The study, “Endometriosis, endometrioma, and ART results: Current understanding and recommended practices,” appeared in the journal Best Practice & Research Clinical Obstetrics & Gynaecology.
Endometriosis may lead to infertility in a variety of ways, including pelvic inflammation, ovarian damage, prolonged lack of ovulation, or persistent painful intercourse, reducing frequency.
Women with endometriosis often require ART, which includes procedures such as in vitro fertilization, to help them conceive. In 2015, 8 percent of women undergoing ART cycles in the U.S. had the disorder.
Data indicate that endometriosis patients have similar ART outcomes as healthy women in terms of live birth rates, despite trends toward higher rates of cancellation and lower numbers of oocytes — cells in the ovaries that may mature to form an egg cell — per ART cycle.
Similar findings were reported from the Society for Assisted Reproductive Technology database from 2008 to 2010, which found that endometriosis was associated with lower oocyte production.
In cases without a parallel diagnosis, such as male infertility, live birth rates were the same or even better than other causes of infertility. However, the presence of other abnormalities in the reproductive tract, along with endometriosis, was linked to the lowest live birth rates.
Studies suggest that lower production of oocytes may be related to reduced oocyte quality. Data from oocyte donation programs also showed lower pregnancy rates if the donor has endometriosis.
Research shows that laparoscopic surgery in the milder disease stages improves spontaneous pregnancy and live birth rates in women with reduced fertility. This was further confirmed in another study, which demonstrated that laparoscopic removal of all visible endometriosis increased implantation and pregnancy rates, as well as live birth rates following ART treatment.
As a result, the European Society of Human Reproduction and Embryology (ESHRE) recommended that surgical removal of endometriosis be considered if laparoscopy is performed before ART.
Regarding the association of endometrioma (ovarian cysts) and ART results, data show that women with endometrioma have a higher cycle cancellation rate and lower production of oocytes than those without endometriosis. However, having endometrioma did not affect outcomes among women with endometriosis.
Surgical treatment of endometrioma did not improve clinical pregnancy rates in clinical trials. Similar findings were observed when comparing untreated women with those who had surgery before ART cycles.
Research also indicated that endometriomas larger than 5 centimeters reduced the number of oocytes in comparison with healthy ovaries. However, no evidence supports the benefit of surgery before ART in the pregnancy rates of infertile women with endometriomas larger than 3 centimeters.
Additional limitations of surgery include potential changes in ovarian hormones, risk of technical difficulties and infection due to the endometrioma, and worsening of the endometrioma after ART, the authors said.
Based on this, ESHRE recommended counseling women with endometrioma on the risks of affected ovarian function after surgery and the possible loss of the ovary. Surgery should only be considered in these women to improve pain or accessibility of ovarian follicles, the group advised.
Despite reports of worsened endometriosis symptoms, mainly pain, during ART, studies do not support this association.
Current research also does not clearly support the benefit of surgery before ART in women with deep infiltrating endometriosis.
Overall, “women with endometriosis appear to have similar ART outcomes compared to controls in terms of live birth rates, despite a lower oocyte quality,” the researchers wrote.
“Management decisions should be individualized based on patient choice, age, associated symptoms, and the risk of repeat surgery,” they said.