Fertility conservation in women with endometriosis

The upward trend of interest in fertility preservation is remarkable among women with endometriosis.

Key Points

Importance:

• Endometriosis is one of the clinical indications for fertility preservation.

Highlights:

• Fertility preservation in the form of the embryo and oocytes freezing is successfully implemented for several years.
• If ovarian hyperstimulation is not possible due to a medical contraindication like endometriosis, the "ovarian cortex tissue preservation" method is promising for fertility conservation.

What's done here:

• Based on an electronic search of the 14 years in PubMed about fertility preservation in endometriosis, 27 abstracts were appropriate.
• After eliminating according to the exclusion criteria, only 7 papers found to be eligible for this systemic review.
• Endometriosis-related changes altering the ovarian reserve and oocyte health are widely discussed to consider better fertility outcomes in future research.

Data:

• Endometriosis is a disease that could work out a decline in ovarian reserve and oocyte quality while the surgical approach as well can lead to another decrease in stocks.
• When we add the risk of developing malignancy in severe endometriotic patients to their histological follicular damage and surgical interventions, the need for fertility preservation rises.
• The reason that endometriosis causes pelvic adhesions and intraperitoneal inflammation, which leads to an unfavorable microenvironment for implantation, fertility concerns are much higher when comparing women with healthy ovaries.

Limitations:

• There is no randomized controlled trial and prospective studies in the literature about 'endometriosis and fertility preservation' to make clear the success rate of the techniques and methods of cryopreservation.

Lay Summary

Endometriosis affects 10-15% of women in their reproductive period and almost half of them may need Assisted Reproductive techniques to conceive. Moreover, increased malignancy risk is threatening the women with severe endometriosis in addition to their decreased ovarian reserve. Due to all these reasons, fertility preservation with ovarian tissue cryopreservation need is rising and becoming a common interest.

Lantsberg et al., from the Department of Obstetrics Gynecology of Monash University, Australia, recently published a literature review to reveal the methods and the results for preserving fertility in women with endometriosis and penned them in the "Journal of Minimal Invasive Gynecology". Three authors systematically reviewed and evaluated the literature for related terms in databases of PubMed/Medline from Jan 1985 to April 2019 excluding the reviews and animal studies.

Among the noteworthy 7 papers that have been selected to review fertility preservation, one study showed that women with endometriosis have an earlier age of menopause when compared to healthy women. Another study revealed that the negative impact of endometriosis was on oocyte quality, which indicates endometriotic women could have the same chance of implantation and pregnancy as healthy women when transferred embryos were derived from oocytes donated by women without endometriosis.

‘Ovary-sparing’ surgical techniques are the best prophylaxis and play a crucial role in the fertility outcome after surgery, the surgeon should be careful with the amount of functioning ovarian tissue that is removed together with the cyst wall, and excessive electrocoagulation is harmful and worsen fertility.

Only two case reports, one histological science study, and four retrospective cohort studies focusing specifically on fertility preservation in women with endometriosis were present, there were no articles with randomized controlled trials or prospective study design. The lack of research in this area may reflect the fact that fertility preservation, in particular, ovarian tissue freezing is not considered as a research subject in women with endometriosis.

Besides ovarian and embryo cryopreservation, another way of preserving fertility is ovarian tissue cryopreservation (OTCP) that involves taking one or two biopsies from healthy ovaries. The main obstacle of OTCP is reducing the number of follicles upon thawing due to ischemic stress experienced by cortical tissue of the ovary. So this procedure is still considered experimental by ASRM, ASCO, ESHRE, and ESMO.

The authors concluded that future researchers should work on the pathophysiological mechanisms of endometriosis that lead to a decline in oocyte quality, quantity and modifiable risk factors of fertility loss to improve fertility preservation techniques.

Research Source: https://www.ncbi.nlm.nih.gov/pubmed/31546067/