Ovarian reserve markers and assisted reproductive technique (ART) outcomes in women with advanced endometriosis

A prospective, cross-sectional study was conducted on 460 infertile women to classify them through laparoscopy according to the presence of endometriosis: those with endometriosis represented the exposed group, and those without endometriosis represented the unexposed group. This study was conducted at the Maternity Teaching Hospital Fertility Centre (MTHFC), Erbil, Kurdistan region, Iraq, from July 1, 2011 to May 1, 2013. All ICSI cycles were performed at MTHFC, which is the only public maternity hospital in the city. The center was established in April 2010 and is the main referral center for infertility in Erbil. Women with a history of infertility are referred to the fertility outpatient clinic, where they are investigated and managed. The standard infertility investigation in our center includes female medical history, clinical examination, gynecological ultrasound, and 2–3 day blood analysis for FSH, LH, estradiol, prolactin, TSH and AMH. Serum progesterone was measured in the midluteal phase of the menstrual cycle for assessment of ovulation. The serum samples were frozen and stored for future analysis. AMH was measured with an ultrasensitive enzyme-linked immunosorbent assay ELISA (AMH Gen II ELISA, Beckman-Coulter, Inc, 250 S. Kraemer Blvd, Brea, CA 92821 U.S.A.). The lowest detection rate limit and intra- and inter-assay variation coefficients were 0.03 ng/mL, 3.4%, and 7.7%, respectively. The unit of measurement for AMH used was ng/mL (1 ng/mL = 7.14 pmol/L). Ovarian ultrasound scanning was performed to evaluate the number and size of antral follicles between 2–10 mm. Antral follicle count involves counting the resting follicles present on both ovaries at the beginning of the proliferative phase of the menstrual cycle by transvaginal ultrasound. All the scans were performed by a single operator on a GE p3 (LOGIG P3, GE Healthcare Wisconsin, USA) equipped with a 6.5 MHz endovaginal probe (probe destination 8CS/E8C). A total of 460 women underwent diagnostic laparoscopy at MTHFC as part of their fertility assessment before starting treatment. At MTHFC, we recommend laparoscopy for all women with 1) infertility for at least 3 years who have regular menstrual cycles (variation 21–35 days) and whose partners have a normal semen analysis, 2) those with abnormal or inconclusive HSG 3) and those who had previous laparoscopy or laparotomy for benign gynecological conditions. All laparoscopies were performed by or in the presence of the first author. When present, the extent of endometriosis was staged surgically according to the American Society for Reproductive Medicine classification of endometriosis [18]. The inclusion criteria of this study were as follows: 1) women receiving their first cycle of ICSI, 2) infertility associated with endometriosis stages III or IV, 3) infertile women with no visual endometriotic lesion as a control group, 4) the absence of polycystic ovarian syndrome (PCOS), and 5) the absence of other endocrine disease (thyroid disease, diabetes mellitus, Cushing’s syndrome). The final study population consisted of 110 women with endometriosis as the study group (group I). The control group (group II) included 175 women undergoing ICSI cycles for infertility not related to endometriosis, The control group were women with tubal factor (47.4%), unexplained infertility (37.7%) and (14.8%) women with mild to moderate male factor infertility. All of them were surgically confirmed for the absence of endometriosis. Women with endometriosis 10% of them had mild to moderate male factor infertility. No severe male factor infertility was found a cross all groups.

Women with endometriosis were further classified according to their surgical history: group Ia with no prior endometrioma surgery (n = 63) and group Ib with a prior history of endometrioma surgery (n = 47). Only women undergoing their first ART cycle were included in the study.

COS was conducted according to a down-regulation protocol, which was achieved by subcutaneously (s.c.) administering 0.1 mg triptorelin acetate (Decapeptyl, Ferring Gmbh, D-24109 Kiel, Germany) daily starting from the midluteal phase of the previous menstrual cycle until the day of human chorionic gonadotropin injection. The gonadotropin treatment was commenced from day 2 or 3 of the subsequent cycle if follicular diameters did not exceed 10 mm and the serum estradiol (E2) level was ≤ 50 pg/mL. Patients received a daily starting dosage of 150 to 300 IU of recombinant follicle-stimulating hormone (r-FSH, Gonal-F, Serono Laboratories, Aubonne, Switzerland) s.c. that was individually chosen according to age, body mass index (BMI), basal FSH, and basal AFC. From day 6, the rFSH dose was adjusted according to the ovarian response. When at least two leading follicles reached 18 mm diameter, s.c. injection of 10,000 IU human chorionic gonadotropin (Choriomon, IBSA, Lugano, Switzerland) was administered, and transvaginal ultrasound-guided oocyte retrieval was scheduled for 36 hours later. Intracytoplasmic sperm injection was performed in all cases because the aim of the center was to minimize the incidence of fertilization failure and to maximize the fertilization rate. This policy aided the study in establishing fertilization uniformity and examining the oocytes for maturity. In Erbil and throughout Iraq, IVF/ICSI treatment is not covered by government funding or private insurance; the financial burden has thus forced patients and clinicians to agree to transfer a larger number of embryos than is accepted in many countries. Therefore, the average number of transferred embryos was 3–4. Embryo transfer was performed on day 2 or 3 after oocyte retrieval. Luteal phase support was provided the day after ovum retrieval with a Cyclogest pessary (Actavis, UK) administering 400 mg progesterone daily in addition to 10 mg oral dydrogesterone (Duphaston, Solvay Pharma Istanbul) three times daily. A serum hCG level >20 IU/L was defined as a pregnancy. A transient increase in hCG was defined as a biochemical pregnancy. In all other pregnancies, an ultrasound scan was performed 5–7 weeks after embryo transfer (ET). Clinical pregnancy is defined by ultrasound visualization of an intra-uterine gestational sac and embryonic pole with a heartbeat. All pregnant women were asked to report back, in writing, the outcomes; if women did not report back, they were phoned to inquire about the pregnancy and birth outcome. The primary outcomes were the number of mature oocytes retrieved in the endometriosis patients and the control group, pregnancy rate and live birth rate. The secondary outcomes were the total gonadotropin dose (IU), number of embryos formed and number of good-quality embryos (embryos with blastomers of equal size and no cytoplasmic fragmentation, or < 20% fragmentation).

The Research Ethics Committee of Hawler Medical University, College of Medicine, approved the study proposal on June 24, 2011, (reference number 1/24-06-2011). Informed consent was obtained from all participants after they were fully informed of the aim, process and confidentiality of the study.

Data were analyzed using the Statistical Package for Social Sciences (SPSS, version 19). One-way analysis of variance (ANOVA) was used to compare among means of three or more groups. A post hoc test (LSD) was used to determine whether the difference between two groups was significant (conducted after the ANOVA). A chi square test of association was used to compare between proportions. When the expected count of more than 20% of the cells of the table was less than 5, Fisher’s exact test was used. Multiple regressions were used when the dependent variable was numerical. The power of the study was estimated to be 80% according to the computer program ‘power and sample size estimation’ version 3.0.43. A ‘P’ value of ≤0.05 was considered statistically significant.