Controversies in the management of endometriomas in patients undergoing assisted reproduction

Introduction The presence of an endometrioma has been proposed to affect the ovarian function in a negative way. Our aim was to present the key evidence on multiple aspects of endometriomas’ management in subfertile couples scheduled for assisted reproduction technologies (ART).

A critical review of the existing literature was performed focusing on the need of endometrioma treatment prior to ART, the relevant options, the potentially participating surgeon’s characteristics and the socioeconomic perspective.

To date, we have no definitive data to suggest whether the damage to the ovaries observed in women with endometriomas may be related to the mere presence of the cyst, the surgical procedure to remove it, the combination of the two, or factors currently unknown. Moreover, there is no conclusive evidence that, for subfertile couples, removal of endometriomas increases the chance of having a baby. The uncertainty regarding the best treatment strategy and factors such as the limited number of tertiary centers for laparoscopic surgery throughout the world seems to further complicate the decision.

Until research addresses the current “grey areas”, the management of endometriomas in patients undergoing ART should be individualized and take into consideration numerous parameters. Similar content being viewed by others

Benaglia L, Somigliana E, Vercellini P et al (2009) Endometriotic ovarian cysts negatively affect the rate of spontaneous ovulation. Hum Reprod 24:2183–2186 Practice Committee of the American Society for Reproductive Medicine (2006) Endometriosis and infertility. Fertil Steril 86(Suppl 1):S156–S160 Kennedy S, Bergqvist A, Chapron C et al (2005) ESHRE guideline for the diagnosis and treatment of endometriosis. Hum Reprod 20:2698–2704 Somigliana E, Vercellini P, Viganό P et al (2006) Should endometriomas be treated before IVF-ICSI cycles? Hum Reprod Update 12:57–64 Jacobson TZ, Duffy JM, Barlow D et al (2010) Laparoscopic surgery for subfertility associated with endometriosis. Cochrane Database Syst Rev 1:CD001398 Gupta S, Agarwal A, Agarwal R, Loret de Mola JR (2006) Impact of ovarian endometrioma on assisted reproduction outcomes. Reprod Biomed Online 13:349–360 Somigliana E, Infantino M, Benedetti F et al (2006) The presence of ovarian endometriomas is associated with a reduced responsiveness to gonadotropins. Fertil Steril 86:192–196 Benaglia L, Pasin R, Somigliana E et al (2011) Unoperated ovarian endometriomas and responsiveness to hyperstimulation. Hum Reprod 26:1356–1361 Hughes E, Brown J, Collins JJ et al (2007) Ovulation suppression for endometriosis. Cochrane Database Syst Rev 3:CD000155 Benschop L, Farquhar C, van der Poel N, Heineman MJ (2010) Interventions for women with endometrioma prior to assisted reproductive technology. Cochrane Database Syst Rev 11:CD008571 Tsoumpou I, Kyrgiou M, Gelbaya TA, Nardo LG (2009) The effect of surgical treatment for endometrioma on in vitro fertilization outcomes: a systematic review and meta-analysis. Fertil Steril 92:75–87 Bongioanni F, Revelli A, Gennarelli G et al (2011) Ovarian endometriomas and IVF: a retrospective case-control study. Reprod Biol Endocrinol 9:81 Benaglia L, Somigliana E, Vighi V et al (2010) Rate of severe ovarian damage following surgery for endometriomas. Hum Reprod 25:678–682 Geber S, Ferreira DP, Spyer Prates LF et al (2002) Effects of previous ovarian surgery for endometriosis on the outcome of assisted reproduction treatment. Reprod Biomed Online 52:162–166 Candiani M, Barbieri M, Bottani B et al (2005) Ovarian recovery after laparoscopic enucleation of ovarian cysts: insights from echographic short-term postsurgical follow-up. J Minim Invasive Gynecol 12:409–414 Horikawa T, Nakagawa K, Ohgi S et al (2008) The frequency of ovulation from the affected ovary decreases following laparoscopic cystectomy in infertile women with unilateral endometrioma during a natural cycle. J Assist Reprod Genet 25:239–244 Almog B, Sheizaf B, Shalom-Paz E et al (2010) Effects of excision of ovarian endometrioma on the antral follicle count and collected oocytes for in