Shedding light on the fertility preservation debate in women with endometriosis: a swot analysis.

Professionals and patients need to consider multiple factors when deciding on fertility preservation for women with endometriosis.

Key Points

Highlights:

• There is no consensus on the fertility preservation strategy to adopt in women with endometriosis.
• Professionals should focus on patient counseling,  patient support for informed decision making considering age, symptoms, disease severity, additional infertility risk factors, the clinical impact of surgery and perceptions about childbearing.

Importance:

• Very few publications have addressed fertility preservation in the context of endometriosis and there are to this date no clinical studies conducted on the topic.

What’s Done Here:

• This study conducted a SWOT (strengths, weaknesses, opportunities, and threats) analysis.

Key Results:

STRENGTHS: 

• Preservation of own oocytes for future use
• A high survival rate of vitrified thawed oocytes
• Clinical outcomes comparable using fresh vs. vitrified oocytes
• OHSS free stimulation protocols using GnRHa triggering
• Double stimulation to maximize the number of oocytes retrieved
• Aneuploidy rates of embryos similar in women with and without endometriosis

WEAKNESSES

• Few case series/no clinical studies
• Ovarian reserve assessment inaccurate in case of hormonal treatment or large endometriomas
• Lack of fertility tests – ovarian reserve does not predict infertility or pregnancy
• Costs, lack of insurance coverage / no cost-effectiveness analysis
• Oocyte accumulation sometimes necessary
• Rick of complication (hemorrhage, ovarian abscess)
• Need for an efficient vitrification program

OPPORTUNITIES

• Pro-fertility counseling
• Identification of women at risk
• Preserve oocytes before impact on ovarian reserve (age, endometrioma surgery)
• Preserve oocyte in women with a good ovarian reserve, avoiding multiple stimulations
• Avoid IVF at an older age with fewer oocytes
• Avoid egg donation in women at risk of poor ovarian response or premature ovarian failure

THREATS

• Psychological impact
• Impact on reproductive decisions
• Lack of data on the impact on repeated stimulations on endometriosis symptoms and severity
• The potential impact of endometriosis on oocyte quality
• Lack of data on the survival rate – the reproductive potential of oocytes preserved specifically in women with endometriosis/endometriomas

Lay Summary

There is little known about fertility preservation in women with endometriosis. Researchers from France and Switzerland conducted a SWOT (strengths, weaknesses, opportunities, and threats) analysis to better understand this topic. Applied to clinical problems, SWOT gives a thorough analysis of a given clinical question and can help in decision making and strategic planning.

The authors found several strengths regarding evidence available on fertility preservation in women with endometriosis. They identify that two main advances have had a major impact on cryopreserving oocytes. First is the use of GnRH antagonists with GnRH agonists has led to better oocyte collection, and, the other is oocyte vitrification which improved survival rates. In addition, the authors report that oocyte quality in women with endometriosis, along with the effect of endometriosis on vitrification, warming/thawing and reproductive outcomes is a debated issue. However, recent evidence has shown that “the effect of endometriosis on oocyte quality does not hinder pregnancy after assisted reproductive therapy”.

Several weaknesses exist regarding fertility preservation in women with endometriosis. To justify oocyte vitrification in endometriosis, women should have an “increased risk of experiencing infertility with higher chances of having a live-birth if undergoing ART” and “ART using cryopreserved oocytes should reasonably improve outcomes compared to fresh ART performed when pregnancy is attempted”. It is, therefore, necessary to predict future fertility and identify women who will benefit from banked oocytes compared to fresh IVF cycles. The authors note that “there is currently no data on long-term fertility in women who do not seek pregnancy at the diagnosis of endometriosis, immediately after surgery or in those treated by a long-term hormonal therapy.” Regarding banking oocytes compared to fresh IVF cycles, there are some women who are at risk of having such a low ovarian reserve that ovarian stimulation for ART will not be an option. Risk factors for this include “the removal of bilateral ovarian cysts, repeated ovarian cystectomies or low ovarian reserve markers at baseline.” Ovarian reserve estimation can also be a challenge, as issues such as the presence of endometriomas can prevent accurate follicular counts by ultrasound and hormonal treatment can lead to an underestimation of the ovarian reserve. Hormonal treatment also interferes with ovarian stimulation for fertility preservation, leading to a reduction in oocyte yield. The authors report that due to the absence of straightforward data, they suggest measuring ovarian reserve parameters and starting ovarian stimulation for fertility preservation 2–3 months after stopping hormonal treatments.

Regarding opportunities, the researchers state that endometriosis patients must be counseled about fertility preservation to improve chances of pregnancy. They report that oocytes vitrification for fertility preservation does not guarantee pregnancy. Having analyzed the current data, they suggest cryopreservation of 15–20 and 25–30 metaphase oocytes in women aged over 38, oocyte cryopreservation only in women at high risk of infertility, and as a third strategy, to take individualized care and fertility preservation considering age, ovarian reserve, disease severity, and symptoms, the impact of potential endometrioma surgery, the risk of relapse and additional infertility risk.

Three threats are mentioned regarding fertility preservation in women with endometriosis. Firstly, discussing the effect of endometriosis on fertility could potentially lead to a psychological burden on young women. Secondly, they report that the effect of ovarian stimulation on endometriosis symptoms and severity are currently unknown, however recent studies have shown promising results. Lastly, they note that there is not enough evidence to determine the quality of cryopreserved oocytes in women with endometriosis. Current evidence reports good survival and pregnancy rates after thawing of vitrified oocytes, but this is limited to women who have donated oocytes.

In conclusion, the authors note that “data on fertility preservation in women with endometriosis is scarce and there is no consensus on the strategy to adopt. Studies about efficiency and cost-effectiveness are also lacking. Further research is warranted to refine the appropriate management for women with endometriosis with the goal of providing a tailored-fertility care. In the meantime, professionals should focus on patient counseling and support individual informed decision making, considering age, symptoms, disease severity, additional infertility risk factors, the clinical impact of surgery and perceptions about childbearing.”

Research Source: https://www.ncbi.nlm.nih.gov/pubmed/30199816