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\begin{document}

\title{Fertility preservation for women with ovarian endometriosis: it is time
to adopt it as routine practice FOR: Fertility preservation is an
integral component of the management of women with ovarian endometriosis}



\author[1]{Sania Latif}%
\author[1]{Ertan Saridogan}%
\author[1]{Ephia Yasmin}%
\affil[1]{University College London Hospitals NHS Foundation Trust}%


\vspace{-1em}



  
  \date{May 21, 2024}


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\emph{Fertility preservation for women with ovarian endometriosis: it is
time to adopt it as routine practice}

\emph{FOR: Fertility preservation is an integral component of the
management of women with ovarian endometriosis}

Sania Latif\textsuperscript{1}, Ertan Saridogan\textsuperscript{1},
Ephia Yasmin\textsuperscript{1}

\textsuperscript{1}Reproductive Medicine Unit, University College London
Hospital NHS FoundationTrust

\textbf{Corresponding author:}

Miss Ephia Yasmin ephia.yasmin@nhs.net

Reproductive Medicine Unit

University College London Hospital

235 Euston Road

London NW1 2BU

\textbf{Keywords:} fertility preservation, oocyte cryopreservation,
embryo cryopreservation, endometriosis, infertility

\emph{FOR: Fertility preservation is an integral component of the
management of women with ovarian endometriosis}

Fertility preservation techniques are widely accepted as standard of
care for women undergoing treatment for cancer who are at risk of
premature ovarian insufficiency. The same approach is not yet well
established in benign conditions.

There is ample evidence that women who have endometriosis are twice as
likely to experience infertility in the future (Prescott et al.
2016\emph{Hum Reprod} 31(7):1475-82). Ovarian endometriomas reduce
ovarian reserve by exposing healthy ovarian tissue to the pathological
process of endometriosis and to mechanical stretch, resulting in a
progressive reduction in the pool of primordial follicles. Surgery to
treat ovarian endometriomas further reduces ovarian reserve due to loss
of normal ovarian tissue during cystectomy and ablation. Following
surgical removal, there is a reduction in ovarian reserve, as measured
by anti-mullerian hormone (AMH) levels, by 30\% in unilateral and 44\%
in bilateral endometriomas (Raffi et al. 2012\emph{, J Clin Endocrinol
Metab.~} 97:3146-3154\emph{).} The risk of premature ovarian
insufficiency after bilateral ovarian endometrioma removal is 2.4\%
(Busacca et al. 2006\emph{, Am J Obstet Gynecol}
195(2):421-5\emph{).}Younger women have a higher recurrence rate of
endometriomas requiring repeated surgery, which compounds the insult to
their ovarian reserve. Accepting this risk, the European Society for
Gynaecological Endoscopy, the European Society for Human Reproduction
and Embryology and the World Endometriosis Society have collaborated in
developing recommendations on the practical aspects of endometrioma
surgery to reduce their adverse impact. Women with endometriosis are
often subjected to the pressure of early childbearing based on their
risk of infertility, whilst there is a societal trend towards delaying
parenthood.

Success rates of IVF are dependent on oocyte yield. The number of
oocytes retrieved from women with endometriomas undergoing ovarian
stimulation is substantially reduced, particularly in the presence of
large and bilateral endometriomas (Kim et al. 2020,
\emph{RBMO}40(6):827-834\emph{).} It is, however, possible to restore
cumulative livebirth rates in women with endometriosis when an
equivalent number of oocytes is retrieved (Cobo et al. 2021,
\emph{RBMO~} 42:725--732\emph{).}There is evidence that almost half of
women who had oocyte cryopreservation due to endometriosis subsequently
used their oocytes, highlighting substantial utilisation of stored
gametes within this group of women (Cobo et al. 2020, \emph{Fertility
and Sterility~} 113:836--844).

In light of this information, it is difficult to justify excluding women
with endometriosis from having fertility preservation. A structured
approach is required to grade the risk to fertility in endometriosis
rather than questioning the validity of fertility preservation in these
women. In order to construct criteria for offering fertility
preservation, prospective data collection is required to understand
long-term fertility patterns. Size of endometrioma, bilaterality,
previous surgery and age are the obvious candidates in determining risk.

An early discussion around reproductive planning is essential in women
with ovarian endometriosis regarding the implications of their
significant risk of diminished ovarian reserve and premature ovarian
insufficiency. Oocyte and embryo cryopreservation offer women with
ovarian endometriosis an effective and reliable option to increase their
chance of reproductive success, particularly in young women with large
or bilateral endometriomas who may require surgical intervention, those
who have had previous surgery and those who are not in a position to
embark upon pregnancy. It is imperative that the risk to ovarian reserve
and fertility as well as the role of fertility preservation are
recognised in women with ovarian endometriosis, just as in women
undergoing treatment for malignancies.

Word count 500 (excluding references)

\emph{References}

\begin{enumerate}
\tightlist
\item
  Prescott J, Farland LV, Tobias DK, Gaskins AJ, Spiegelman D, Chavarro
  JE, Rich-Edwards JW, Barbieri RL, Missmer SA. A prospective cohort
  study of endometriosis and subsequent risk of infertility. Hum Reprod.
  2016 Jul;31(7):1475-82. doi: 10.1093/humrep/dew085. Epub 2016 May 1.
  PMID: 27141041; PMCID: PMC4901880.
\item
  Raffi F,~Metwally M, Amer S.~The impact of excision of ovarian
  endometrioma on ovarian reserve: a systematic review and
  meta-analysis. J Clin Endocrinol Metab.~2012;~97:~3146-3154
  https://doi.org/10.1016/j.fertnstert.2018.06.025.
\item
  Busacca M, Riparini J, Somigliana E, Oggioni G, Izzo S, Vignali M,
  Candiani M. Postsurgical ovarian failure after laparoscopic excision
  of bilateral endometriomas. Am J Obstet Gynecol. 2006
  Aug;195(2):421-5. doi: 10.1016/j.ajog.2006.03.064.
\item
  Kim SK, Kim SJ, Lee J, Suh C, Kim S. Oocyte cryopreservation for
  fertility preservation in women with ovarian endometriosis.
  Reproductive BioMedicine Online 2020 40(6) 827-834.
\item
  Cobo A, Coello A, Jos\selectlanguage{ngerman}é de los Santos M, Giles J, Pellicer A, Remohí J,
  García-Velasco J. Number needed to freeze: cumulative live birth rate
  after fertility preservation in women with endometriosis.~Reproductive
  BioMedicine Online~2021 42: 725--732.
  https://doi.org/10.1016/j.rbmo.2020.12.013.
\item
  Cobo A, Giles J, Paolelli S, Pellicer A, Remohí J, García-Velasco J.
  Oocyte vitrification for fertility preservation in women with
  endometriosis: an observational study.~Fertility and Sterility
  2020~113: 836--844. https://doi.org/10.1016/j.fertnstert.2019.11.017.
\end{enumerate}

\textbf{Funding}

This research received no specific grant from any funding agency in the
public, commercial or not-for-profit sectors.

\textbf{Author Statement}

SL, ES and EY drafted, revised and approved the final manuscript and are
in agreement to be accountable for all aspects of the work.

\textbf{Conflict of Interests}

The authors have no conflicts of interest to declare.

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