{"paper_id":"8cbcce80-b777-44b8-b013-0fdf0cd76bcd","body_text":"REPRODUCTIVE HEALTH  •  August 2019 EMJ EUROPEAN MEDICAL JOURNAL66\nFertility Preservation in Women with Endometriosis: \nIt is About Time We Talk About it!\nAuthors: Márcia Mendonça Carneiro,1,2,3 Ana Luiza Lunardi Rocha,³ Ivete de \nÁvila,1,2 *Marcia Cristina França Ferreira1,2,3\n1. Endometriosis Multidisciplinary Team, Mater Dei Hospital, Belo Horizonte, Brazil\n2. Human Reproduction Center, Mater Dei Hospital, Belo Horizonte, Brazil\n3. Department of Obstetrics and Gynecology, Universidade Federal de Minas Gerais, \nBelo Horizonte, Brazil\n*Correspondence to marciamc.ufmg@gmail.com\nDisclosure: The authors have declared no conflicts of interest. \nReceived: 18.04.18\nAccepted: 17.01.19\nKeywords: Endometrioma, endometriosis, fertility preservation, ovarian reserve, pregnancy.\nCitation: EMJ Repro Health. 2019:5[1]:66-73.\nAbstract\nEndometriosis is a common benign disease that affects young women and carries a significant risk to \nthe reproductive organs. Studies have shown that endometriosis is associated with diminished ovarian \nreserve and worse prognosis in assisted reproductive technology treatments. Surgical treatment \naims to remove the disease while maintaining reproductive potential with minimal damage to the \nreproductive organs. The authors reviewed the published literature regarding fertility preservation in \nendometriosis, focussing on patient selection criteria, available treatment options, and follow-up. The \ngoal of this study was to find evidence to answer the following clinical questions: how should women \nCarneiro et al. face the important issue of how to preserve fertility \nin women with endometriosis: a condition that affects >10% of \nwomen in reproductive age. Besides reviewing the pathophysiological \nmechanisms related to endometriosis and the consequential infertility \nthat often develops in these women, the review analyses data in the literature \nconcerning the safety and reproductive repercussions of surgical treatment. \nRecent studies have indeed questioned surgical treatment which can further \ncompromise the fertility of these women. The article indicates recommendations \nfor physicians to follow to manage patients with endometriosis, starting from \novarian reserve evaluation, by measuring appropriate hormones, such as follicle-\nstimulating hormone and anti-Müllerian hormone, considering age, antral follicular \ncount, ovarian volume, and other aspects. The article also considers the options \navailable to preserve fertility in these patients, such as oocyte, ovarian tissue and \neven embryo preservation. Overall, the review represents a complete guide for \nphysicians and gynaecologists who face this problem every day. \nProf Elisabetta Baldi\nUniversity of Florence, Italy \n\nCreative Commons Attribution-Non Commercial 4.0 August 2019  •  REPRODUCTIVE HEALTH 67\nINTRODUCTION\nFertility preservation is increasingly attracting \nthe attention of physicians and patients. The \nadvances in oncologic care worldwide have \nmade it possible for young women undergoing \ncancer treatment, with a significant disease-free \nlife expectancy, to consider maternity. Similarly, \nwomen with other medical conditions have now \nturned their attention to fertility. This is the case \nfor women with endometriosis, a condition that \naffects about 10% of women of reproductive age \nand up to 50% of women with chronic pelvic pain \nand infertility.1\nEndometriosis is associated with infertility \nvia several pathophysiological mechanisms, \nincluding hormonal dysfunction; oocyte \ndysfunction; dysfunction of the secretory phase \nof the menstrual cycle; inflammation, which \ninterferes with sperm–oocyte interaction; low \nembryo quality; reduced implantation rate; and  \ndecreased ovarian reserve.1 Studies have shown \nthat endometriosis is associated with diminished \novarian reserve2 and worse prognosis in assisted \nreproductive technology (ART) treatments. 1,3 \nIn some cases, an interaction between the the \nnumerous pathophysiological alterations may \ncombine together and act through mechanisms \nthat have not yet been fully elucidated.1 \nThe exact effect of endometriosis on ovarian \nreserves is yet to be established. The presence of \novarian endometriomas is detrimental to ovarian \nreserve markers, such as anti-Müllerian hormone \n(AMH), by either affecting their production or \nthrough a direct, as yet unknown, effect. 