Interventions for women with endometrioma prior to assisted reproductive technology.
BACKGROUND
Endometriomata are cysts of endometriosis in the ovaries. As artificial reproductive technology (ART) cycles involve oocyte pickup from the ovaries, endometriomata may interfere with the outcome of ART.


OBJECTIVE
To determine the effectiveness and safety of surgery, medical treatment, combination therapy or no treatment for improving reproductive outcomes among women with endometriomata, prior to undergoing ART cycles.


METHODS
The review authors searched: Cochrane Menstrual Disorders and Subfertility Group Specialised Register of trials, CENTRAL (The Cochrane Library), EMBASE, MEDLINE, PubMed, PsycINFO, CINAHL, DARE, trial registers for ongoing and registered trials, citation indexes, conference abstracts on the ISI Web of Knowledge, Clinical Study Results, OpenSIGLE (July 2010) and handsearched Fertility and Sterility (2008 to 2010).


METHODS
Randomised controlled trials of any medical, surgical or combination therapy or expectant management for endometriomata prior to ART.


METHODS
The trials were independently identified and assessed for risk of bias by two authors. The authors of the trials that were potentially eligible for inclusion were contacted for additional information. Outcomes were expressed as Peto odds ratios and mean differences (MD).


RESULTS
Eleven trials were identified of which seven were excluded and four with 312 participants were included.No trial reported live birth outcomes. One trial compared gonadotropin-releasing hormone (GnRH) agonist with GnRH antagonist. There was no evidence of a difference for clinical pregnancy rate (CPR), however the number of mature oocytes retrieved (NMOR) was greater with GnRH agonists (MD -1.60, 95% CI -2.44 to -0.76) and the ovarian response was increased (estradiol (E2) levels on day of human chorionic gonadotropin (hCG) injection) (MD -456.30, 95% CI -896.06 to -16.54).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 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 (COH) (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.


CONCLUSIONS
There was no evidence of an effect on reproductive outcomes in any of the four included trials. Further RCTs of management of endometrioma in women undergoing ART are required.
Department of Obstetrics & Gynaecology Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands.
Laura
L
Benschop
Cindy
C
Farquhar
Nicolien
N
van der Poel
Maas Jan
MJ
Heineman
D004715:Endometriosis / Q000150:complications / Q000188:drug therapy* / Q000601:surgery*; D005260:Female; D007987:Gonadotropin-Releasing Hormone / Q000819:agonists / Q000037:antagonists & inhibitors; D006801:Humans; D007247:Infertility, Female / Q000209:etiology; D016471:Ovarian Hyperstimulation Syndrome / Q000517:prevention & control; D011247:Pregnancy; D016032:Randomized Controlled Trials as Topic; D027724:Reproductive Techniques, Assisted; D020554:Sperm Injections, Intracytoplasmic
D007987:Gonadotropin-Releasing Hormone