Unilateral Endometrioma Research Articles

GnRH antagonist protocol with hCG triggering ameliorates fertilization defect caused by failure of cumulus cell pentraxin-3 expression in unilateral endometriomas.

The aim of the study was to determine the expression pattern of long pentraxin 3 (PTX3) mRNA in cumulus cells (CCs) isolated from metaphase II oocytes of women with unilateral endometrioma undergoing controlled ovarian stimulation using a gonadotropin-releasing hormone antagonist (GnRHa) protocol. A total of 60 CC samples, 30 from the affected ovary and 30 from the contralateral ovary, were collected from 12 patients with unilateral endometrioma who underwent flexible GnRHa protocol with recombinant human chorionic gonadotropin (rhCG) trigger. Thirty CC samples collected from the left ovary of 12 women with male factor infertility were used as external controls. Long PTX3 mRNA expression in each group was analyzed by real-time polymerase chain reaction (RT-PCR). Relative gene expression (fold-change) was calculated according to the 2-ΔΔCt equation. Fertilization rates after intracytoplasmic sperm injection (ICSI) were recorded for each group. CC-PTX3 mRNA expression in the unilateral endometrioma group was significantly lower than the mRNA expression of the disease-free ovary (0.90±0.01 vs. 0.25±0.02, p<0.01). CC-PTX3 mRNA expression of MII oocytes of the disease-free ovary was found to be similar to the control group (1.02±0.03 vs. 0.90±0.01, p=0.107). A significant 3.6-fold downregulation was observed in the CC-PTX3 mRNA expression of the endometrioma group compared to the CC-PTX3 mRNA expression in the contralateral ovary. CC-PTX3 mRNA expression in the endometrioma group was downregulated 4.08-fold compared to the CC-PTX3 mRNA expression of the control group (1.02±0.03 vs. 0.25±0.02, p<0.001). The cumulus morphologies of the endometrioma group with low CC-PTX3 expression and the groups with normal CC-PTX3 levels were similar. Fertilization rates of the endometrioma group were similar to the contralateral ovary and control groups. Unilateral endometrioma reduces CC-PTX3 expression but does not affect disease-free ovaries. The GnRHa protocol improved the fertilization rates, suggesting that failed CC-PTX3 expression is an in vivo pathology.

Oocyte cryopreservation for women with endometriosis: Justification, indications, and reproductive outcomes.

Women with endometriosis often experience diminished ovarian reserve and a decreased number of oocytes retrieved. This reduction is exacerbated after surgery. Nevertheless, oocyte quality does not seem to be compromised in these patients. When embryos of good quality are obtained, in vitro fertilization outcomes are generally satisfactory. Oocyte cryopreservation may represent a fertility preservation option for women with planned and/or prior surgery, as it enables the collection of oocytes in advance. Given the diverse manifestations of endometriosis, which vary by type, age, and ovarian reserve, the decision to pursue oocyte cryopreservation should be weighed individually. Moreover, the potential benefits of this approach on future fertility must be carefully considered. Considering current guidelines, the most appropriate candidates for oocyte cryopreservation among women with endometriosis are: patients with bilateral endometriomas, typically larger than 3 cm; those with prior surgery for unilateral endometrioma who exhibit ipsilateral or contralateral recurrence; and those with unilateral endometrioma on a single ovary. However, the size criteria for endometrioma warrant further discussion. Conversely, oocyte cryopreservation is inadvisable for patients: with unilateral endometrioma smaller than 3 cm and good ovarian reserve; who have undergone surgery for bilateral endometriomas, regardless of recurrence; and who have diminished ovarian reserve. While consensus indicates that decisions regarding diminished ovarian reserve should be individualized, fertility preservation should often be considered for patients with serum anti-Müllerian hormone levels below 0.5 ng/mL. In such cases, a prolonged duration may be necessary to retrieve the desired 10 to 15 oocytes.

Ovarian reserve after dienogest therapy versus laparoscopic cystectomy for unilateral endometriomas: A randomized clinical trial

Objective: To assess the effect of Dienogest versus surgical management of endometriomas on ovarian reserve. Methods: This randomized clinical trial was conducted at Suez Canal university hospital from November 1st, 2020, to July 31st, 2022. We recruited patients with endometriomas according to particular inclusion and exclusion criteria. The study population was allocated into two groups: group one received Dienogest, and group two had laparoscopic cystectomy. Eligible patients were subjected to history and examination to evaluate pelvic pain using the Biberoglu and Behrman score and the visual analogue scale. Ultrasound examination was done to diagnose ovarian endometrioma and its diameter. Ovarian reserve was evaluated by the antral follicle count and serum anti-mullerian hormone. After 3 months, patients were reevaluated regarding cyst diameter, antral follicle count, pain scores, and the anti-mullerian hormone. The primary outcome measure was to evaluate the ovarian reserve before and after intervention in both groups. Results: The antral follicle count and anti-mullerian hormone increased significantly after Dienogest therapy and decreased significantly after surgical excision ( p &lt; 0.001). Only induration was significantly decreased in the medical treatment group ( p &lt; 0.001). Both management options resulted in a noticeable reduction in the visual analogue scale scores in each group individually. Conclusion: Dienogest rescued ovarian reserve in women with endometriomas.

