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