Bowel Endometriosis and Fertility with IVF-ICSI

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Bowel Endometriosis and Fertility with IVF-ICSI

SUMMARY: BOWEL ENDOMETRIOSIS AND FERTILITY

In this study, infertile women diagnosed with bowel endometriosis had normal fertility outcomes, without prior surgery, following IVF-ICSI cycles with a 36.8% clinical pregnancy rate, and 32.3% live birth rate, per embryo transfer, with no endometriosis related complications observed.

doi.org/10.1016/j.fertnstert.2020.09.032

Background

The impact of bowel endometriosis on fertility remains debated among researchers. Bowel endometriosis is commonly diagnosed alongside endometriotic lesions elsewhere in the body. This makes pathophysiology studies particularly challenging and leaves any fertility related findings open to debate.

Currently, bowel endometriosis associated infertility is treated by surgery and or assisted reproductive technology. Each option has its advantages and disadvantages. Assisted reproductive technology (ART) results in acceptable rates of pregnancy but fails to treat the lesions or associated pain. On the other hand, surgery carries the risk of severe complications and postoperative adhesions.

For women diagnosed with bowel endometriosis and trying to conceive, the option to treat endometriosis surgically, followed by ART if necessary, would make logical sense. However, several studies have since reported worse ART outcomes following endometriosis surgery. 

Interestingly there have been no studies to date reporting the cumulative live-birth rate (LBR) following ART in women with bowel endometriosis and no prior endometriosis surgery.

Aim

To evaluate the ART cumulative LBR in a large cohort of bowel endometriosis patients who had not undergone surgery for endometriosis.

Methodology

Women up to the age of 43, with endometriosis-related infertility, undergoing in vitro fertilization and intracytoplasmic sperm injection (IVF-ICSI) were prospectively recruited for this study.

Bowel endometriosis, involving at least the muscularis layer of the bowel, was diagnosed using transvaginal ultrasound and MRI. Classification of endometriotic lesions was performed by a single experienced radiologist to reduce operator variance.

Any woman with prior surgery for endometriosis or using donated oocytes was excluded from this study.

Women who subsequently satisfied the inclusion exclusion criteria had a full history and symptoms of pain documented, and standard fertility investigations performed, before proceeding with ART.

During ART cycles, a variety of controlled ovarian stimulation protocols (GnRH antagonist, Long agonist, Short agonist) was used according to individual patient characteristics. Embryo transfer was carried out on day 2 or at blastocyst stage with ART, obstetric and perinatal outcomes recorded for later analysis.

Results

A total of 101 eligible women, underwent 176 cycles, with 201 embryo transfers. Mean age was 32.3 (±3.8) years with a mean duration of infertility of 28.5 (±18.4) months.

Initial pre-ART investigations revealed that 89 out of 101 women had associated adenomyosis, while 80 women had severe dysmenorrhea and 47 reported severe gastrointestinal symptoms. Overall, mean AMH level was 3ng/mL and AFC was 15.

There was a total of 49/176 (27.8%) ART cycles cancelled, due to poor response, lack of oocytes, fertilisation failure or poor embryo quality.

However, post embryo transfer analysis revealed surprisingly normal rates of clinical pregnancy (36.8%) and live birth (32.3%) per embryo transfer. In fact, after 4 ART cycles, 73.3% of women fell pregnant and 64.4% had a live birth, with no endometriosis related complications observed during the cycles or pregnancy.

Advanced statistical (univariate) analysis of patient characteristics showed that infertility greater than 30 months, AMH <2ng/mL or AFC <10 was associated with lower live birth rates. Although further (multivariate) analysis suggests that only AMH levels significantly correlates with live birth rates in this group of women.

Interestingly, no association was found between adenomyosis and live birth rates in this analysis.

Limitations

  1. Live birth rates may be different (i.e. higher) in women with less severe bowel endometriosis.
  2. Pooling of results (different ovarian stimulation protocols and embryo transfer day).

Funding

No external funding was declared for this study.

Glossary

Adenomyosis
A condition where cells from the uterus lining grow into the muscle of the uterus.

Antral Follicle Count (AFC)
A test performed via ultrasound to evaluate a female’s ovarian reserve.

Anti-Mullerian Hormone (AMH)
A hormone produced by the small follicles in a woman’s ovaries, commonly used as a marker of oocyte quantity.

Assisted Reproductive Technology (ART)
Any fertility treatment in which either eggs or embryos are handled (i.e. IVF, ICSI).

Blastocyst
A fertilised embryo that has developed an inner cell mass and outer layer (trophoblast) some time from day 4 onwards.

Dysmenorrhea
Pain during menstruation.

Muscularis layer
A region of muscle adjacent to the submucosa layer.

Oocyte
Unfertilised immature / mature egg.

Pathophysiology
The study of disordered physiological processes associated with a disease

Perinatal
Period of time from birth of baby up to 1 years of age.

Similar studies

Maignien C, et al. (2020). Deep Infiltrating Endometriosis: a Previous History of Surgery for Endometriosis May Negatively Affect Assisted Reproductive Technology Outcomes. https://doi.org/10.1007/s43032-019-00052-1

Bendifallah S, et al. (2017). Colorectal endometriosis-associated infertility: should surgery precede ART? https://doi.org/10.1016/j.fertnstert.2017.07.002

Ballester M, et al. (2012). Cumulative pregnancy rate after ICSI–IVF in patients with colorectal endometriosis: results of a multicentre study. https://doi.org/10.1093/humrep/des012


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