In vitro fertilization outcome in women with unoperated bilateral endometriomas

The presence of bilateral endometriomas at the time of IVF affects responsiveness to hyperstimulation but does not affect the quality of the oocytes retrieved and the chances of pregnancy.

Laura Benaglia, M.D., Alfonso Bermejo, M.D., Edgardo Somigliana, M.D., Ph.D., Sonia Faulisi, M.D., Guido Ragni, M.D., Luigi Fedele, M.D., Juan A. Garcia-Velasco, M.D.

Volume 99, Issue 6, Pages 1714-1719, May 2013


To evaluate IVF outcome in women with unoperated bilateral endometriomas.

Multicenter retrospective cohort study.

Two infertility units.

Thirty-nine women with bilateral endometriomas matched to 78 unexposed controls.

Analysis of data from patients who underwent in vitro fertilization (IVF)–intracytoplasmic sperm injection.

Main Outcome measures:
Ovarian responsiveness and oocyte quality.

Responsiveness to ovarian hyperstimulation was significantly reduced in women with bilateral endometriomas. The total number of developing follicles in cases and controls was 9.6 ± 3.3 and 14.1 ± 6.8, respectively. The number of oocytes retrieved was 7.1 ± 3.2 and 9.8 ± 5.5, respectively. Conversely, oocyte retrieval was not hampered by the presence of the ovarian endometriomas. The rate (Interquatile Range-IQR) of oocytes retrieved per total number of developing follicle in cases and controls was 77% (57-88%) and 71% (63-79%), respectively. Moreover, the quality of the retrieved oocytes did not differ. The fertilization rate (IQR) was 67% (56-100%) and 70% (57-100%), respectively. The rate (IQR) of top quality embryos per oocyte used was 33% (25-50%) and 33% (20-43%), respectively. The implantation rate was 22% and 23%, respectively. The clinical pregnancy rate and the delivery rate also did not differ.

Although the presence of bilateral endometriomas at the time of IVF affects responsiveness to hyper-stimulation, the quality of the oocytes retrieved and the chances of pregnancy are not influenced.

  • Jashoman Banerjee

    Excision or no excision is the question? Endometriomas are known to intervene with the retrieval process- larger ones may mask existing follicles. Could the authors describe any method to avoid such hindrances? The other question is the oocyte quality. Oocytes unexposed to inflammatory markers or agents may be as healthy as controls. What makers were used to designate the oocyte quality?

  • This is a beautifully designed study because it addresses with finality a simple question of high clinical frequency: “Will my patient gain any type of ART advantage by the excision of endometriomas?”
    Indeed, the focused work of these authors (and others) over the past decade is helping to end a subculture of “debulking” advanced-stage endometriosis that has vexed our fertility patients for a generation. If the pendulum is finally swinging towards a minimalist approach to severe endometriosis in infertility patients we owe it – aside from the great progress of ART – to the accumulation of evidence such as this.

    Your latest work also gives us the chance to remind to all of us in the field that indications for excision of endometriomas in infertility patients still exist (aside from patients with pain, obviously) and should remain very clear in our mind. I am referring in particular to two relatively common clinical scenarios: 1) radiologic diagnosis of “endometriomas” over 4 cm in diameter without prior pathologic diagnosis, and 2) endometriomas as the sole identifiable infertility factor. Surgery in the former will avoid the rare but unforgivable occurrence of missing a patient with ovarian cancer (in the presence of a radiologically identified complex ovarian cyst); intervention in the latter will brilliantly resolve a substantial number of infertility cases without any need to resort to ART.

    Antonio R. Gargiulo, MD
    Brigham and Women’s Hospital
    Harvard Medical School

  • Juan Garcia-Velasco, MD

    Expectant management is the ideal choice UNLESS the women is in pain. Then surgery is 1st option. But, as suggested, size is not an issue but if access to healthy ovarian tissue is not possible and we need to go through the cyst, this may be one of the indications for surgery: NOT the size but the easy access (or not) to the growing follicles

  • David Olive, MD

    Very nicely done manuscript. I
    believe the conclusions are consistent with current thinking and
    practice by most physicians dealing with endometriomas and IVF. However,
    my question is about endometrioma size: You state that there was no
    evidence that endometriomas interfered with the retrieval, but these
    were relatively small in most cases. What if you singled out the cases
    with large endometriomas, say 4cm or larger? Was the rate of oocyte
    retrieval per follicle lower in those cases? 5cm? larger still?

  • Congratulations for your work. The question continues open: in which cases do we have to perform surgery prior to IVF and in which cases no, but your work adds more data in favour of an expectant management. As we know that the capsule of endometrioma contains antral folicles in a high percentage of cases, I think that your results are consistent with what a lot of us think: to individualize, of course, but to try not to touch endometriomas before IVF if possible. Thanks

    • Micah Hill

      I agree with your comments also and feel this article adds more evidence that surgical intervention for endometriomas purely for an indication of ART is not warranted. Im curious what indications the authors or other readers do use to operate on endometriomas in an ART population: symptoms? size? location that might interfere with oocyte retrieval?

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