1,2 In \naddition, large endometriomas may interfere  \nwith ovarian vascularisation. Moreover, \nendometriosis treatment frequently requires \nsurgery, particularly in patients that present \nwith ovarian cysts and deep endometriosis \n(DE).1,2 Surgical treatment candidates include \nwomen in whom pain was not improved \nwith medical treatment and those seeking to  \nbecome pregnant.1,3\nRecently, the safety and reproductive \nrepercussions of endometrioma resection have \nbeen questioned. The discovery of ovarian  \ntissue containing follicles present in the \nendometriotic cyst walls has raised the \nconcern that surgery for endometriotic cysts \ncan further compromise fertility in women  \nwith endometriosis.4-6\nIn addition, recent data have shown that \nendometriosis affects approximately 35–54% of \nwomen with symptoms of chronic pelvic pain  \nand dysmenorrhea, and most of them \nhave advanced Stage III or IV disease. It \nis important to note that most of these \nadvanced cases include the occurrence of \nextensive tubo-ovarian adhesions in addition to  \nendometriomas, resulting in an adverse effect \non the reproductive potential. 7 As a result, \nfertility preservation has become a main focus in \nwomen undergoing surgery for endometriosis. \nThe patients should be adequately counselled \nregarding fertility issues before the procedure \nand given evidence-based information about \ndisease progression, ovarian reserve, the  \navailable therapeutic options, and the risks \nassociated with each procedure.8,9\nOocyte and embryo cryopreservation are \nestablished fertility preservation techniques. 10 \nBoth techniques require controlled ovarian \nhyperstimulation and oocyte retrieval. \nFor patients that have a partner, embryo \ncryopreservation is preferred. For single and \nyounger patients, oocyte cryopreservation is the \nsuggested course of action. Other techniques, \nof reproductive age with endometriosis be managed, and what fertility-sparing options are available? \nCryopreservation of embryos and mature oocytes are established techniques for preserving fertility \nin women during the reproductive period. Fertility preservation is a key consideration in the care of \nyoung girls and women with endometriosis, mainly those with ovarian endometriomas and advanced \ndisease. Although no cohort studies have been published on the subject to date, adequate information \ndetailing disease progression, treatment options, and the risks involved should be made available for \nthese women. Available fertility preservation strategies include embryo and oocyte crypreservation, \nand women should be counselled individually on the risks, benefits, and costs involved with these \noptions. In this scenario, management by a multidisciplinary endometriosis team is a fundamental \nstep for producing successful results. \n\nREPRODUCTIVE HEALTH  •  August 2019 EMJ EUROPEAN MEDICAL JOURNAL68\nsuch as immature oocyte retrieval and in vitro \nmaturation for cryopreservation and ovarian \ntissue cryopreservation, have also been studied, \nbut they are not currently recommended as \nstandard options for clinical practice.10,11\nThe authors set out to perform a review of the \nrelevant articles without language restriction \nbased on a PubMed search from 1966–December \n2018 using the keywords: “fertility preservation”, \n“endometriosis”, “endometriomas”, “surgical \ntreatment”, “pregnancy”, and “assisted \nreproductive technology”. Society guidelines,  \nsuch as the European Society of Human \nReproduction and Embryology (ESHRE), \nthe American College of Obstetricians and \nGynecologists (ACOG), and the Royal College \nof Obstetricians and Gynaecologists (RCOG) \nwere also searched. The authors reviewed the \npublished literature detailing fertility-preserving \nmanagement in endometriosis focussing on \nthe selection criteria of the patients, available \ntreatment options, and follow-up. The authors \naimed to find evidence to answer the following \nclinical questions: how should we manage \nreproductive age women with endometriosis,  \nand what fertility-sparing options are available? \nHOW SHOULD WE MANAGE \nREPRODUCTIVE AGE WOMEN  \nWITH ENDOMETRIOSIS?