{"paper_id":"decbc3c2-7c4e-4343-aef7-71068c3c09a5","body_text":"Original Article  | JOGCR. 2024; 9(5): 479-486 \n     Volume 9, September – October 2024       Journal of Obstetrics, Gynecology and Cancer Research \n Journal of Obstetrics, Gynecology and Cancer Research | ISSN: 2476-5848 \n \nSurgery for Severe Endometriosis and ART Outcome and Effect of Time \nInterval Between Surgery and FET \n \nMaryam Karimi1, Zahra Asgari2, Zahra Rezaee3, Fatemeh Davari Tanha3*, Mahbod Ebrahimi3,  \nSara Saeedi4, Fateme Salehi4, Elham Feizabad4 , Mania Kaveh5, Zahra Kaveh6 \n \n1. Department of Obstetrics and Gynecology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran \n2. Department of Obstetrics and Gynecology, Arash hospital, School of Medicine, Tehran University of Medical Sciences, \nTehran, Iran  \n3. Department of Infertility, Yas Hospital, Tehran University of Medical Sciences, Tehran, Iran  \n4. Department of Obstetrics and Gynecology, Yas Hospital, Tehran University of Medical Sciences, Tehran, Iran \n5. Department of Obstetrics and Gynecology, Faculty of Medicine, Zabol University of Medical Sciences, Zabol, Iran  \n6. Research Center of Yas Hospital, Tehran University of Medical Sciences, Tehran, Iran \n \nArticle Info  ABSTRACT \n  \n          10.30699/jogcr.9.5.479 \n \n \n \nBackground & Objective:  To evaluate fertility outcomes in infertile women with \nsevere endometriosis who underwent Frozen embryo transfer (FET) after laparoscopic \nsurgery and assess the optimal time interval between laparoscopy and FET. \nMaterials & Methods: Number of 215 females with advanced-stage endometriosis \nwere included in this retrospective cohort study. At first embryo were then laparoscopic \nsurgery was performed. Patients received  gonadotropin-releasing hormone \nagonist (GnRH agonist) for the next three months after the laparoscopic surgery.  FET \nwas scheduled during the next several time-points after the laparoscopic surgery. The \nresults of treatment such as live birth, the interval between the operation and pregnancy, \nimproved dysmenorrhea/dyspareunia, and post -\noperative complications were \nevaluated. \nResults: A total of 215 patients with a mean ± SD age of 34.33 ± 6.62 were included, \namong which, 143 cases (86.2%) had no past medical history. Ninety-three individuals \n(44%) were referred for the first IVF procedure. The mean ± SD of the infertility period \nwas 4.71 ± 5.43 years.    The mean ± SD number of frozen embryos was 2.53 ± 3.36 \nand the period between the laparoscopic intervention and IVF was 1.58 ± 2.65 months.  \nConclusion: Women with severe endometriosis may benefit from embryo freezing \nbefore laparoscopic surgery then FET. The optimal time between laparoscopy and \nembryo transfer is seemed to be between two and four months. \nKeywords: Endometriosis, Laparoscopic Surgery, In vitro fertilization, Fertility  \nReceived:  2024/03/04; \nAccepted: 2024/06/25; \nPublished Online: 18 Aug 2024; \n \n \nUse your device to scan and read the \narticle online \n \n \nCorresponding Information:  \nFatemeh Davari Tanha, \nDepartment of Infertility, Yas Hospital, \nTehran University of Medical Sciences, \nTehran, Iran \n \nEmail: Fatedavari@gmail.com \n \n \nCopyright © 2024, This is an original open-access article distributed under the terms of the Creative Commons Attribution-noncommercial 4.0 International License \nwhich permits copy and redistribution of the material just in noncommercial usages with proper citation. \n \n \nIntroduction\nEndometriosis has been considered as a persistent \ninflammatory situation that plays a crucial role in \nfertility, with a prevalence rate of 25 –40% in infertile \nwomen (1). Endometriosis is accountable for about \n10% of the indications for In vitro fertilization (IVF) \n(2). This disease can make the in vivo atmosphere \ndestructive for oocyte/embryo and reduce the ovarian \nreserve. Treatment of endometriosis depends on \nseveral factors, such as the severity of symptoms, \nextent and location of lesions, the patient's desire to \nbecome pregnant, and the age of the patient. In mild to \nmoderate endometriosis, surgery may not have a \nsignificant and satisfactory result on PR (pregnancy \nrate). However, tubal  blockage, toxicity of the \nenvironment, and formation of hydrosalpinx  are \nusually detected in more advanced stages \nof endometriosis which may impair tube patency, \ncause infertility, and