To operate or not to operate on women with deep infiltrating endometriosis (DIE) before in vitro fertilization (IVF)

Abstract

Deep infiltrating endometriosis (DIE) can cause infertility and pelvic pain. There is little evidence of a clear connection between DIE and infertility, and the absolute benefits of surgery for DIE have not been established. This paper aimed to review the current literature on the effect of surgery for DIE on fertility, pregnancy, and IVF outcomes. Clinicians should bear in mind that a comprehensive clinical history is useful to identify patients at risk for endometriosis, although many women remain asymptomatic. Imaging can be useful to plan surgery. The effect of surgery on the fertility of women with DIE remains unanswered due to the heterogeneous nature of the disease and the lack of trials with enough statistical power and adequate follow-up. Surgery is not recommended when the main goal is to treat infertility or to improve IVF results. Decisions should be tailored according to the individual needs of each woman. Patients must be provided information on the potential benefits, harm, and costs of each treatment alternative, while the medical team observes factors such as presence of pelvic pain, patient age, lesion location, and previous treatments. In this scenario, management by a multidisciplinary endometriosis team is a key step to achieving successful outcomes.

Endometriosis-Associated Infertility

“…Undoubtedly the management of these patients should be done by a multidisciplinary team. the technique used, it seems that excisional surgery is associated with better spontaneous pregnancy rates in a 9-12 months interval as opposed to ablative surgery 27 . Two randomized control studies of laparoscopic management of endometriomas have demonstrated an increased pregnancy rate when performing cyst wall excision as opposed to cyst wall ablation, with pregnancy rates of 61% versus 23.4% after a two year interval 33 .…”

“…Th e pregnancy rates were 2.45 times higher in the group of women submitted to surgery before IVF. When DIE is associated with endometriomas, the pregnancy rate is declined furthermore, as compared to DIE alone (82.5% versus 69.4%) 27,34,35 .…”

“…Even superfi cial peritoneal implants produce infl ammatory cytokines and chemokines causing an increased oxidative stress and an altered hormonal profile. Th e endometriomas directly aff ect folliculogenesis leading to poor oocyte and embryo quality and also poor response during ovarian stimulation 27 . Hemolysis of trapped blood leads to high iron level within the cyst suggesting cytotoxic oxidative stress 1 .…”

“…Compared to other cells, the cytoplasm of mature oocytes has a higher mitochondrial content, up to 105 mitochondria. It was discovered that the oocytes of women with endometriosis have a higher percentage of abnormal mitochondria and a lower number overall (84.6±39.8 versus 50.7±288.5) 27,30 .…”

“…An important aspect has to be taken into consideration when dealing with a patient with endometriosis wishing to conceive: counselling the patient about her real changes to conceive before and after surgery 27 . A well known detrimental eff ect of surgery is the further decline in ovarian reserve in an already infertile patient.…”