\nOvarian Reserve Evaluation \nProgressive loss of ovarian follicles is frequently \nresponsible for subfertility and may also have \na negative impact on the results achieved by \nART. Progressive loss of ovarian follicles also \naffects patients who are not seeking pregnancy \nat present but are interested in preserving their \nchances of conceiving a child in the future. 12 \nOvarian reserve evaluation is a step of foremost \nimportance in the treatment of women with \nendometriosis, especially those seeking fertility \ncare, and thus should guide physicians regarding \nfertility preservation. The oocyte yield can be \ncompromised by the presence of endometriotic \nlesions and cysts, and the surgical procedures \nperformed to treat these women may jeopardise \nthe ovarian reserve.6\nA woman’s age is the single most important \npredictor for success with ART, with pregnancy \nrates declining with advancing age.13 Therefore, \novarian reserve markers should be assessed \nto better inform patients of the expected \nsuccess rates before engaging in any fertility  \npreservation procedure or in endometriosis \nsurgery. The available tests include early \nfollicular phase follicle-stimulating hormone \nlevels, AMH dosage, antral follicle count (AFC), \nand ovarian volume estimated by transvaginal \nultrasound, which are predictive of the number \nof oocytes retrieved with ovarian stimulation \nand are associated with pregnancy rates. 14 The \nideal marker would show a significant change in \nlevels from adolescence to the late reproductive \nperiod and should enable age-independent \nprediction of an individual’s reproductive \nlife span and spontaneous pregnancy in the  \ngeneral population.15\nAFC and AMH are the most reliable and most \ncommonly used ovarian reserve markers. 16-18 \nAFC consists of counting the number of follicles \nwith a diameter ranging from 2–10 mm and is  \nextensively used in ART clinics, due to its prompt \navailability and ease of access. AFC correlates \nwell with response to gonadotropin stimulation.\nThe presence of ovarian endometriosis is \nassociated with diminished serum AMH, lower \nAFC, lower response to controlled ovarian \nstimulation, and higher doses of gonadotropins \nused in ART cycles.19 Diminished ovarian reserve \nhas been reported not only in women with  \novarian endometriomas,20 but also in those with \nminimal-to-mild disease.2\nExcised endometriomas consistently exhibit \noocytes containing ovarian cortex firmly  \nattached to the cyst wall, which makes the \ndamage to the ovarian reserve a main concern \nin endometriotic cyst surgery, and Busacca et \nal.21 reported a 2.4% risk of ovarian failure after  \nbilateral ovarian endometrioma excision. \nCystectomy can also have negative effects on  \nthe ovarian blood supply and spontaneous \novulation rates.22 The impact of cystectomy in the \novarian reserve can be reliably assessed by serum \nAMH dosages.23\nAlthough it is assumed that cyst drainage and \nwall ablation can be less harmful to the ovarian \nreserve, they are associated with lower pain \nimprovement and higher rates of endometrioma \nrecurrence; therefore, the two techniques are \nnot recommended as a first choice procedure.3 \nThus, patients considering pregnancy should  \n\nCreative Commons Attribution-Non Commercial 4.0 August 2019  •  REPRODUCTIVE HEALTH 69\nnot undergo repetitive surgery to preserve  \nthe ovaries and minimise damage to the follicle \nreservoir,3 while a fertility preservation approach \nshould be considered before endometrioma \nsurgery in those who do not plan to become \npregnant immediately. Martyn et al. 15 reported \nthat AMH screening should be offered to all \nwomen in their 30s who are not contemplating \npregnancy because clinical risk factors will only \nidentify about 50% of women at risk of reduced \novarian reserve.\nWhen managing endometriosis, physicians  \nshould focus on early recognition of subfertility  \nrisk and provide immediate referral to an \nART specialist when needed. 24 Moreover, low \npreoperative AFC or AMH can help to predict the \nneed for repeated stimulation cycles to obtain \na satisfactory oocyte yield that would provide \nan improved chance of success for future in \nvitro fertilisation (IVF) with thawed oocytes. \nThese measurements should also indicate to \nsurgeons that they should pursue less aggressive \ntechniques to minimise harm to fertility potential \nin this setting.