Endometrioma and in vitro fertilization

8 03 2011

To the Editor:

We read the article by Almog et al. (1) with interest. Similar to what we showed on a smaller scale (2), and in contrast to what showed by Somigliana et al. (3), they found that the number of oocytes retrieved from a cohort of patients bearing endometrioma and undergoing in vitro fertilization (IVF) is similar to that retrieved from unaffected patients, and that the presence of unilateral endometriomas has no impact of the number of oocytes retrieved. The straightforward recommendation was that one should proceed to IVF without preliminary removal of endometrioma (1). This is similar to what was suggested by Garcia-Velasco et al (4).

However, neither recommendation takes into account IVF success rates in untreated patients, and therefore are not beneficial to further discussion on this controversial issue. Although removal of endometriomas does not seem advantageous with regard to clinical pregnancy rate (5), evidence that untreated patients have more favorable IVF outcomes is lacking.

In our small study (2), we suggested that the presence of endometriomas does not influence oocyte and embryo quality, thus providing the only (albeit limited) biological data available in the literature on this issue. Moreover, we provided data on IVF outcomes, all of which were unsuccessful despite the young female ages and the different cycle type administered (2).

Biological findings and IVF success rate are the only meaningful data on which a ‘recommendation’ should be based. Given that the number of retrieved oocytes does not correlate necessarily with IVF outcome in this model and that the presence of endometriomas may still have an impact on pregnancy rate, we suggest a more sensible use of recommendations on this issue than has hitherto been the case.

Angelo Tocci, M.D, Ph.D.
Caterina Lucchini, Ph.D.
Reproductive Medicine Unit
Nuova Villa Claudia Clinic
Rome, Italy

References
1. Almog B, Shehata F, Sheizaf B, Lin Tan S, Tulandi T. Effects of ovarian endometrioma on the number of oocytes retrieved for in vitro fertilization. Fertil Steril 2011; 95: 525-7.

2. Tocci A, Lucchini C, Minasi MG, Greco E. Unilateral ovarian endometriotic cysts do not impair follicles development, oocyte and embryo quality: report on eight controlled ovarian hyperstimulations and ICSI cycles. Human Reprod 2010;25:288-9.

3. Somigliana E, Infantino M, Benedetti F, Arnoldi M, Calanna G, Ragni G. The presence of ovarian endometriomas is associated with a reduced responsiveness to gonadotropins. Fertil Steril 2006; 86: 192-6.

4. Garcia-Velasco JA and Somigliana E. Management of endometriomas in women requiring IVF: to touch or not to touch. Hum Reprod 2009; 24: 496-501.

5. 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: 75-87.

Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2011.03.015

The Authors Respond:

We are perplexed by the comments of Drs. Tocci and Lucchini concerning our article (1).

Based on their case report of 3 patients, they stated “removal of endometriomas might not beneficial to COH” (2). This is basically similar to the recommendation from authors of much larger studies (1,3). As we and others previously demonstrated, excision of ovarian endometrioma is associated with reduced ovarian reserve (1, 4-6).

In our present study (1), the numbers of retrieved oocytes in the presence or absence of ovarian endometrioma are similar. It becomes clear that an asymptomatic ovarian endometrioma does not require removal before IVF. Note that the quantity of oocytes retrieved in COH for IVF cycle is associated with success (7) and that reduced ovarian response may become the major issue to overcome, rather than the primary cause of infertility including endometriosis.

Concerning the quality of oocytes and embryos created, previous reports on the effects of endometriomas and endometriosis on embryo quality have been conflicting (8-10). Our upcoming publication shows that there is no effect of endometriomas on oocyte or embryo quality (11).

We maintain that IVF treatment should be performed without prior removal of an ovarian endometrioma. Of course, a large endometrioma that hinders oocyte collection should be first removed.

Benny Almog, M.D.
Ishai Levin, M.D.
Togas Tulandi, M.D., M.H.C.M.
Department of Obstetrics and Gynecology
McGill Reproductive Center
McGill University Health Center
Montreal, Quebec, Canada

References
1. Almog B, Shehata F, Sheizaf B, Tan SL, Tulandi T. Effects of ovarian endometrioma on the number of oocytes retrieved for in vitro fertilization. Fertil Steril 2011;95:525-7.

2. Tocci A, Lucchini C, Minasi MG, Greco E. Unilateral ovarian endometriotic cysts do not impair follicles development, oocyte and embryo quality: report on eight controlled ovarian hyperstimulations and ICSI cycles. Human Reprod 2010;25:288-9.

3. Garcia-Velasco JA, Somigliana E. Management of endometriomas in women requiring IVF: to touch or not to touch. Hum. Reprod 2009;24:496-501

4. Ragni G, Somigliana E, Benedetti F, Paffoni A, Vegetti W, Restelli L, et al. Damage to ovarian reserve associated with laparoscopic excision of endometriomas: a quantitative rather than a qualitative injury. Am J Obstet Gynecol 2005;193:1908-14.

5. Ho HY, Lee RK, Hwu YM, Lin MH, Su JT, Tsai YC. Poor response of ovaries with endometrioma previously treated with cystectomy to controlled ovarian hyperstimulation. J Assist Reprod Genet 2002; 19:507-11.

6. Nargund G, Cheng WC, Parsons J. The impact of ovarian cystectomy on ovarian response to stimulation during in-vitro fertilization cycles. Hum Reprod 1996;11:81-3.

7. Hughes EG, Fedorkow DM, Daya S, Sagle MA, Van de Koppel P, Collins JA. The routine use of gonadotropin-releasing hormone agonists prior to in vitro fertilization and gamete intrafallopian transfer: a meta-analysis of randomized controlled trials. Fertil Steril 1992;58:888-96.

8. Pellicer, A. Oliveira N, Ruiz A, Remohí J, Simón C, Exploring the mechanism(s) of endometriosis-related infertility: an analysis of embryo development and implantation in assisted reproduction. Hum Reprod 1995;10 Suppl 2: 91-7.

9. Kumbak B, Kahraman S, Karlikaya G, Lacin S, Guney A. In vitro fertilization in normoresponder patients with endometriomas: comparison with basal simple ovarian cysts. Gynecol Obstet Invest 2008;65:212-6.

10. Tinkanen H, Kujansuu E. In vitro fertilization in patients with ovarian endometriomas. Acta Obstet Gynecol Scand 2000;79: 119-22.

11. Reinblatt SL , Levin I, Shehata F, Son WY, Tulandi T, Almog B, Effects of endometrioma on embryo quality. Fertil Steril (In Press).

Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2011.03.014

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