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Assisted Reproduction and Infertility
Surgery Reduced ovarian follicle development has been reported after
The added value of reproductive surgery in cases of endometriosis, cystectomy with no impact on oocyte quality.
23,24
In a recent paper,
adhesiolysis and treatment of tubal pathology has been questioned. Garcia-Velasco et al.
22
concluded that there is no deleterious effect of
First, surgery must be evaluated in terms of whether it creates a realistic surgery on pregnancy rates despite evidence of a reduced ovarian
opportunity for patients to conceive spontaneously, and second, it has reserve. Even assuming that fertilisation rates, implantation rates and
to be evaluated in terms of whether it can enhance the probability of pregnancy rates are identical in the presence or absence of
pregnancies in case of IVF treatment. endometriotic cysts, omitting the necessity for surgical correction is
not desirable. Some studies report that increased stages of
Endometriosis endometriosis correlate inversely with fertilisation potential.
25,26
As a result of its multifactorial aspect, the treatment of endometriosis Recently, Somigliana et al.
27
reported on a spontaneous pregnancy
remains a debatable topic. There is increasing evidence that the rate of 44% following surgery for endometriosis, but surprisingly 51%
diagnosis and treatment of endometriosis, whatever its stage, is of the remaining infertile patients did not intend to undergo IVF, even
important in patients with infertility. Surgical treatment of minimal and after persistant infertility for three years. This demonstrates that in
experienced centres IVF played only a minor role in the treatment of
endometriosis-associated infertility. In case of repeated IVF failures,
consecutive laparoscopic treatment also resulted in a reported
The paradox of surgery in
spontaneous conception rate of 76%.
28,29
However, results have to be
endometriosis-associated infertility
evaluated carefully as there is a choice of control group (this is usually
tubal factor infertility), which may include untreated hydrosalpinges
is that the efficiency is higher in
and/or untreated chronic pelvic inflammatory disease. Furthermore,
patients with severe rather than
there are variables and unreliable approaches in the diagnosis or
exclusion of endometriosis whether or not the patient has received
minimal or mild stages.
previous medical or surgical treatment, and whether correcting or
compensating effects of medication and procedures associated with
IVF are present.
mild endometriosis in infertility remains controversial. The paradox of
surgery in endometriosis-associated infertility is that the efficiency is As an endometrioma is an extra-ovarian cyst,
30,31
some ovarian
higher in patients with severe rather than minimal or mild stages.
11
follicles can be removed, possibly causing a diminished
ovarian reserve. The study of Muzii
32
clearly reveals that stripping of
In a retrospective study of patients with unexplained infertility, the cyst occurs in the ovarian stroma, which in the distended part is
Akande et al.
12
found that when these patients had minimal or mild thin and contains few or no follicles but at the hilus exposes healthy
endometriosis that was left untreated, the time to natural ovarian tissue, where excision and coagulation can be destructive for
conception was significantly prolonged. Results of the Canadian the follicles and ovarian blood supply. As the endometrioma is mostly
Collaborative Study Group on the ablation of minimal and mild an extra-ovarian cyst, opening the cyst at the site of inversion
endometriosis
13
showed an increased monthly fecundity rate (from followed by excision of the fibrotic ring, drainage and ablation is a
3.2 to 6.1), but failed to restore normal fertility assuming that factors more logical approach, causing less damage to the ovarian tissue but
other than the implants and adhesions interfere with fertility. carrying the possible risk of a higher recurrence rate.
33
However, the study supports the view that detecting and treating
these lesions at an early stage is beneficial in subfertile women. It can be concluded that the accurate diagnosis of endometriosis
These findings were not confirmed by a smaller Italian randomised (even at the time of IVF) remains an important element in the
study.
14
A recent review combining the results of both trials into a exploration of the infertile couple. Endometriomas detected by
meta-analysis showed that surgical treatment is more favourable ultrasound in asymptomatic women attending the infertility clinic
than expectant management (odds ratio [OR] for pregnancy 1.7; 95% require minimally invasive surgery with maximal preservation of
confidence interval [CI] 1.1–2.5).
15
normal ovarian cortex.
Two large studies
16,17
showed that surgical reconstruction of large ovarian There is a lack of consensus among studies as to whether ovarian
endometriomas need not impair IVF outcome, and a recently published response is adequate or sub-optimal in patients with ovarian
meta-analysis confirmed these findings.
18
However, the question of endometriosis. Surgery of the ovarian endometrioma before IVF is
whether a normal fertilisation rate in these patients is a result of the recommended on the basis that ovarian cysts require a histological
surgery or the gonadotropin-releasing hormone (GnRH) agonist diagnosis to exclude malignancy. Currently, to the best of my
therapies preceding or concomitant with the IVF-ET procedure has not knowledge there is no single publication reporting on the fate of these
been answered. Two prospective randomised studies of GnRH-agonist patients with severe endometriosis not treated surgically and directly
treatment have suggested an improvement of pregnancy outcome in referred to IVF programmes.
IVF patients with endometriosis.
19,20
Distal Tubal Occlusion
A meta-analysis of 22 studies demonstrated a nearly 50% reduction in Conventionally, outpatient hysterosalpingogram (HSG) makes the
IVF pregnancy outcomes in the presence of endometriosis compared diagnosis of tubal impairment. Interstitial spasm, inadequate filling of
with a control of tubal pathology, with decreased fertilisation and the ampullary segment, a tortuous tube and peri-tubal adhesions may
implantation rates and a reduced number of retrieved oocytes.
21
occasionally produce false images of a proximal block or a
However, these data have not been confirmed by other studies.
22
hydrosalpinx. HSG is of no use for the detection of lesions beyond
22 EUROPEAN OBSTETRICS & GYNAECOLOGY
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