Characteristics of Endometrioma Recurrence Patients

Objective: To identify the characteristics of endometrioma recurrence cases. Method: This study was a descriptive retrospective, using secondary data taken from all medical records of Clinic Aster and Medical Records Installation in Dr. Hasan Sadikin General Hospital, Bandung, from 1st January 2018 – 31st December 2022. Data were presented in tables. Results: Of the 37 endometrioma recurrences, most of the patients are 20 to 35 in age. None of them has a parity history after the first surgical procedure. Both previous and recent cases are dominantly unilateral endometriomas. The history of postoperative medication is higher (54,1%). Obstetricians/Gynecologists appear to perform the most surgical procedure (67,6%). Mass is the main clinical manifestation of the recurrence. While menstrual and BMI profiles appear to be normal. Conclusions: The characteristic of the recurrence of endometrioma is related parity status after the first surgery, history of the previous medical treatment, and previous form of endometrioma are related to the current characteristic of endometrioma (age, lesion form, clinical manifestation, and recurrence interval).

Is there an association between endometriosis and thyroid autoimmunity?

It has been suggested that non-uterine endometrial implants can express thyroid-stimulating hormone receptors, thus inducing the formation of thyroid-stimulating immunoglobulin. We aimed to compare the autoantibody positivity in patients with and without endometriosis and to determine whether there is a difference in the incidence of thyroid diseases. This prospective observational study was conducted on 102 women who had been operated on for benign gynecological diseases. Cases enrolling in the study were divided into two groups: the study group with endometriosis (n=51) and the control group without endometriosis (n=51). The blood tests for thyroid-stimulating hormone, free thyroxine (fT4), thyroid-stimulating immunoglobulin, and anti-thyroid peroxidase antibody levels were checked. The mean thyroid-stimulating immunoglobulin level was found to be higher in the endometriosis group than in the control group. However, this difference was not statistically significant. No significant difference was detected between endometriosis and control groups in terms of anti-thyroid peroxidase antibody and thyroid-stimulating hormone levels. The mean fT4 value (0.97±0.13 ng/dL) of the endometriosis patients was found to be significantly lower than the control group (1.08±0.21 ng/dL) (p=0.002; p<0.05). The mean anti-thyroid peroxidase antibody value of cases with bilateral endometrioma (82.21±252.29 IU/mL) was significantly higher than cases with unilateral endometrioma (15.81±83.13 IU/mL) (p=0.028; p<0.05). There is a positive and significant relationship between the size of endometriosis and anti-thyroid peroxidase antibody values (p=0.011; p<0.05). This study points to an association between endometrioma diameter and anti-thyroid peroxidase antibody values which can be a stepping stone for new studies evaluating this hypothesis further.

Endometriosis-Associated Ovarian Cancer: What Are the Implications for Women with Intact Endometrioma Planning for a Future Pregnancy? A Reproductive Clinical Outlook.

Endometriosis is a chronic, universal, and prevalent disease estimated to affect up to 1:10 women of reproductive age. Endometriosis-associated ovarian cancer (EAOC) developing at reproductive age is challenging and of concern for women and practitioners alike. This outlook review focuses on the occurrence of EAOC, especially in infertile women or those planning for a future pregnancy, from the perspective of a reproductive endocrinologist, based on recent evidence. Contemporary pathogenesis, genetic profiles, evidence of causality, clinical diagnosis, prognosis, and up-to-date management are discussed. EAOC seems to be merely associated with endometrioma and includes clear-cell and endometrioid ovarian carcinoma. Although endometrioma is frequently found in women of reproductive age (up to 1:18 of women), EAOC appears to be a rare occurrence. These women are of more advanced reproductive age, nulliparous, and hyperestrogenic, with a large-sized unilateral endometrioma (>9 cm) containing solid components and papillary projections. Each case suspected to have EAOC has specific characteristics, and a multidisciplinary discussion and appropriate patient counseling should be conducted to reach an optimal therapeutic plan. Since most of these cases are diagnosed at an early stage with a favorable prognosis, fertility-sparing surgery may be feasible. The pros and cons of fertility preservation techniques should be discussed.

Association of Endometrioma Size with Serum Anti-mullerian Hormone.