vitro fertilization. Fertil Steril 94:2340–2342 Donnez J, Wyns C, Nisolle M (2001) Does ovarian surgery for endometriomas impair the ovarian response to gonadotropin? Fertil Steril 76:662–665 Alborzi S, Ravanbakhsh R, Parsanezhad ME et al (2007) A comparison of follicular response of ovaries to ovulation induction after laparoscopic ovarian cystectomy or fenestration and coagulation versus normal ovaries in patients with endometrioma. Fertil Steril 88:507–509 Ercan CM, Sakinci M, Duru NK et al (2010) Antimullerian hormone levels after laparoscopic endometrioma stripping surgery. Gynecol Endocrinol 26:468–472 Roman H, Tarta O, Pura I et al (2010) Direct proportional relationship between endometrioma size and ovarian parenchyma inadvertently removed during cystectomy, and its implication on the management of enlarged endometriomas. Hum Reprod 25:1428–1432 Fernando S, Breheny S, Jaques AM et al (2009) Preterm birth, ovarian endometriomata, and assisted reproductive technologies. Fertil Steril 91:325–330 Benaglia L, Somigliana E, Vighi V et al (2009) Is the dimension of ovarian endometriomas significantly modified by IVF-ICSI cycles? Reprod Biomed Online 18:401–406 Benaglia L, Somigliana E, Santi G et al (2011) IVF and endometriosis-related symptom progression: insights from a prospective study. Hum Reprod 26:2368–2372 Matsunaga Y, Fukushima K, Nozaki M et al (2003) A case of pregnancy complicated by the development of a tubo-ovarian abscess following in vitro fertilization and embryo transfer. Am J Perinatol 20:277–282 Kelada E, Ghani R (2007) Bilateral ovarian abscesses following transvaginal oocyte retrieval for IVF: a case report and review of literature. J Assist Reprod Genet 24:143–145 Benaglia L, Somigliana E, Iemmello R et al (2008) Endometrioma and oocyte retrieval-induced pelvic abscess: a clinical concern or an exceptional complication? Fertil Steril 89:1263–1266 Somigliana E, Viganό P, Parazzini F et al (2006) Association between endometriosis and cancer: a comprehensive review and critical analysis of clinical and epidemiological evidence. Gynecol Oncol 101:331–341 Somigliana E, Vercellini P, Vigano P et al (2010) Non-invasive diagnosis of endometriosis: the goal or own goal? Hum Reprod 25:1863–1868 Somigliana E, Arnoldi M, Benaglia L et al (2008) IVF-ICSI outcome in women operated on for bilateral endometriomas. Hum Reprod 23:1526–1530 Demirol A, Guven S, Baykal C, Gurgan T (2006) Effect of endometrioma cystectomy on IVF outcome: a prospective randomized study. Reprod Biomed Online 12:639–643 de Ziegler D, Borghese B, Chapron C (2010) Endometriosis and infertility: pathophysiology and management. Lancet 376:730–738 Farquhar C, Sutton C (1998) The evidence for the management of endometriosis. Curr Opin Obstet Gynecol 104:321–332 Sallam HN, Garcia-Velasco JA, Dias S et al (2006) Long-term pituitary down-regulation before in vitro fertilization (IVF) for women with endometriosis. Cochrane Database Syst Rev 1:CD004635 Canis M, Mage G, Wattiez A et al (2003) The ovarian endometrioma: why is it so poorly managed? Laparoscopic treatment of large ovarian endometrioma: why such a long learning curve? Hum Reprod 18:5–7 Lalchandani S, Baxter A, Phillips K (2005) Is helium thermal coagulator therapy for the treatment of women with minimal to moderate endometriosis cost-effective? A prospective randomised controlled trial. Gynecol Surg 2:255–258 Medeiros LR, Rosa DD, Bozzetti MC et al (2009) Laparoscopy versus laparotomy for benign ovarian tumour. Cochrane Database Syst Rev 2:CD004751 Moayeri SE, Lee HC, Lathi RB et al (2009) Laparoscopy in women with unexplained infertility: a cost-effectiveness analysis. Fertil Steril 92:471–480 Hart RJ, Hickey M, Maouris P, Buckett W (2008) Excisional surgery versus ablative surgery for ovarian endometriomata. Cochrane Database Syst Rev 2:CD004992 Maheshwari A, Gibreel A, Bhattacharya S, Johnson NP (2009) Dynamic tests of ovarian reserve: a systematic review of diagnostic accuracy. Reprod Biomed Online 18:717–734 Tsolakidis D, Pados G, Vavilis D et al (2010) The impact on ovarian reserve after laparoscopic ovarian cystectomy versus three-stage management in patients with endometriomas: a