{"paper_id":"e3160d9a-ea06-4bc5-bf86-637ec66e01f0","body_text":"RESEARCH Open Access\n© The Author(s) 2023. Open Access  This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, \nsharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and \nthe source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this \narticle are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included \nin the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will \nneed to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The \nCreative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available \nin this article, unless otherwise stated in a credit line to the data.\nZareii et al. BMC Women's Health          (2023) 23:327 \nhttps://doi.org/10.1186/s12905-023-02482-1\nBMC Women's Health\n*Correspondence:\nElham Askary\nelliaskary_md@yahoo.com\nFull list of author information is available at the end of the article\nAbstract\nIntroduction Investigation of endometrioma size and its laterality on the quality of the embryo in patients with \nendometrioma compared to healthy subjects.\nMaterials and methods In this retrospective and cross-sectional study, 70 patients with unilateral and bilateral \nendometrioma were recruited and compared with 70 age-matched infertile patients as the control group in terms \nof AMH before ovum pick-up, embryo quality as well as pregnancy outcome. Additionally, in the case group, we \ndivided both unilateral (n = 32) and bilateral endometrioma patients (n = 38) into three groups based on the size of \nendometrioma. (1–3 cm, 3–6 cm, 6–10 cm)\nResults There was no difference in terms of age, BMI, parity, and age of menarche between the case and control \ngroups. Moreover, no significant difference was observed in the baseline level of AMH between the case 2.96 ± 2.72 \nng/dl (0.21–11.3) and control 2.73 ± 2.39 (0.21–12.8) groups. (P = 0.59) There was also no significant difference \nconcerning AMH level between unilateral 3.58 ± 3.20 ng/dl (0.21–12.8) and bilateral endometrioma 2.45 ± 2.14 \n(0.21 − 0.20) groups. In terms of the quality and number of embryos, there was no significant difference between \nthe case and control groups. (P = 0.30) Although the AMH level decreased with the increase in endometrioma size, \nthis difference was not statistically significant. (P = 0.07) There was no significant difference in terms of the embryo \nquality between the groups based on the size of endometrioma. (P = 0.77) In addition, no significant difference was \nobserved between the case and control groups in the terms of birth weight and pregnancy complications, such as \npremature delivery, cesarean section rate, neonatal respiratory distress, jaundice, as well as hospitalization rate. Head \ncircumference of the newborns was higher in the endometrioma group while their Apgar score was lower in the case \ncompared to the control group.\nEvaluation of endometrioma size effect \non ovarian reserve, embryo quality \nand pregnancy outcome after in vitro \nfertilization cycle; a cross-sectional study\nAfsson Zareii1, Elham Askary1,4* , Ameneh Ghahramani1, Kefayat Chamanara2,  \nAlimohammad Keshtvarz Hesam Abadi3 and Azadeh Afzalzadeh2\n\nPage 2 of 7\nZareii et al. BMC Women's Health          (2023) 23:327 \nIntroduction\nEndometriosis is seen in 8.1–12.8% of women in the \nreproductive age [ 1– 3]. Among this population, 30–50% \nsuffer from infertility and about 25–40% have superficial \nor deep ovarian endometrioma [ 4– 7]. Endometrioma \nis seen in ultrasound as a round cyst with a thick wall \nand ground glass appearance. Ultrasound sensitivity \nin the diagnosis of endometrioma (OMA) is 83.3% [ 8]. \nThe presence of endometrioma is associated with more \nadvanced stages of endometriosis disease, which is a \nsign of disruption of normal pelvic anatomy in affected \nwomen [ 1, 2, 9– 11]. Endometrioma is accompanied \nwith mechanical pulling effect based on its size as well \nas its content (inflammatory markers and proteolytic \nenzymes). Furthermore, cellular degrading agents lead to \nfibrosis and smooth muscle metaplasia and decrease cor -\ntex specific stromal cell. Accordingly, oxidative stress in \nthe normal tissues around endometrioma is much higher \ncompared to that around the other benign cysts [12– 14].