Invited Lecture delivered by Dr Sujoy Dasgupta in a scientific meeting organized by Ferring Pharmaceutical Pvt Ltd in June 2018 at Kolkata

1. Fertility Management in Ovarian
Endometrioma
Dr Sujoy Dasgupta
MBBS (Gold Medalist, Hons)
MS (OBGY- Gold Medalist)
DNB (OBGY)
MRCOG (London)
Consultant, Genome: The Fertility Centre, Kolkata
Secretary, Subfertility & Reproductive Endocrinology
Committee, Bengal Obstetric and Gynaecological Society
(BOGS)- 2018-19
Managing Committee Member, BOGS- 2018-19
Member, Quiz Committee, FOGSI East Zone, 2018-19
Member, Food and Drug Committee, FOGSI, 2018-19
Peer Reviewer, BMJ Case Reports

2. Introduction
• Ovarian endometrioma, a subtype of endometriosis,
affects 17–44% of women with endometriosis.
• Also known as ‘chocolate cysts’, contain thick, old
haemorrhage that appears as a brown fluid.
• 30% cases are bilateral.
• more frequently located in the left hemipelvis and
left ovary.
• Commonly present with pelvic endometriotic lesions.
• Up to 50% cases are accidently diagnosed during
laparoscopy/ laparotomy.
2

3. Etiology: Ovarian Endometrioma
• Exact cause about ovarian endometrioma is not
known
• Three postulated theories
1. Invagination of ovarian cortex secondary to bleeding of a superficial
implant (Hughesdon, 1957)
2. Invagination of ovarian cortex secondary to metaplasia of coelmic
epithelium in cortical inclusion cysts (Donnez et al, 1996)
3. Endometriotic transformation of functional cysts (Nezhat et al,1992)
3

4. Patho-physiology of
Reduced Fertility in Endometrioma
 Adhesions, tubal blockage and anatomical
distortion
 Associated with chronic pelvic pain, and therefore
dysparaeunia
 Inflammatory response damaging oocytes, sperms
and fertilization capacities
 Poor embryo quantity and quality
 Poor ovarian reserve
 Inflammation affecting endometrial receptivity
4

5. Diagnosis
Assessment Features
Clinical Dyspareunia, subfertility
Laparoscopy Gold Standard
Transvaginal USG Ground glass
echogenicity of cyst fluid
3D USG For adhesions and
anatomical distortion
Color Doppler + sign of peripheral
blood flow
MRI T1 bright lesion for
localizing cyst adhesions 5

6. Conservative management for spontaneous
conception
(RCOG, 2017)
• Young women with regular menstrual cycles and an incidental finding
of an ovarian endometrioma without suspicion of malignancy who wish
to conceive
- should be encouraged to try natural conception before seeking fertility
treatment.
A prospective observational study (n = 244) reported a 43% spontaneous
pregnancy rate during the 6-month follow up period in the presence of
unilateral endometriomas of varying sizes (diameter 5.3 1.7 cm [mean SD]).
Similar ovulation rates in the affected ovary to the healthy ovary (49.7%
versus 50.3%) [Hum Reprod, 2015]
• For women with a naturally or abnormally reduced ovarian reserve
- conservative management for fertility should be weighed against the
potential benefits of surgery or fertility treatment
6

7. Medical Management
7

8. NICE, 2017
• Do not offer hormonal
treatment to women with
endometriosis who are
trying to conceive, because
it does not improve
spontaneous pregnancy
rates.
8

9. Surgical treatment for
spontaneous conception
• It may improve spontaneous pregnancy rates by restoring the pelvic
anatomy
• It remains unclear as to whether surgical intervention on the ovary itself
is beneficial as it may not reverse the inflammatory and biomolecular
changes shown to influence fertilisation and implantation.
• It is still controversial if cumulative pregnancy rate is more after surgery
but time to achieve the first pregnancy in infertile patients was
significantly shorter
• A reported reduction in the ovarian reserve (more with repeated Sx)
• A small added risk of requiring an oophorectomy
• Management should be individualised and based upon clinical factors,
including pain symptoms, size of the cysts and concerns over potential
malignancy.
• Consideration should be given to surgical treatment being undertaken
by a gynaecologist with specific expertise in endometriosis and fertility,
in order to minimise the impact on the ovarian reserve
9

10. 10

11. Which Surgery
(RCOG 2017, NICE 2017)
Compared with drainage and coagulation,
Cystectomy is associated with
• an overall lower recurrence risk
• higher spontaneous postoperative pregnancy
rate,
• particularly if the cyst is ≥3 cm in diameter.
• (OR 5.24, 95% CI 1.92–14.27; n = 88; two trials)
[Cochrane Database Syst Rev 2008;(2):CD004992]
11

12. ESHRE, 2013
12
Endometrioma is a false cyst and its cyst wall is the
same as the ovarian cortex. Therefore unsafe removal
of pseudocyst may damage the ovary and interfere
with future fertility.