\nSurgery\nPain relief and improved fertility are the primary \ngoals of surgical tretament of endometriosis. \nRemoving the disease while maintaining \nreproductive potential with mininmal damage to \nthe reproductive organs remains a challenge3,25 in \nDE, superficial, ovarian endometeriosis.26,27\nOvarian Endometrioma Surgery \nIn the therapeutic planning for women who \nwish to maintain their reproductive potential, \nit is of paramount importance to consider that \nthe presence of endometriosis in any form  \n(superficial, ovarian, or deep) is capable \nof interfering in ovarian function, and that \nendometrioma surgery can aggravate this.22,28\nSuperficial endometriosis is associated with  \nlower fecundity rates and reduced ovarian \nreserve with low AMH levels. 2,6 The presence \nof endometrioma also impacts ovarian \nfunction, although the relationship between  \nendometriomas and damage to the ovarian \nreserve remains controversial. 28 The rate of \nspontaneous ovulation is lower in the ovary with \nendometrioma.22 Follicle density is lower and \nfibrosis is more frequent in the ovarian cortex \ncontaining endometriomas.29 In addition, the \npresence of DE may be associated with reduced \novarian reserve and a lower number of oocytes \nretrieved in IVF cycles, probably due to the pelvic \ninflammatory process found in DE.30\nEndometrioma surgery reduces follicular \nreserve and impairs ovarian function. This was \ndemonstrated by the significant decrease in \nserum levels of AMH after cystectomy and by \nthe decrease in ovulation rates after laparoscopic \ncystectomy, compared to the indexes before \nsurgery.29 The decrease in AMH is greater when \ncystectomy is bilateral compared with unilateral. \nIn IVF cycles, a lower number of oocytes were \nobtained with a decrease in pregnancies and live \nbirth rates after bilateral cystectomy compared \nto cycles without endometriomas. 31 Muzii et \nal.,28 on the other hand, used AFC to assess \novarian reserve endometrioma surgery in their \nmeta-analysis. They found that ovarian reserve \nwas not decreased following endometrioma  \nremoval. However, operating on recurrent \nendometriomas seems to be more detrimental to \nthe ovarian reserve. Thus, indications for surgical \ntreatment for recurrent endometriomas should \nbe viewed with caution.32\nClearly, the larger the ovarian endometriomas \nand the more extensive and complex the pelvic \nadhesions are the worse the reproductive  \nprognosis will be, and it is the surgeon’s \nresponsibility not to aggravate such a situation. \nThe principles that govern these objectives \nare, fundamentally, the preservation of ovarian \nfollicular reserve and the prevention of \npostoperative pelvic adhesions with minimal \npossibility of residual disease. \nSurgery for Deep Endometriosis  \nand Infertility \nDE is considered a specific entity that has \nbeen arbitrarily defined in histological terms \nas endometriotic lesions extending >5 mm in  \ndiameter underneath the peritoneum, 33 and \nit is usually responsible for painful symptoms. \nAlthough DE is frequently associated with \ninfertility, the evidence of a clear connection \nbetween the disease and infertility is weak. \nStudies suggest that infertility in these women is \nprobably due to the strong link between DE and \nadhesions, superficial endometriotic implants, \novarian endometriomas, and adenomyosis. 34 \nAlthough there is evidence that DE is associated \n\nREPRODUCTIVE HEALTH  •  August 2019 EMJ EUROPEAN MEDICAL JOURNAL70\nwith infertility, it is still unclear whether surgery \nto treat this form of the disease is capable of \nimproving fertility because the primary indication \nof this operative approach has been for the \ntreatment of pelvic pain.35\nDuffy et al. 36 found that laparoscopic surgery  \nwas associated with an increased live birth or \nongoing pregnancy rate, as well as a clinical \npregnancy rate in comparison to diagnostic \nlaparoscopy. No solid conclusions of safety could \nbe drawn as there was insufficient evidence \nregarding adverse events.\nWhile some specialists advocate complete \nsurgical removal of endometriotic lesions to \nimprove fertility,37,38 others recommend that \nextensive surgery for intraperitoneal and DE in \ninfertile women does not improve global fertility \nprognosis and may be associated with a higher \ncomplication rate.39,40 Vercellini et al.41 highlighted \nthat women should be carefully counselled on \nthe chances of getting pregnant after surgery. \nThey found that pregnancy rates dropped by 15% \nin those who sought spontaneous conception  \nafter surgery in comparison to those who \nunderwent IVF, which dropped from 39% to 24%.