{"paper_id":"7bbef224-3a17-410b-a824-dad8ffedb3ac","body_text":"Muzii et al. J In Vitro Fertilization 2017, 1(1):1-3\nVolume  1 | Issue 1\n*Corresponding author: Ludovico Muzii, Department of Ob-\nstetrics and Gynecology, Sapienza University of Rome, Viale \ndel Policlinico 155, 00161 Rome, Italy, Tel: +39-06-4940550, \nFax: +39-06-49973128, E-mail: ludovico.muzii@uniroma1.it\nReceived: June 27, 2017: Accepted: October 10, 2017: \nPublished online: October 12, 2017\nCitation: Muzii L, Tucci CD, Feliciantonio MD, et al. (2017) \nInfertility Associated with Ovarian Endometriomas: Surgery or \nIn-Vitro Fertilization?. J In Vitro Fertilization 1(1):1-3\nCopyright: © 2017 Muzii L, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution \nLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source \nare credited.\nShort Commentary Open Access\nSCHOLARLY PAGES\nJournal of In Vitro Fertilization\n• Page 1 •\nInfertility Associated with Ovarian Endometriomas: Sur -\ngery or In-Vitro Fertilization?\nLudovico Muzii*, Chiara Di Tucci, Mara Di Feliciantonio, Ludovica Verrelli, Giulia Galati \nand Pierluigi Benedetti Panici\nDepartment of Obstetrics and Gynecology, Sapienza University of Rome, Italy\nAbstract\nOvarian endometriomas are frequently associated with female infertility. The choice of treatment in these cases is one of \nthe most discussed topics in Reproductive Medicine, and the approach to the patient should be tailored based on different \nparameters. Management options include surgery, In-Vitro Fertilization (IVF), or a combination of both. Laparoscopic \nexcision of the ovarian endometrioma should be the treatment of choice when there is associated pain. Surgery should \nbe performed following appropriate techniques to reduce the possible damage to the ovarian reserve. Pregnancy rates \naround 50% have been consistently reported after surgery, which compare favorably with those obtained with IVF. IVF \nmay be preferred in case of associated male or tubal factor, in case of a reduced ovarian reserve, or if previous surgery has \nfailed, particularly if there is no associated pain, and when the ultrasonographic features of the ovarian cyst are reassuring. \nSometimes IVF may be preceded by surgery, when a difficult access to follicles at pick-up, due to the size and location of \nthe ovarian cyst, or to severe adhesions, is anticipated.\nKeywords\nEndometrioma, Endometriosis, In-Vitro Fertilization, Infertility, Laparoscopy\nIntroduction\nPelvic endometriosis is present in 25%-50% of infer-\ntile women [1-3]. In 17%-44% of these women, an endo-\nmetrioma may be present [3-5]. The scenario of an in-\nfertile woman with an endometrioma is therefore a very \ncommon one in clinical practice. Unfortunately, many \nissues regarding the management of the infertile pa-\ntients with an ovarian endometrioma are not addressed \nin Randomized Clinical Trials (RCTs), and the choice of \ntreatment in these cases represents therefore a very chal-\nlenging situation for the clinician.\nIn case of endometrioma-associated infertility, treat-\nment options include expectant management, surgical \nexcision, or In-Vitro Fertilization (IVF). Medical therapy \nsuppresses ovulation and has no role in the infertile pa-\ntient [1,4-6]. The only exception is for medical treatment \nadministered before IVF, which has been associated with \nbetter results for subsequent IVF [7].\nRecent guidelines from the European Society of Hu-\nman Reproduction and Embryology (ESHRE) [6] suggest \nthat, in stage III-IV endometriosis associated with infer-\ntility, clinicians should consider operative laparoscopy, \ninstead of expectant management, to increase spon-\ntaneous pregnancy rates, although there are no RCTs \ncomparing reproductive outcome after surgery and af-\nter expectant management. This suggestion is based on \nprospective cohort studies showing crude spontaneous \npregnancy rates of 57-69% for moderate and 52-68% \nfor severe endometriosis, which compare favorably with \n33% and 0% respectively for moderate and severe endo-\nmetriosis after expectant management [6,8]. However, \nconcerns have been raised in recent years as to the pos-\nsible damage to the ovarian reserve as a consequence of \nexcisional surgery [9]. Consequently, the ESHRE guide-\nline [6] “recommends that the clinician counsels the pa-\n\n• Page 2 •\nCitation: Muzii L, Tucci CD, Feliciantonio MD, et al. (2017) Infertility Associated with Ovarian Endometriomas: \nSurgery or In-Vitro Fertilization?. J In Vitro Fertilization 1(1):1-3\nSCHOLARLY PAGES\nMuzii et al. J In Vitro Fertilization 2017, 1(1):1-3\ntient with an ovarian endometrioma regarding the risks \nof a reduced ovarian function after surgery”. Given these \nconcerns, some authors advocate direct referral to IVF \nin case of endometrioma-associated infertility [8,10]. \nSurgery before IVF, in fact, has not been demonstrated \nto improve live birth rates compared to direct referral to \nIVF [3].