The impact of endometrioma on IVF/ICSI outcomes: a systematic review and meta-analysis

BACKGROUND: Endometriosis is a disease known to be detrimental to fertility. Women with endometriosis, and the presence of endometrioma, may require artificial reproductive techniques (ART) to achieve a pregnancy. The specific impact of endometrioma alone and the impact of surgical intervention for endometrioma on the reproductive outcome of women undergoing IVF/ICSI are areas that require further clarification. The objectives of this review were as follows: (i) to determine the impact of endometrioma on IVF/ICSI outcomes, (ii) to determine the impact of surgery for endometrioma on IVF/ICSI outcome and (iii) to determine the effect of different surgical techniques on IVF/ICSI outcomes. METHODS: We performed a systematic review and meta-analysis examining subfertile women who have endometrioma and are undergoing IVF/ICSI, and who have or have not had any surgical management for endometrioma before IVF/ICSI. The primary outcome was live birth rate (LBR). Our secondary outcomes were clinical pregnancy rate (CPR), mean number of oocyte retrieved (MNOR), miscarriage rate (MR), fertilization rate, implantation rate, antral follicle count (AFC), total stimulating hormone dose, and any rates of adverse effects such as cancellation and associated complications during the IVF/ICSI treatment. RESULTS: We included 33 studies for the meta-analysis. The majority of the studies were retrospective (30/33), and three were RCTs. Compared with women with no endometrioma undergoing IVF/ICSI, women with endometrioma had a similar LBR (odds ratio OR 0.98; 95% CI 0.71, 1.36, 5 studies, 928 women, I(2) = 0%) and a similar CPR (OR 1.17; 95% CI 0.87, 1.58, 5 studies, 928 women, I(2) = 0%), a lower mean number of oocytes retrieved (SMD -0.23; 95% CI -0.37, -0.10, 5 studies, 941 cycles, I(2) = 37%) and a higher cycle cancellation rate compared with those without the disease (OR 2.83; 95% CI 1.32, 6.06, 3 studies, 491 women, I(2) = 0%). Compared with women with no surgical treatment, women who had their endometrioma surgically treated before IVF/ICSI had a similar LBR (OR 0.90; 95% CI 0.63, 1.28, 5 studies, 655 women, I(2) = 32%), a similar CPR (OR 0.97; 95% CI 0.78, 1.20, 11 studies, 1512 women, I(2) = 0%) and a similar mean number of oocytes retrieved (SMD -0.17; 95% CI -0.38, 0.05, 9 studies, 810 cycles, I(2) = 63%). CONCLUSIONS: Women with endometrioma undergoing IVF/ICSI had similar reproductive outcomes compared with those without the disease, although their cycle cancellation rate was significantly higher. Surgical treatment of endometrioma did not alter the outcome of IVF/ICSI treatment compared with those who did not receive surgical intervention. Considering that the reduced ovarian reserve may be attributed to the presence of endometrioma per se, and the potential detrimental impact from surgical intervention, individualization of care for women with endometrioma prior to IVF/ICSI may help optimize their IVF/ICSI results.