Normal fertilization but a reduced implantation rate per embryo transfer(esp.in stage 3-4)

Cumulative pregnancy rate and live birth rate were comparable after 5cycles of IVF with tubal infertility but poorer response and needed higher dose of gonadotropins.

Overall 54% reduction in pregnancy rate in all of stages(metaanalysis) were seen after IVF.

Also,this reduction showed in all of stages(oocytes number, mean number of embryos transferred, implantation and pregnancy rate)

Impairment of implantation is due to intrinsic deficiencies within the endometrium(aberant uterine response to sex steroid hormones)

Poorer IVF outcome in sever endometriosis related to oocyte or embryo factor rather than decreased uterine receptivity.

Ovarian endometriosis

Are and Endometriosis
ART and Endometriosis

Small endometrioma(<3cm) aspirated,irrigated and inspected with ovarian cystoscopy and interior wall can be vaporized to destroy the mucosal lining of the cyst.large cyst (>3cm)aspirated and removed cyst wall from ovarian cortex.

Large endometriomas may interfere with follicular recruitment,impose difficulties during oocyte retrieval, and theoretically produce substances that are toxic to maturing oocytes and affect cell cleavage after fertilization.

Women with history of past or current endometriomas had fewer oocytes retrieved during IVF than tubal factor,but fertilization rate, embryo quality or pregnancy outcome were not affected.

Routine laprascopic cystectomy before IVF dosenot improve outcome.(with lower peak estradiol level on the day of hcG adminstration and a higher total gonadotropin)[compare to intact ovarian endometrioma]

In one study 36 patients with recurrences after previous operation compared with 55 patients without recurrence during IVF:clinical pregnancy was 38% in group 1vs 22% in group2.

It means extensive resection couse no recurrence but diminished ovarian reserve.

Another study showed no difference in the number of oocytes, fertilization rate, number of embryo transferred, implantation rate and clinical pregnancy rate between two group of patients with previous surgery for endometrioma>3cm and without it.

Despite early report:elective aspiration of endomertioma is associated with an increased risk of infection.

Recent study showed transvaginal ultrasound-guided endometrioma cyst aspirated had the same success as laprascopic resection without more sideeffects and with lower dose of gonadotropins and more oocytes after ART.

In another study:cystectomy and laprascopic ovarian fenesteration and coagulation have same response to COH.

Therefore avaiable evidence showed resection of endometrioma may compromise or destroy adjacent normal ovarian tissue by removing part of the ovarian cortex and thus reduction ovarian reserve.

On the basis of retrospective studies,the reproductive outcome of patients with endometriosis appears to be enhanced if downregulation with GnRH agonist is used before ovarian stimulation for IVF, but there isnot any evidence of benefit of suppression with gestrinone or danazol.

Are and Endometriosis
ART and Endometriosis

Particulary in patients with moderatesever endometriosis after prolonged (3- 6mon) downregulation with GnRH agonist,clinical pregnancy rate per cycle and per transfer were more higher(25% vs 3.9% per cycle and 33%vs 5.3% per transfer)

Significant higher pregnancy rate in patients with various stages of endometriosis undergoing IVF who received GnRHagonist for 60 days or more before stimulation in comparsion with standard midluteal downregulation.(67% vs 27%)

Also,higher cumulative conception rates shown with longer protocol compared with short or ultrashort protocol.(50.3% vs 8.3%)

Sequential adminstration of the GnRH antagonist cetrolix in a 3mg dosage once weekly over 8weeks creates a new opportunity for medical treatment of symptomatic endometriosis without side effects. (including mood changes,hot flush, loss of libido,vaginal dryness and other symptoms)

In one study before ICSI triptrolein and cetrorelix were used and outcomes were similar in patients with mild to moderate endometriosis (implantation rates were 12.5%anta vs 14.8%ago and clinical pregnancy rates 20.5%anta vs 24.2%ago)

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