\nIn this article we will briefly review the pros and cons \nof the surgical excision of an ovarian endometrioma, \nwith the aim of addressing the question of which ap-\nproach, surgery or IVF, should be considered as the first \ntreatment option for patients presenting with associated \ninfertility.\nSurgery: The Pros\nAs outlined above, surgery yields satisfactory results in \nterms of postoperative pregnancy rates. A meta-analysis by \nVercellini, et al., [11], pooling the results of several uncon-\ntrolled case series, reports a cumulative pregnancy rate of \n50% after surgery for endometriosis, and represents prob-\nably the highest level of scientific evidence that is available \nin the absence of RCTs. The 50% pregnancy rate after sur-\ngery compares favorably with the 29% clinical pregnancy \nrate per oocyte pick-up reported by the ESHRE for IVF \n[12], which corresponds approximately to a 21-22% term \npregnancy rate per initiated cycle. In addition, spontaneous \npregnancy after surgery is not at higher risk for multiple \ngestations, and subsequent pregnancies following the first \none after surgery do not need additional treatments.\nBesides these results in terms of pregnancies, surgery al-\nlows also immediate postoperative pain relief, as document-\ned in a recent meta-analysis [13]. Therefore, when infertility \nis associated with pelvic pain, surgery represents the only \napproach that may be effective on both pain and fertility. \nMedical therapies, in fact, may only treat pain, whereas IVF \nmay only resolve the fertility issue.\nIn case of non-reassuring sonographic features, or in \ncase of fast-growing cysts, surgery should be considered \nmandatory [5], in order to obtain tissue for histology and \nexclude an ovarian malignancy. However, even in case of \ncarefully selected patients, with reassuring sonographic \nfeatures with the typical aspects of an ovarian endome-\ntrioma, final histology may reveal un unexpected malig-\nnancy in approximately 0.9% of the cases [14]. Therefore, \namong the pros of surgery, there is also the possibility \nof obtaining a surgical specimen for histology diagnosis, \nwhich rules out the rare cases of unexpected malignancy \n[6].\nAs a final consideration on the advantages of surgery, \nthe presence on ovarian endometriomas may determine \nthe derangement of normal ovarian anatomy, and some-\ntimes, a difficult access to follicles at pick-up, due to the \nsize and location of the ovarian cyst, or to severe adhe-\nsions, may be anticipated. In these particular cases, even \nsmaller cysts may need surgery before IVF in order to \ngain an easier access to the follicles [15].\nSurgery: The Cons\nBesides the generic risks associated with a surgical \nprocedure, laparoscopic excision of an ovarian endome-\ntrioma has been specifically associated with a damage \nto the ovarian reserve, as demonstrated by a decrease \nof 38% in Anti-Mullerian Hormone (AMH) levels af-\nter surgery [9]. Also, worse responses to gonadotropin \nstimulation for In-Vitro Fertilization (IVF) have been re-\nported by many authors after surgery [16]. Additionally, \nin case of bilateral ovarian endometriomas, premature \novarian failure after surgery has been reported in 2.4% of \nthe patients [17]. Studies on the histology of the excised \ncyst specimen demonstrated that some ovarian tissue is \ninadvertently removed with the cyst capsule [18], and \nthis may partly explain the reduced ovarian reserve after \nsurgery. Also, additional damage may be exerted on the \nremaining ovary by excessive bipolar coagulation [13]. \nThis worrying postsurgical scenario may however be less \nworrying if, for example, ovarian reserve is evaluated \nwith Antral Follicle Count (AFC) rather than AMH. In a \nrecent meta-analysis [19], in fact, no change in AFC has \nbeen reported after surgery.