IVF Pregnancy Outcomes same in Endometriosis Patients compared to normal controls: Study

Endometriosis is a chronic disorder due to ectopic endometrium that responds to the monthly hormonal cycle. Its main symptom is chronic cyclic pain that may manifest to chronic continuous pelvic pain. Patient complaints may vary, including complaints of bowel movement, complaints of urination, dyspareunia, and infertility.

Endometriosis is often diagnosed late with a significant lag time between the first appearance of symptoms and definitive diagnosis. Even in developed countries, patients may remain undiagnosed for up to 7 years. Understandably, infertile patients with endometriosis present themselves at an advanced stage, having experienced a longer and more severe preoperative symptom and higher healthcare utilization costs. Surgery is thus necessary, with patients often recommended to undergo IVF subsequently.

Endometriosis is related to infertility through various mechanisms. The presence of ectopic endometrium anywhere in the peritoneal cavity incites slow yet progressive damage. Its continuous low-grade inflammation in the reproductive tract impairs folliculogenesis, fertilisation, embryo transport, and subsequent implantation. The inflammation also causes significant pelvic adhesions distorting normal pelvic anatomy, dyspareunia reducing the frequency of sexual intercourse, ovarian damage due to the endometriosis itself and/or endometrioma and its subsequent corrective surgeries, and prolonged anovulation due to medical treatments. A combination of one or more mechanisms mentioned contributes to infertility.

The link between endometriosis and infertility leads to a significant increase in assisted reproductive technology (ART) utilization particularly in vitro fertilisation (IVF). Multiple factors, in addition to the underlying pathology, influence IVF procedures success rates. A crucial parameter often overlooked is the time to pregnancy (TTP), which is how long patients recognise their disease, opt for consultation, enroll in an IVF program, and eventually conceive. This is pertinent for endometriosis as patients often require years to establish a diagnosis, cited as the delay in endometriosis management. There are still limited data on the TTP in IVF amongst patients with endometriosis compared to nonendometriosis patients, including those in Indonesia. This study was performed to compare the time to pregnancy in IVF between endometriosis and nonendometriosis patients to further guide clinical management accordingly.

This was an observational retrospective cohort study. Authors included 291 patients (53 with endometriosis and 238 without endometriosis) achieving biochemical pregnancy, whether singleton or multifetal (serum beta-hCG >5 mIU/mL), between 1st January 2014 and 31st March 2020. They excluded patients with incomplete case notes and those declining participation. Time to pregnancy is the interval between the time when infertility was established to the date of confirmed biochemical pregnancy, expressed in months. Endometriosis diagnosis includes any form of endometriosis through surgical confirmation. A statistical analysis was done through the Mann–Whitney U test. Time to pregnancy was assessed through the Kaplan–Meier test. A p value < 0.05 was considered statistically significant.

Endometriosis patients had a shorter infertility duration (4 years vs. 5 years, p = 0.024). Both groups had similar median age and body mass index at presentation. There was no significant difference in the TTP between endometriosis and nonendometriosis groups (57.7 vs. 70.9 months, p = 0.060), further confirmed by a Cox regression test incorporating confounders (IVF protocol (OR: 1.482, 95% CI 0.667–3.292, and p = 0.334) and type of the cycle (OR 1.071, 95% CI 0.803–1.430, and p = 0.640)). The endometriosis group reached the maximum cumulative pregnancy rate at around 169 months postinfertility diagnosis, whilst the nonendometriosis group at around 255 months postinfertility diagnosis.

Endometriosis is a common gynaecologic disorder that continues to exert significant reproductive morbidity among Asian women. This study found that the TTP among endometriosis patients does not differ significantly from nonendometriosis patients. This is surprising as one would expect endometriosis patients to achieve pregnancy in a longer time compared to those without.

Study findings of no significant differences in TTP for endometriosis and nonendometriosis patients may be explained in the following ways. First, the facilities are private fertility centres operating outside the national health insurance coverage and IVF is currently not covered by the Indonesian national health insurance scheme. As a result, there is an inherent selection bias for all Indonesian studies as presenting patients come from a middle to upper social class with good educational background. Study patients often already have a good prior knowledge of their diseases and tend to have had previous medical treatment and/or surgeries at other facilities prior to presenting to this facility.

Second, authors did not account previous treatment histories in this analysis. Patients presenting to facility may have had other treatments elsewhere. This is unsurprising for endometriosis patients, as their chronic pain often led them having sought treatment elsewhere. They did not include this potential confounder as the fragmented nature of the Indonesian health system which made it very difficult for them to confirm the patient’s treatments and/or surgical history. Patient notes from other hospitals would be very difficult to retrieve. There may also be a significant recall bias when patients are asked to recall information on details of their surgeries and/or treatments.

Third, the patients’ past endometriosis treatment would have corrected most of the pathology responsible for the failure of conception. This also applies to endometriomas. This may have allowed the patient to gain an advantage in IVF compared to patients without endometriosis. This might be the explanation behind the earlier TTP of patients with endometriosis, even after being stratified by age.

Authors also found that those with endometriosis often presented earlier to the fertility centre compared to those without and they tended to present after 4 years of infertility. Patients with endometriosis did not differ significantly from those without endometriosis in their time to pregnancy with IVF.

Source: Hartanto Bayuaji et al; Wiley Obstetrics and Gynecology International Volume 2024, Article ID 4139821, 6 pages https://doi.org/10.1155/2024/4139821