Fertility preservation in women with endometriosis: for all, for some, for none?

Abstract

The increasing confidence with the techniques of oocyte and ovarian cortex freezing has prompted their potential use for patient categories other than those at risk of early menopause due to cancer treatments. Women affected by every iatrogenic or pathologic condition known to compromise ovarian function severely have been considered as potential candidates for fertility preservation. Among them, women with endometriosis may represent a particularly suitable group since they are at increased risk of premature ovarian exhaustion and about half of them will experience infertility. Based on the currently available notions on the intricate relationships between endometriosis, infertility and damage to the ovarian reserve, we speculate that fertility preservation may be of interest for women with endometriosis, in particular for those with bilateral unoperated endometriomas and for those who previously had excision of unilateral endometriomas and require surgery for a contralateral recurrence. Young age at diagnosis may be an independent but pivotal additional factor to be taken into consideration in the balance of the pros and cons of fertility preservation. On the other hand, we argue against the introduction of fertility preservation for endometriosis in routine clinical practice. To date, only few cases have been reported and there are insufficient data for robust cost-utility analyses. It is noteworthy that endometriosis is a relatively common disease and systematically including affected women in a fertility preservation program would have profound clinical, logistic and financial effects. More clinical data and in-depth economic analysis are imperative prior to recommending its routine use.

Is the oocyte quality affected by endometriosis? A review of the literature

“…Hence, the extent to which the negative effect of endometriosis on oocyte quality might also impair the performances of fertility preservation techniques remains unexplored and this option should still be considered with caution [7]. …”

“…To some extent, decreased oocyte quality could in fact also be implicated in the adverse pregnancy outcomes observed in endometriosis patients [4–6]. Deeper understanding of the impact of the disease on oocyte quality also becomes fundamental as fertility preservation techniques are gaining attention in the counselling and treatment of patients affected by endometriosis [7, 8]. Both oocyte freezing and ovarian tissue cryopreservation rely on autologous folliculogenesis: disregarding any effect of endometriosis on follicular/oocyte quality at both the time of freezing and thawing may represent a major pitfall in the management of endometriosis patients.…”

Challenges of fertility preservation in non‐oncological diseases

“…Moreover, additional action should be proposed, such as oral contraceptives, to reduce the risk of recurrence of endometriosis . The benefits of fertility preservation should be carefully evaluated according to the severity of the disease (bilateral or unilateral), the type of surgery previously performed, recurrence, and ovarian or peritoneal involvement . As emergency fertility preservation is not mandatory, the first option is oocyte/embryo vitrification after COS.…”

The Effect of Surgery for Endometriomas on Fertility

“…Follicle depletion may be secondary to damage induced by the endometriosis‐associated inflammatory reaction and by increased tissue oxidative stress leading to fibrosis . A group of potentially toxic agents, such as free iron, that can diffuse through the cyst wall of the endometrioma, as well as long‐lasting mechanical stretching of ovarian cortex, can all have a detrimental impact on the ovarian reserve . Most importantly, however, is the negative effect of ovarian surgery on ovarian reserve, especially if performed repeatedly (see sections , 4.1.3 and 4.1.4).…”

“…15 A group of potentially toxic agents, such as free iron, that can diffuse through the cyst wall of the endometrioma, as well as long-lasting mechanical stretching of ovarian cortex, can all have a detrimental impact on the ovarian reserve. 16…”