2. Introduction
Ovarian reserve is injured following surgical excision of ovarian endometriomas
Garcia-Velasco JA, Somigliana E., Hum Reprod, 2009
Bilateral disease:
Surgery: severe impairment of the ovarian reserve and even ovarian failure
Busacca M et al. Am J Obstet Gynecol 2006
Somigliana E et al. Hum Reprod 2008
growing consensus  ovarian endometriomas should not be systematically removed in asymptomatic women IVF
standard procedure:
laparoscopic stripping of the cyst wall

3. Introduction
It is unclear whether the presence of ovarian edtomas may be detrimental per se to the ovarian reserve
available evidence is conflicting
reduced follicular number and activity before surgery in endometriomas compared with teratomas or benign cystadenomas
Maneschi F et al., Am J Obstet Gynecol 1993
unoperated women with monolateral endometriomas, the rate of spontaneous ovulation in the affected ovaries is significantly lower
Horikawa T, et al., J Assist Reprod Genet 2008
Benaglia L, et al. Hum Reprod 2009

4. Introduction Two articles (2011):
outcome in women with monolateral unoperated endometriomas
ovarian responsiveness was similar in the affected and contralateral intact gonads
Almog B, et al. Fertil Steril 2011 Benaglia L, et al. Hum Reprod 2011 (both retrospective)

5. Objective:
to evaluate IVF outcome in women with unoperated bilateral endometriomas
Focusing on women with bilateral rather than monolateral disease
more reliable data on ovarian responsiveness and oocytes quality
compensatory effect of the intact gonads is lacking.

6. Materials and Methods multicenter retrospective cohort study
Infertility Unit of Fondazione Ca Granda, Ospedale Maggiore Policlinico (Milan, Italy)
IVI Infertility Unit (Madrid, Spain)
(ICSI) cycles
January 2006 to July 2010
aged < 40 years
bilateral endometriomas
Diagnosis: two ultrassound
Control subjects
women who had not undergone previous ovarian surgery
and who did not have any USG evidence of edt or nonedt ovarian cysts
without a history of endometriosis
Exclusion criterion.
Previous surgery for endometriomas

7. Materials and Methods
Statistics Package for Social Sciences (SPSS 18.0)
Statistically significant differences:
unpaired Student t test
nonparametric Wilcoxon unpaired test
chi-square test
or Fisher exact test as appropriate
P value of < 0,05 was considered to be statistically significant

8. Results

9. Results
Seventeen women (44%) were diagnosed with more than one endometrioma per ovary
the mean size of cysts
Right: 20 (+/- 10)mm
Left: 21 (+/- 10)mm

10. Results

11. Results
oocytes retrieved/total number of follicle in case and control subjects were
77% (57%–88%) in case
71% (63%–79%) in control
fertilization rates
67% (56%–100%) in case
70% (57%–100%) in control
top-quality embryos per oocyte
33% (25%–50%) in case
33% (20%–43%) in control

12. Results
inadvertent puncture of the endometriomas did not occur in any case
no pelvic in- flammatory disease following oocyte retrieval was observed.

13. Discussion
Responsiveness to ovarian hyperstimulation is reduced in women with bilateral unoperated endometriomas
On the other hand
rates of oocytes retrieved per developing follicle were similar
 oocyte retrieval is not hampered by the presence of the endometriomas
the quality of the retrieved oocytes was not influenced by the proximity of these cysts
The fertilization rate, the rate of top-quality embryos per oocyte used, the implantation rate, and the chances of pregnancy  the same

14. Discussion The mean diameter of the cysts was 22–23 mm.
larger cysts may be more detrimental to oocyte quality
Patients with larger cysts may be more symptomatical  surgery
Italian legislation banning a systematic policy of embryo freezing
Not possible to obtain data on the cumulative pregnancy rate per retrieval
histologic confirmation of the diagnosis of endometriosis was missing
Sensitivity 84%–100%  USG
Specificity 90%–100%  USG
Savelli L. Ultrasound Obstet Gynecol 2009
mechanisms behind the reduced responsiveness on ovaries with endometriomas were not investigated in the present study

15. In conclusion
the presence of bilateral edtomas at the time of IVF seems to affect responsiveness to hyperstimulation
the quality of the oocytes retrieved and the chances of pregnancy are not affected
Given the risks of severe damage to the ovarian reserve consequent to surgery in these asymptomatic women, the intervention does not appear to be a suitable

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