\nIn summary, the effect of surgery on the fertility \nof women with deep infiltrating endometriosis \nremains unanswered due to the heterogeneous \nnature of the disease, as well as lack of adequate \ntrials with enough power and follow up to  \nstudy this.\nWHAT ARE THE FERTILITY-SPARING \nOPTIONS AVAILABLE?\nEmbryo, Oocyte, and Ovarian  \nTissue Cryopreservation \nCryopreservation of embryos and mature  \noocytes are established techniques for  \npreserving fertility in women of reproductive \nage.9 Controlled hyperstimulation of the ovaries \nis necessary, followed by oocyte recovery \nwith transvaginal ultrasound for the successful \ncryopreservation of embryos and mature \noocytes. The mature oocytes obtained may be \ncryopreserved or fertilised and the resulting \nembryos cryopreserved. Cryopreservation of \nembryos is an effective option provided there \nis time to perform ovarian stimulation and an \navailable sperm donor. Oocyte cryopreservation \nis the best choice for fertility preservation \nin women with endometriosis who wish to \npostpone pregnancy or those who will undergo \nsurgical treatment for endometriosis in the \nfuture.42 Vitrification is an efficient method \nof cryopreserving oocytes while maintaining  \nfertilisation and pregnancy rates similar to IVF \ntechniques with fresh oocytes.43\nAlthough fertility preservation was initially \ndesigned for cancer patients, recently  \nElizur et al. 8 reported a case of oocyte \ncryopreservation in a 25-year-old woman \nwith endometriosis and chronic pelvic pain. \nThe patient had undergone oophoretomy but  \nretained significant pelvic pain and was at \nrisk of losing the remaining ovary. After three \ncycles of ovarian hyperstimulation, 21 oocytes  \nwere cryopreserved. \nFertility Preservation Using Oocytes \nGarcia-Velasco et al.42 published their experience \nwith 38 endometriosis patients who underwent \noocyte cryopreservation to maintian their future \nfertility. No pregnancies have been reported \nin the group to date. Rad et al. 45 published \nan observational study detailing fertility \npreservation in 62 women with endometriosis, \nbut only 49 patients underwent controlled ovarian  \nstimulation and oocyte vitrification. Previous \nendometrioma surgery was associated with \nreduced response to controlled ovarian \nstimulation. No outcomes after oocyte thawing \nand pregnancy are reported. The authors \nreported that fertility preservation is an  \nimportant issue in young women with severe \nendometriosis and individualised couselling \nshould take into consideration the patient’s age, \ndisease extent, and progression, as well as the \npresence or absence of ovarian endometrioma \nand previous or present indication of  \novarian surgery.\nThere is concern regarding the quality of the \nresponse in cases of endometriosis, since some \nstudies suggest that women with endometriosis \nwho undergo IVF cycles have lower rates of \npregnancy and implantation when compared  \nto those with tubal infertility.46 This would occur  \nas a result of reduced oocyte quality and \nembryonic development, as well as endometrial \nreceptivity. Harb et al. 47 published a meta-\n\nCreative Commons Attribution-Non Commercial 4.0 August 2019  •  REPRODUCTIVE HEALTH 71\nanalysis showing reduced rates of fertilisation \nin women with Grade I/II endometriosis, as well \nas pregnancy and implantation in women with  \nGrade III or IV endometriosis. Therefore, more \ncycles of controlled ovarian stimulation and \nIVF may be necessary to obtain sufficient good  \nquality oocytes to generate embryos with \ndevelopment and quality suitable for freezing. \nOvarian hyperstimulation does not appear to \nincrease the risk of progression of endometriosis \nor recurrence of lesions in patients already \ntreated.48,49 In addition, the presence of \nendometrioma at the time of ovular collection \nmay increase the risk of pelvic infection and \nabscess formation.50\nIn infertile patients with ovarian endometrioma, \nthe surgical approach should be carefully \ndiscussed. Excision of the endometrioma capsule \nincreases the spontaneous pregnancy rate in  \nthe postoperative period compared to drainage \nand electrocoagulation of the endometrioma \nwall;50 however, such surgical techniques may \npresent a risk of decreased ovarian reserve,  \neither by removal of normal ovarian tissue \nduring excision or by thermal damage to the \novarian cortex during ablation. Published data \nshows that the presence of endometriomas \nsignificantly reduces AMH values in comparison \nto the absence of endometriosis. 