To evaluate the relationship between the size of endometrioma and serum Anti-mullerian hormone (AMH). A Descriptive study. This study was conducted at the Bagcilar Training and Research Hospital, Istanbul, Turkey, from January 2015 to January 2020. Healthy women of reproductive age, who were found to have unilateral endometrioma in ultrasonography, were included in the study group. There were 82 female patients with unilateral endometrioma in the study group and 96 healthy female patients with male factor infertility in the control group. Women with autoimmune disease, a history of pelvic infection or surgery, polycystic ovary syndrome, pregnancy, those undergoing infertility treatment, family history of premature ovarian failure, and those with atypical or suspected endometrioma were excluded. Age, gravida, serum AMH value, and endometrioma size of the study and control groups were recorded. In addition, the endometrioma group was divided into 2 groups with a cut-off size of greater or less than 40 mm. AMH values ​​were evaluated in these two groups. AMH values ​​of women with endometrioma were significantly lower than the control group (2.03 ng/ml and 3.87 ng/ml, respectively, p<0.001). When the relationship between endometrioma size (greater than 40 mm and less than 40 mm) and AMH was examined, no statistically significant difference was found among serum AMH values (1.89 ng/ml and 2.07 ng/ml, respectively, p=0.65). The presence of endometrioma was associated with lower AMH suggesting lower ovarian reserve, but endometrioma size was not associated with significant difference in the AMH values. Endometrioma, AMH, Ovarian reserve, Endometrioma size.

The Impact of Enucleation of Unilateral Endometriomas on the Ovarian Reserve and Reproductive Function

Background: The data concerning the impact of endometrial cystectomy on the ovarian reserve is controversial. It is not clear how the cyst size and women age influence the outcome of surgical intervention in participants with ovarian endometrioma. Objectives: The study was aimed to evaluate the impact of enucleation of unilateral endometriomas on the ovarian reserve and reproductive function with regard to cyst size and women age. Materials and Methods: The study included 60 participants aged 19-40 years, with unilateral endometrioma and infertility, who underwent laparoscopy. Study participants were divided into 2 groups by the size of cyst: &lt;3 and ≥ 3 cm. Each group was divided into subgroups by the age of participants: &lt;35 and ≥ 35 years. The serum level of anti-mullerian hormone and antral follicle count were determined before, after 1 and 6 months of cystectomy. The rate of pregnancy was recorded during 1 year of post-surgery. Results: The level of anti-mullerian hormone and antral follicle count were significantly low in participants aged ≥ 35. Ovarian reserve decreased in all participants after 1 month of surgery, restored after 6 months in younger women, but didn’t reach the preoperative level. The pregnancy rate was low in participants aged ≥ 35 with cyst ≥ 3cm and no significant difference was found between smaller vs. larger cyst groups. Conclusion: Endometrial cyst size does not affect the reproductive outcome in women after laparoscopic cystectomy; however, the age of participants and preoperative ovarian reserve are significant factors regarding reproductive function. Thus, preoperative ovarian reserve should be considered before surgery, especially in women aged ≥35 years.

Long-Term Follow-Up Of Anti-Mullerian Hormone Levels After Laparoscopic Endometrioma Cystectomy.

Objective: The study aims to evaluate long-term ovarian reserve change by serum anti-Mullerian hormone (AMH) level and determine the factors that affect the changes after laparoscopic endometrioma cystectomy.Methods: In a prospective longitudinal study, 104 patients with unilateral (n=77) and bilateral (n=27) endometrioma underwent laparoscopic endometrioma cystectomy. AMH levels were measured preoperatively and at 1, 3, 6, and 12 months postoperatively. Multivariate linear regression analysis was performed to determine factors related to AMH level changes.Results: Median preoperative AMH levels significantly declined from 3.77 ng/mL to 1.60 ng/mL (P<0.001), 1.66 ng/mL (P<0.001), 1.67 ng/mL (P<0.001), and 1.72 ng/mL (P<0.001) at 1, 3, 6, and 12 months postoperatively, respectively. The rate of decrease in AMH was unchanged six months after surgery, 52.2%, 53.7%, 54.8% at 1, 3, 6 months, respectively, and declined to 43.2% at 12 months. Although most factors were associated with AMH level changes in monovariant linear regression, multivariant linear regression analysis showed only three factors that reached the statistical significance, including bilateral endometriomas, mean size of the endometrioma, and preoperative AMH levels.Conclusions: Serum AMH levels decline significantly after laparoscopic cystectomy of endometriomas but recovered at 12 months compared with the first 6 months with unilateral endometrioma. Bilateral endometriomas, size of the cyst, and preoperative AMH levels might independently affect AMH levels at 12 months after surgery.

Absorbable Hemostatic Particles to Reduce the Damage on the Follicular Reserve After Ovarian Endometriomas Stripping

Objective: to reduce the surgical damage to the ovarian reserve, after stripping of ovarian endometrioma, of the necrotic type given by the electrohaemostasis or ischemic type given by the suture. Design: perform haemostasis on ovarian parenchyma with topical haemostatic agents. Materials and methods: we used Arista AH which is a powder made up of microporous polysaccharide hemospheres that act by osmotic action and accelerate the natural coagulation process. We used Arista AH in 27 women with mono- or bilateral ovarian endometriosis. Results: in all treated cases we obtained a rapid and optimal haemostasis. There were no post-surgical complications related to haemostatic defects. Three months after the surgery, we checked the Antral Follicle Count (AFC) with a trans-vaginal ultrasound probe. AFC in 24 women with full follow-up gave the following results: unilateral endometrioma – AFC between 5 and 8 (MV: 6.3), bilateral endometriomas – the AFC between 5 and 7 (MV: 5.8). Conclusions: The use of Arista AH powder allows highly effective hemostasis and is easy to use, fully respecting the residual ovarian parenchyma after stripping.

