Facing endometriosis cysts and fertility, a potential concession must be made between an ovarian surgery with a possible negative effect on ovarian reserve or continue suppression with OCs and an “unorthodox” management with an “emergency” IVF
The presence of ovarian endometriosis cysts poses a major dilemma in decision – making analyses regarding subfertility and assisted reproduction. The main reason is that at the time of infertility workup we commonly identify women with a history of ovarian surgery for endometriotic cysts also presenting with premature ovarian insufficiency, in some cases even nearing menopause, if the cysts were bilateral. From a clinical perspective it is bewildering to associate the medical treatment of a common, benign and transient (up to menopause) disease with a decreased ovarian reserve to the point of curbing the probability of pregnancy. Therefore clinicians and patients when deciding towards ovarian surgery for endometriosis cysts should seriously take into consideration if the benefits of surgery override the long-term consequences on the ovarian reserve and the subsequent negative effects on fertility.
Endometriosis is a common disease in women with very broad and heterogeneous spectrum of manifestation. It either does not interfere or
It is bewildering to associate the medical treatment of a common, benign and transient disease with a decreased ovarian reserve
interferes partly with various grades during the reproduction process, and finally recedes at menopause. There is no evidence showing that “treatments” such as surgery, cautery and medical castration positively influences assisted reproduction outcome. The clinical variability and heterogeneity of endometriosis has made most related scientific papers of low quality with very little evidence-based information.
A holistic strategy must be developed for the management of endometriosis cysts. It is best to be identified as early as possible and promptly begin administration of oral contraceptives (OC) as a hold on the cyst expansion and a suppression of endometriosis is anticipated. That seems to be the best management strategy until the consideration for pregnancy. At that time, the option of an “emergency” IVF can be introduced and discussed with the couple, even if it may seem illogical and unfair to proceed with an IVF cycle before any significant exposure to pregnancy.
The concept is to have a successful IVF cycle relatively immediately after OCs treatment without undergoing ovarian surgery. It is possible that stopping the OCs to attempt pregnancy might once again aggravate endometriosis and restart cyst growth. During ovarian stimulation we observe that the thin ovarian tissue around the endometriosis cysts contain the growing follicles. That tissue can easily damaged if operated at surgery. In the case of a failed IVF cycle, OCs should be restarted immediately. Interestingly, in the case of a full term pregnancy nearly all cysts tend to subside, even disappear. Pregnancy can be considered a strong treatment force for endometriosis.
To further assist in decision-making regarding the management of ovarian endometriosis cysts, an antimullerian hormone (AMH) test must be done, as a measure to provide an estimation of the ovarian reserve. This is necessary since there is increasing evidence that behind endometriosis lays a coexisting premature ovarian insufficiency. This is not yet confirmed but
A low AMH coexisting with endometriosis cysts and infertility provides a strong rationale for avoiding surgery and deciding towards “emergency” IVF
frequently both endometriosis and low ovarian reserve are in the same clinical picture. It may be possible that endometriosis per se can interfere in some ways with changes in the ovarian reserve. Ovarian surgery therefore will further decrease ovarian reseve. A low AMH coexisting with endometriosis cysts and infertility provides a strong rationale for avoiding surgery and deciding towards “emergency” IVF.
Facing endometriosis cysts and fertility, a potential concession must be made between an ovarian surgery with a possible negative effect on ovarian reserve or continue suppression with OCs and an “unorthodox” management with an “emergency” IVF. If there is no oncologic reason for surgery we advocate an “emergency” IVF. The benefit can be eggs to become babies and recession of endometriosis cysts after birth. An ovarian surgery will reduce available eggs, even brings menopause, if cysts are bilateral. However, the idea to try IVF without unsuccessful efforts for pregnancy is also difficult to communicate with couples, particularly since this is a strategic management and is not yet supported by properly designed randomized trials.