Postoperative ovulation induction in infertile women with minimal to mild endometriosis

Ovulation rate similarly increased following laparoscopic operation in infertile women with minimal to mild endometriosis.

Key Points

Highlights:

• Ovulation induction, clomiphene citrate or letrozole, may be recommended postoperatively to infertile women with minimal to mild endometriosis to provide a higher ovulation rate.

Importance:

• Women with minimal to mild endometriosis should be informed about ovulation induction methods following laparoscopic management when experience fertility problems.

What’s done here?

• This prospective randomized controlled trial was performed in infertile women having minimal to mild endometriosis by the revised American Fertility Society classification.
• All patients underwent operative laparoscopy and the diagnosis was histopathologically confirmed. 
• The study population was randomized to three groups: only laparoscopy, or ovulation induction with either letrozole or clomiphene citrate postoperatively.
• The cumulative pregnancy rate was investigated as the primary outcome while ovulation rate, live birth rate, and miscarriage rate measures were secondary outcomes.

Key results:

• A total of 210 women who met the eligibility criteria were enrolled for this study.
• Ovulation induction with clomiphene citrate and letrozole postoperatively increased ovulation rate significantly compared to the control group.
• The cumulative pregnancy rate was also increased at 3, 6, 12 months in women who used clomiphene citrate and letrozole postoperatively, without significant difference.
• Live birth rate and miscarriage rate did not show any significant difference between three groups.

Limitations:

• No evaluation of endometrial thickness as a secondary outcome measure could be accepted as the limitation of the study.

Lay Summary

Infertility is an important problem that is encountered in 30-50% of women with endometriosis.

Several etiopathogenetic mechanisms for the development of reproductive problems in women with endometriosis have been proposed including abnormal peritoneal microenvironment, ovarian dysfunction and/or decreased oocyte quality, impaired fertilization, and implantation. No consensus has yet been developed for the management of endometriosis-associated infertility. Ovulation induction may be recommended to patients with minimal to mild endometriosis following operative laparoscopy.

Zhou et al, from China, published a randomized clinical study titled  “Ovulation induction with clomiphene citrate or letrozole following laparoscopy in infertile women with minimal to mild endometriosis: a prospective randomised controlled trial” in the journal named "Journal of Obstetrics and Gynaecology".

The authors aimed to investigate the effectiveness of ovulation induction with either clomiphene citrate or letrozole regarding ovulation rate, cumulative pregnancy rate, live-birth rate and miscarriage rate in women with minimal to mild endometriosis following operative laparoscopy. They randomized 210 patients into three groups: only laparoscopy (as the control group); ovulation induction with letrozole postoperatively or ovulation induction with clomiphene citrate postoperatively.

Ovulation induction with both clomiphene citrate and letrozole postoperatively increased the ovulation rate significantly compared to the control group. The cumulative pregnancy rate was also increased at 3, 6, 12 months in women who used clomiphene citrate and letrozole postoperatively, with no significant difference. Live birth rate and miscarriage rate did not show any significance between the three groups.

“For infertile women with minimal to mild endometriosis, ovulation induction with letrozole or clomiphene citrate after laparoscopy significantly increases ovulation rate, which is comparable; but does not demonstrate a significant advantage on improving pregnancy rate and live-birth rate when compared to laparoscopy alone,” the authors concluded.

Research Source: https://pubmed.ncbi.nlm.nih.gov/34020578/