21,22 Surgical \nexcision of endometriomas seems to negatively \ninfluence ovarian reserve but only temporarily.51 \nOthers suggest that the mere presence of \nan endometrioma adversely affects ovarian \nreserve and it may be difficult to measure such \neffects before surgery. 52 Therefore, despite \nefforts to minimise surgical damage, the ovarian \nreserve may still be affected by the presence \nof endometrioma per se. Endometrioma size, \nbilaterality risk of subsequent ovarian failure, \nsurgical technique, and the surgeon's expertise, \nas well as the patient’s age, should also be taken \ninto account before surgical excision if future \nfertility is a concern.50-52\nOvarian tissue cryopreservation is currently used \nto preserve fertility in women of reproductive  \nage who are at high risk of losing ovarian  \nfunction (chemotherapy, radiotherapy, and \nsome benign conditions are associated with \na high risk of premature ovarian failure). 53 In \nprepubertal girls at risk of losing reproductive \npotential, ovarian tissue cryopreservation may  \nbe the only alternative theraputic option  \navailable. However, it should be noted that \nthe procedure is still considered to be  \nexperimental.53-55 In patients with endometriosis, \nhealthy fragments of ovarian cortex can be \nisolated and cryopreserved during surgical \nremoval of endometrioma. The technique \nshould be evaluated with caution, as there is a \nrisk of transfer of small foci of endometriosis in \nthe cryopreserved tissue.9,42 The advantage of \ntissue cryopreservation is that there is no need \nfor ovarian hyperstimulation. Many unanswered \ntechnical questions remain, related to the choice \nof cryopreservation technique, chances of \novarian function recovery after transplantation, \nand pregnancy rates after the procedure. 55 \nData remain scarce regarding the use of this \nfertility preservation technique in women with \nendometriosis; further studies are needed \nbefore cryopreservation of ovarian tissue can be \nindicated as the first choice in preserving fertility \nin patients with endometriosis.42\nCONCLUSION\nEndometriosis is a common benign disease that \ncarries significant risk to the reproductive organs. \nFertility preservation is a key consideration \nin the care of young girls and women with  \nendometriosis, particularly those with ovarian \nendometriomas and advanced disease.  \nAlthough there have been no cohort studies \npublished on the subject so far, adequate \ninformation on disease progression, treatment \noptions, and the risks involved should be \navailable for these women. It is still too early to \ndefine fertility preservation as the standard of \ncare for all women with endometriosis because \nvery few cases have been reported and the \navailable data does not allow for robust cost–\nutility analyses. However, fertility preservation \nshould be taken into consideration for those with \nbilateral unoperated endometriomas and those \nwho previously had unilateral endometriomas \nremoved and require surgery for a contralateral \nrecurrence.56 Available strategies include embryo \nand oocyte crypreservation, and women should \nbe counselled individually on the risks, benefits, \nand costs involved with all available techniques.  \nIn this scenario, management by a multidisciplinary \nendometriosis team is a fundamental step  \ntowards achieving successful outcomes.\n\nREPRODUCTIVE HEALTH  •  August 2019 EMJ EUROPEAN MEDICAL JOURNAL72\nReferences\n1. Tanbo T, Fedorcsak P. Endometriosis-\nassociated infertility: Aspects of \npathophysiological mechanisms \nand treatment options. Acta Obstet \nGynecol Scand. 2017;96(6):659-67.\n2. Muzii L et al. Antimüllerian hormone \nis reduced in the presence of ovarian \nendometriomas: A systematic review \nand meta-analysis. Fertil Steril. \n2018;110(5):932-40.\n3. Dunselman GA et al.; European \nSociety of Human Reproduction \nand Embryology. ESHRE guideline: \nManagement of women with \nendometriosis. Hum Reprod. \n2014;29(3):400-12.\n4. Garcia-Velasco JA, Somigliana E. \nManagement of endometriomas \nin women requiring IVF: To touch \nor not to touch. Hum Reprod. \n2009;24(3):496-501.