study of the Arbeitsgmeinschaft Gynakologische Onkologie (AGO) Study Group. Eur J Cancer. 2013; 49:1905–14.4 4 Palomba S, Zupi E, Russo T, Falbo A, Del NS, Manguso F, et al. Comparison of two fertility‐sparing approaches for bilateral borderline ovarian tumours: a randomized controlled study. Hum Reprod. 2007; 22(2):578–85.
5 5 Fauvet R, Poncelet C, Boccara J, Descamps P, Fondrinier E, Darai E. Fertility after conservative treatment for borderline ovarian tumors: a French multicenter study. Fertil Steril. 2005; 83(2):284–90.
6 6 Nam JH. Borderline ovarian tumors and fertility. Curr Opin Obstet Gynecol. 2010; 22(3):227–34.
7 7 Daraï E, Fauvet R, Uzan C, Gouy S, Duvillard P, Morice P. Fertility and borderline ovarian tumor: a systematic review of conservative management, risk of recurrence and alternative options. Hum Reprod Update. 2013; 19(2):151–66.
8 8 Tourgeman DE, Lu JJ, Boostanfar R, Amezcua C, Felix JC, Paulson RJ. Human chorionic gonadotropin suppresses ovarian epithelial neoplastic cell proliferation in vitro. Fertil Steril. 2002; 78(5):1096–9.
9 9 Basille C, Olivennes F, Le Calvez J, Beron‐Gaillard N, Meduri G, Lhommé C, et al. Impact of gonadotrophins and steroid hormones on tumour cells derived from borderline ovarian tumours. Hum Reprod. 2006; 21(12):3241–5.
10 10 Denschlag D, von Wolff M, Amant F, Kesic V, Reed N, Schneider A, et al. Clinical recommendation on fertility preservation in borderline ovarian neoplasm: ovarian stimulation and oocyte retrieval after conservative surgery. Gynecol Obstet Invest. 2010; 70:160–5.
11 11 Suh‐Burgmann E. Long‐term outcomes following conservative surgery for borderline tumor of the ovary: a large population‐based study. Gynecol Oncol. 2006; 103(3):841–7.
12 12 Uzan C, Kane A, Rey A, Gouy S, Duvillard P, Morice P. Outcomes after conservative treatment of advanced‐stage serous borderline tumors of the ovary. Ann Oncol. 2010; 21(1):55–60.
13 13 Boran N, Cil AP, Tulunay G, Ozturkoglu E, Koc S, Bulbul D, et al. Fertility and recurrence results of conservative surgery for borderline ovarian tumors. Gynecol Oncol. 2005; 97(3):845–51.
14 14 Zanetta G, Rota S, Chiari S, Bonazzi C, Bratina G, Mangioni C. Behavior of borderline tumors with particular interest to persistence, recurrence, and progression to invasive carcinoma: a prospective study. J Clin Oncol. 2001; 19(10):2658–64.
15 15 Zanetta G, Rota S, Lissoni A. Ultrasound, physical examination and CA125 measurement for the detection of recurrence after conservative surgery for early borderline ovarian tumours. Gynecol Oncol. 2001; 81:63–6.
16 16 Gallot D, Pouly JL, Janny L, Mage G, Canis M, Wattiez A, et al. Successful transfer of frozen‐thawed embryos obtained immediately before radical surgery for stage IIIa serous borderline ovarian tumour: case report. Hum Reprod. 2000; 15(11):2347–50.
17 17 Lawal A, B‐Lynch C. Borderline ovarian cancer, bilateral surgical castration, chemotherapy and a normal delivery after ovum donation and in vitro fertilisation‐embryo transfer. Br J Obstet Gynaecol. 1996; 103:931–2.
18 18 Bjørnholt S, Kjaer S, Nielsen T, Jensen A. Risk for borderline ovarian tumours after exposure to fertility drugs: results of a population‐based cohort study. Hum Reprod. 2015; 30(1):222–31.
19 19 Rizzuto I, Behrens R, Smith L. Risk of ovarian cancer in women treated with ovarian stimulating drugs for infertility. Cochrane Database Syst Rev. 2013;( 8), CD008215.
21 The patient with an endometrioma
Spyros Chouliaras1 and Luciano G. Nardo2
1 Sidra Medicine; and Weill Cornell Medicine, Doha, Qatar
2 Reproductive Health Group, Daresbury and Manchester Metropolitan University, Manchester, UK
Case History 1: A 35‐year‐old woman with a history of primary infertility was seen in the reproductive medicine clinic. Her anti‐Müllerian hormone (AMH) and the semen analysis of her partner were within normal range. Transvaginal pelvic ultrasound scan found she had bilateral ovarian cysts with features of endometriomas (low‐level echoes). The left ovarian cyst measured 2.8 × 2.5 × 2.3 cm and the right ovarian cyst measured 3.7 × 2.5 × 2.4 cm.
Case History 2: A 40‐year‐old woman with a 3 year history of primary infertility is known to suffer from endometriosis. She had a laparoscopic right ovarian cystectomy 2 years previously. The initial investigations found an AMH of 1.2 pmol/l as well as oligo‐astheno‐teratozoospermia for her partner. Transvaginal pelvic ultrasound demonstrated the presence of a left ovarian cyst measuring 4.5 x 4.2 x 5.2 mm with features typical for an endometrioma. There was some ovarian stroma seen separately containing three antral follicles. The right ovary was small with two antral follicles. Both ovaries were accessible for oocyte retrieval.
Background
Approximately 25–35% of infertile women suffer with endometriosis. The ovaries are known to be one of the most common sites of endometriosis. Progressive invagination of the ovarian cortex over endometriotic deposits leads to formation of an endometrioma. An endometrioma is a pseudocyst that contains ectopic endometrial deposits [1,2]. Around 5% of women referred for in‐vitro fertilization (IVF) have endometriomas, either unilateral or bilateral [3,4]. The presence of ovarian endometriomas is associated with moderate or severe stage disease according to the r‐ASRM (revised American Society for Reproductive Medicine) classification.
Anatomical damage to the ovaries and the fallopian tubes as well as formation of pelvic adhesions may cause impairment of fertility. An endometrioma is associated with reduced follicular count and reduced response to controlled ovarian stimulation with exogenous gonadotropins during IVF [5,6]. Oocyte retrieval may be challenging in the presence of an endometrioma and pelvic adhesions, and the occurrence of a pelvic abscess is not an uncommon complication.
Management options
Management of women with endometriomas during IVF treatment represents a common challenge for the clinician, especially as endometriosis is prevalent amongst infertile women. The treatment plan should be individualized, taking into account the patient’s age, results of the tests of ovarian reserve (anti‐Müllerian hormone [AMH] or antral follicle count [AFC]) and the outcome of previous medical or surgical treatments.
In order to address the controversies in the management of the patient with endometriosis and provide clinical recommendations, several national and two international guidelines have been developed. However, it appears that there are still substantial variations in the recommendations, and the recommendations are not always supported by good quality evidence.
When critically appraised, the guideline produced by the European Society of Human Reproduction and Embryology (ESHRE) in 2013 was regarded as the highest quality guideline [7,8].
IVF is frequently recommended as a therapeutic approach to overcome endometriosis associated infertility. Results of a meta‐analysis showed that pregnancy rate following controlled ovarian hyperstimulation and intrauterine insemination (IUI) is reduced in women with endometriosis, but not following IVF [9]. Another meta‐analysis found that surgical treatment of endometriomas did not alter the outcome of IVF treatment cycles compared with women who did not receive surgical intervention (10).
