Endometriosis is a chronic estrogen-dependent disease with high morbidity that affects approximately 10% of women of reproductive age.1,2 It is strongly associated with infertility, either alone or as an adjunct to other causal factors. This disease generates a chronic systemic inflammatory process and predisposes to anatomical, tubal and ovulatory changes, being present in up to 50% of infertile couples. 3
Often the patients undergo chronic pain treatments, including long-term hormones administration (GnRH-agonist, hormonal contraceptives based on estradiol and/or progesterone), analgesics and anti-inflammatory drugs, and finally surgical treatment. 2,4 The latter has been less used over time and aims to remove adhesions and eliminate endometriotic focus in the pelvic and abdominal cavities. These treatments also cause infertility, since amenorrhea is an adverse effect commonly presented. 1
One of the locations most affected by the endometriosis lesions is the ovaries, either by invagination of endometrial tissue by the ovarian cortex in situations of retrograde menstruation or by celomic metaplasia. These lesions called endometriomas generate cysts with a content rich in macrophages and hematic cells, being easily detected on transvaginal ultrasound. Local deleterious effect due to simple “mass effect” or the presence of toxic substances could explain why these patients have less ovarian reserve (OR) and experience infertility more frequently than the healthy population. 4
Recent published studies also demonstrate impairment of oocyte quality and follicular quantity in this population, stimulating the surgical removal of these lesions in order to reduce the symptoms and restore normal ovarian function when focusing on pregnancy. 5 However, more recently, it is postulated that when performing ovarian surgical procedures to eliminate these lesions, the ovarian reserve could also be compromised, predisposing these women to premature ovarian failure, early menopause and infertility. 1,6 Experts affirm that the surgical approach should be avoided, performing only in exceptional situations, because by drying the lesions and keeping the “free margins” healthy ovarian tissue with its follicular population is also eliminated. 1 This is confirmed by studies that show a sharp drop in Anti-Mullerian Hormone (AMH) and antral follicle count (AFC) of post-surgical patients. 7
On the other hand, the fertility preservation (FP) is increasingly used, especially in women over 35 years of age, where the decline in reproductive potential is more evident. Situations where the ovarian reserve is diminished, even where biological age is not so advanced, are also often indications of FP. These conditions include patients suffering from endometriosis, where follicular depletion occurs faster.1
With the advent of vitrification and high rates of success in thawing (reaching 83%), the freezing of oocytes, embryos and ovarian tissue has been increasingly used. Especially the preservation of oocytes, given the great experience already acquired on the subject and the favourable results published over the years. The freezing of ovarian tissue, despite being described for more than 20 years, is complex, expensive and little used, being an alternative only for emergency situations where it is impracticable to wait for controlled ovarian stimulation (COS) or when there is an indication for oophorectomy. Embryo vitrification is also less used for FP, given the ethical conflicts generated and the need for the partner at the time of oocyte extraction, in addition to controversial situations in the event of the couple separating.8
Regardless of the technique used to preserve the fertility of these patients, especially those affected by advanced endometriosis, there is a consensus that the treatment can and should be proposed by the attending physician, since it increases the possibilities of future pregnancy in patients with evolutionary endometriosis or with compromised ovarian reserve in post-surgical conditions.1,2
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