Abstract

Introduction

Materials and methods

Results

Comment

References

Abstract

Objective Ovarian hyper-stimulation during IVF is associated with a significant raise in serum estrogens and one may expect detrimental effects on estrogen-dependent diseases such as endometriosis. However, available evidence from large case series of affected women performing IVF is generally reassuring with the possible exception of women carrying deep invasive lesions. On this basis we deemed important investigating more in depth whether women with deep invasive endometriosis could be a subgroup at higher risk of recurrence or disease progression during IVF. Study design Women with endometriosis who underwent IVF and who had a second evaluation after 3–۶ months from a failed cycle were retrospectively reviewed. The main inclusion criteria were the presence of deep invasive endometriosis and/or a history of surgery for this form of the disease. The primary aim of the study was to determine the frequency of endometriosis-related complications in the interval between the two evaluations. Secondary aims were pain symptoms and lesion size modifications.
Results Eighty-four women were ultimately selected: baseline ultrasound documented deep invasive lesions in 60 of them. One case of possible endometriosis-related complication was recorded, corresponding to a rate of 1.2% (95%: 0.05%–۵٫۵%) for the whole cohort and 1.7% (95%CI: 0.08–۷٫۶%) for the subgroup of women with ultrasound detected lesions. This rate appears similar to the reported frequency of endometriosis progression in women not receiving IVF. No significant modifications in pain symptoms or lesions size occurred.
Conclusions Women with deep invasive endometriosis who underwent IVF do not seem to be exposed to a substantially increased risk of recurrence/disease progression. Larger evidence from independent groups is however required for a definitive conclusion.

Introduction

In vitro fertilization (IVF) is a possible option for the treatment of infertile women with endometriosis [1,2]. However, IVF not only exposes women to the well-known general risks of the procedure but, also, to some specific endometriosis-related risks [3]. Of relevance here is the hazard of disease-progression during the procedure. Indeed, endometriosis is an estrogen-dependent disease and peripheral levels of estrogens increase up to 10-folds during ovarian hyper-stimulation. Given this premise, some harmful effects on the natural history of the disease could be expected. However, the available evidence does not generally support this concern [4]. Several independent large case series failed to highlight major detrimental effects [5–۱۰]. On the other hand, these reassuring data contrast with some case reports of severe complications [11–۱۵]. The main characteristics of these cases are summarized in Table 1. Noteworthy, deep invasive peritoneal lesions (ie nodules infiltrating the peritoneum by >5 mm) [16] were highly common in these published cases, being present in at least 9 out of 13 affected women. On these bases, we hypothesized that women with deep invasive endometriosis may be a subgroup of women who are more vulnerable to the potential detrimental effects of ovarian hyper-stimulation. To the best of our knowledge, only one study specifically reported evidence on deep lesions and failed to show detrimental effects. However, the evaluation of the lesions was a secondary finding, the number of included cases was extremely limited (n = 9) and the study did not focus on clinical complications [8]. Given the clinical relevance of the described cases, we deemed important exploring more in-depth this issue.