\nThe presence of endometrioma at the time of ovum \npick up reduces antral follicular count, as a result of \nwhich ovum retrieval is disturbed [ 15]. Numerous infer-\ntility specialists refuse to enter endometrioma due to the \npossibility of an abscess formation or missing an occult \nearly stage of cancer. However, miss management has not \nbeen reported to date [16].\nDespite the high prevalence of endometriosis in infer -\ntile women, the best treatment method for reducing the \npain and recurrence and improving fertility outcomes \nstill remain controversial.\nAlthough cystectomy is considered as the method of \nchoice for definitive diagnosis of endometrioma, recent \nresearch has shown that cystectomy before performing \nIVF does not improve the clinical pregnancy rate and \ncauses a drop in ovarian reserve due to further damage to \nhealthy ovarian tissues; in addition, removal of endome -\ntrioma of below 3 cm causes more damage to the ovarian \ntissue compared to those of a larger size [ 17]. Nonethe-\nless, the results of meta-analysis of 33 studies indicated \nthat live birth rate and cumulative pregnancy rate in \ncases with endometrioma are not different in comparison \nto healthy people [18].\nThere is scarce research on the comparison of the \nquality of embryos in patients with endometrioma and \nhealthy people and also the effect of endometrioma size \non embryo quality and pregnancy outcome.\nThe present study therefore aimed to investigate the \nsize of endometrioma and its laterality on the quality \nof embryo in patients with endometrioma compared to \nhealthy subjects of the same age.\nMaterial and method\nThe present study is a retrospective, cross-sectional study \nunder the code of ethics IR.SUMS.MED.REC.1400.159. It \nincludes patients referred to Hazrat Zainab Hospital due \nto infertility from April 2015 to April 2019.\nIn order to homogenize the studied population, some \npatients left out from the beginning and they were not \nconsidered among the study samples, including: a his -\ntory of autoimmune, infectious or inflammatory diseases \nover the last three months prior to the ovum pickup, any \ntype of malignancies, previous endometriosis surgeries, \nprevious ovarian or pelvic surgeries, a history of spon -\ntaneous pregnancy without IVF procedure, polycystic \novary syndrome, severe male factor infertility, FSH > 10, \nAMH < 0.5, a history of abdomino-pelvic radiotherapy or \nchemotherapy for any reason, the presence of leiomyoma \nand adenomyosis simultaneously.\n140 patients 18 to 37 age who had a history of infertility \nfor up to 1 year were included in this study. Exclusion cri-\nteria was included unwillingness to continue participat -\ning in the study.\nHerein, 70 patients with unilateral and bilateral endo -\nmetrioma were recruited, whose ovarian involvement \nwas diagnosed by a skilled gynecologist through ultra -\nsound as the case group. There were on the other hand 70 \nage-matched infertile patients in the control group who \ndid not have endometrioma or endometriosis and had \nundergone IVF for an unknown reason or tubal factor.\nInformed consent was obtained from all the participants \nin the study. The demographic data, clinical records and \nultrasound characteristics of all the patients with endo -\nmetriosis were collected through their clinical records.