The outcome of in vitro fertilization in advanced endometriosis with previous surgery: A case-controlled study

doi:10.1067/mob.2003.13

American Journal of Obstetrics and Gynecology

Volume 188, Issue 2, February 2003, Pages 371-375

https://doi.org/10.1067/mob.2003.13 Get rights and content

Abstract

Objective: This study was undertaken to evaluate the outcome of in vitro fertilization (IVF) in patients with advanced pelvic endometriosis and previous surgical treatment. Study design: A case controlled study was performed. Results: Patients with the diagnosis of stage IV endometriosis with previous surgical treatment were treated by IVF (group A = 85). An age-matched group of patients (group B = 177) with tubal factor infertility were treated with the same protocol of IVF. In group A, cycle cancellation because of poor response occurred in 29.7% compared with 1.1% in the control group (relative risk 26.03, 95% CI 6.02-112.45). There were 13 (15.3%) clinical pregnancies per stimulated cycle in group A compared with 93 (52.5%) clinical pregnancies in the control group, P < .0001 (odds ratio 0.29, 95% CI 0.15-0.55). Conclusion: The outcome of IVF in stage IV endometriosis with previous surgery was significantly lower compared with an age-matched group of tubal factor infertility. (Am J Obstet Gynecol 2003;188:371-5.)

Section snippets

Material and methods

During the period from May 1999 to May 2001, 85 patients with the diagnosis of advanced endometriosis underwent IVF in our center (group A). The diagnosis of advanced endometriosis was confirmed on clinical and ultrasound basis and by previous surgical reports. All patients underwent previous laparoscopic or open surgical procedures for the treatment of endometriosis and pelvic adhesiolysis. In all patients, biopsy specimens were taken during previous surgeries and diagnosis was confirmed by

Results

The mean age of the patients in group A was 33.1 ± 4.1 years and the mean infertility duration was 6.6 ± 4.2 years. An age-matched control group of patients with tubal factor treated by IVF during the same period were included in the study (group B). The mean age of group B was 31.1 ± 4.6 years and the mean infertility period was 7.6 ± 4.1 years. There was no significant difference in the age or infertility periods between groups A and B (Table).There was no significant difference in the number

Comment

The current work deals with a group of patients with the diagnosis of severe endometriosis grade 4 according to the American Fertility Society classification. All patients had previous surgical procedures for treatment of endometriosis in different clinics before they were finally referred to us for IVF after failure to achieve pregnancy. Most of the patients had had more than one previous surgical procedure.

Our work demonstrated a highly significant lower pregnancy rate and a higher withdrawal

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Cited by (79)

