Fertility preservation in women with endometriosis

Abstract

Background: Endometriosis is a chronic disease that can compromise fertility in up to 30-50% of affected patients, and it is estimated that patients affected by endometriosis represent about 10% of patients undergoing ART treatments. The hypothesized underlying mechanisms explaining infertility are various, but great attention has been given to the relationship between ovarian endometriomas and reduced ovarian reserve.

Objective and rationale: Infertility in patients with endometriosis does not have univocal management, since surgical therapy can increase the chances of natural conception, but at the same time increases the risk of damage to the ovarian reserve. In some cases, IVF procedures should be considered instead of surgery, within a personalized strategy. It has therefore been proposed that patients with endometriosis are eligible for fertility preservation.

Search methods: This article is based on a critical review of literature on peer-reviewed article indexing databases including PubMed, Scopus and Medline, using as keywords: 'fertility preservation', 'oocyte vitrification', 'endometriosis', 'endometrioma', 'ovarian reserve' and 'in vitro fertilization'.

Outcomes: Data regarding the feasibility of oocyte cryopreservation in patients with endometriosis have increased over recent years, indicating that these patients seem to have the same number of oocytes retrieved and IVF outcomes similar to those who perform fertility preservation for other indications. However, probably due to a reduced ovarian reserve, several cycles of ovarian stimulation may be needed to gather a suitable number of retrieved oocytes per patient. Age, ovarian reserve, and previous ovarian surgery are the main factors affecting the success of fertility preservation. Bilateral endometriomas, a history of unilateral endometrioma surgery with a contralateral recurrence, and preoperative reduced ovarian reserve are the most common indications for fertility preservation. The choice between primary surgery and ART is often complex, requiring a therapeutic strategy tailored to the patient's clinical characteristics and needs, such as age, type and severity of endometriosis lesions, presence of symptoms, surgical history, and desire for pregnancy.

Limitations reasons for caution: The development of endometriosis-related infertility and the severity of ovarian damage due to endometriosis lesions per se or their surgical treatment are difficult to predict, and data are lacking concerning which subgroups of patients with endometriosis might benefit most from fertility preservation.

Wider implications: Women with endometriosis, and in particular women with bilateral ovarian endometriomas or recurrent surgery on the ovaries, should be advised about risk of ovarian reserve damage. Oocyte cryopreservation is an established technique that has been demonstrated as feasible and successful for these patients; however, the specific indications have not yet been established.

Study funding/competing interests: There are no funding sources for the study and no conflicts of interest to declare.

Keywords: IVF; endometrioma; endometriosis; fertility preservation; oocyte vitrification; ovarian reserve.

Figure 1.

Proposed algorithm for the management of fertility preservation in women with endometriosis. The algorithm described focuses on managing a patient who wishes to preserve fertility, and it is divided into two main pathways based on the patient’s preferences. If the patient desires immediate pregnancy, two options are offered: the first involves attempting to conceive naturally or undergoing first-line treatment with IVF. The second option involves an initial surgical approach if there are medical conditions that could benefit from surgery. In this scenario, surgery is considered the first line of treatment, followed by IVF if natural conception is not achieved. If the patient wishes to preserve fertility for the future and does not wish to conceive in the short term, an evaluation of ovarian reserve is required. If the ovarian reserve is low, immediate fertility preservation is recommended, particularly if the patient is not socially ready to conceive. Low ovarian reserve refers to a reduced quantity or quality of oocytes, assessed using markers like AMH, AFC, and age. If the ovarian reserve is normal, the algorithm calls for an assessment of age: if the patient is over 35, fertility preservation is advised if they are not socially ready to conceive. If under 35, fertility preservation is only considered if there are high-risk factors, such as severe endometriosis, prior ovarian surgeries, or conditions that significantly threaten fertility. This personalized approach ensures the treatment pathway is tailored to the patient’s clinical conditions and reproductive goals. AMH: anti-Müllerian hormone; AFC: antral follicle count.