\nPrimary outcome\nThe number and quality of embryos in the case and con -\ntrol groups; the effect of unilateral or bilateral endome -\ntrioma and its size on the number and quality of embryos \nin the case group.\nSecondary outcome\nComparison of the primary AMH level in the case and \ncontrol groups, along with the effect of unilateral or bilat-\neral endometrioma and its size on the AMH level in the \ncase group.\nConclusion The presence of endometrioma by itself does not affect the main result of IVF procedures, including the \nnumber and quality of embryos and pregnancy outcome. Thus, IVF and embryo preservation and even pregnancy \nbefore surgery seem to be reasonable for endometriotic patients.\nKeywords Endometriosis, AMH, IVF, Pregnancy complications\n\nPage 3 of 7\nZareii et al. BMC Women's Health          (2023) 23:327 \nThe embryo quality was divided into three groups:\nGrade A: 6–8 cells embryos without fragmentation and \nblastomeres of the same size;\nGrade B: 6–8 cells embryos, 30–50% fragmentation or \nunequal blastomeres;\nGrade C: 6–8 cells embryos with > 50% fragmentation \nor unequal blastomeres [19].\nStatistical analysis\nThe data were analyzed with SPSS software version 22 \nand the rank variables were compared with k2 test or \nFisher’s exact test while quantitative variables were com-\npared with T- test or man Whitney test. Klomogorov \nSmirinoff test was used for checking the data distribu -\ntion. Moreover, the quantitative results were reported as \nmean and standard deviation and rank variables as fre -\nquency and percentage. A P-value of below 0.05 was con-\nsidered as the level of significance.\nResults\nAs shown in Table  1, there was no difference in terms of \nage, BMI, parity, and age of menarche between the case \nand control groups.\nFive patients in the case group and six in the control \ngroup were hypothyroid. In the case group, two subjects \nhad bicornuate uterus.\nIn the case group, 32 patients (45.7%) out of 70 had \nunilateral endometrioma and 38 (54.3%) had bilateral \nendometrioma. We divided both unilateral and bilateral \nendometrioma patients into three groups based on the \ncyst size, whose results are summarized in Table 2.\nThere was no significant difference concerning Baseline \nAMH level between the case 2.96 ± 2.72 ng/dl (0.21–11.3) \nand control 2.73 ± 2.39 (0.21–12.8) groups. (P = 0.59)\nIn addition, no significant difference was seen in terms \nof AMH level between the unilateral 3.58 ± 3.20 ng/\ndl (0.21–12.8) and bilateral endometrioma 2.45 ± 2.14 \n(0.21 − 0.20) groups. All the above-mentioned data are \nsummarized in Table 3.\nThere was no significant difference in the quality and \nnumber of embryos between case and control groups, \nand even between unilateral and bilateral endometrioma \ncases with the controls in pairwise comparison. (P = 0.30) \nTable 4 represents the results of the comparison between \nthe embryo quality and the number of embryos retrieved \nfrom all the patients.\nThere was no significance difference in terms of AMH \nlevel and embryo quality between different sizes of endo -\nmetrioma. Based on Table  5, although the AMH level \ndecreases with the rise in the endometrioma size, this \ndifference was not statistically significant. (P = 0.07) There \nwas no significant difference concerning the embryo \nquality between the groups based on the size of endome -\ntrioma. (P = 0.77)\nTable 6 summarizes pregnancy outcome based on the \ncase (unilateral and bilateral endometrioma) and control \ngroups. There was no significant difference between the \nTable 1 Demographic data of both groups\nVariable Case (N = 70) Control (N = 70) P-value\nMean (SD) Min -Max Mean Min -Max\nMean Age (SD) (4.40)30.68 39 − 21 (4.06)31.04 39 − 22 *0.760\nMean Height (SD) (6.79)159.71 170 − 147 (6.77)158.87 170 − 147 *0.440\nMean Weight (SD) (8.99)65.82 77 − 40 (8.15)64.47 77 − 45 *0.155\nBody Mass Index (kg/m2) (3.95)25.95 35.17–16.02 (3.73)25.69 35.66–17.22 **0.569\nMean Age of Menarche (SD) year (2.37)12.05 16 − 9 (1.81)12.41 16 − 9 *0.255\nMean Duration of Disease (SD)\nYear\n(3.67)3.95 20.00–1.00\n*: Mann Whitney test, **: Independent Sample T-test\nTable 2 Cyst size in the case group\nVariable Unilateral Endo-\nmetrioma (N = 32)\nBilateral \nEndometrioma \n(N = 38)\nTotal\n(N = 70)\nMean size ± SD\nCm\n4.34 (2.04) 4.97 (2.25) 4.68 \n(2.17)\nSize Classification, Number & %\n1–3 cm 6 (18.8) 5 (13.2) 11 (15.7)\n3–6 cm 16 (50.0) 18 (47.4) 34 (48.6)\n6–10 cm 10 (31.3) 15 (39.5) 25 (35.7)\nTable 3 Comparison of the pre-pickup level of AMH level among the unilateral, bilateral OMA, and control groups\nVariables Unilateral Endometrioma\n(N = 32)\nBilateral Endometrioma\n(N = 38)\nControl\n(N = 70)\nP-value\nMean (SD) Min-Max Mean\n(SD)\nMin-Max Mean (SD) Min-Max\nMean AMH Level (SD) 3.58(3.20) 0.21–12.80 2.43(2.14) 0.21–10.20 2.73(2.39) 0.21–11.30 *0.330\n*: Kruskal Wallis Test\n\nPage 4 of 7\nZareii et al. BMC Women's Health          (2023) 23:327 \ncase and control groups in the terms of birth weight and \npregnancy complications, such as premature delivery, \ncesarean section rate, neonatal respiratory distress, jaun -\ndice, as well as hospitalization rate. Head circumference \nof the newborns was higher in the endometrioma group \nwhereas the Apgar score was lower in the case compared \nto that in the control group. As demonstrated, no signifi -\ncant difference was observed between the groups.\nDiscussion\nIn our age-matched retrospective study, there was no sig-\nnificance difference in the AMH level neither between \nthe case and control groups nor the unilateral and bilat -\neral endometrioma subgroups. The quality and number \nof embryos were the same in the case and control groups. \nDespite the decrease in AMH level with a rise in the size \nof endometrioma, this decrease was not statistically sig -\nnificant and the size of endometrioma did not therefore \nhave a significant effect on the quality and number of \nembryos.\nTable 4 Comparison of the embryo quality and number of embryos retrieved from all the patients\nVariables Unilateral Endometrioma\n(N = 32)\n(N & %)\nBilateral Endometrioma\n(N = 38)\n(N & %)\nControl\n(N = 70)\n(N & %)\nP-value\nEmbryo Quality 0.616*\nA\nB\nC\n13(46.4)\n13(46.4)\n2(7.1)\n15(40.5)\n20(54.1)\n2(5.4)\n34(50.7)\n32(47.8)\n1(1.5)\nNumber of Embryo 0.555*\n0\n1\n2\n3\n4\n5\n6\n7\n10\n4(12.5)\n3(9.4)\n5(15.6)\n4(12.5)\n9(28.1)\n1(3.1)\n2(6.3)\n2(6.3)\n2(6.3)\n1(2.6)\n1(2.6)\n11(28.9)\n6(15.8)\n10(26.3)\n1(2.6)\n5(13.2)\n2(5.3)\n1(2.6)\n3(4.3)\n5(7.1)\n14(20.0)\n14(20.0)\n18(25.8)\n12(17.1)\n3(4.3)\n1(1.4)\n0(0)\n*: Fisher Exact Test\nTable 5 Comparison of the AMH level and embryo quality according to the endometrioma size\nVariables 1–3 cm\nN = 5\n(N & %)\n3–6 cm\nN = 18\n(N & %)\n6–10 cm\nN = 15\n(N & %)\nP-value\nMean AMH Level (SD)\nNg/dl\n3.22(4.00) 2.65(2.11) 1.91(1.26) 0.077*\nEmbryo Quality\nA (N = 15)\nB (N = 20)\nC (N = 2)\n1(6.7%)\n4(20.0%)\n0(0.0%)\n8(53.3%)\n8(40.0%)\n1(50.0%)\n6(40.0%)\n8(40.0%)\n1(50.0%)\n0.773**\n*: Kruskal Wallis Test; **: Fisher Exact Test\nTable 6 Comparison of pregnancy outcomes in the endometrioma patients and control group\nVariables Unilateral\nN = 32\n(N & %)\nBilateral\nN = 38\n(N & %)\nControl\nN = 70\n(N & %)\nP-value\nPre-term Labor 3(9.4) 4(10.5) 5(7.1) 0.925*\nRespiratory Distress 2(6.3) 4(10.5) 9(12.9) 0.636*\nNeonatal Admission 6(18.8) 9(23.7) 10(14.3) 0.480**\nJaundice 10(31.3) 13(34.2) 17(24.3) 0.513**\nMean Birth Weight, gram (SD) 2882.88\n(276.05)\n2866.62\n(267.05)\n2939.70\n(338.97)\n0.644†\nMean Head Circumference, cm (SD) 34.81(1.22) 34.69(1.11) 34.16(1.61) 0.046††\nApgar Score (5 min) 8.84(0.954) 8.65(0.937) 8.96(1.13) 0.081††\n*: Fisher Exact Test, **: Chi-Square Test, †:One Way ANOVA, ††:Kruskal Wallis Test\n\nPage 5 of 7\nZareii et al. BMC Women's Health          (2023) 23:327 \nA few studies have investigated the effect of laterality \nand size of endometrioma on the quality and number of \nembryos. Most previous papers have examined the effect \nof endometrioma surgery on ART outcomes as well as \novarian reserve, but there are not enough data on the \neffect of endometrioma itself and its size as well as later -\nality on ovarian reserve and fertility outcomes. However, \nthe majority of studies in this field were single-arm with -\nout a control group [ 15, 18], which makes our study one \nof the firsts in this field to date.