Ovarian function following use of various hemostatic techniques during treatment for unilateral endometrioma: Arandomized controlled trial.

To compare the effect of hemostatic techniques (bipolar energy versus hemostatic sealants versus suture) on the ovarian reserve of patients submitted to laparoscopic cystectomy for the surgical excision of unilateral endometrioma. A randomized controlled trial conducted in a teaching hospital included 84 patients with unilateral endometrioma. The patients underwent laparoscopic stripping for excision of the unilateral endometrioma between March 2018 and February 2020. Three different hemostatic techniques-bipolar energy (Group 1), hemostatic sealants (Group 2), and suture (Group 3)-were compared. Anti-Müllerian hormone (AMH) levels were measured before, and 1 and 6months after surgery to determine changes in ovarian function. Following surgery, AMH levels decreased in all the groups; however, this decrease was not statistically significant. Comparison between groups showed no statistically significant differences in AMH levels between the three hemostatic techniques used. Six months after surgery, median AMH levels were: 1.65ng/mL (interquartile range [IQR] 0.62-2.08ng/mL) in Group 1, 1.87ng/mL (IQR 1.27-2.97ng/mL) in Group 2, and 1.53ng/mL (IQR 1.18-2.44ng/mL) in Group 3. The present study suggests that there is no difference between the different hemostatic techniques used in laparoscopic cystectomy for the treatment of unilateral endometriomas. Registered at ClinicalTrials.gov: NCT03430609. https://clinicaltrials.gov/ct2/show/NCT03430609.

Mapping of endometriosis in patients with unilateral endometrioma.

To map the distribution of the sites most affected by endometriosis in patients with unilateral ovarian endometriomas.A descriptive case series of 84 patients with unilateral endometriomas undergoing laparoscopy for the treatment of endometriosis. To evaluate the distribution of the sites of endometriosis lesions, the peritoneal compartments were divided into 5 zones: zone 1/the anterior compartment, including the anterior uterine serosa, vesicouterine fold, round ligament, and bladder; zone 2/the lateral compartment, including the left and right ovary, ovarian fossa, tubes, mesosalpinx, uterosacral ligaments, parametrium, and the ureter; zone 3/the posterior compartment, including posterior uterine serosa, the pouch of Douglas, posterior vaginal fornix, and bowel; zone 4 consisting of the abdominal wall; and zone 5 consisting of the diaphragm.Of the 5 zones evaluated, the lateral compartment (zone 2) was the most affected, with 60.7% of the patients having dense adhesions around the left ovarian fossa and 57.1% around the right ovarian fossa. The ovarian endometriomas were more commonly found on the left side (54.8%) compared to the right (45.2%). In the posterior compartment (zone 3), the posterior cul-de-sac was obliterated in 51.2% of the patients. In the anterior compartment (zone 1), there were lesions in the vesicouterine fold in 30.9% of the patients and in the bladder in 19%. Lesions were found in the abdominal wall (zone 4) and diaphragm (zone 5) in 21.4% and 10.7% of patients, respectively.Unilateral endometriomas are important markers of the severity of endometriosis.

P–323 Ovarian response to stimulation according to endometrioma size, in women with deep infiltrating endometriosis – A comparative study

