Endometriosis and Infertility: A Long-Life Approach to Preserve Reproductive  Integrity

Maria Elisabetta Coccia; Luca Nardone; Francesca Rizzello

doi:10.3390/ijerph19106162

Endometriosis Fertility and Outcomes

Endometriosis and Infertility: A Long-Life Approach to Preserve Reproductive Integrity

Coccia ME, Nardone L, Rizzello F

Published May 19, 2022 International Journal of Environmental Research and Public Health, 19(10), 6162

DOI 10.3390/ijerph19106162 PMID 35627698 PMC PMC9141878

RRM Academy Synopsis

Surgery for bilateral endometriomas is linked to lower ovarian reserve

A 2022 review of endometriosis and infertility reports that surgery for cysts on both ovaries is linked to a smaller egg supply. That comes from the authors' own earlier study. Trials the review cites found that surgery for minimal and mild endometriosis raised pregnancy rates over a look-only laparoscopy.

Key Findings

Two randomized trials pooled in a meta-analysis (n = 444) found that surgery to ablate or resect minimal and mild endometriosis, with adhesiolysis, raised ongoing pregnancy and live births over diagnostic laparoscopy.
A Cochrane review of fourteen randomized controlled trials found moderate-quality evidence that surgery raised ultrasound-confirmed pregnancy over diagnostic laparoscopy alone. None of those trials reported live births.
In the authors' earlier study, women with bilateral endometriomas operated on before IVF-ICSI had 28.2% cycle cancelation and 4.6 ± 3.4 oocytes, versus 7.3 ± 4.8 with unoperated endometriomas.
Women who had endometriosis surgery reached menopause at a mean age of 45.3 ± 4.3 years, against 51.2 ± 3.8 in Italian reference data.
Three systematic reviews reported 42 to 44% pregnancy after excision of rectovaginal endometriosis, without control groups. One review of natural pregnancies in infertile women with deep endometriosis found 24% (95% CI 20–28%).

Interpretation

These findings come from a literature review that includes the authors' own earlier clinic data. Women who had surgery for cysts on both ovaries before IVF-ICSI lost more cycles and had fewer eggs than women who kept their cysts. Women who had endometriosis surgery also reached menopause earlier. Surgery for mild endometriosis raised pregnancy and birth rates over a look-only surgery. The findings support larger studies on this question.

RRM Context

Restorative reproductive medicine looks for the cause of infertility and treats it. The review's own treatment algorithm turns to IVF-ICSI when ovarian reserve is low. IVF bypasses the disease.

Our editorial summary of this paper, not the article's abstract.

Abstract

Laparoscopic surgery was originally considered the gold standard in the treatment of endometriosis-related infertility. Assisted reproductive technology (ART) was indicated as second-line treatment or in the case of male factor. The combined approach of surgery followed by ART proved to offer higher chances of pregnancy in infertile women with endometriosis. However, it was highlighted how pelvic surgery for endometriosis, especially in cases of ovarian endometriomas, could cause iatrogenic damage due to ovarian reserve loss, adhesion formation (scarring), and ischemic damage. Furthermore, in the last few years, the trend to delay the first childbirth, recent technological advances in ultrasound diagnosis, and technological progress in clinical and laboratory aspects of ART have certainly influenced the approach to infertility and endometriosis with, ART assuming a more relevant role. Management of endometriosis should take into account that the disease is chronic and involves the reproductive system. Consequently, treatment and counselling should aim to preserve the chances of pregnancy for the patient, even if it is not associated with infertility. This review will analyse the evolution of the management of infertility associated with endometriosis and propose an algorithm for treatment decision-making based on the most recent acquisitions.

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Topics

Endometriosis › Fertility and Outcomes › Ovarian Reserve · Reproductive Surgery › Laparoscopy › Minimally Invasive Approaches · Assisted Reproduction › Procedures and Protocols › IVF Protocols

Maria Elisabetta Coccia, Luca Nardone, Francesca Rizzello

M Coccia, L Nardone, F Rizzello

PMID 35627698 35627698 DOI 10.3390/ijerph19106162 10.3390/ijerph19106162 Coccia et al. 2022, Coccia 2022