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Human Reproduction, Vol.24, No.9 pp. 2183– 2186, 2009
Advanced Access publication on June 5, 2009 doi:10.1093/humrep/dep202

ORIGINAL ARTICLE Infertility

Endometriotic ovarian cysts negatively
affect the rate of spontaneous
ovulation
1
`
Infertility Unit, Fondazione Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, Via M. Fanti 6, 20122 Milan, Italy 2Universita degli Studi di Milano, Milan, Italy
3

Correspondence address. Tel: þ 39-02-55034303; Fax: þ 39-02-55034302; E-mail: laurabenaglia@hotmail.it

background: A growing body of evidence suggests that ovarian reserve is damaged after excision of ovarian endometriomas. However, it may not be excluded that gonadal damage is at least partly caused by the very presence of an endometrioma per se, thus preceding surgery. To clarify this aspect, we set up a prospective study in women with monolateral endometriomas in order to assess the rate of ovulation in affected ovaries.

materials and methods: Seventy women with monolateral endometriomas who had not undergone previous adnexal surgery underwent serial ecographic examinations to determine the side of ovulation.

results: Ovulation occurred in the affected ovary in 22 cases (31%; 95% CI: 22–43%). Assuming that the expected rate of ovulation in both ovaries in healthy women is similar, this difference is statistically significant (P ¼ 0.002).

conclusion: The physiological mechanisms leading to ovulation are deranged in ovaries with endometriomas. Key words: endometriosis / endometrioma / ovulation

Introduction
Endometriosis affects approximately 10% of the female population in their fertile years (Eskenazi et al., 2001). Ovarian endometriomas are a common form of the disease and may be present in up to 30 –40% of women with endometriosis (Redwine, 1999; Vercellini et al., 2006).

A growing body of evidence suggests that ovarian reserve is
damaged after excision of ovarian endometriomas (Busacca et al., 2006; Gupta et al., 2006; Somigliana et al., 2006a, 2008; Horikawa et al., 2008, Tsoumpou et al., 2008; Garcia-Velasco and Somigliana, 2009). The ovulation rate has been repeatedly shown to be reduced in operated gonads compared with contralateral intact gonads (Loh et al., 1999; Candiani et al., 2005; Horikawa et al., 2008). Moreover, data from IVF –ICSI cycles consistently showed a decreased ovarian responsiveness to hyper-stimulation in previously operated ovaries (Ragni et al., 2005; Somigliana et al., 2006a, 2008; Tsoumpou et al., 2008). The damage inflicted by surgery to ovarian reserve may be due to the removal of healthy tissue by laparoscopic stripping, the surgery-related local inflammation or vascular compromise following electrosurgical coagulation (Somigliana et al., 2008).

However, it may not be excluded that gonadal damage is at least partly caused by the very presence of an endometrioma per se, thus preceeding surgery. Scientific evidence on this issue is extremely scarce. Maneschi et al. (1993) found a reduced follicular number and activity antecedent to surgery in ovarian tissue adjacent to endometriomas when compared with teratomas or benign cystadenomas. The functional consequences of this finding have been poorly investigated. In a previous study on women selected for IVF who were found to have unoperated monolateral small endometriomas, we observed a 25% (95% CI; 6–44%) reduction in the number of developing follicles in the affected gonad (Somigliana et al., 2006b). However, these women represent a highly selected population and inference of these results to the whole population of women with endometriomas is debatable. Unfortunately, data on natural cycle ovulation in unselected women with ovarian endometriomas is very limited. Recently, Horikawa et al. (2008) investigated the rate of ovulation in 28 infertile women with monolateral endometriomas and found a 34% ovulation rate in the affected gonad but the small sample size hampered these authors to provide a statistical...
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