First-line surgery followed by ART versus ART alone among women with colon-involving endometriosis.

The benefit of first-line surgery on fertility rates among women with colon-involving endometriosis who undergo ART.

Key Points

Highlights: 

• The correlation of fertility outcomes (pregnancy rates, live-birth rates, and cumulative fertility rate) among women with colon-involving endometriosis was investigated
• There is a fertility benefit seen among a specific population of women with colon-involving endometriosis who undergo first-line surgical intervention for their endometriosis before beginning ART.

Key Results:

• Surgery followed by ART is a beneficial option for women with colorectal endometriosis-associated infertility, especially for those with factors negatively impacting fertility outcomes.

What’s done here?

• The correlation of fertility outcomes (pregnancy rates, live-birth rates, and cumulative fertility rate) among 110 women with colon-involving deeply infiltrating endometriosis (DIE) was investigated.
• The impact of first-line assisted reproductive technology (ART) and first-line colorectal surgery followed by ART on fertility outcomes were assessed.
• ART was performed by intracytoplasmic sperm injection (ICSI-IVF) while the surgery performed depending on the extent and location of the endometriotic lesions present in each patient. 

Limitations: 

• While this study aimed to elucidate the true effects of either treatment approach on fertility rate, it was not a large-scale randomized control study.

Lay Summary

Endometriosis, a disease characterized by the presence of endometrial tissue outside the uterus, may cause pelvic and gynecologic complications that affect fertility in women of reproductive age. Several forms of endometriosis have been observed that are characterized by the varying anatomic spreading of endometriotic lesions. One classification, deep infiltrating endometriosis (DIE), is marked by highly invasive endometriotic lesions to the outer portion of the pelvis and may include the colon. The aim of this study was to examine the correlation of fertility outcomes including pregnancy rates, live-birth rates, and cumulative fertility rate among women with colon-involving endometriosis.

This study took data from 110 women with diagnosed colorectal endometriosis from January 2005 to June 2014 and examined their fertility data. Colorectal endometriosis was defined as a patient with DIE with infiltration of at least the rectal muscular layer. Patients were grouped in either the first-line ART or first-line surgery followed by ART cohorts. ART was performed by intracytoplasmic sperm injection (ICSI-IVF) while the surgery performed depending on the extent and location of the endometriotic lesions present in each patient. Using a certain statistical analysis method (propensity score matching or PSM), researchers then aimed to understand which of the two cohorts had better fertility outcomes according to epidemiologic factors and clinical outcomes.

The analysis found that no differences in age, BMI, duration of infertility, duration of infertility, anti-Mullerian hormone (AMH) level were found between the two cohorts. Out of 110 women with colon endometriosis, the pregnancy rate was 49% and the live-birth rate was 35.7%. Between the first-line ART versus first-line surgery followed by ART, the pregnancy rate for the first cycle was 42.4% and 62.2%, respectively. Women who had a good prognosis for live birth (age ≤ 35 years, AMH >2ng/ml), benefited equally from either cohort strategy. However, for women with at least one negative factor, the pregnancy rate was significantly higher for women underwent first-line surgery first before ART. Summarized, the women with good prognosis had an overall (average the two cohorts’ pregnancy rates) pregnancy rate of 52.7 while women aged 35 and AMH level below 2ng/ml had an overall pregnancy scores of 40% and 50%, respectively.

Things to consider when comparing the success rates of fertility studies is that there is a very large heterogeneity between the treatment practices, strategies, and patient populations involved in these studies. While this study aimed to reduce the effect of these limitations on the true effects of either treatment approach on fertility rate, it was not a large-scale randomized control study. Thus, further larger scale studies are needed comparing characteristics of women with colon endometriosis that would benefit from undergoing prior surgery before ART. A discussion on the benefit of undergoing surgery for endometriosis before beginning ART should be initiated with your gynecologist before making a decision.

Research Source: https://www.ncbi.nlm.nih.gov/pubmed/28807397