New treatment strategy for endometriosis using progestin-primed ovarian stimulation with dienogest: A prospective cohort study, comparison of dienogest versus dydrogesterone
2021, Reproductive Biology
Dienogest (DNG) is an oral progestin effective for the treatment of symptomatic endometriosis, such as reduction of endometrial lesion and control of pain intensity. Progestin-primed ovarian stimulation (PPOS) is a new controlled ovarian hyperstimulation (COH) regimen, and several reports have shown that dydrogesterone (DYG) is an appropriate progestin for PPOS. The purpose of this study was to evaluate the efficacy of DNG in patients undergoing PPOS during COH in comparison with DYG. This was a prospective, cohort, parallel-group, non-inferiority trial of 150 women with endometriosis undergoing assisted reproductive technology between February 2018 and May 2020 at the single fertility center. The assignment to each protocol was based on the optimal treatment for each patient. Patients taking DNG 2 mg continuously were assigned in the DNG group(n = 73). The other patients were allocated in DYG group(n = 77). All viable embryos were cryopreserved for subsequent transfer. The main outcome measures were the mature oocyte and fertilization rates. During this study, no premature LH surge was detected. A smaller number of oocytes were retrieved in the DNG group than in the DYG group (6.18 ± 3.60 vs. 9.85 ± 5.77); however, the rate of mature oocytes was significantly higher in the DNG group than in the DYG group (89.1 % vs. 78.9 %). The fertilization rate was comparable between two groups. Therefore, patients taking DNG for PPOS can continue endometriosis treatment and obtain good-quality embryos during COH. Further prospective randomized-controlled trial should be performed to confirm of this novel strategy of DNG.
Down-regulation of the CYP19A1 gene in cumulus cells of infertile women with endometriosis
2015, Reproductive BioMedicine Online
Aromatase plays a fundamental role in the establishment of oocyte quality, which might be compromised in infertile women with endometriosis. The expression of the CYP19A1 gene (that encodes aromatase) was compared in cumulus cells and oestradiol concentrations in the follicular fluid of infertile women with and without endometriosis submitted to ovarian stimulation for intracytoplasmic sperm injection. Cumulus cells were isolated and the expression of the CYP19A1 was quantitated through real-time polymerase chain reaction. Oestradiol concentrations in follicular fluid were measured by chemiluminescence immunoassay. A lower expression of the CYP19A1 in the cumulus cells of infertile women with endometriosis was observed compared with controls (0.17 ± 0.13 and 0.56 ± 0.12, respectively), and no significant difference in the follicular fluid oestradiol concentrations was observed between groups. Our results show reduced expression of the CYP19A1 in cumulus cells of infertile women with endometriosis, which may play a role in the pathogenesis of endometriosis-related infertility.
Stages of endometriosis: Does it affect invitro fertilization outcome
2014, Taiwanese Journal of Obstetrics and Gynecology
Citation Excerpt :
Some investigators have reported poor IVF outcome in women with endometriosis-related infertility [4,5], whereas others reported high success rates comparable to those in women with tubal factor infertility [6,7]. Furthermore, some studies reported that women with advanced stage endometriosis and previous surgery responded less well to gonadotropin stimulation and had lower fertilization rates but the effect of different stages of endometriosis on IVF-ET outcome remains unclear [8]. The present study was undertaken to investigate whether or not the stage of endometriosis affects the IVF outcome in order to give the best patient counseling.
Women with endometriosis often need in vitro fertilization (IVF) to conceive. There are conflicting data on the results of IVF in patients with endometriosis. The present study was undertaken to investigate whether or not the stage of endometriosis affects the IVF outcome in order to give the best patient counseling
We compared IVF outcome measures between 40 patients with surgically confirmed minimal and mild endometriosis (American Society for Reproductive Medicine Stage I/II) and 38 patients with moderate and severe endometriosis (Stage III/IV). Each group was also compared with a control group of 157 patients with tubal factor infertility. Outcome measures included number of follicles, number of oocytes, mean number of ampoules of gonadotropins, cumulative pregnancy, and live birth rates
Higher cancelation rates, higher total gonadotropin requirements, and lower oocyte yield were found in women with endometriosis Stage III and IV compared with both the Stage I/II and control groups. The fertilization rate was higher in Stage III/IV endometriosis compared to Stage I/II. Clinical pregnancy and live birth rates were comparable between patients with endometriosis Stage I/II and control group, whereas they were significantly lower in patients with endometriosis Stage III/IV compared to other two groups.
The American Society for Reproductive Medicine classification of endometriosis is useful in predicting IVF outcome. Advanced endometriosis means a worse prognosis for IVF treatment compared to milder stages or tubal factor infertility. The decreased fertilization rate in Stage I/II endometriosis might be a cause of subfertility in these women, as a result of a hostile environment caused by the disease.
In vitro fertilization is a successful treatment in endometriosis- associated infertility
2012, Fertility and Sterility
To assess success rates of IVF and intracytoplasmic sperm injection in women with various stages of endometriosis.
Retrospective cohort study.
Reproductive medicine unit in a university hospital.
Infertile women (n = 2,245) with various stages of endometriosis or tubal factor infertility.
IVF or intracytoplasmic sperm injection.
Dose of FSH, number of oocytes retrieved, fertilization rate, implantation rate, pregnancy rate (PR), live birth/ongoing PR.
Women with endometriosis had similar pregnancy and live birth/ongoing PR as did women with tubal factor infertility, but the American Society for Reproductive Medicine (ASRM) stage I and II endometriosis patients had a lower fertilization rate, and stage III and IV patients required more FSH and had fewer oocytes retrieved. Splitting the stage III and IV groups into patients with and without endometriomas showed that the endometrioma group required more FSH and had a significantly lower pregnancy and live birth/ongoing PR.