\n5. Ruiz-Flores FJ, Garcia-Velasco \nJA. Is there a benefit for surgery \nin endometrioma-associated \ninfertility? Curr Opin Obstet Gynecol. \n2012;24(3):136-40.\n6. Shah DK. Diminished ovarian reserve \nand endometriosis: Insult upon injury. \nSemin Reprod Med. 2013;31(2):144-9.\n7. Brosens I et al. Endometriosis in \nadolescents is a hidden, progressive \nand severe disease that deserves \nattention, not just compassion. Hum \nReprod. 2013;28(8):2026-31.\n8. Elizur SE et al. Cryopreservation \nof oocytes in a young woman \nwith severe and symptomatic \nendometriosis: A new indication for \nfertility preservation. Fertil Steril. \n2009;91(1):293.e1-3.\n9. Bedoschi G et al. Fertility \npreservation options in women with \nendometriosis. Minerva Ginecol. \n2013;65(2):99-103.\n10.  Practice Committees of American \nSociety for Reproductive Medicine; \nSociety for Assisted Reproductive \nTechnology. Mature oocyte \ncryopreservation: A guideline. Fertil \nSteril. 2013;99(1):37-43.\n11. ACOG: Committee Opinion No. 584: \nOocyte cryopreservation. Obstet \nGynecol. 2014;123(1):221-2.\n12. Carrillo L et al. The role of fertility \npreservation in patients with \nendometriosis. J Assist Reprod Genet. \n2016;33(3):317-23. \n13. Cil AP et al. Age-specific \nprobability of live birth with oocyte \ncryopreservation: An individual \npatient data meta-analysis. Fertil \nSteril. 2013;100(2):492-9.\n14. Practice Committee of the American \nSociety for Reproductive Medicine. \nTesting and interpreting measures of \novarian reserve: A committee opinion. \nFertil Steril. 2012;98(6):1407-15.\n15. Martyn F et al. Review of clinical \nindicators, including serum anti-\nMüllerian hormone levels, for \nidentification of women who should \nconsider egg freezing. Int J Gynaecol \nObstet. 2017;138(1):37-41.\n16. La Marca A et al. Serum anti-Mullerian \nhormone throughout the human \nmenstrual cycle. Hum Reprod. \n2006;21(12):3103-7. \n17. Garavaglia E et al. Fertility \npreservation in endometriosis \npatients: Anti-Müllerian hormone is a \nreliable marker of the ovarian follicle \ndensity. Front Surg. 2017;25(4):40.\n18. Yoo JH et al. Serum anti-Müllerian \nhormone is a better predictor of \novarian response than FSH and age in \nIVF patients with endometriosis. Clin \nExp Reprod Med. 2011;38(4):222-7. \n19. Hock DL et al. Contribution of \ndiminished ovarian reserve to \nhypofertility associated with \nendometriosis. J Reprod Med. \n2001;46(1):7-10. \n20. Gupta S et al. Impact of ovarian \nendometrioma on assisted \nreproduction outcomes. Reprod \nBiomed Online. 2006;13(3):349-60.\n21. Busacca M et al. Postsurgical ovarian \nfailure after laparoscopic excision \nof bilateral endometriomas. Am J \nObstet Gynecol. 2006;195(2):421-5.\n22. Busacca M, Vignali M. Endometrioma \nexcision and ovarian reserve: A \ndangerous relation. J Minim Invasive \nGynecol. 2009;16(2):142-8.\n23. Iwase A et al. Serum anti-Mullerian \nhormone level is a useful marker for \nevaluating the impact of laparoscopic \ncystectomy on ovarian reserve. Fertil \nSteril. 2010;94(7):2846-9.\n24. Senepati S, Barnhart K. Managing \nendometriosis associated infertility. \nClin Obstet Gynecol. 2011;54(4):720-\n6. \n25. Abbott J. Surgical treatment is an \nexcellent option for women with \nendometriosis and infertility. Aust N Z \nJ Obstet Gynaecol. 2017;57(6):679-81.\n26. Roman H et al. [Strategies \nand surgical management of \nendometriosis: CNGOF-HAS \nEndometriosis Guidelines]. Gynecol \nObstet Fertil Senol. 2018;46(3):326-\n30. (In French).\n27. Brink Laursen J et al. Surgery \nversus conservative management of \nendometriomas in subfertile women. \nA systematic review. Acta Obstet \nGynecol Scand. 2017;96(6):727-35.\n28. Muzii L et al. The effect of surgery \nfor endometrioma on ovarian reserve \nevaluated by antral follicle count: A \nsystematic review and meta-analysis. \nHum Reprod. 2014;29(10):2190-8.\n29. Raffi F et al. The impact of excision \nof ovarian endometrioma on ovarian \nreserve: A systematic review and \nmeta-analysis. J Clin Endocrinol \nMetab. 2012;97(9):3146-54.\n30. Papaleo E et al. Deep pelvic \nendometriosis negatively affects \novarian reserve and the number \nof oocytes retrieved for in vitro \nfertilization. Acta Obstet Gynecol \nScand. 2011;90(8):878-84.\n31. Somigliana E et al. IVF-ICSI outcome \nin women operated on for bilateral \nendometriomas. Hum Reprod. \n2008;23(7):1526-30.