Abstract Study question Does endometrioma (OMA) size affect the number of oocytes retrieved after ovarian stimulation (OS) in women with deep infiltrating endometriosis (DIE)? Summary answer: No significant difference in the number of oocytes retrieved was observed according to the endometrioma size. What is known already Ovarian endometriosis lesions (OMA) per se and above all, the surgical excision, appears to result in a risk of alteration of the ovarian reserve. In vitro fertilization (IVF) is a validated therapeutic option to treat infertility related to endometriosis. Nevertheless, it has been described that the presence of OMA could have a detrimental impact on ovarian responsiveness to hyperstimulation involving mechanisms still unclear. Some recent studies suggest that the size of the OMA may be relevant and that there may be a threshold in cyst diameter above which ovarian responsiveness might be affected. Study design, size, duration: This was an observational study using data prospectively collected in a cohort of infertile women aged between 18 and 43 years presenting OMA associated with DIE lesions, between December 2012 and July 2019. Every patient underwent their first in vitro fecundation or intracytoplasmic sperm injection (IVF/ICSI) cycle. Included women were women with an adequate imaging work up with Transvaginal ultrasound and/or magnetic resonance imaging (TVUS/MRI) performed by senior radiologists before the beginning of the OS. Participants/materials, setting, methods One hundred and eighty-two women were included in the study. Women were allocated in 5 groups according to the largest diameter of their ovarian endometriosis lesions: OMA &amp;lt; 2 cm, 2 cm ≤ OMA &amp;lt; 4 cm, 4 cm ≤ OMA &amp;lt; 6 cm, 6 cm ≤ OMA &amp;lt; 8 cm, OMA ≥ 8 cm. The main outcome was the number of oocytes retrieved. Main results and the role of chance Mean age of the included women was 32.8 years. 96(52.7%) women had unilateral endometrioma and 86 (47.3%) had bilateral endometriomas. The mean OMA size was 3.63 cm for right ovary and 3.60 cm for left ovary. Considering the largest diameter of OMA retained, the mean size was 4.12 cm. Repartition among groups, according to the size of the largest OMA diameter was: OMA &amp;lt; 2cm group (n = 32); 2 £OMA&amp;lt; 4 cm (n = 70); 4 £OMA&amp;lt; 6 cm, (n = 37); 6 £OMA&amp;lt; 8 cm (n = 27); OMA8 cm (n = 16). Mean number of oocytes retrieved was not significantly different between groups (p = 0.635): 8.4±5.7 for OMA&amp;lt; 2 cm, 7.3 ± 5.4 for 2 cm≤OMA&amp;lt;4 cm, 6.6 ± 3.9 for 4 cm≤OMA&amp;lt; 6 cm, 8.6 ± 5.8 for 6 cm ≤OMA&amp;lt;8 cm and 7.1 ± 3.6 for OMA≥8 cm. Mean number of matures oocytes was also comparable between groups (p = 0.674). Clinical pregnancy rate and live birth rate was similar between groups (p = 0.798 and p = 0.913). No significant difference was found concerning the number of cancelled cycles between groups (p = 0.703). Limitations, reasons for caution For almost half of the included women, endometriosis diagnosis was based on imaging technics, without histological proof of endometriosis. However, it was performed by specialized seniors radiologists. Wider implications of the findings: Our study suggests that whatever endometrioma size, OS can be benefit for women with endometrioma, even for largest ones, without the requirement of prior treatment to reduce their size Trial registration number NA

P-321 The impact of endometrioma and ovarian cystectomy in patients with major indications for IVF/ICSI with endometriosis

Abstract Study question Does presence of endometrioma has worse IVF/ICSI outcome than endometriosis per se? What about the impact of cystectomy of endometrioma on IVF/ICSI outcomes? Summary answer IVF/ICSI outcome of patients with endometrioma is comparable than with endometriosis. Cystectomy for endometrioma did not alter IVF/ICSI outcomes if ovarian reserve is comparable. What is known already Previous studies revealed women with endometrioma undergoing IVF/ICSI had similar reproductive outcomes compared with those without. Most of the comparisons are between women with endometrioma and women without endometriosis. However, endometrioma per se, different from endometriosis may have specific impact on IVF/ICSI outcomes. There is now molecular, histological and morphological evidence to suggest endometrioma is detrimental to the ovaries. Studies comparing IVF/ICSI outcomes between women with endometrioma and women with endometriosis are few. Cystectomy of endometrioma may worse ovarian reserve, and subsequently adversely affect IVF/ICSI outcomes. But there are possible complications associated with the persistence of endometrioma during IVF/ICSI. Study design, size, duration Retrospective analysis of 2153 IVF/ICSI cases during Jan/01/2014 to Dec/31/2018 in VGHTC. We included women who received ART due to endometriosis(n = 208). Exclusion criteria including patients &amp;gt;40 years-old, simulation day &amp;lt; 5 days, severe male factor, uterine factor (including adenomyosis) and immunological factors. Patients whose embryos were not completely transferred back or who received embryo transfer from different OPU cycles are excluded. We followed up these patients till 2020/6. The primary outcome is cumulative LBR Participants/materials, setting, methods For first analysis, we divided 208 cases to patients with endometrioma during IVF/ICSI(n = 89), and patients only diagnosed of endometriosis (n = 119). Second analysis on the effect of cystectomy of endometrioma on IVF/ICSI outcomes. Patients with endometrioma (n = 89) during IVF/ICSI were further divided to patients with primary endometrioma (n = 70) and patients with recurrent endometrioma (n = 19, ever received cystectomy for endometrioma). Another group is patients without endometrioma during IVF/ICSI, but ever received cystectomy before (n = 40) Main results and the role of chance For the first analysis, age, BMI and AMH were comparable in endometrioma (n = 89) and endometriosis group(n = 119). The usage gonadotropin dose was significantly higher in the endometrioma group (FSH 3619IU vs 3471IU, p = 0.001. LH 1224 IU vs 941 IU, p = 0.009). The Blastocyst formation rate is lower in the endometrioma group (49.4% vs. 57.7% p = 0.005). The OPU number, LBR and cumulative LBR were comparable in both groups (10.3 vs 12.4 p = 0.131, 33.3% vs 37%, p = 0.687, 49.4% vs 60.5%, endometrioma vs endometriosis). For the second analysis, when comparing cystectomy before IVF/ICSI group with primary endometrioma group, cystectomy group were younger (32.8 vs 34.8 p = 0.006). AMH level were comparable. The BC formation rate was significantly higher in the cystectomy group (61.5% vs 50.4% 0= 0.007). The LBR and cumulative LBR were comparable in both groups (43.5% vs 28.1%, 60% vs 48% in cystectomy vs primary endometrioma group). As for the recurrent endometrioma group, the age and AMH level were comparable with cystectomy group, but the usage gonadotropin dose was significantly higher than other two groups. The BC formation rate was also lower than cystectomy group (47.8% vs 61.5% p = 0.042). The LBR and cumulative LBR were comparable with other two groups (55.6%, 57.9%). Limitations, reasons for caution This is a retrospective study, and the sample size is limit. We did not analysis the size of endometrioma nor the unilateral or bilateral endometrioma. Wider implications of the findings Cystectomy for endometrioma must be carefully selected since it did not alter IVF/ICSI outcome only if the ovarian reserve is not affected. Recurrent endometriomas do not have a worse impact on IVF/ICSI outcome than primary endometrioma. If there is recurrent endometrioma, IVF/ICSI may be the first priority. Trial registration number not applicable