With the exception of patients with endometrioma, infertile women with various stages of endometriosis have the same success rates with IVF and intracytoplasmic sperm injection as patients with tubal factor. This contrasts with the systematic review on which the European Society of Human Reproduction and Embryology bases its recommendations.
The effect of the hormonal milieu of pregnancy on deep infiltrating endometriosis: Serial ultrasound assessment of changes in size and pattern of deep endometriotic lesions
2012, European Journal of Obstetrics and Gynecology and Reproductive Biology
Citation Excerpt :
Surgery for deep infiltrating endometriosis should be performed only by highly experienced surgeons to reduce the risk of complications. They should avoid too-radical surgery in patients with the diagnosis of DIE who desire pregnancies [11]. Actually, decidualization with the resultant decrease in size of a transmural endometriotic nodule may lead to perforation, by weakening of the intestinal wall, mainly during the third trimester [6].
Deep infiltrating endometriosis (DIE) is associated with severe painful symptoms and represents a complex management challenge.
To analyse the effect of pregnancy on deep infiltrating lesions and related symptomatology.
As part of a longitudinal study performed over the past 3 years to determine the efficacy of hormonal treatment in treating women with DIE, we identified three cases of advanced pelvic endometriosis, all with DIE (deep recto-vaginal and recto-sigmoid involvement) where patients achieved spontaneous pregnancies. They were followed up by transvaginal ultrasound (TV-US). The main outcome measures were analysis of the size and echographic pattern of deep infiltrating lesions of endometriosis and evaluation of clinical symptoms during pregnancy.
We observed modifications in lesion size and pattern. In the two patients observed in the third trimester, the lesions were more homogeneous with less evident limits of nodules and band-like echoes, less fibrotic-like. All patients showed complete resolution of symptoms during pregnancy.
The hormonal environment produced by pregnancy might determine significant modifications of endometriotic lesions and reduce painful symptoms. As surgery for DIE is difficult, complex and can lead to major complications, the achievement of a pregnancy-specific hormonal state, through pregnancy or hormonal treatment, may be a valid option in selected cases.
Laparoscopic stripping of endometriomas negatively affects ovarian follicular reserve even if performed by experienced surgeons
2011, Reproductive BioMedicine Online
In order to estimate the impact of laparoscopic stripping of endometriomas on the ovarian follicular reserve, 43 normo-ovulatory women were studied by endocrine (anti-Müllerian hormone (AMH), FSH, LH, inhibin B, oestradiol) and ultrasonographic (antral follicle count (AFC)) methods before surgery, and 3 and 9 months after surgery. The operation was performed by experienced laparoscopists, particularly aware of the need to avoid damaging the healthy part of the ovary. Serum AMH concentrations significantly decreased after the operation (1.4 ± 0.2 ng/ml after 3 months and 1.3 ± 0.3 ng/ml after 9 months versus 3.0 ± 0.4 ng/ml before surgery; P < 0.0001), whereas basal FSH, LH, oestradiol and inhibin B concentrations remained unchanged. The volume of the operated ovary significantly diminished after surgery (P < 0.0001), whereas the AFC was not significantly altered. Overall, the data show that laparoscopic stripping of endometriomas reduces ovarian reserve. The significant decrease of AMH after surgery confirms that part of the healthy ovarian pericapsular tissue, containing primordial and preantral follicles, is removed or damaged despite all the surgical efforts to be atraumatic. This must be carefully considered when laparoscopic cystectomy surgery is scheduled for patients with no relevant symptoms besides infertility or with already small ovarian reserve.
Ovarian endometriomas are removed to relieve symptoms or to improve either spontaneous fertility or the outcome of subsequent pro-fertility treatments. The surgical treatment of ovarian endometriosis by laparoscopic ‘stripping’, probably the most widespread technique, may improve symptoms, but was repeatedly reported to worsen the ovarian responsiveness to ovulation induction in patients later submitted to IVF. This study aims to estimate the impact of laparoscopic stripping of endometriomas on the ovarian follicular reserve. We studied 43 normo-ovulatory women by endocrine (anti-Müllerian hormone (AMH), FSH, LH, inhibin B, oestradiol) and ultrasonographic (antral follicle count (AFC)) methods before and some months after laparoscopic cystectomy. The operation was performed by experienced laparoscopists who were aware of the need to avoid damaging the healthy part of the ovary. Serum AMH concentrations significantly decreased after the operation (P < 0.0001) and basal FSH concentrations slightly increased (non significantly); LH, oestradiol and inhibin B remained unchanged. The volume of the operated ovary significantly diminished after surgery (P < 0.0001), whereas the AFC was not significantly altered. Overall, our data show that, even when performed by experienced surgeons, the laparoscopic stripping of endometriomas reduces ovarian reserve. Part of the healthy ovarian pericapsular tissue is removed or damaged despite all the surgical efforts to be atraumatic. This must be carefully considered when laparoscopic cystectomy surgery is scheduled for patients with no relevant symptoms besides infertility or with already small ovarian reserve (e.g. those aged over 38 years).

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^☆: Reprint request: M. Aboulghar, MD, Egyptian IVF-ET Center, 3, St 161, Hadaek Al Maadi, Maadi, Cairo, Egypt. E-mail: [email protected]

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General Obstetrics and Gynecology GynecologyThe outcome of in vitro fertilization in advanced endometriosis with previous surgery: A case-controlled study☆

Abstract

Section snippets

Material and methods

Results

Comment

Fertil Steril

Fertil Steril

Fertil Steril

Lancet

Fertil Steril

Am J Obstet Gynecol

Fertil Steril

Fertil Steril

Fertil Steril

Fertil Steril

Surgical treatment of endometriosis-associated infertility: meta-analysis compared with surgical analysis

Am J Obstet Gynecol

The role of surgery in the treatment of pelvic endometriosis in subfertile patients

Middle East Fertil Soc J

General Obstetrics and Gynecology Gynecology
The outcome of in vitro fertilization in advanced endometriosis with previous surgery: A case-controlled study☆