Is removal of endometriomas necessary before IVF/ICSI
treatment?
F. Kübra BOYNUKALIN, M.D., M.s.C
Bahçeci Health Group
Endometrioma
•
Prevalence
-0.5-5 % general population -25-40 % infertile women
Ozkan et al. 2008
- 10-25% IVF patients
-17-44% of those have endometriomas.
Redwine 1999
http:/www.sart.org
Endometriosis
Dysmenorrhea 60–80%
Chronic pelvic pain 40–50%
Deep dyspareunia 40–50%
Infertility 30–50%
Irregular flow or premenstrual spotting
10–20%
Other 2-4%
Common symptoms of endometriosis and rate of occurance
JAARG 2010
Agenda
• The effect of unoperated ovarian endometrioma on ovarian reserve
• The effect of unoperated ovarian endometrioma on IVF/ICSI outcome
• IVF/ICSI outcome after endometrioma surgery
The effect of ovarian endometrioma on ovarian reserve
Endometriomas and Ovarian Reserve
• Mechanical streching
Meneschi et al.,1993
• Biochemical negative influence
Khamsi et al.,2001
• Adhesions which typically surround affected ovaries
Kaplan et al.,1989
Ovarian Reserve Tests
• D3 FSH
• D3 E
2• Inhibin
• CC chagellenge test
• AMH
• AFC
• Previous IVF performance
Uncu et al Hum. Rep. 2013
The effect of unoperated ovarian endometrioma on IVF/ICSI outcome
• Number of follicles growth during COH
• Number of oocytes retrieved
• Oocyte and embriyo quality
• Ongoing pregnancy rates
• Live birth rates
Somigliana et.al. 2006
Beneglia et.al Hum. Rep. 2011
Almog et.al. Fertil.Steril. 2011
Filippi et.al Fertil.Steril 2014
Benaglia et.al Fertil.Steril.2013
Benaglia et.al Fertil.Steril.2013
Morphokinetic Parameters
Endometrioma Control p
No of emriyos 264 175
tPB2 6.51±9.07 3.71±1.98 p<0.01
tPNa 12.50±7.87 11.13±3.74 p<0.01
tPNf 25.90±6.31 25.30±7.87 NS
t2 28.64±5.24 28.25±5.40 NS
t3 38.02±6.87 37.67±6.33 NS
t4 41.44±7.35 40.19±6.29 NS
t5 50.51±9.86 49.76±10.41 NS
t6 55.28±10.14 53.77±9.91 NS
t7 58.11±10.14 58.33±10.28 NS
t8 62.67±11.80 61.45±11.09 NS
t9 71.57±13.37 69.62±11.58 NS
Bahçeci Unpublished Data
Ballester et.al.Fertil.Steril.2013
Opoein Fert & Steril 2012
• Avoidance of pelvic abscess / rupture
• Avoidance of occult malignancy (0.8%)
• Retrieval difficulties
• Contamination with endometrioma content
• Endometriosis progression
Advantages Of Surgery
Disadvantages of Surgery
• Major (1.4%) and minor (7.5%) L/S complications
• Increased cost
• Increased time to conception
• Surgery mediated ovarian damage
Surgery mediated damage
• Presence of healthy ovarian tissue adjacent to removed the cyst wall
Muzzi et al.,2002; Hachisuga and Kawarabayashi,2002
• Excission of healthy ovarian cortex with follicles
Brosens et al.,2004
• Surgery related local inflamation and
electrocoagulation during haemostasis
La Torre et al.,1998;Marconi et al.,2002;Fedele et al.,2004
The effect of endometrioma surgery on IVF/ICSI outcome
• Ovarian reserve
• Number of follicles growth during COH
• Number of oocytes retrieved
• Oocyte and embriyo quality
• Ongoing pregnancy rates
• Live birth rates
Impact of sugical treatment of
endometriosis on AMH
Impact of surgical treatment of
endometriosis on AMH
Vignali Gynecol and Obstet Research 2016
Tsoumpou Fertil Steril 2009
Tsoumpou Fertil Steril 2009
Cochrane Database 2010
Cochrane Database 2010
Cochrane Database 2010
Cochrane Database 2010
Harada JAARG 2015
Drawbacks that may affect outcome
• Different patient types undergoing IVF
– Endometrioma with no previous surgery
– Surgically resected endometrioma and disease free at the time of ART
– Surgical resected endometrioma with recurrence at the time of ART
• Diameter of the endometrioma
• Bilaterality
• Surgical technique
• Length of follow-up (surgery – IVF)
International Guidelines
ESHRE 2005 ASRM 2006 RCOG 2006
Stage I-II Limited benefit:
Recomended
Small benefit:
Recomended
Demostrated benefit:
Recomended Stage III-IV Possible but unproven
benefit: Recomended
Possible benefit:
Recomended
Possible benefit:
Recommendation uncertain
Recurrent endometriosis
No recomendations Second line surgery not recomended
No recomendation
ESHRE Guidline 2014
Garcia Velasca Human Repr 2009
Characteristics Favours Surgery Favours expectant management
Previous surgery None ≥1
Ovarian reserve Intact Damaged
Pain Symptoms Present Absent
Bilaterality Monolateral disease Bilateral disease Sonographic feature of
malignancy
Present Absent
Growth Rapid growth Stable