P–321 The impact of endometrioma and ovarian cystectomy in patients with major indications for IVF/ICSI with endometriosis

Abstract Study question Does presence of endometrioma has worse IVF/ICSI outcome than endometriosis per se? What about the impact of cystectomy of endometrioma on IVF/ICSI outcomes? Summary answer IVF/ICSI outcome of patients with endometrioma is comparable than with endometriosis. Cystectomy for endometrioma did not alter IVF/ICSI outcomes if ovarian reserve is comparable. What is known already Previous studies revealed women with endometrioma undergoing IVF/ICSI had similar reproductive outcomes compared with those without. Most of the comparisons are between women with endometrioma and women without endometriosis. However, endometrioma per se, different from endometriosis may have specific impact on IVF/ICSI outcomes. There is now molecular, histological and morphological evidence to suggest endometrioma is detrimental to the ovaries. Studies comparing IVF/ICSI outcomes between women with endometrioma and women with endometriosis are few. Cystectomy of endometrioma may worse ovarian reserve, and subsequently adversely affect IVF/ICSI outcomes. But there are possible complications associated with the persistence of endometrioma during IVF/ICSI. Study design, size, duration Retrospective analysis of 2153 IVF/ICSI cases during Jan/01/2014 to Dec/31/2018 in VGHTC. We included women who received ART due to endometriosis(n = 208). Exclusion criteria including patients &amp;gt;40 years-old, simulation day &amp;lt; 5 days, severe male factor, uterine factor (including adenomyosis) and immunological factors. Patients whose embryos were not completely transferred back or who received embryo transfer from different OPU cycles are excluded. We followed up these patients till 2020/6. The primary outcome is cumulative LBR Participants/materials, setting, methods For first analysis, we divided 208 cases to patients with endometrioma during IVF/ICSI(n = 89), and patients only diagnosed of endometriosis (n = 119). Second analysis on the effect of cystectomy of endometrioma on IVF/ICSI outcomes. Patients with endometrioma (n = 89) during IVF/ICSI were further divided to patients with primary endometrioma (n = 70) and patients with recurrent endometrioma (n = 19, ever received cystectomy for endometrioma). Another group is patients without endometrioma during IVF/ICSI, but ever received cystectomy before (n = 40) Main results and the role of chance For the first analysis, age, BMI and AMH were comparable in endometrioma (n = 89) and endometriosis group(n = 119). The usage gonadotropin dose was significantly higher in the endometrioma group (FSH 3619IU vs 3471IU, p = 0.001. LH 1224 IU vs 941 IU, p = 0.009). The Blastocyst formation rate is lower in the endometrioma group (49.4% vs. 57.7% p = 0.005). The OPU number, LBR and cumulative LBR were comparable in both groups (10.3 vs 12.4 p = 0.131, 33.3% vs 37%, p = 0.687, 49.4% vs 60.5%, endometrioma vs endometriosis). For the second analysis, when comparing cystectomy before IVF/ICSI group with primary endometrioma group, cystectomy group were younger (32.8 vs 34.8 p = 0.006). AMH level were comparable. The BC formation rate was significantly higher in the cystectomy group (61.5% vs 50.4% 0= 0.007). The LBR and cumulative LBR were comparable in both groups (43.5% vs 28.1%, 60% vs 48% in cystectomy vs primary endometrioma group). As for the recurrent endometrioma group, the age and AMH level were comparable with cystectomy group, but the usage gonadotropin dose was significantly higher than other two groups. The BC formation rate was also lower than cystectomy group (47.8% vs 61.5% p = 0.042). The LBR and cumulative LBR were comparable with other two groups (55.6%, 57.9%). Limitations, reasons for caution This is a retrospective study, and the sample size is limit. We did not analysis the size of endometrioma nor the unilateral or bilateral endometrioma. Wider implications of the findings: Cystectomy for endometrioma must be carefully selected since it did not alter IVF/ICSI outcome only if the ovarian reserve is not affected. Recurrent endometriomas do not have a worse impact on IVF/ICSI outcome than primary endometrioma. If there is recurrent endometrioma, IVF/ICSI may be the first priority. Trial registration number Not applicable