need excision before assisted \nconception (3). Pharmaceutical methods such as \nprogestin, danazol, and Gonadotropin releasing \nhormone (GnRH) analogues are among the treatment’s \nmethods. According to the European society for human \nreproduction and embriology (ESHRE) guidelines, in \nwomen with endometriosis -associated infertility, \nsurgical excision of deep nodular lesions previous to \nassisted repr oductive technology (ART) is not \nrecognized with regard to reproductive outcome (4). \nSurgical interventions of severe endometriosis are \n\n\nMaryam Karimi et al. 480 \n      Volume 9, September – October 2024       Journal of Obstetrics, Gynecology and Cancer Research \neffective in generating a constructive location for \nvictorious conception (5).  \nIn addition, in suspicion of severe dysm enorrhea or \ncancer, surgery before IVF may be essential and \nwarranted. However, some surgical methods may \ndiminish the ovarian reserve, which may culminate in \nenhancing the risk of infertility (6). Between primary \nsurgery and ART, it is uncertain which gives the \ngreatest managing. Laparoscopy  is the most frequent \ntechnique applied to identify and treat patients with \nsevere endometriosis, who suffer from pelvic pain. The \nprobability of being pregnant in infertile cases with \nminimal/mild endometriosis is esti mated to be about \n30% several months after surgery, which can be \nreduced further (7). In complex reproductive \ntechnology (ART) -related pregnancies, laparoscopic \nsurgery of mild to moderate endometriosis has been \ndetected to enhance PR as compared with diagnostic \nlaparoscopy alone (8). Colorectal endometriosis was \ndetermined by Deep infiltrating endometriosis (DIE) of \nat least the rectal muscularis. Rectal shaving requires \nthe excision of subserosal/superficial muscularis, and \nfull thickness discoid excision . Segmental colorectal \nresection also necessitates opening of the bowel lumen, \nwhich may culminate in infection and further \ncomplications such as suture/anastomotic dehiscence, \nconfiguration of rectovaginal fistula, neurogenic \nbladder, bowel dysfunction, a nd stenosis of the \nanastomosis (9). The successful role of surgery in the \nmanagement of endometriosis in patients with \ninfertility is still controversial. In addition, \nmodification of the chronic inflammatory alterations \nand changes of molecular biology of  neighborhood \ntissue may not be capable by surgery alone (10). Hence, \nsurgery may not be competent to completely renovate \nthe side effects of endometriosis on fertility. Numerous \nstudies have recommended that the surgical removal of \nDIE and deep endometrio sis nodules might have a \nfavorable impact on IVF outcomes (11) . Additionally, \nthe likelihood of spontaneous pregnancy after the \nsurgery in cases undergoing total resection of DIE was \nacceptable in previously reported studies (12) . \nTherefore, it is of great  importance to successfully \nforecast the possibility of fertility, avoid the \nreappearance of endometriosis, and manage this \ndisease in the long -term. Performing the IVF practice \nin these patients seems to be logical and cost-effective. \nThere are two definite indications for surgery, severe \npain unresponsive to Conservative treatment and \nhydrosalpinx. \nIn order to discover the fertility rate in patients with \nsevere endometriosis and infertility after laparoscopic \nsurgery, we performed a retrospective cohort study and \nanalyzed the clinical data of patients, with the aim of \nimproving the pregnancy rate, using IVF method. \n \nMethods \nA total of 215 patients with severe endometriosis, \ninfertility, previous history of laparoscopic surgery or \ndrug therapy, and several previous unsuccessful IVF in \nInfertility Clinic of Yas and Arash Hospitals from \nJanuary 2018 to March 2019 were enrolled in this \nretrospective cohort study. However, 49 patients were \nexcluded from the study and 166 cases were finally \nincluded in the study.   