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With patient-centered care being the mantra of 21st-century medicine, the decision to proceed with fertility surgery in women with endometriosis should be based on the individual patient, her reproductive expectations, her specific disease pattern, her support, family network, and available health care resources.
That is the consensus of a panel on fertility surgery at the American Association of Gynecologic Laparoscopists (AAGL) 2020 Virtual Global Congress.
“Although obstetricians and gynecologists are the ultimate advocates of women’s health, the decision to proceed to surgery or in vitro fertilization (IVF) cannot be simply based on empiric evidence,” said moderator Anusch Yazdani, MD, medical director of the Queensland Fertility Group in Brisbane, Australia. “The key is interdisciplinary management, with the focus on the woman and her expectations.”
As with endometriosis, “infertility is not a single defined entity,” Yazdani told Contemporary OB/GYN. “It is a complex interplay of numerous factors, including functional, biological and environmental influences, that cannot be conveniently isolated.
Additionally, the impact of endometriosis on fertility is likely mediated by numerous mechanisms. “Most obviously, as the disease progresses and pelvic damage increases, the passage of gametes and embryos through the reproductive tract is impaired,” Yazdani said.
Endometriosis also alters the pelvic environment, mostly due to endometriosis-associated inflammation. “This change may impair the function of both eggs and sperm, fertilization, embryo development and implantation,” Yazdani said.
Increasing evidence shows that both the quality and quantity of oocytes in women with endometriosis is affected. “However, it is unclear whether this is a direct effect of the disease or if endometriosis is a confounder,” Yazdani said.
Evidence also indicates that in the reproductive tract of woman with endometriosis, the eutopic endometrium displays altered metabolomic and proteomic profiles that change the endocrine response. “Hence there is a reduction in implantation and an increased chance of miscarriage and other obstetric complications,” Yazdani said. “There is no evidence that endometriosis surgery will improve either scenario.”
Laparoscopic surgery to treat mild and moderate endometriosis reduces overall pain and increases spontaneous live birth or ongoing pregnancy rates, according to moderate-quality evidence. “But there is no high-quality evidence that laparoscopic excision and ablation improves the outcomes of assisted reproduction,” Yazdani said.
Similarly, while the treatment of advanced disease is probably linked to an increased chance of spontaneous pregnancy, there is limited evidence to suggest that such therapy improves the success rates of IVF.
Irrespective of the stage of endometriosis, the absolute pregnancy rate per cycle remains low compared to a cycle of IVF. “While the clinical pregnancy rate in women undergoing IVF with endometriosis may be lower than that of other infertility aetiologies, there is no good evidence that this can be improved by surgery,” Yazdani said.
In fact, a history of surgery for endometriosis, including cystic ovarian disease, has been shown to be associated with lower pregnancy rates.
Regardless of whether the endometriomas are surgically stripped or ablated, there is no evidence that such techniques increase live birth rates via IVF. Instead, they have been shown to reduce ovarian reserve as measured by the level of anti-mllerian hormone (AMH), decrease the number of oocytes retrieved, increase gonadotrophin requirements, and reduce peak oestradiol levels.
“This lack of surgical efficacy needs to be balanced against the challenges of diagnosis, ovarian access, pelvic infection, pain and cycle cancellation rates, all of which are more prevalent in women with endometriomata,” Yazdani said.
Dr. Yazdani is a minority shareholder in Virtus Health.