prospective randomized study. Fertil Steril 94:71–77 Pados G, Tsolakidis D, Assimakopoulos E et al (2010) Sonographic changes after laparoscopic cystectomy compared with three-stage management in patients with ovarian endometriomas: a prospective randomized study. Hum Reprod 25:672–677 Muzii L, Bellati F, Palaia I et al (2005) Laparoscopic stripping of endometriomas: a randomized trial on different surgical techniques. Part I: clinical results. Hum Reprod 20:1981–1986 Muzii L, Bellati F, Bianchi A et al (2005) Laparoscopic stripping of endometriomas: a randomized trial on different surgical techniques. Part II: pathological results. Hum Reprod 20:1987–1992 Mossa B, Ebano V, Tucci S et al (2010) Laparoscopic surgery for the management of ovarian endometriomas. Med Sci Monit 16:MT45–MT50 Saeki A, Matsumoto T, Ikuma K et al (2010) The vasopressin injection technique for laparoscopic excision of ovarian endometrioma: a technique to reduce the use of coagulation. J Minim Invasive Gynecol 17:176–179 Vercellini P, Somigliana E, Vigano P et al (2009) Surgery for endometriosis-associated infertility: a pragmatic approach. Hum Reprod 24:254–269 Yu HT, Huang HY, Soong YK et al (2010) Laparoscopic ovarian cystectomy for endometriomas: surgeons’ experience may affect ovarian reserve and live-born rate in infertile patients with in vitro fertilization-intracytoplasmic sperm injection. Eur J Obstet Gynecol Reprod Biol 152:172–175 Canis M, Pouly JL, Tamburro S et al (2001) Ovarian response during IVF-embryo transfer cycles after laparoscopic ovarian cystectomy for endometriotic cysts of >3 cm in diameter. Hum Reprod 16:2583–2586 Donnez J, Lousse JC, Jadoul P et al (2010) Laparoscopic management of endometriomas using a combined technique (cystectomy) and ablative surgery. Fertil Steril 94:28–32 Moses SH, Clark JT (2004) Current practice for the laparoscopic diagnosis and treatment of endometriosis: a national questionnaire survey of consultant gynaecologists in UK. BJOG 111:1269–1272 Jones KD, Fan A, Sutton CJ (2002) The ovarian endometrioma: why is it so poorly managed? Indicators from an anonymous survey. Hum Reprod 17:845–849 Ball E, Koh C, Janik G, Davis C (2008) Gynaecological laparoscopy: ‘see and treat’ should be the gold standard. Curr Opin Obstet Gynecol 20:325–330 Balasch J (2010) Ageing and infertility: an overview. Gynecol Endocrinol 26:855–860 Al-Azemi M, Bernal AL, Steele J et al (2000) Ovarian response to repeated controlled stimulation in in-vitro fertilization cycles in patients with ovarian endometriosis. Hum Reprod 15:72–75 Oddens BJ, den Tonkelaar I, Nieuwenhuyse H (1999) Psychosocial experiences in women facing fertility problems-a comparative study. Hum Reprod 14:255–261 Matsubayashi H, Hosaka T, Izumi S et al (2001) Emotional distress of infertile women in Japan. Hum Reprod 16:966–969 Dyer SJ, Abrahams N, Hoffman M, van der Spuy ZM (2002) ‘Men leave me as I cannot have children’: women’s experiences with involuntary childlessness. Hum Reprod 17:1663–1668 Zhao SZ, Wong JM, Davis MB et al (1998) The cost of inpatient endometriosis treatment: an analysis based on the Healthcare Cost and Utilization Project Nationwide Inpatient Sample. Am J Manag Care 4:1127–1134 Gao X, Outley J, Botteman M et al (2006) Economic burden of endometriosis. Fertil Steril 86:1561–1572 Simoens S, Hummelshoj L, Dunselman G et al (2011) Endometriosis cost assessment (the EndoCost study): a cost-of-illness study protocol. Gynecol Obstet Invest 71:170–176 Acknowledgments The authors would like to thank Elena Gagari, DMD, DMSc (Assistant Professor of Mucosal Diseases-Dermatology, University of Athens, School of Medicine) for all her advice on the English grammar and syntax of the manuscript. Conflict of interest None. Author information Authors and Affiliations Corresponding author Rights and permissions About this article Cite this article Siristatidis, C., Chrelias, C., Sioulas, V.D. et al. Controversies in the management of endometriomas in patients undergoing assisted reproduction. Arch Gynecol Obstet 286, 1563–1569 (2012). https://doi.org/10.1007/s00404-012-2538-5 Received: Accepted: Published: Issue date: DOI: https://doi.org/10.1007/s00404-012-2538-5