We had also 72 patients with \nhistory of more than two previous IVF, and \nendometriosis with implantation failure, that \nunderwent surgery for removal of deep DIE. Following \nDIE resection, they underwent FET for further \npregnancy. The diagnosis of advanced stage \nendometriosis was made, based on American Society \nof Fertility (ASF) in 1985 (13). Most of the cases had \ncolorectal endometriosis, with length of colorectal \nspecimen 78 (mm) (range: 21–19). These patients had \nsevere endometriosis infiltrating the rectum up to 14 \ncm from the anus, with more than 21 mm in length, and \nwith at least the muscular layer in depth, and up to 45% \nof rectal circumference. The diameter of the largest \nrectal nodule was 28 mm (range: 14-39). Height of the \nlowest nodule (mm from an al verge) was 83 (range: \n29–146). \nAfter providing the informed consent, all patients \nunderwent laparoscopic surgery and followed- up for \ntwo years. The surgeon -specific method volume is \nabout 50 cases each year. The Committee of Human \nResearch and instituti onal review board at Yas and \nArash Hospitals and Tehran University of Medical \nSciences approved the using clinical information in our \nstudy. The inclusion criteria included patients with \nhistologically confirmed diagnosis of severe \nendometriosis and infert ility, and women who had \nentire and detailed clinical, follow -up data evidence. \nNon-childbearing age patients, cases with previous \nhistory of hysterectomy, and any female with \nincomplete clinical or follow -up data were excluded \nfrom the study (54 patients) in Fig1 and Table 1\n.  \n \nTable 1. Demographic data of patient \nParameters Number=161 \nAge (years) 19-45 (34.33±6.62) \nBMI 16.4–34.2 \nSurgical antecedents 47 (28.1%) \nHistory of IVF 72 (57%) \n\n481 Surgery Endometriosis and ART Outcome \n      Volume 9, September – October 2024       Journal of Obstetrics, Gynecology and Cancer Research \nParameters Number=161 \nInfertility period (years) 0- 27 ( 4.71±5.43) \nAnti-müllerian hormone (AMH) (pmol/L) 0.1-17 (3.93±4.2) \nIrregular periods 46 (27.5%) \nUnsuccessful pregnancy attempt for >12 months 143±3.25 \ndysmenorrhea 26 (7.2±0.25) \nDyschezia 31 (2.42±0.27) \nDyspareunia 52 (4.1±0.28) \nN=numbers of patients, Mean±SD, %=percent of the patients \n \n \nFigure 1. The diagram of allocated patients and fertility outcome of included patients.  \n \nManaged endometriosis and \ninfertility\nn=215\n54 cases were \nexcluded\nSurgical treatment\nn=123\nlap endometriosis\nn=108\nFertility preservation and FET\nn=72\nNo referral due to \nCovid-19\nn=17\nSpantaneuse pregnancy\nn=9\nFull-term pregnancy\nn=23\nFail Of FET\nn=21\nAbortion     n=1\nEctopic Pregnancy     n=1\nTotal hystrectomy \nn=15\nReserved GnRH agonist \ncandidate for surrogacy\nMedical treatment\nn=38\nDident continue medical \nintervention\ndue to Covid-19\nn=9 \nGnRH agonist \ntreatment\nn=29\n\nMaryam Karimi et al. 482 \n      Volume 9, September – October 2024       Journal of Obstetrics, Gynecology and Cancer Research \nAt first fertility preservation was scheduled by \nembryo freezing, and then all patients underwent \nlaparoscopic surgery by an extremely expert surgeon \nspecializing in treatment for severe endometriosis. We \nperformed rectal shaving for endometriotic invasion to \nserosal or inadequate infiltration of the rectal \nmuscularis. Depending on multifocality and lesion \nsize, excision of a full -thickness disc or resection of \nsegmental colorectal was performed, if patients \nconfronted with deep muscularis infiltration. All  \npatients received  Gonadotropin-releasing hormone \nagonist (GnRH agonist) for the next three months after \nthe laparoscopic surgery. After this time-point, patients \nwere followed -up after surgery till spontaneous \npregnancy was occurred in some cases or accor ding to \nher accompanied disorders,  we performed Frozen \nembryo transfer (FET) during next several time -points \nafter the laparoscopic surgery and investigated the \npregnancy. Only patients with evidence of severe \nendometriosis in the pathology specimens were \nincluded. The purpose of surgery was to correct \nanatomical disorders, remove hydrosalpinx, cyst, and \nrelease pelvic floor adhesions. Fever, infection, \nbleeding, leukocytosis, and hematoma were considered \nas minor postoperative complications.   \n \nThe initial outcome would be considered as \nspontaneous pregnancy after surgical intervention. The \nsecondary outcome was defined as chemical pregnancy \n(positive human chorionic gonadotropin (hCG) two \nweeks after FET), clinical pregnancy (detection of \ngestational sac and detection of heart beat in six weeks \nof gestation), and take -home baby which is defined as \na successful delivery of a healthy baby. All the patients \nreceived Diphereline drug for three months after \nsurgery. The follow -up assessments included general \ninformation, live birth, the interval between the \noperation and pregnancy, improved dysmenorrhea/  \ndyspareunia, and post-operative complications. A beta-\nhCG test was performed two weeks after embryo \ntransfer. If it was positive, it was considered that the \nwoman had a  biochemical pregnancy. Several \nultrasound examinations were performed in follow -\nups, to confirm the fetal heart and visualization of one \nor more gestational sacs. \nRegarding ART, women were supervised as claimed \nby institutional clinical protocols. Controlled ovarian \nstimulation (COS) protocols were used with \nGonadotrophin-releasing hormone (GnRH) antagonist \nfixed protocol. Several patients' characteristics such as \nage, Body mass index (BMI), Antral follicles count \n(AFC), and AMH were explanatory for starting dose of \ngonadotropins. Retrieval of oocyte was scheduled 36 \nhours after HCG injection, and IVF was accomplished \naccording to standard operating procedure.  \nFertilization was defined as the manifestation of two \npronuclei. Embryos were frozen on the  third check to \nfifth day. Specially selected embryos were frozen and \nwe discarded others. Pregnancies were defined by an \nincreasing concentration of serum b-hCG 14 days after \nET.  \nStatistical analysis \nStatistical analysis was performed using SPSS®, v19 \n(IBM SPSS Statistics, IBM Corporation. Chicago, IL, \nUSA). The distribution of the quantitative variable was \nchecked for normality and then for the study of \nquantitative data based on the type of distribution, \nMann-Whitney U Test or  independent t -test. The \ncumulative pregnancy rate was compared by Kaplan –\nMeier (KM) method and log rank test.  P value < .05 \nwas considered statistically significant.  \n \nResults \nAccording to Table 2 , a total of 166 patients with \nmean ± SD age of 34.33 ± 6.62 (range: 19- 45) were \nincluded in this study. When reviewing the past \nmedical history of cases, one patient (0.6%) had \nhyperthyroidism, 21 individuals (12.6%) had \nhypothyroidism, and 144 cases (86.8%) had no past \nmedical history. Past abdominal surgical history was \nreported in 47 women (28.1%); while 71.3% of cases \n(n=119) had not undergone any surgical procedure. \nHistory of IVF was detected in 73 cases (56%); while \n93 individuals (44%) were referre d for the first IVF \nprocedure. The mean ± SD of dysmenorrhea, \nN=numbers of patients, dyschezia, and dyspareunia \nscore according to visual analog pain score (0 -10) was \n7.2 ± 0.25, 2.42 ± 0.27, and 4.1 ± 0.28. The mean ± SD \nof the infertility period was 4.71  ± 5.43 years (ranged: \n0- 27). The mean ± SD of anti -müllerian hormone \n(AMH) was 3.93± 4.2 pmol/L (range: 0-21). A total of \n46 women (27.5%) had irregular periods; while regular \ncycles were detected in 72.5% of included patients \n(n=120). Analysis of the tr eatment strategy revealed \nthat 30 patients (18.1%) received the drug (Gnrh -a for \nthree months before embryo transfer); while 110 \nindividuals (66.3%) underwent the surgical process. A \ntotal of 10 cases (6%) did not receive surgical care due \nto the COVID -19 pandemic. Those individuals \nundergoing FET following laparoscopic technique had \nmore take home baby than drugs group (p˂0.0001). \nAdhesiolysis on posterior cul-de-sac was performed in \n28 cases (16.86%); while segmental resect anastomosis \nand shaving were ap plied in four (3.21%) and 40 \n(28.07%) patients, respectively. The mean ± SD \nnumbers of frozen embryos transferred were 2.53 ± \n3.36 (range: 0-4). The period between the laparoscopic \nsurgery of endometriosis and FET was 2.58 ± 3.65 \nmonths (range: 3-12). Rectal endometrial nodules were \ndetected in 87 individuals (52.4%). The rate of minor \ncomplications was 3% (n=5). The fertility outcomes \nare depicted in \nFigure 1 . A total of 32 live births \n(19.3%) occurred at the end of the follow-up; while 134 \nwomen (80.7%) did not undergo the IVF procedure. \nThose with a time interval of three to six months after \nsurgery had more favorable outcomes with a \nsignificantly higher PR compared with those with six \nto 12 months (p<0/03). Biochemical pregnancy w as \ndefined as positive B -hCG 14 days after embryo \ntransfer (ET). Ultrasound examinations in follow -ups \n\n483 Surgery Endometriosis and ART Outcome \n      Volume 9, September – October 2024       Journal of Obstetrics, Gynecology and Cancer Research \nat six weeks after ET also confirmed the fetal heart and \nclinical pregnancy.  \nTable 2. Intraoperative finding and surgical procedures \nParameters                                                        Patients N=161 \nOperative Rout \nLaparoscopic                                                                                        108 \nLaparoscopic converted to open surgery                                                3 \nProcedure Performed On The Rectum \n                                            Adhesiolysis                                                                                          28 \n                                            Shaving                                                                                                 29 \n                                            Full thickness disc excision                                                                   1 \n                                           Colorectal segmental resection                                                              14 \n                                           Rectal endometrial nodules                                                                   84 \n                                           Diameter of Largest rectal nodule (mm)                                               28 \n                                           Length of colorectal specimen (mm)                                                    48 \n                                           Height of the lowest nodule (mm from anal verge)                              78 \nManagement of Urethral Endometriosis \n                                           Advanced ureterolysis                                                                           24 \n                                           Resection of bladder nodule                                                                   3 \n                                           Bladder endometriosis                                                                           12 \n                                           Colostomy                                                                                               1 \n                                           Omentectomy                                                                                          6 \n                                           Resection of posterior vagina                                                                 6 \n                                           Appendectomy                                                                                       3 \n                                           Adenomyosis                                                                                         36 \n                                                                                                   R=7 \n                                           Salpingectomy                                                                                    L=17 \n                                                                                               Both=15 \n \nDiscussion \nThe results of the current study demonstrated \nimprovement in the fertility rate after FET treatment in \ninfertile women with advanced -stage endometriosis \nafter laparoscopic surgical intervention. We also \nverified that patients undergoing ET after laparoscopic \nsurgery obtained more satisfactory clinical pregnancy \nrate compared to group who received drug therapy \nbefore FET (p˂0.001). The outcomes depicted higher \naccomplishment of laparoscopic surgical intervention \ncompared to ART alone. \nEndometriosis has been considered as the most \ncommon gynecologic disease with a negative impact \non female fertility rate that can reduce the ovarian \nreserve (14). There are several available data about the \ncorrelation between the severity of endometrios is and \ninfertility (15). This situation can be caused following \noxidative stress, exacerbating surgical approach, and \nimproved pelvic inflammatory responses (16, 17).  \nThe impact of surgical intervention in mild and \nsevere endometriosis remains controversy  regarding \nreproduction ability (8). Although laparoscopic surgery \ndemonstrated enhancement in fertility outcomes of \nminimum to mild endometriosis, it is still uncertain by \nhow much it is improved. In addition, there is no \nobvious and accurate data about t he improvement in \nthe reproductive outcomes by the use of surgical \nintervention before IVF in advanced -stage \nendometriosis. However, in one study it was \ndemonstrated that surgical intervention to renovate the \nuterine anatomy, may improve the results of IVF  in \nwomen with severe endometriosis and infertility (18) . \nThe results of one study in 2018 demonstrated that IVF \n\nMaryam Karimi et al. 484 \n      Volume 9, September – October 2024       Journal of Obstetrics, Gynecology and Cancer Research \npregnancy rate was unenthusiastically associated with \nthe severity of the endometriosis. They also concluded \nthat endometrioma had no impact on  IVF clinical \nresults (8). We confirmed that in severe endometriosis, \nsurgery may be required prior to any intervention, and \nIVF technique may assist in contacting with follicles \nduring oocyte recovery, and progress the response of \nthe ovary.  \nHydrosalpinx is a situation that happens while a \nfallopian tube is blocked and serous or clear fluid is \nfilled distal to the uterus, which gives the tube a \nsausage-like or retort-like shape feature. This situation \nwill reduce the PR after the laparoscopic surgery. As a \nresult, in the current study if a noticeable hydrosalpinx \nwas detected in sonography or hysterosalpingography \nand salpingectomy was scheduled before FET.    \nBowel surgery for colorectal endometriosis has been \nconsidered as a fertility -enhancing interfere nce. \nSegmental resection is associated with a higher \ncomplication rate compared with disk excision; \nhowever, the procedure of disk excision is not always \npractical and preferred choice for colorectal surgeons. \nSegmental colorectal resection is still freque ntly \nconducted, particularly in patients with various \nrectosigmoid nodules and sub-occlusive stenosis of the \nrectosigmoid junction.  \nIn one study in 2017 on 60 patients with severe \nendometriosis, 15 patients experienced rectal shaving, \nthree full thickness es underwent excision of the disc \nand 42 cases underwent segmental colorectal resection. \nThe results demonstrated that only one out of ten \nwomen was debilitated by colorectal resection (19) . In \naccordance with the previous mentioned article, \npresent study was obtained satisfactory results \nfollowing segmental resection anastomosis in infertile \nwomen with severe endometriosis.  \nThe interval from surgery of severe endometriosis to \nFET had a noteworthy consequence on the PR in our \nstudy. In one study Garcia-Velasco, Mahutte (20), 133 \nwomen (147 cycles) who underwent laparoscopic \ncystectomy due to endometrioma were compared with \n56 women (63 cycles) who underwent a transvaginal \nultrasound for the diagnosis of endometrioma cysts. \nThe first group entered the IVF cy cle 12 months after \nsurgery, and the second group underwent IVF \nimmediately after the surgery. There was no significant \ndifference between the two groups in terms of number \nof retrieved oocytes, mature oocytes, number of \ntransferred embryos, fertilization rate, laboratory and \nclinical pregnancy rate, and abortion rate. They \nconcluded that direct entry into ovarian stimulation \ncycle in asymptomatic endometrioma reduced the time \nto reach pregnancy and diminished the cost of \ntreatment and surgical complication s, and that \nlaparoscopic cystectomy improved the IVF outcome. \nAlthough Nesbitt-Hawes, Campbell (21) have depicted \na one -year median time in patients who conceive \nnaturally following laparoscopic surgery for severe \nendometriosis, several studies demonstrate d that \ninterval from surgical intervention of endometriosis \nand FET does not play a crucial role on the PR (22) . \nThe results of the present study showed that the \nmaximum PR was attained in patients undergoing FET \ncycle in the first three months following endometriosis \noperation. It seems that FET would be better to be \nperformed during the first months after the \nendometriosis surgery.  \nIn a meta -analysis of women with endometrioma \nunder IVF between 1985 and 2007, twenty studies \nwere assessed, and in five stu dies surgical treatment \nwas compared with expected treatment. The rate of \nclinical pregnancy was not different between the \npatients underwent surgical intervention and those with \ngonadotropin stimulation (23). In the study of Sallam, \nGarcia‐Velasco (24) patients with surgically diagnosed \nendometriosis were divided into two groups of patients \nreceiving GnRH agonist treatment for three to six \nmonths before IVF and the control group with no \nintervention before IVF. The result of PR was \nsignificantly improved i n study group by diminishing \nthe concentrations of diverse inflammatory cytokines \n(25, 26). They concluded that extended pituitary down-\nregulation prior to IVF could be supportive for infertile \nwomen with endometriosis. The results of the current \nstudy revealed that the PR rate was significantly higher \nin patients undergoing FET after laparoscopic surgical \nintervention, compared to patients who received drug \ntherapy without surgery before FET.   \nIn the current study, all patients undergoing \nendometriosis and laparoscopic surgery are candidates \nfor pre-surgery embryo freezing, as the ovarian reserve \nis reduced, apoptosis will occur, and numerous healthy \nfollicles are removed along with the cyst wall in these \ntypes of patients. The remained follicles will not \nrespond satisfactory to induction and the number of M2 \nfollicles is scarce. As a result, in this study at first \noocytes retrieval and embryo freezing were scheduled \nbefore laparoscopic surgery.    \nSeveral publications have highlighted the \neffectiveness of laparoscopic surgery on PRs, in stages \nI-II of endometriosis (8, 27) . It seems that the efficacy \nof laparoscopy and further FET in severe form of \ndisease is of great importance (28) . The novelty of the \ncurrent study is that a triple approach was chosen \naccording to the previously published studies. At first, \nembryos were collected and frozen and then the patient \nunderwent laparoscopic surgery and finally GnRH \nagonist for three months. In the next step, the transfer \nof fetus is conducted via FET with a favor able \nsuccessful rate. Finding the best approach for treating \nsevere endometriosis is of great importance due to the \nhigh incidence of endometriosis among infertile \npatients. This goal may be more achievable with a \nlong-term study period and large sample si ze, which \nwill be performed in the near future. Further \nprospective studies are required to ascertain more -\ndetailed strategies for maintaining the fertility of \nwomen with severe endometriosis.  \n\n485 Surgery Endometriosis and ART Outcome \n      Volume 9, September – October 2024       Journal of Obstetrics, Gynecology and Cancer Research \nConclusion \nIn this study, the three -phase approaches to severe \nendometriosis (embryos collection, laparoscopic \nsurgery, GnRH agonist for three months) were \nscheduled. Here we defined the optimal management \nsuch as surgery versus first-line ART for patients with \nsevere deep endometriosis. Despite the lack of \ndefinitely recognized relation between severe \nendometriosis and infertility, IVF treatment may \nenhance the fertility rates in patients with severe \nendometriosis. Laparoscopic surgery for \nendometrioma cysts before FET improved fertility. \nAdditionally, direct entry o f individuals into the \novulation stimulation cycle does not cause surgical \ncomplications and saves costs and time.  \nAcknowledgments \nWe appreciate all of the patients for their \nparticipating in the study protocol and there was not \nany conflict of interest or financial disclosures. \n \nConflict of Interest \nThe authors declare that they have no conflict of \ninterest. \n \nFunding \nThis research did not receive any specific grant from \nfunding agencies in the public, commercial, or not-for-\nprofit sectors. \n \n \n1. Ozkan S, Murk W, Arici A. Endometriosis and \ninfertility: epidemiology and evidence‐based \ntreatments. Ann N Y Acad Sci. 2008;1127(1):92-\n100. [DOI:10.1196/annals.1434.007] [PMID\n] \n2. Mneimneh AS, Boulet SL, Sunderam S, Zhang Y, \nJamieson DJ, Crawford S, et al. 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J Obstet \nGynecol Cancer Res. 2021;6(3):110-5.  \n[DOI:10.30699/jogcr.6.3.110] \n \nHow to Cite This Article:  \nKarimi, M., Asgari, Z., Rezaee, Z., Davari Tanha, F., Ebrahimi, M., Saeedi, S.,  et al. Surgery for Severe \nEndometriosis and ART Outcome and Effect of Time Interval Between Surgery and FET. J Obstet Gynecol Cancer \nRes. 2024;9(5):479-86. \nDownload citation:                             RIS | EndNote | Mendeley |BibTeX |","source_license":"CC0","license_restricted":false}