\nConclusion\nThe management of an ovarian endometrioma asso-\nciated with infertility should be tailored on each patient, \nafter careful consideration of various parameters, such \nas age and ovarian reserve of the patient, previous treat-\nments for the disease, the presence of associated pain, and \nassociated infertility factors. Recently, a multiparametric \nscore to guide the clinician in the choice of treatment of \nthe ovarian endometrioma has been developed [5].\nSurgery should be preferred in case of non-reassur-\ning features or rapid growth of the cyst at sonography, \nor when moderate to severe pain symptoms are pres-\nent. Surgery should be performed following appropriate \ntechniques to reduce the possible damage to the ovarian \nreserve [20]. IVF may be preferred in case of associated \nmale or tubal factor, in case of a reduced ovarian reserve, \nor if previous surgery has failed. If surgery is withheld, \nand the patient is directly referred to IVF, or managed \nexpectantly, the possibility of an unexpected ovarian \nmalignancy still exists, and close follow-up with serial \nultrasound scans is mandatory. The patient should be \naccurately counseled as to the pros and cons of both ap-\nproaches, and a shared decision should be reached. Due \nto the lack of robust scientific evidence in the context of \nendometrioma-associated infertility, RCTs are strongly \nneeded.\n\n• Page 3 •\nCitation: Muzii L, Tucci CD, Feliciantonio MD, et al. (2017) Infertility Associated with Ovarian Endometriomas: \nSurgery or In-Vitro Fertilization?. J In Vitro Fertilization 1(1):1-3\nSCHOLARLY PAGES\nMuzii et al. J In Vitro Fertilization 2017, 1(1):1-3\nReferences\n1. Practice Committee of the American Society for Reproduc-\ntive Medicine (2012) Endometriosis and infertility: A com-\nmittee opinion. Fertil Steril 98: 591-598.\n2. Meuleman C, Vandenabeele B, Fieuws S, et al. (2009) High \nprevalence of endometriosis in infertile women with normal \novulation and normospermic partners. Fertil Steril 92: 68-74.\n3. Brink Laursen J, Schroll JB, Macklon KT, et al. (2017) Sur-\ngery versus conservative management of endometriomas \nin subfertile women. A systematic review. Acta Obstet Gy-\nnecol Scand 96: 727-735.\n4. Chapron C, Vercellini P, Barakat H, et al. (2002) Management \nof ovarian endometriomas. Hum Reprod Update 8: 591-597.\n5. Ludovico Muzii, Chiara Di Tucci, Mara Di Feliciantonio, et \nal. (2017) Management of endometriomas. Semin Reprod \nMed 35: 025-030.\n6. Dunselman GA, Vermeulen N, Becker C, et al. (2014) ESH-\nRE guideline: Management of women with endometriosis. \nHum Reprod 29: 400-412.\n7. Hughes E, Brown J, Collins JJ, et al. (2007) Ovulation sup-\npression for endometriosis. Cochrane Database Syst Rev \nCD000155.\n8. Olive DL, Stohs GF, Metzger DA, et al. (1985) Expectant \nmanagement and hydrotubations in the treatment of endo -\nmetriosis-associated infertility. Fertil Steril 44: 35-41. \n9. Raffi F, Metwally M, Amer S (2012) The impact of excision \nof ovarian endometrioma on ovarian reserve: a systemat-\nic review and meta-analysis. J Clin Endocrinol Metab 97: \n3146-3154.\n10. Ruiz-Flores FJ, Garcia-Velasco JA (2012) Is there a bene -\nfit for surgery in endometrioma-associated infertility? Curr \nOpin Obstet Gynecol 24: 136-140.\n11. Vercellini P, Somigliana E, Viganò P, et al. (2009 ) Surgery \nfor endometriosis-associated infertility: a pragmatic ap-\nproach. Hum Reprod 24: 254-269.\n12. European IVF-Monitoring Consortium (EIM) for the Europe-\nan Society of Human Reproduction and Embryology (ESH-\nRE), Calhaz-Jorge C, de Geyter C, et al. 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(2002) Laparoscopic \nexcision of ovarian cysts: is the stripping technique a tis-\nsue-sparing procedure? Fertil Steril 77: 609-614.\n19. Muzii L, Di Tucci C, Di Feliciantonio M, et al. (2014) The \neffect of surgery for endometrioma on ovarian reserve eval-\nuated by antral follicle count: a systematic review and me-\nta-analysis. Hum Reprod 29: 2190-2198.\n20. Muzii L, Marana R, Angioli R, et al. (2011) Histologic analy-\nsis of specimens from laparoscopic endometrioma excision \nperformed by different surgeons: does the surgeon matter? \nFertil Steril 95: 2116-2119.","source_license":"CC0","license_restricted":false}