Endometriomas and In Vitro Fertilisation

Endometriomas and in vitro fertilization outcomes.

This article reports the effects of endometriomas and infertility treatments on their out-come mainly in cases of in vitro fertilization.

The main conclusions are: the absence of any deleterious effects on IVF results in cases of endometriomas, the conservation of the stock oocytes in the ovary after any type of surgery for ovarian endometriomas (Cystectomy or more drainage laser vaporization), the poor out-come of iterative surgical approach of endometriomas, the risk of ovarian abscess after puncture during an IVF procedure.


INTRODUCTION

The presence of endometriomas in the course of a cycle of in vitro fertilization (IVF) raises several concerns among practitioners

• The risk of poor ovarian response,
• The low chance of pregnancy, The risk of an "outbreak" of the endometriomas by hormonal stimulation, and
• The risk of infection and abcédation of endometriomas after follicular puncture.

Most of these concerns about endometriomas and IVF date from a study in 1989 Dlugi become obsolete since the advent of analogues of Gn-RH [1]. This study suggested a deleterious effect of endometriomas and called for their removal prior to IVF.

On the other hand, surgery for endometriomas has often been accused of being "destructive" for the ovarian reserve.


Endometriomas AND RISKS OF IVF

Most of the fears reported in the introduction are quite imaginary. Indeed, no cases have been reported endometriosis cyst rupture after IVF or any outbreak of endometriosis or endometriomas after ovarian stimulation. Only one case of endometriosis cyst rupture during pregnancy IVF is found in the literature.

However, there are a dozen publications reporting cases of infection of endometriomas. Team Clermont-Ferrand reported a case of bilateral endometriomas abscess in early pregnancy with birth of twins. This case (unpublished) was instructive in many respects.

* The germ of 2 identical sides, which proves that the good seed punctures IVF follicles and, despite aseptic precautions and antibiotic prophylaxis, as the authors emphasize.
* Drainage percoelioscopique these endometriomas abcédés proved as ineffective in many publications.
* This is a vaginal drainage that resulted in the healing of the patient.
* Nevertheless, the pregnancy continued.

Thus, it is necessary to avoid a drain on endometriomas during IVF to avoid the risk of abcédation. This is not to drain through a endometriomas is not always easy or even feasible. The antibiotic appears to be ineffective. As an anecdote, a Japanese publication reports an attempt to endometriomas of alcohol to avoid infection after puncture. This attempt ended in failure and a abcédation of endometriomas. Rest postponction monitoring to intervene as soon as possible in case of complications.


IMPACT OF SURGERY ON endometriomas ovarian response in IVF

As we have seen, there is no scientific evidence that proves the need for the endometriomas to improve the outcome of IVF.

In contrast, the surgical treatment of endometriomas can achieve spontaneous pregnancy in many cases, but it has also been accused of having a negative impact on ovarian reserve and thereby to risk compromising the chances of IVF.

Moreover, the modalities of surgical treatment have long been discussed between the kystectomie with drainage and spraying. Especially for the team in Brussels, vapourizing LASER would avoid the destruction of eggs located on the outskirts of the endometriomas. Team Clermont supports the opposite theory.

In one study, we compared the IVF outcomes of 3 groups of women, made of endometriomas (kystectomie), those made of endometriosis without endometriomas and a group of tubal pathology [6]. If the number of oocytes collected was somewhat lower among women who had a kystectomie, this number is generally good (on average 9.5 oocytes) and the rates of pregnancies and deliveries are identical in the 3 groups (Table V). This publication shows that the trained hands, the kystectomie had no major impact on ovarian reserve.

Thereafter, the team compared Give the results after IVF treatment of endometriomas by kystectomie or by drainage and LASER vaporization [7] with a control group of endometriosis without endometriomas. If the number of oocytes collected was somewhat lower in the group kystectomie, it is nevertheless correct, and finally the rate of pregnancies and births are identical in the 3 groups (Table VI).

In a study by the analysis based on the size of endometriomas, Give with a difference in the number of oocytes according to the size of endometriomas, but not according to the type of surgery (table VII ).

In light of these studies, it appears that the argument for the destruction of stock oocyte may be an argument of choice in the type of surgery.

However, Beretta in a randomized comparative study gets better pregnancy rates after kystectomie (60% versus 25% at 20 months), but a risk of recidivism much lower (6.6% versus 18%) [8].

This increased risk of recurrence and reoperation after spraying LASER is found in the study of Saleh with reoperation rates of 10 and 50% [9].

All calls instead for the creation of a kystectomie when surgical treatment is indicated before IVF.

As to the likelihood of achieving pregnancy after intervention endometriomas, it remains a difficult element to measure. Most authors report figures between 30 and 50%. The main prognostic factors do not appear to be in technique or procedure or in the size of endometriomas, but many more in associated pathologies, and particularly in the degree adhérentiel. pelvic.
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CONCLUSION

Our conclusion will be made in the form of answers to questions we are most frequently asked questions.

Should we make the endometriomas before IVF?
o Yes, because the intervention results in spontaneous pregnancies and surgery and not well made does not iterative any future IVF.
o No, if one considers that the surgery has been very fortunate to achieve a pregnancy and that IVF is indicated. This is particularly the case of recurrence or in the case of endometriosis ultrasound and clinically very severe.
Should réopérer a recurrent endometriomas before switching to IVF?
o No, because this will not impact either positive or negative effect on IVF.
o Similarly, the discovery of a endometriomas during stimulation for IVF is not an indication to stop IVF.
o However, if very large endometriomas, drainage préventif could facilitate the puncture. The best technique is the drainage under ultrasound.
Which surgical technique should be used?
o Finally, there is no big difference between the drainage and kystectomie LASER vaporization with respect to the alteration of the oocyte stock.
o The first is the more accessible material and appears to have a lower recidivism rate.
o However, all endometriosis cysts are not readily clivables and in this case, the technique of coagulation drainage is preferable.
Should drains an endometriomas during IVF puncture?
o No, because this is not enough to make and increase the risk of abcédation.
o Yes, it is with pain, but with caution and under antibiotic coverage.
Can we drain follicles by passing through a endometriomas?
o Clearly, it is best to avoid in order not to risk a abcédation.
o However, this complication is not frequent and if it is sometimes impossible to do otherwise. The presence of liquid chocolate in the sample did not affect the outcome of IVF when the oocytes were treated immediately by the biologist.
What is the best treatment for endometriomas on ovarian abscess after oocyte aspiration?
o The drainage vaginally, if possible, is the technique most effective and least aggressive.
o The approach coelioscopique is a second-best, because there is often a pelvic armor that makes the start of the ovary very difficult.