\nThe current work is a retrospective study with all the \nlimitations of other retrospective studies. The sample size \nherein was small. Additionally, our study lacks sub-clas -\nsification in patients with unilateral endometrioma and \ncomparison between the affected and healthy ovaries.\nA number of papers have evaluated the effect of endo -\nmetrioma on ovarian reserve due to its inflammatory fac-\ntors present in the cyst [10, 13]. Some researchers believe \nthat endometrioma, with the increase in intra ovarian \npressure, capsule stretching and reduced blood supply, \ncan induce a fall in ovarian reserve and the quality of eggs \nas a result. Nevertheless, the impact of endometrioma on \nreproductive outcome is still controversial [ 12, 20]. (13, \n20) In the current study, there was no significant differ -\nence in AMH level between the age-matched case and \ncontrol groups. On the contrary, Radzinsky and Yanush -\npolsky reported that endometrioma has a negative effect \non the number of retrieved oocytes, quality of embryos \nand the implantation rate in ART cycle [21, 22].\nOn the other hand, in the study by Ashrafi et al., it was \nshown that despite the decreasing number of retrieved \noocytes in endometrioma compared to that in the healthy \ncontrol group, live birth rate is similar in both [23].\nRegarding the size of the endometrioma and its effect \non the ovarian reserve, Schubert et al. showed a decrease \nin follicle density in the ovarian cortex surrounding the \nendometrioma compared to other benign ovarian cysts \ndue to the destruction of the ovarian tissue. Menshi et \nal. also suggested that endometrioma may damage the \novarian tissue even before any operation, which increases \nwith the rise in the size of endometrioma [ 24, 25]. \nDespite the existing theories, the effect of endometri -\noma on reproductive outcome and ART success remains \nunresolved.\nA 2020 study by Alshehre et al. reported a significantly \nlower number of total oocytes and M2 oocytes retrieved \nin women with endometrioma compared with the \nhealthy controls [ 24]. This finding is not consistent with \nours, but there is no difference between its results and \nours in terms of the quality of embryos, live birth rate \n(I2 = 67%), clinical pregnancy rate (I2 = 0%), and implanta-\ntion rate (I2 = 0%) [26].\nIn accordance with our results, in a systematic review \npublished in 2021 by Dongye et al., the results of 22 \nstudies were reviewed. They concluded that high-quality \nembryos, embryo formation rate and cleavage rate were \nsimilar in women with endometrioma and the healthy \ncontrol group. Furthermore, in women with the unilat -\neral endometrioma, the quality of the embryos obtained \nfrom ovaries containing endometrioma was not signifi -\ncantly different compared to that of healthy ovaries on \nthe opposite side [ 27]. Hence, endometrioma does not \nseem to affect the quality of embryos.