pmol/l as well as oligo‐astheno‐teratozoospermia for her partner. Transvaginal pelvic ultrasound demonstrated the presence of a left ovarian cyst measuring 4.5 x 4.2 x 5.2 mm with features typical for an endometrioma. There was some ovarian stroma seen separately containing three antral follicles. The right ovary was small with two antral follicles. Both ovaries were accessible for oocyte retrieval.
Background
Approximately 25–35% of infertile women suffer with endometriosis. The ovaries are known to be one of the most common sites of endometriosis. Progressive invagination of the ovarian cortex over endometriotic deposits leads to formation of an endometrioma. An endometrioma is a pseudocyst that contains ectopic endometrial deposits [1,2]. Around 5% of women referred for in‐vitro fertilization (IVF) have endometriomas, either unilateral or bilateral [3,4]. The presence of ovarian endometriomas is associated with moderate or severe stage disease according to the r‐ASRM (revised American Society for Reproductive Medicine) classification.
Anatomical damage to the ovaries and the fallopian tubes as well as formation of pelvic adhesions may cause impairment of fertility. An endometrioma is associated with reduced follicular count and reduced response to controlled ovarian stimulation with exogenous gonadotropins during IVF [5,6]. Oocyte retrieval may be challenging in the presence of an endometrioma and pelvic adhesions, and the occurrence of a pelvic abscess is not an uncommon complication.
Management options
Management of women with endometriomas during IVF treatment represents a common challenge for the clinician, especially as endometriosis is prevalent amongst infertile women. The treatment plan should be individualized, taking into account the patient’s age, results of the tests of ovarian reserve (anti‐Müllerian hormone [AMH] or antral follicle count [AFC]) and the outcome of previous medical or surgical treatments.
In order to address the controversies in the management of the patient with endometriosis and provide clinical recommendations, several national and two international guidelines have been developed. However, it appears that there are still substantial variations in the recommendations, and the recommendations are not always supported by good quality evidence.
When critically appraised, the guideline produced by the European Society of Human Reproduction and Embryology (ESHRE) in 2013 was regarded as the highest quality guideline [7,8].
IVF is frequently recommended as a therapeutic approach to overcome endometriosis associated infertility. Results of a meta‐analysis showed that pregnancy rate following controlled ovarian hyperstimulation and intrauterine insemination (IUI) is reduced in women with endometriosis, but not following IVF [9]. Another meta‐analysis found that surgical treatment of endometriomas did not alter the outcome of IVF treatment cycles compared with women who did not receive surgical intervention (10).
Management options for endometriomas before IVF include conservative, medical and surgical; however, there is no robust evidence to support one treatment over others. As a result, treatment should be individualized to optimize the outcome and minimize the short and long‐term risks.
Conservative management of endometriomas prior to IVF should be the first option for small endometriomas (≤3 cm). A systematic review has demonstrated that surgical treatment of endometriomas before IVF does not improve pregnancy rate or ovarian response to stimulation [11]. Surgical excision or ablation of endometriomas may lead to damage to healthy ovarian tissue, which in turn can reduce ovarian reserve and performance [12,13]. Women with previous history of multiple surgeries on the ovaries or those known to have reduced ovarian reserve should be advised against surgical treatment if attempting pregnancy by IVF, as this may further compromise the low ovarian reserve.
Surgery for endometrioma may be advocated in women with larger endometriomas (common thresholds for defining “large” being > 3 cm or > 4 cm). Laparoscopy is the preferred surgical approach as this is associated with less postoperative pain, shorter hospital stay, less risk of adhesions and quicker recovery compared with laparotomy [14]. Excision of endometrioma has been demonstrated to be superior to drainage or ablation of the cystic capsule in terms of recurrence and spontaneous pregnancy rate [15]. A scoring system to aid the clinician in the decision‐making process has been suggested by Muzii and colleagues (16). It would make sense that any potential surgery is planned and undertaken by a gynecologist with special interest and expertise in the management of endometriosis and infertility, as they may be more considerate towards preserving the normal ovarian tissue.
Medical management can reduce the size of the endometrioma by up to 57% [17,18]. Older studies suggested that administration of gonadotropin releasing hormone (GnRH) agonist for a period of 3–6 months prior to IVF significantly improves clinical pregnancy rate [19], although a 2020 randomized placebo‐controlled trial showed no difference [20]. Segmentation of the cycle especially for older patients is an approach which may also be beneficial and with the optimization of freezing techniques is gaining in popularity. Transferring the cryopreserved blastocysts in a subsequent scheduled cycle could eliminate the compromise to endometrial performance associated with controlled ovarian stimulation [21,22].
Currently, there are only a few well‐conducted trials that have evaluated the management of endometriomas in infertile women undergoing IVF [23]. Due to the lack of robust evidence on the benefits of the available options for the treatment of endometriomas, as well as the potential risks of compromising the ovarian reserve after surgical intervention, management should be highly tailored. Furthermore, women should be made aware of the advantages and disadvantages of each approach to help them make a well‐informed decision.
Practical considerations for the treating clinician include:
Careful monitoring of the cycle, as ultrasound imaging may be suboptimal.
Access at the time of transvaginal oocyte retrieval, as this can be challenging.
Risk of infection during oocyte retrieval.
At the time of oocyte retrieval, it is important to avoid draining or puncturing the endometrioma as the cyst fluid has toxic effect on gametes and embryos and may also cause pelvic infection. In the event of inadvertently entering the endometriotic cyst during oocyte recovery, the needle must be washed with culture media before continuing to aspirate other follicles. To reduce the risk of pelvic infection and abscess following oocyte retrieval, intraoperative prophylactic antibiotics are recommended to all women with an endometrioma.
Key points
Challenge: The patient with an endometrioma.
Background:
Occurs in around 5% of IVF patients.
Reduces ovarian response to stimulation.
IVF is commonly recommended, particularly if other infertility factors coexist.
Surgical treatment before IVF does not increase pregnancy rate.
Management options:
Diagnose endometriomas by transvaginal ultrasound scan.
Establish outcomes of previous surgical and/or medical treatments.
Check ovarian reserve (AMH, AFC).
Evaluate access for oocyte retrieval.
Recommend treatment with IVF and consider segmentation of the cycle.
Consider laparoscopic excision for symptomatic patients with large (common thresholds for “large” is > 4 cm) endometriomas, no previous surgery, adequate ovarian reserve and difficult vaginal access to the ovaries for oocyte retrieval
Avoid surgery in patients with previous history of surgeries and reduced ovarian reserve.