P–293 Ovarian endometriomas are heterogenous for the steroidogenic function and the expression of estrogen and progesterone receptors

Abstract Study question Do all ovarian endometriomas have steroidogenic function and express estrogen and progesterone receptors? Summary answer No, they are heterogenous for the steroidogenic function and the expression of the estrogen and progesterone receptors. What is known already Excessive ectopic estrogen production and up-regulation of estrogen receptor- β, which drives inflammation together with aberrant progesterone signaling leading to impaired decidualization and establishment of ectopic endometrial implants together with down-regulated progesterone receptor (PR) expression are the cardinal molecular features of the disease. However, several fundamental questions still remain to be answered as to whether all ovarian endometriomas carry these molecular aberrations and are steroidogenically active; and if so, the amount of sex steroids they produce correlate with the level of expression of steroidogenic enzymes. We aimed to address these questions in the current study. Study design, size, duration A molecular research study on the surgical specimens collected between April 2020 and December 2020. Seven histopathologically confirmed benign endometriotic cyst capsules obtained from the patients undergoing laparoscopic excision of unilateral ovarian endometriomas without deep infiltrating endometriosis during early follicular phase were used in the study. Participants/materials, setting, methods The mean age±SD (range) of the patients were 32.8±4.9 (30–39). The mean endometrioma size was 5±1.2cm (5–7.5 cm). The samples were cut into equal size pieces of 0.5x0.5cm size and cultured for one day to measure their E2and P4production; and analyzed for the expression of steroidogenic enzymes with quantitative immunoblotting and for the expression of FSH-R, ER and PR with real-time qRT-PCR methods. Luteinized granulosa cells and ovarian cortex were set as references. Main results and the role of chance StAR expression was consistently observed in all samples. However, we noticed significant discrepancies among the samples regarding their steroidogenic function and the expression of aromatase and 3 β-HSD enzymes. E2 production exhibited significant variation (from 5 to 1177pg/mL) from sample to sample despite comparable levels of aromatase expression. ER- βup-regulation as a cardinal molecular feature of endometriosis, was observed in all but one samples (1.46 to 5.48 folds, p &amp;lt; 0.0001). However, its expression level did not correlate with either aromatase expression or the amount of E2 the samples produced. A similar phenomenon was observed in P4 arm of steroidogenesis. Even though 3 β-HSD was expressed by all but one samples detectable amount of P4 was produced only by two samples (up to 15ng/mL). PR expression was down-regulated only in two samples (0.3 to 0.07 folds, p &amp;lt; 0.0001), and significantly up-regulated in the other samples (1.2 to 4.7 folds, p &amp;lt; 0.001). No correlation was found among the samples regarding the expression of PR, 3 β-HSD and P4 output. FSH-R was detected in all samples at the levels comparable to ovarian cortex but its expression level did not show any correlation with ER, aromatase expression and E2 production. Limitations, reasons for caution These results need to be confirmed in studies with larger sample size and different types of endometriotic lesions. Wider implications of the findings: The regulation of steroidogenic activity of endometriomas cannot simply be explained by the expression level of the steroidogenic enzymes, underscoring the importance of other mechanisms that post-translationally regulate their enzymatic activity and metabolism of estrogen and progesterone. PR is not always down-regulated and FSH-R is commonly up-regulated in ovarian endometriomas. Trial registration number Not applicable

Is There a Role of 25-Hydroxy Vitamin D in the Pathogenesis of Mild and Moderate-to-Severe Endometriosis?

Objective: To evaluate the possible associations between serum 25-hydroxy vitamin D levels and clinical and laboratory parameters in endometriosis.Study design: A total of 53 women with endometriosis and 37 women without endometriosis were evaluated in a, case-controlled study. The demographic features, clinical, and laboratory parameters of the two groups were compared.Results: The serum 25-hydroxy vitamin D levels were significantly decreased in both stage 1-2 and stage 3-4 groups compared to the controls (p&lt;0.001 and p&lt;0.001); although the difference between the stage 1-2 and stage 3-4 groups remained nonsignificant. The serum 25-hydroxy vitamin D levels had no correlation with the presence of infertility, deep infiltrating endometriosis, or Douglas pouch obliteration. The women who had bilateral endometrioma had significantly lower levels of 25-hydroxy vitamin D compared to the women with unilateral endometrioma (8.4±2.7 ng/mL vs 11.1±5.6 ng/mL, p=0.047). Mean serum 25-hydroxy vitamin D levels in women with and without dysmenorrhea were not significantly different from each other in the endometriosis and non-endometriosis subgroups. Serum 25-hydroxy vitamin D had no correlation with dysmenorrhea-VAS scores (r=-0.157, p=0.267).Conclusion: The mean serum 25-hydroxy vitamin D levels were significantly decreased in both mild and moderate to severe endometriosis groups compared to the controls. The serum 25-hydroxy vitamin D levels had no correlation with the presence of infertility, deep infiltrating endometriosis, or Douglas pouch obliteration. The women who had bilateral endometrioma had significantly lower levels of 25-hydroxy vitamin D compared to the women with unilateral endometrioma.

