LONDON – Improved pregnancy rates after fertility treatment were achieved by the surgical removal of ovarian cysts in a 10-year longitudinal study of women with endometriomas.
After surgery, 63% of women became pregnant after assisted conception methods whereas before surgery only 7% conceived; overall, 46% of women became pregnant at both time points combined.
"Endometrioma itself is associated with significantly reduced reproductive performance in the long term," said study investigator Dr. Saad Amer of the Royal Derby (England) Hospital.
However, "surgery does not seem to compromise the reproductive performance any further," he said at the annual meeting of the European Society of Human Reproduction and Embryology.
Sara Freeman/IMNG Medical Media
Dr. Saad Amer
The rates of unassisted pregnancy were about the same before (48%) and after surgery (50%), with an overall rate of 65% in the surgical groups combined versus 98% for women without endometriomas but who had endometriosis (P = .001)
The rationale for the study was that evidence suggests that ovarian reserve is reduced after excision surgery (J. Clin. Endocrinol. Metab. 2012;97:3146-54), although the long-term impact of other types of surgery remains to be seen.
Between January 1999 and December 2009, 704 women with ovarian endometriosis who had surgery, of which 153 had surgery for endometriomas, were identified from hospital records.
Women who had endometriomas were sent a questionnaire and asked to attend an interview about their reproductive history. There was a 45% response rate (n = 151), with 68 women with endometriomas actually participating; they were compared with an age- and weight-matched control group of 68 apparently healthy women.
The median ages of women in both the study group and the control group were similar, at 40 and 41 years, respectively. A similar percentage of patients had a smoking history (8% and 10%), with a little more than half of all women having regular menstruation, and 75% and 84% in each group desiring to become pregnant.
Of the 68 women with endometriomas, 33 underwent excision (n = 27) or ablation (n = 6) procedures, with 21 women having oophorectomy and 14 having the cysts drained. The median diameter of the endometriomas was 6 cm. Surgery was performed by 10 consultant gynecologists, with 53% of procedures performed laparoscopically.
If the women who conceived spontaneously and those who became pregnant following fertility treatment were grouped together, the overall rates of pregnancy before and after endometrioma surgery were 50% and 71%, respectively, with a combined overall pregnancy rate of 80%. This compares well with the 98% of women who had spontaneous pregnancy in the control group, Dr. Amer noted.
A similar percentage of patients became pregnant after single (70%, n = 23) or multiple (73%, n = 15) surgical procedures, although the number of women included in the analysis was small.
There was a trend toward a lower pregnancy rate in women who had bilateral versus unilateral surgeries, at 67% vs. 77%, although the number of patients in this analysis was again small. There also was no significant difference in pregnancy rates when the type of surgery was considered.
"These findings are reassuring for patients with endometrioma who are seeking fertility and need surgery for their disease."
Importantly, surgery was not found to alter the timing or age of menopause, Dr. Amer said. Nine (13%) women who had surgery were postmenopausal, compared with six (9%) of those in the control group. The median age of menopause was 48 years in the surgical group overall versus 49 years in the control group.
The main conclusion of the study was that surgery itself does not appear to affect women’s long-term reproductive performance.
Although the findings are limited by the retrospective design of the study and further validation is needed, the results do suggest that endometriomas per se, rather than surgery, appear to be the main reason for reduced long-term reproductive function.
"These findings are reassuring for patients with endometrioma who are seeking fertility and need surgery for their disease," Dr. Amer said.
Dr. Amer reported having no relevant financial disclosures.