To the Editor:
We read the article by Tsoumpou et al. (1) with interest and commend the authors’ attempt to address this topical issue. The decision on what to do with regard to endometriomas in women having IVF remains an everyday challenge. The authors have done well to summarize the available data addressing this issue.
Their article clearly highlights the paucity of good quality evidence in managing endometrioma in women embarking on IVF, and here-in lies the problem with this systematic review. The validity of the results of a systematic review is only as good as the quality of the studies reviewed. A good meta-analysis of data derived from design-weak studies obviously results in conclusions based on weak evidence. It is for this reason that experts propose that only methodologically sound studies should be included in a meta-analysis. Apart from the obvious non-randomized nature of the studies included in this meta-analysis, the population in the various studies were in no way similar.
Following the systematic review, the authors conclude that “available data suggest surgical management of endometriomas has no significant effect on IVF pregnancy rates and ovarian response to stimulation compared with no treatment.” We wonder how this conclusion, which is based on very weak evidence, will impact on the clinical decisions of the readers. We agree with the authors that randomized controlled trials are needed to guide clinical decisions in these cases. Until such a time, treatment should be individualized and the decision to proceed to surgery or not before IVF must be made on a case-by-case basis.
Various factors will influence clinical decisions. These include (but are by no means limited to) size of the cyst, previous ovarian surgery, previous ovarian response to stimulation/IVF outcome and, not the least, the patient’s choice. It is important that in counseling the patients we do make it clear that there is no proven correct answer in these cases, as the evidence is sparse. Several assumptions including the purported adverse effect of the cyst content on oocyte quality as alluded by the authors in their discussion have little or no evidence to support them.
Finally, the authors have suggested an easy and seemingly logical flow chart for the management of endometrioma in women undergoing IVF. This also is not based on any evidence, and as such patients should not be treated in boxes. We strongly agree with the authors that best practice recommendations on this topic must await randomized controlled trials. Until then, each case must be treated on its own merits.
Vivek Nama, MRCOGa
Emmanuel Kalu, MRCOGb
aWomen’s Health Department
Kingston Hospital NHS Trust
Kingston-upon-Thames, Surrey, United Kingdom
bAssisted Conception Unit
Queen Mary’s Hospital
London, United Kingdom
1. Tsoumpou I, Kyrgiou M, Gelbaya TA, Nardo LG. The effect of surgical treatment for endometrioma on in vitro fertilization outcomes: a systematic review and meta-analysis. Fertil Steril. 2009;92(1):75-87.
Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2009.09.003
The Authors Respond:
We would like to thank Drs. Nama and Kalu for their interest in our recent manuscript.
A systematic review aims to collect, review, present and critically appraise all available evidence regardless of how weak or strong that might be. We believe that we have clearly accomplished that in this paper.
As far as the meta-analysis is concerned we agree entirely that the quality of a meta-analytical pooling depends on the quality of the included trials. To date the relevant available data come from retrospective, case-controls and prospective cohort studies. We do not agree that they should be dismissed from inclusion as non-methodologically sound. The decision to include these studies in our review and meta-analysis was based on the fact that they addressed the same clinical question, and neither the clinical nor the methodological heterogeneity amongst them appeared to alter the treatment effect.
The authors refer to the conclusions in the abstract emphasizing that no definite conclusion can be drawn from the available evidence. We were cautious indeed to mention that randomized controlled trials (RCTs) are needed before producing best-practice recommendations on this topic. Further, as stated in the “Conclusions” section of the manuscript, standard management of endometrioma in subfertile women undergoing IVF remains controversial, owing to the insufficient evidence to suggest superiority of one treatment strategy over another. We also stated that until a large, properly designed RCT is conducted and definite conclusions presented, the management of endometrioma before IVF should be individualized. In the last paragraph of our discussion we stated that, based on the available evidence including this systematic review we were far from reaching any robust recommendations for routine clinical practice.
Regarding the flow chart, we aimed to propose what could be seen as at-a-glance guidance for the management of subfertile women with endometriomas needing IVF treatment. The arbitrary cut-off we proposed was based on our clinical experience and is far from being considered as evidence-based guidelines.
Ioanna Tsoumpou, M.B. Ch.B.
Tarek A. Gelbaya, M.D.
Luciano G. Nardo, M.D.
Department of Reproductive Medicine
St Mary’s Hospital
Manchester, United Kingdom
Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2009.09.004