\n32. Muzii L et al. Second surgery for \nrecurrent endometriomas is more \nharmful to healthy ovarian tissue and \novarian reserve than first surgery. \nFertil Steril. 2015;103(3):738-43.\n33. Cornillie FJ et al. Deeply infiltrating \npelvic endometriosis: Histology and \nclinical significance. Fertil Steril. \n1990;53(6):978-83.\n34. Somigliana E, Garcia-Velasco JA. \nTreatment of infertility associated \nwith deep endometriosis: Definition \nof therapeutic balances. Fertil Steril. \n2015;104(4):764-70.\n35. Carneiro MM et al. To operate or not \nto operate on women with deep \ninfiltrating endometriosis (DIE) before \nin vitro fertilization (IVF). JBRA Assist \nReprod. 2017;21(2):120-5.\n36. Duffy JM et al. Laparoscopic \nsurgery for endometriosis. \nCochrane Database Syst Rev. \n2014;(4):CD011031.\n37. Daraï E et al. Fertility after \nlaparoscopic colorectal resection for \nendometriosis: preliminary results. \nFertil Steril. 2005;84(4):945-50.\n38. Ferrero S et al. Fertility after bowel \nresection for endometriosis. Fertil \nSteril. 2009;92(1):41-6.\n39. Vercellini P et al. The second time \naround: Reproductive performance \nafter repetitive versus primary \nsurgery for endometriosis. Fertil \nSteril. 2009;92(4):1253-5. \n40. Douay-Hauser N et al. Infertile \nwomen with deep and intraperitoneal \nendometriosis: Comparison of fertility \noutcome according to the extent of \nsurgery. J Minim Invasive Gynecol. \n2011;18(5):622-8.\n41. Vercellini P et al. Effect of patient \nselection on estimate of reproductive \nsuccess after surgery for rectovaginal \nendometriosis: Literature \nreview. Reprod Biomed Online. \n2012;24(4):389-95.\n42. Barnett R et al. Endometriosis and \nfertility preservation. Clin Obstet \nGynecol. 2017;60(3):517-23. \n43. Cobo A, Diaz C. Clinical application \nof oocyte vitrification: A systematic \nreview and meta-analysis of \nrandomized controlled trials. Fertil \nSteril. 2011;96(2):277-85.\n44. Garcia-Velasco JA et al. Five years' \n\nCreative Commons Attribution-Non Commercial 4.0 August 2019  •  REPRODUCTIVE HEALTH 73\nexperience using oocyte vitrification \nto preserve fertility for medical and \nnonmedical indications. Fertil Steril. \n2013;99(7):1994-9.\n45. Raad J et al. Oocyte vitrification for \npreserving fertility in patients with \nendometriosis: First observational \ncohort study… and many unresolved \nquestions. Letter to the Editor. \nEur J Obstet Gynecol Reprod Biol. \n2018;220:140-1.\n46. Barnhart K et al. Effect of \nendometriosis on in vitro fertilization. \nFertil Steril. 2002;77(6):1148-55.\n47. Harb H et al. The effect of \nendometriosis on in vitro \nfertilisation outcome: A systematic \nreview and meta-analysis. BJOG. \n2013;120(11):1308-20.\n48. D’Hooghe TM et al. Is the \nendometriosis recurrence \nrate increased after ovarian \nhyperstimulation? Fertil Steril. \n2006;86(2):283-90. \n49. Benaglia L et al. IVF and \nendometriosis-related symptom \nprogression: Insights from a \nprospective study. Hum Reprod. \n2011;26(9):2368-72. \n50. Hart RJ et al. Excisional surgery \nversus ablative surgery for ovarian \nendometriomata. Cochrane Database \nSyst Rev. 2008;(2):CD004992.\n51. Goodman LR et al. Effect of surgery \non ovarian reserve in women with \nendometriomas, endometriosis and \ncontrols. Am J Obstet Gynecol. \n2016;215(5):589.e1-589.e6.\n52. Uncu G et al. Prospective assessment \nof the impact of endometriomas and \ntheir removal on ovarian reserve and \ndeterminants of the rate of decline \nin ovarian reserve. Hum Reprod. \n2013;28(8):2140-5.\n53. Practice Committee of the American \nSociety for Reproductive Medicine. \nOvarian tissue cryopreservation: \nA committee opinion. Fertil Steril. \n2014;101(5):1237-43. \n54. Jadoul P et al. Fertility preservation \nin girls during childhood: Is it feasible, \nefficient and safe and to whom \nshould it be proposed? Hum Reprod \nUpdate. 2010;16(6):617-30. \n55. von Wolff M et al. Cryopreservation \nand autotransplantation of human \novarian tissue prior to cytotoxic \ntherapy—A technique in its \ninfancy but already successful in \nfertility preservation. Eur J Cancer. \n2009;45(9):1547-53.\n56. Decanter C et al. [Endometriosis and \nfertility preservation: CNGOF-HAS \nEndometriosis Guidelines]. Gynecol \nObstet Fertil Senol. 2018;46(3):368-\n72. (In French).\nFOR REPRINT QUERIES PLEASE CONTACT:   +44 (0) 1245 334450","source_license":"CC0","license_restricted":false}