13. Laparoscopic Cystectomy
• It remains the first line choice for conservative
treatment of endometriotic cysts.
• Method: inner lining of the cyst is dissected from the
ovary by 2 atraumatic grasping forceps that are
pulled in opposite directions.
• The removed tissue helps in histopathological
characterization.
• Recurrence rate with or without medication
is reported to be 5-20%.
13

14. Laparoscopic Fenestration,
Drainage, and Ablation of Cyst Wall
• Method: Surgical biopsy followed by bipolar
coagulation of the inner lining
• Careful and skilled method allows the preservation of
ovarian follicular reserve
• Recurrence rate is reported to be 2-30%.
14

15. Adjuvant to Surgery
15

16. Ultrasound-guided Aspiration
• Transvaginal USG-guided drainage without surgery does not
seem to be effective.
• a high recurrence rate
• To decrease recurrence rate, aspiration is combined with in
situ injection of tetracycline/ethanol/methotrexate
• Disadvantages:
 Complications: infection, abscess formation, and pain
 inability to rule out any malignancy
 risk of pelvic adhesion
16

17. IUI in Endometrioma
(ESHRE, 2013)
17

18. IVF in Endometrioma
(ESHRE, 2013)
18

19. Effect of endometriomas on IVF
outcome
• Evidence of the impact of an endometrioma on
ovarian response during IVF is equivocal.
• Systematic reviews showed- similar ovarian
responses
[Fertil Steril 2002, Hum Reprod Update 2015]
1. in women with endometriosis to controls with
no evidence of endometriosis
2. in women with a unilateral ovarian
endometrioma compared to contralateral
normal ovaries.
19

20. Endometrioma and IVF Outcome
• Endometrioma compared with no endometriosis,
1. ovarian response was lower, with a lower number of
oocytes retrieved (mean difference –0.23; 95% CI 0.37–0.1)
2. a higher cancellation rate (OR 2.83; 95% CI 1.32–6.06)
3. the total stimulation dosage of gonadotrophin used was
comparable.
4. live birth (OR 0.98; 95% CI 0.71–1.36), pregnancy (OR 1.17;
95% CI 0.87–1.58) and miscarriage rates (OR 1.7; 95% CI
0.86–3.35) were similar [Fertil Steril, 2012]
• Endometrioma vs other areas of endometriosis
- IVF outcomes (live birth, pregnancy, miscarriage and cycle
cancellation rates, and mean number of oocytes retrieved) were
similar [Hum Reprod Update 2015]
20

21. Predictors of ART Success in
Women with Endometrioma
• Age
• D3 FSH
• AMH
• AFC
21

22. Medical treatment before ART
(ESHRE, 2013)
22

23. Surgical treatment prior to IVF
• A systematic review (five controlled studies; n = 655) [Hum Reprod
Update 2015]
• surgically-treated endometriomas compared to those with intact
endometriomas, both having IVF
• similar live birth (OR 0.9; 95% CI 0.63–1.28), clinical pregnancy (OR 0.97;
95% CI 0.78–1.2) and miscarriage rates (OR 1.32; 95% CI 0.66–2.65)
• number of oocytes retrieved and the cancellation rates were comparable,
• lower AFC
• required higher doses of gonadotrophins for ovarian stimulation.
• Women who had undergone surgical management for a unilateral
endometrioma had a lower number of oocytes retrieved from the
surgically-treated ovary (mean difference –2.59; 95% CI –4.13 to –1.05)
when compared with the contralateral normal ovary
• The potential physiological compensation by the normal ovary
23

24. Complications during and after OPU
(RCOG, 2017)
• Technical difficulties during oocyte retrieval is low,
• No data to suggest that surgery will prevent adhesion reformation and
facilitate oocyte retrieval effectively.
• Progression of pelvic endometriosis and ovarian endometriomas- ?
• Risks of infection from an endometrioma (0–1.9%)
• Follicular fluid contamination (2.8–6.1%)
• The risk of missing an occult malignancy in an endometrioma is
extremely low
• The lifetime probability of Ca ovary increasing from 1% to 2% in the
presence of an endometrioma.
• In the context of IVF treatment, delaying surgery for a few months or
years, until the treatment has been completed or following delivery,
would usually be a reasonable course of action unless there are other
immediate concerns. 24

25. ESHRE, 2013
25

26. RCOG Recommendations (2017)
Directly ART
• Asymptomatic women,
• women of advanced
reproductive age,
• those with reduced
ovarian reserve,
• bilateral endometriomas
• a history of prior ovarian
surgery
Surgery before IVF
• highly symptomatic
women,
• with an intact ovarian
reserve,
• unilateral and large cysts,
• cysts with suspicious
radiological and clinical
features.
26

27. Latest
• Auto-transplantation of
cryopreserved or fresh, healthy
ovarian tissue
• cryopreservation of oocytes or
embryos
27

28. Conclusion
Medical management is still controversial and
its use is limited to very few cases.
Endometriomas with infertility should always
be managed surgically.
Surgery not only improves symptoms for a
longer period of time, but also increases the
pregnancy rate.
Routine surgery before ART is not justified
28