FOR: Fertility preservation is an integral component of
the management of women with ovarian endometriosis
Fertility preservation techniques are widely accepted as standard of
care for women undergoing treatment for cancer who are at risk of
premature ovarian insufficiency. The same approach is not yet well
established in benign conditions.
There is ample evidence that women who have endometriosis are twice as
likely to experience infertility in the future (Prescott et al. 2016Hum Reprod 31(7):1475-82). Ovarian endometriomas reduce ovarian
reserve by exposing healthy ovarian tissue to the pathological process
of endometriosis and to mechanical stretch, resulting in a progressive
reduction in the pool of primordial follicles. Surgery to treat ovarian
endometriomas further reduces ovarian reserve due to loss of normal
ovarian tissue during cystectomy and ablation. Following surgical
removal, there is a reduction in ovarian reserve, as measured by
anti-mullerian hormone (AMH) levels, by 30% in unilateral and 44% in
bilateral endometriomas (Raffi et al. 2012, J Clin Endocrinol
Metab. 97:3146-3154). The risk of premature ovarian
insufficiency after bilateral ovarian endometrioma removal is 2.4%
(Busacca et al. 2006, Am J Obstet Gynecol 195(2):421-5).Younger women have a higher recurrence rate of endometriomas requiring
repeated surgery, which compounds the insult to their ovarian reserve.
Accepting this risk, the European Society for Gynaecological Endoscopy,
the European Society for Human Reproduction and Embryology and the World
Endometriosis Society have collaborated in developing recommendations on
the practical aspects of endometrioma surgery to reduce their adverse
impact. Women with endometriosis are often subjected to the pressure of
early childbearing based on their risk of infertility, whilst there is a
societal trend towards delaying parenthood.
Success rates of IVF are dependent on oocyte yield. The number of
oocytes retrieved from women with endometriomas undergoing ovarian
stimulation is substantially reduced, particularly in the presence of
large and bilateral endometriomas (Kim et al. 2020, RBMO40(6):827-834). It is, however, possible to restore cumulative
livebirth rates in women with endometriosis when an equivalent number of
oocytes is retrieved (Cobo et al. 2021, RBMO 42:725–732).There is evidence that almost half of women who had oocyte
cryopreservation due to endometriosis subsequently used their oocytes,
highlighting substantial utilisation of stored gametes within this group
of women (Cobo et al. 2020, Fertility and
Sterility 113:836–844).
In light of this information, it is difficult to justify excluding women
with endometriosis from having fertility preservation. A structured
approach is required to grade the risk to fertility in endometriosis
rather than questioning the validity of fertility preservation in these
women. In order to construct criteria for offering fertility
preservation, prospective data collection is required to understand
long-term fertility patterns. Size of endometrioma, bilaterality,
previous surgery and age are the obvious candidates in determining risk.
An early discussion around reproductive planning is essential in women
with ovarian endometriosis regarding the implications of their
significant risk of diminished ovarian reserve and premature ovarian
insufficiency. Oocyte and embryo cryopreservation offer women with
ovarian endometriosis an effective and reliable option to increase their
chance of reproductive success, particularly in young women with large
or bilateral endometriomas who may require surgical intervention, those
who have had previous surgery and those who are not in a position to
embark upon pregnancy. It is imperative that the risk to ovarian reserve
and fertility as well as the role of fertility preservation are
recognised in women with ovarian endometriosis, just as in women
undergoing treatment for malignancies.
Word count 500 (excluding references)