Surgical diminished ovarian reserve after endometrioma cystectomy versus idiopathic DOR: comparison of in vitro fertilization outcome.
OBJECTIVE
Does the live birth rate after IVF depend on the etiology of diminished ovarian reserve (DOR)?


CONCLUSIONS
IVF outcome and live birth rate are significantly impaired in women with DOR caused by a previous cystectomy for endometrioma compared with women with idiopathic DOR.


BACKGROUND
The safety of the surgical treatment of endometriomas is being discussed in terms of damage to ovarian reserve. Several studies have reported a poor response to controlled ovarian stimulation and a significantly impaired IVF outcome in women with DOR consecutive to an endometrioma cystectomy compared with women with tubal factor infertility.


METHODS
Retrospective case-control study conducted in women aged under 40 treated in our Reproductive Medicine Center between January 2010 and January 2014 for a DOR defined by anti-Müllerian hormone level <2 ng/ml. Two groups of patients were selected: group A included patients with a DOR diagnosed after cystectomy(s) for endometrioma(s), group B included patients with an idiopathic DOR. In each group, subgroups of patients 'poor ovarian responders', based on the ESHRE criteria ('Bologna criteria'), have been established.


METHODS
A total of 51 patients in group A were matched to 116 patients in group B, representing respectively 125 and 243 IVF cycles. Among them, 39 patients in group A and 78 patients in group B validated strictly by the Bologna criteria, representing 99 and 189 IVF cycles, respectively. Each patient underwent a controlled ovarian hyperstimulation and IVF with fresh embryo transfer. Primary end-point was the live birth rate. Secondary end-points were the number of retrieved oocytes, fertilization rate, implantation rate, clinical pregnancy rate, spontaneous abortion rate and cycle cancelation rate.


RESULTS
Significantly lower pregnancy (11.2% in group A versus 20.6% in group B, P = 0.02) and live birth (7.2 versus 16.9% respectively, P = 0.01) rates per cycle were assessed in women in group A compared with women in group B. The same results were obtained in the Bologna criteria subgroup analysis with a significantly lower pregnancy (9.1 versus 20.1%, P = 0.016) and live birth (5.1 versus 15.3%, P = 0.001) rates per cycle in women in subgroup A compared with women in subgroup B. Patients in group A required significantly higher gonadotrophins doses (2881 IU ± 1111 versus 2526 IU ± 795, P = 0.005), longer ovarian stimulation (10.6 Days ± 2.8 versus 9.9 Days ± 2.4, P = 0.019) and higher cancelation rate for poor response (12 versus 6.2%, P = 0.05). Despite a mean number of retrieved oocytes similar with the group B (5.4 ± 3.1 and 5.1 ± 3.2, NS), and a significantly higher fertilization rate (65.7 versus 47.2%, P < 0.001), women in group A showed a significantly lower implantation rate (7.2 versus 13.5%, P = 0.03). Abortion rate, ectopic pregnancy rate and multiple pregnancy rate were similar in both groups.


CONCLUSIONS
Data were collected retrospectively using the database of our Department. Sample size is relatively small but our study provides statistically significant evidence that the chances of IVF success are decreased in women with DOR after cystectomy for endometrioma. Further larger series are needed to confirm these findings.


CONCLUSIONS
To our knowledge, this is the first study evaluating IVF outcome in patients with DOR after cystectomy(s) for endometrioma(s) versus in patients with an idiopathic DOR. In addition to the risk of damaging ovarian reserve, we hypothesize that endometrioma surgery would not have qualitative benefits on results in IVF in patients with DOR.


BACKGROUND
The authors have no competing interests to declare.
Department of Gynecology, Obstetric and Reproductive Medicine, Gynepôle, AP-HM La Conception, 147 bd Baille, 13005 Marseille, France Aix Marseille Université, CNRS, IRD, Avignon Université, IMBE UMR 7263, 13397 Marseille, France audrey.roustan@gmail.com.
Audrey
A
Roustan
Department of Gynecology, Obstetric and Reproductive Medicine, Gynepôle, AP-HM La Conception, 147 bd Baille, 13005 Marseille, France Aix Marseille Université, CNRS, IRD, Avignon Université, IMBE UMR 7263, 13397 Marseille, France CECOS, Laboratory of Medical Reproduction, Department of Gynecology, Obstetric and Reproductive Medicine, Gynepôle, AP-HM La Conception, 147 bd Baille, 13005 Marseille, France.
Jeanne
J
Perrin
Department of Public Health, Research Unit EA3279, Aix Marseille Université, 13005 Marseille, France.
Mathias
M
Debals-Gonthier
Department of Gynecology, Obstetric and Reproductive Medicine, Gynepôle, AP-HM La Conception, 147 bd Baille, 13005 Marseille, France Department of Histology-Embryology, Faculty of Medicine, Aix-Marseille Université, 13005 Marseille, France.
Odile
O
Paulmyer-Lacroix
Department of Gynecology, Obstetric and Reproductive Medicine, Gynepôle, AP-HM La Conception, 147 bd Baille, 13005 Marseille, France.
Aubert
A
Agostini
Department of Gynecology, Obstetric and Reproductive Medicine, Gynepôle, AP-HM La Conception, 147 bd Baille, 13005 Marseille, France Aix Marseille Université, CNRS, IRD, Avignon Université, IMBE UMR 7263, 13397 Marseille, France.
Blandine
B
Courbiere
D000328:Adult; D001724:Birth Weight; D016022:Case-Control Studies; D004624:Embryo Transfer / Q000379:methods; D004715:Endometriosis / Q000601:surgery*; D004717:Endometrium / Q000601:surgery*; D005260:Female; D005307:Fertilization in Vitro; D013509:Gynecologic Surgical Procedures / Q000379:methods; D006801:Humans; D065851:Ovarian Reserve; D010062:Ovulation Induction / Q000379:methods; D011247:Pregnancy; D011256:Pregnancy Outcome; D018873:Pregnancy Rate; D012189:Retrospective Studies; D016896:Treatment Outcome
IVF; bologna criteria; diminished ovarian reserve; endometrioma; pregnancy