Coexistence of endometriomas with extraovarian endometriosis and adhesions

ObjectiveThe aim of the study is to show the coexistence of the endometriomas with peritoneal and deep infiltrating endometriosis, as well as with the adhesions.Study designIt's a randomized retrospective study. Patients treated for endometrioma at Academic Hospital Cologne Weyertal from January 2014 to October 2019 were included. In total there were 1054 patients. 310 medical records were chosen at random without a special selection and the data were analysed. ResultsIn our study, endometriomas were alone, which means without extraovarian endometriosis and/or adhesions, in only 2.3% of the cases. In the total population, 80.6% (250) of the patients had peritoneal endometriosis, 43.2% (134) of the patients had deep infiltrating endometriosis and 38% (118) of the patients had peritoneal and deep infiltrating endometriosis. In our analysis we found that in unilateral endometriomas there is no relationship between endometrioma size and adnexal adhesions. The risk of Douglas obliteration increases with the size of the endometriomas in unilateral endometriomas. In bilateral endometriomas, the risk of a complex adhesions is independent of the size of the endometriomas and relevantly higher than in unilateral endometriomas (Douglas obliteration 31.5% vs 16%, bilateral adnexal adhesions 45.2% vs 21.1%). Unilateral adnexal adhesions occurred in bilateral endometriomas only in 13.7%. ConclusionEndometriomas are the relevant problem in gynaecological practice. It must be taken into account here that endometriomas usually occur with peritoneal endometriosis and that surgical therapy may be useful. However, adhesions and DIE are to be expected with surgical treatment, which could make the operation more difficult. Especially in large and bilateral endometriomas, a high coexistence with extraovarian endometriomas and adhesions is observed. Therefore, surgery should be performed by an experienced surgeon.

Assisted reproductive technique outcomes in patients with endometrioma undergoing sclerotherapy vs laparoscopic cystectomy: Prospective cross-sectional study.

PurposeThe authors compared assisted reproductive technique (ART) outcomes and the recurrence rate of endometrioma in the infertile patients undergoing sclerotherapy vs laparoscopic ovarian cystectomy.MethodsIn this prospective cross‐sectional study, a total of 101 infertile patients, with unilateral endometriomas, were divided into two groups. The first group (n = 57) underwent ART after 1 year of unsuccessful spontaneous pregnancy after laparoscopic ovarian cystectomy; the second group (n = 44) had ethanol sclerotherapy (EST) at the time of oocyte retrieval. The authors measured the number of oocytes, clinical pregnancy rate (CPR), live birth rate (LBR), complication, and recurrence of endometriomas as the primary and secondary outcomes.ResultsThe two groups had no significant differences in baseline characteristics and ovarian stimulation markers and also total number of oocytes. 42.1% and 34.1% of the patients (n = 24 and 15) had clinical pregnancy, and 38.6% and 29.5% (n = 22 and 13) had live birth following ART cycles in the surgery group and sclerotherapy group (P = .41, 0.34). The recurrence rates were 14.0% and 34.1% in the surgery and sclerotherapy groups (P = .017, X 2 = 5.67).ConclusionsEthanol sclerotherapy can be a good alternative to surgery concerning the treatment of endometrioma; however, the recurrence of the disease in this group is significantly higher.

Are women with small endometriomas who undergo intracytoplasmic sperm injection at an elevated risk for adverse pregnancy, obstetric, and neonatal outcomes?

ObjectiveThe aim of the study was to investigate pregnancy, obstetric, and neonatal outcomes in women with small (<4 cm) unilateral endometriomas.MethodsThis retrospective study included 177 patients: 91 patients with small endometriomas and 86 controls with unexplained or tubal factor infertility who were treated at the Süleymaniye Gynecology and Maternity Training and Research Hospital Infertility Unit between January 2010 and July 2015. The groups were matched with regards to demographic characteristics such as age, body mass index, and infertility duration. All of the women in this study conceived via intracytoplasmic sperm injection. We compared pregnancy, obstetric, and neonatal outcomes between these groups.ResultsWomen with endometriomas had a higher biochemical pregnancy rate, but lower clinical pregnancy and live birth rates than women with unexplained and tubal factor infertility (p<0.05 for all). However no significant differences were found in terms of obstetric and neonatal complications between the two groups (p>0.05 for all).ConclusionIn this study, we found that women with endometriomas less than 4 cm were more prone to early pregnancy complications. We also showed that this group did not have any increased risks of late pregnancy, obstetric, and neonatal complications.