutic options for infertility and fertility preservation methods in women with endometriosis.
• A gynecologist team from Switzerland, Dr. Necula et al. made a review of related recent literature.

Key Points:

• Endometriosis related infertility: 
• The importance of ovarian reserve and oocyte quality is discussed. 
• Decreased oocyte quality and alteration of the immune system are associated with endometriosis-related infertility and can cause premature menopause compared to the general population.
• Endometrioma itself affects the surrounding healthy oocytes by toxic radicals, cytokines, and may result in not only infertility, but also causes unwanted pregnancy outcomes like miscarriage, fetal growth restriction, or preterm birth.
• The presence of adenomyosis negatively affects IVF/ISCI outcome.
• Therapeutic options: Medical therapies, the role of surgery, and assisted reproductive techniques are reviewed.
• Surgery remains the gold standard for endometriosis treatment, but concerning its harmful effects, a multidisciplinary team and individualized therapy are mandatory.
• During endometrioma surgery, mechanical removal of healthy ovarian tissue is not the only mechanism for decreased AMH and follicular loss. Secondary inflammation and edema after excision can contribute to extensive damage of ovarian tissue.
• Endometriomas >5cm should be operated. Small endometriomas should not be punctured during oocyte retrieval for IVF. 
• Endometriosis Fertility Index (EFI) has been developed to estimate the chance of pregnancy in women with endometriosis. In order to predict fertility rates after surgery r-ASRM scoring will be helpful and ART or other approaches for infertility treatment could be managed.
• Oocyst, embryo, and ovarian tissue cryopreservation should be considered for especially for patients under 35 years of age who are planning to conceive in the future.

Lay Summary

This review entitled "The impact of endometriosis on the outcome of assisted reproductive techniques: role of fertility preservation" was written by Necula et al. from Gynecology and Obstetrics Unit, Biel, Switzerland, and recently published in the journal "Hormone, Molecular Biology and Clinical Investigation".

Endometriosis is a major cause of infertility. Although different types of endometriosis may require different types of therapy, recent understanding shows that individual treatment for every patient is important. The development of ART techniques facilitates to get conceived, however, the application of ART before or after surgery still remains in discussion according to the literature.

For cost-benefit and fertility outcomes, surgery for infertile women with painless endometriosis is not recommended. Diagnostic surgery planned for stage I and II endometriosis is advised to remove peritoneal implants for better further fertility outcomes. Generally, a 25% spontaneous pregnancy rate can be expected after 12 months of laparoscopic surgery which is equal to one cycle of IVF in the same group of patients.

Deep infiltrating endometriosis frequently associated with severe pain and surgery is the main treatment. Cryopreservation is a reasonable way to protect the fertility rate for these women. Decision on the cryopreservation method depends on the patient's age, partner status, religious and ethical objections. It is known that surgery could have a significant negative impact on the cases of bilateral endometrioma, however, more powerful studies are necessary for the appropriate management in this group of patients.

Larger endometriomas more than 5 mm should be operated before the IVF cycle to reduce the mechanical compression on ovarian tissue to achieve a better reaction to given ovarian stimulations. But to aspirate smaller endometriomas for the same purpose might be failed due to the risk of developing inflammation and pelvic abscess.

"The most important part of endometriosis management is "early diagnosis" and "progression control" while taking into account the fertility concerns of the patient. The financial aspects of endometriosis seem to be another problem due to unsupported medical insurance systems in many countries such as Switzerland" finalized the authors.

Research Source: https://pubmed.ncbi.nlm.nih.gov/33691349/