Outcomes of fertility preservation in women with endometriosis: comparison of progestin-primed ovarian stimulation versus antagonist protocols

Emmanuelle Mathieu D’Argent,Emile Daraï,Naouel Ahdad-Yata,Anne-Sophie Boudy,Clément Ferrier,Adèle Cantalloube,Sofiane Bendifallah,Rachel Levy,Jean-Marie Antoine,Chrysoula Zacharopoulou

doi:10.1186/s13048-020-00620-z

Abstract

BackgroundPPOS protocols, initially described for FP in women with cancer, have many advantages compared to antagonist protocols. PPOS protocols were not evaluated for women with endometriosis. The objective of the study was to describe fertility preservation outcomes in women with endometriosis and to compare an antagonist protocol with a Progestin-Primed Ovarian Stimulation (PPOS) protocol.MethodWe conducted a prospective cohort study associated with a cost-effectiveness analysis in a tertiary-care university hospital. The measured outcomes included the numbers of retrieved and vitrified oocytes, and direct medical costs. In the whole population, unique and multiple linear regressions analysis were performed to search for a correlation between individual characteristics and the number of retrieved oocyte.ResultsWe included 108 women with endometriosis who had a single stimulation cycle performed with either an antagonist or a PPOS protocol. Overall, 8.1 ± 6.6 oocytes were retrieved and 6.4 ± 5.6 oocytes vitrified per patient. In the multiple regression model, age (p = 0.001), prior ovarian surgery (p = 0.035), and anti-Mullerian hormone level (p = 0.001) were associated with the number of retrieved oocytes. Fifty-four women were stimulated with an antagonist protocol, and 54 with a PPOS protocol. A mean of 7.9 ± 7.4 oocytes were retrieved in the antagonist group and 8.2 ± 5.6 in the PPOS group (p = 0.78). A mean of 6.4 ± 6.4 oocytes were vitrified in the antagonist group and 6.4 ± 4.7 in the PPOS group (p = 1). In the cost-effectiveness analysis, the PPOS protocol was strongly dominant over the antagonist protocol.ConclusionFertility preservation procedures are feasible and effective for patients affected by endometriosis. Antagonist and PPOS protocols were associated with similar results but the medico-economic analysis was in favor of PPOS protocols.

Highlights

Progestin-Primed Ovarian Stimulation (PPOS) protocols, initially described for fertility preservation (FP) in women with cancer, have many advantages compared to antagonist protocols
In the cost-effectiveness analysis, the PPOS protocol was strongly dominant over the antagonist protocol
Antagonist and PPOS protocols were associated with similar results but the medico-economic analysis was in favor of PPOS protocols

Summary

Introduction

PPOS protocols, initially described for FP in women with cancer, have many advantages compared to antagonist protocols. PPOS protocols were not evaluated for women with endometriosis. The objective of the study was to describe fertility preservation outcomes in women with endometriosis and to compare an antagonist protocol with a Progestin-Primed Ovarian Stimulation (PPOS) protocol. In France, an estimated 2.1 to 4.2 million women are affected by endometriosis which is responsible for 30 to 40% of cases of hypo- or infertility [1,2,3,4]. In France, fertility preservation (FP) is authorized and has been fully covered by the healthcare system since the 2004 Bioethics Laws (modified in 2011) especially for women with potentially fertility-associated disorders such as endometriosis [5, 6]. Among the various techniques reported for FP (oocyte cryopreservation, freezing of embryos, and ovarian cortex cryopreservation) [10], oocyte cryopreservation has been reported to be the best option because of its low negative impact on ovarian reserve and low associated morbidity compared to other FP techniques [11]

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