\nIn a 2013 study, Benaglia et al. stated that the ovar -\nian hyperstimulation response was significantly lower in \nwomen with bilateral endometrioma than that in con -\ntrols [28]. The number of growing follicles and retrieved \noocytes were lower, but no difference was observed in \nterms of oocyte quality. Clinical pregnancy rate and \ndelivery rate were similar. The final conclusion was that \nalthough the presence of bilateral endometrioma at the \ntime of IVF affected the response to hyperstimulation, \nthe quality of retrieved oocytes and the chance of preg -\nnancy did not differ [ 28, 29]. Most previous works have \nexamined the effect of endometrioma surgery on ART \noutcome and ovarian reserve rather than the effect of \nendometrioma itself on the outcome.\nIn line with our results, in the review by Ashrafi et al. \nin 2014 indicated that patients with unilateral or bilateral \nendometrioma of below 3 cm represented similar results \nas the healthy control group with mild male factor infer -\ntility in terms of follicles number, embryo grading (A or \nB), and pregnancy rate in IVF cycles [ 23]. However, in \n2020, Somigliana et al. concluded that endometriums \nlarger than 4  cm can interfere with ovarian response \nin IVF cycles [ 30]. Additionally, Orazov et al. in 2019 \nreported that egg quality declined in patients with endo -\nmetrioma of larger than 3 cm. Endometrioma has a nega-\ntive effect on oocyte quality and ovarian reserve, and has \npersistent and harmful effects on ovarian reserve after \ncystectomy [ 31]. Meanwhile, in agreement with us, in a \n2014 systematic review by Barbosa et al., endometriosis \nin ART-treated patients showed a similar chance of clini-\ncal pregnancy and live birth rates compared to that in \npatients with other infertility-causing issues. No differ -\nence was reported in live birth rate among patients with \nstage 3–4 endometriosis compared to those with stage \n1–2 [ 32].\nThe fact that an increase in endometrioma size causes \na decrease in oocyte quality contradicts the results of our \nstudy.\nIn agreement with our findings, Almog et al. in 2011 \nconcluded that there was no difference in the number \nof antral follicles and retrieved oocytes between ovaries \nwith endometrioma and healthy ovaries. They also found \nno correlation between endometrioma size and retrieved \noocytes [ 33]. (The number of antral follicles and oocytes \nretrieved in patients with endometrioma was equal to \n\nPage 6 of 7\nZareii et al. BMC Women's Health          (2023) 23:327 \nthat of the control patients, and the presence of ovarian \nendometrioma in the ovarian stimulation cycle for IVF \nwas not found to be related to the reduction in retrieved \noocytes.\nRegarding pregnancy outcomes, according to a 2011 \nstudy by Bongioanni et al., the ovarian endometrioma \npresence does not reduce IVF outcome compared to \npatients with tubal factor infertility, and laparoscopic \nendometrioma resection does not improve IVF out -\ncomes. However, ovarian response to gonadotropins and \nantral follicle count may decrease [ 34]. Similar to our \nresults, in a systematic review conducted by Hamdan et \nal. in 2015, women with or without endometriosis had \nsimilar results in terms of live birth rates, yet there was \ninsufficient evidence to recommend surgery to endome -\ntriosis patients before starting an ART cycle [ 18]. More-\nover, in the meta-analysis of Gupta in 2006, he concluded \nthat the clinical pregnancy rate in the endometrioma \ngroup is not different compared to that in the control \ngroup, and the ovarian response to ovarian hyperstimula-\ntion in patients with endometrioma is due to a decrease \nin the number of follicles compared to that in the control \ngroup [35].\nIn a study conducted by Saeed Alborzi et al., AMH lev -\nels significantly decreased after laparoscopic cystectomy \nfor endometrioma, which remained unchanged over time \n(9 months after the surgery). The patients with bilateral \nendometrioma had significantly lower AMH levels than \ntheir baseline levels after 1 week, 3 weeks and 9 months. \nThose older than 18 years of age had lower AMH levels \nafter the surgery. The FSH and antral follicle count level \nincreased significantly compared with their baseline lev -\nels 3 months following the surgery [17].