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Evidence summaries

Surgery Prior to Assisted Reproductive Technology for Women with Endometrioma

Surgery prior to assisted reproductive technology may not be effective for increasing pregnancy rates in women with endometrioma. Level of evidence: "C"

Comment: The quality of evidence is downgraded by study limitations (selective reporting and lack of blinding and).

Summary

A Cochrane review [Abstract] 1 included 4 studies with a total of 312 subjects. In two trials, surgery (aspiration or cystectomy) versus expectant management (EM) showed no evidence of a benefit for clinical pregnancy with either technique. Aspiration was associated with greater number of mature oocytes retrieved (NMOR) (MD 0.50, 95% CI 0.02 to 0.98) and increased ovarian response (E2 levels on day of hCG injection) (MD 685.3, 95% CI 464.50 to 906.10) compared to EM. Cystectomy was associated with a decreased ovarian response to controlled ovarian hyperstimulation (MD -510.00, 95% CI -676.62 to -343.38); no evidence of an effect on the NMOR compared to EM. Aspiration versus cystectomy showed no evidence of a difference in CPR or the NMOR in one trial. One trial compared gonadotropin-releasing hormone (GnRH) agonist with GnRH antagonist. There was no evidence of a difference for clinical pregnancy rate, however the number of mature oocytes retrieved was greater with GnRH agonists.

A meta-analysis 3 assessed surgical intervention of endometrioma and the infertility issue. One meta-analysis of observational studies compared endometrioma (no surgery) vs. without endometriosisand found no significant difference in clinical pregnancy rate (CPR) in IVF outcomes (OR, 1.26; 95% CI 0.78 to 2.05, n=237). Another meta-analysis of observational studies showed similar CPR (OR, 1.17; 95% CI 0.87 to 1.58; n=1512) in surgically treated vs. intact endometrioma, andsimilar CPR (OR, 0.97; 95% CI 0.78 to 1.20; n=893) in surgically treated endometrioma vs. peritoneal endometriosis alone (all IVF outcomes). A third meta-analysis of observational studiescomparing endometrioma cystectomy group vs. control group with unoperated ovaries found no significant difference in the pregnancy rate (OR, 0.98; 95% CI 0.82 to 1.18; n=2330) in IVF outcomes.

A meta-analysis 2 compared surgery versus no treatment of endometrioma on the outcome of assisted reproduction treatment (ART). 11 studies were included (mostly retrospective case-control studies, only one RCT). 10 studies compared surgical treatment for endometrioma with untreated endometrioma and 4 studies compared surgical treatment of endometrioma with aspiration of endometrioma. Live birth rate/cycle favoured surgical treatment, but the result was insignificant (OR 0.75, 95 CI to 0.54 to 1.06, 4 trials, n=647). There were no significant differences in pregnancy rate per cycle (OR 0.88, 95% CI 0.60 to 1.29, 5 trials) and clinical pregnancy rate (OR 1.08, 95% CI 0.80 to 1.45, 7 trials) between women who underwent surgery for endometrioma and those who did not.

Clinical comments

Note

Date of latest search: 2020-01-10

References

  • Benschop L, Farquhar C, van der Poel N et al. Interventions for women with endometrioma prior to assisted reproductive technology. Cochrane Database Syst Rev 2010;(11):CD008571. [PubMed]
  • Nickkho-Amiry M, Savant R, Majumder K et al. The effect of surgical management of endometrioma on the IVF/ICSI outcomes when compared with no treatment? A systematic review and meta-analysis. Arch Gynecol Obstet 2018;297(4):1043-1057. [PubMed]
  • Park HJ, Kim H, Lee GH et al. Could surgical management improve the IVF outcomes in infertile women with endometrioma?: a review. Obstet Gynecol Sci 2019;62(1):1-10. [PubMed]

Primary/Secondary Keywords