\nA systematic review conducted by Nickkho-Amiry et \nal. in 2017 examined the effect of surgical management \nof endometrioma on IVF/ICSI outcomes compared to no \ntreatment. It was concluded that there is no significant \ndifference in pregnancy rate per cycle, clinical pregnancy \nrate and live birth rate between women with a history \nof endometrioma surgery and those without that. The \noutcome of ART cycles in women with endometriosis-\nrelated infertility was similar to other women. The final \nconclusion was that specialists should evaluate the risk of \nsurgical intervention on ovarian reserve before planning \na surgery [36].\nAccording to the results of this study, the presence of \nendometrioma, by itself, does not affect the main result \nof IVF procedures, including the number and quality of \nembryos and pregnancy outcome. Accordingly, IVF and \nembryo preservation and even pregnancy before surgery \nseems reasonable for patients because after the surgery, \nthere would be a significant and irreversible decrease in \nAMH level and also response to IVF treatments.\nFurther clinical and prospective research with high \npower and sufficient sample sizes are needed to evaluate \nthe effect of endometrioma itself on ovarian function. In \naddition, further investigation is needed to compare the \nquality of embryos obtained from affected ovaries and \nhealthy ones in patients with unilateral endometrioma.\nUltimately, it could be concluded that it is better to \npostpone endometriosis surgery in women who desire \npregnancy until there is enough frozen embryos.\nAbbreviations\nIVF  In vitro fertilization\nAMH  Anti-müllerian hormone\nBMI  Body mass index\nFSH  Follicle-stimulating hormone\nART  Assisted Reproductive Technology\nICSI  Intracytoplasmic sperm injection\nAcknowledgements\nThe authors would like to thank all the staff members of our surgical and \nlaboratory units for their expert assistance in data collection.\nAuthors contributions\nA.Z. Conception, design of study and data revising; E.A. design of study & \nfinal approach, Data interpretation & manuscript preparation, A.G. Patient \nrecruitment & data collection; K.C. Patient recruitment, drafting & design; \nA.K.h.a Data analysis and interpretation; A.A: Patient recruitment & data \ncollection. All authors read and approved the final manuscript.\nFunding\nNo financial support/funding was received for this study.\nData Availability\nThe datasets used and/or analyzed during the current study are available from \nthe corresponding author on reasonable request.\nDeclarations\nEthics approval and consent to participate\nInformed written consent, data on epidemiology, and medical history were \ncollected prospectively at the time of inclusion. The protocol of the study \nwas according to the Declaration of Helsinki and was approved by the Ethics \nCommittee of Shiraz University of medical sciences, Shiraz, Iran (IR.SUMS.MED.\nREC.1400.159).\nConsent for publication\nNot Applicable.\nCompeting interests\nThe authors declare no competing interests.\nAuthor details\n1Department of Obstetrics and Gynecology, School of Medicine, Infertility \nResearch Center, Shiraz University Of Medical Sciences, Shiraz, Iran\n2Department of Obstetrics and Gynecology, Shiraz University Of Medical \nSciences, Shiraz, Iran\n3Clinical Research Development Center of Nemazee Hospital, \nDepartment of Statistics, Shiraz University of Medical Sciences, Shiraz, Iran\n4Obstetrics and Gynecology Office, Shahid Faghihi Hospital, Zand \nAvenue, Shiraz 7134844119, Iran\nReceived: 26 September 2022 / Accepted: 14 June 2023\n\n\nPage 7 of 7\nZareii et al. BMC Women's Health          (2023) 23:327 \nReferences\n1. Jenkins S, Olive DL, Haney AF. 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