O-309 Surgery versus IVF/ICSI in infertile women with rectosigmoid endometriosis: the FERTILITY-RECTOSIGMOID study
Authors: Barra F , Scala C , Bogliolo S , Di Donato N , Ceccaroni M , Ferrero S 
Published: June 2022

Abstract

Study question
To compare the live birth rate in infertile patients with rectosigmoid endometriosis treated by surgery or IVF/ICSI.

Summary answer
In infertile women with rectosigmoid endometriosis, IVF/ICSI is associated with a higher live birth rate and a shorter time to conceive than first-line surgery.

What is known already
The choice between surgery and IVF/ICSI is based on several variables including concomitant infertility factors, presence of (sub)occlusive symptoms, preference of patients. Until now, there is no evidence to favor first-line IVF/ICSI or first-line surgery in women affected by rectosigmoid endometriosis wishing to conceive.

Study design, size, duration
This was a prospective patient’s preference study enrolling infertile women with rectosigmoid endometriosis who underwent first-line surgery or IVF/ICSI. Symptoms and fertility outcomes were compared between the two groups.

Participants/materials, setting, methods
Rectosigmoid endometriosis was diagnosed by transvaginal ultrasonography and magnetic resonance enema. All study patients underwent computed tomographic colonography (CTC) to assess the degree of stenosis of the intestinal lumen. Inclusion criteria were infertility; bilateral tubal patency; age &lt; 40 years. Exclusion criteria were history of surgery for endometriosis; previous IVF/ICSI cycles; oocyte donation or vitrified oocyte procedures; poor ovarian reserve; estimated bowel stenosis &gt; 70% at CTC; (sub)occlusive symptoms; oligospermia (sperm count &lt; 15 million/mL).

Main results and the role of chance
Two hundred twenty-nine patients underwent IVF/ICSI. Patients underwent up to 4 IVF/ICSI cycles. Overall, 128 women had a live birth (55.9%; 95% C.I., 49.2%-62.4%). Two bowel sub occlusions occurred during IVF-ICSI. 198 patients underwent surgical treatment of rectosigmoid endometriosis. Nine patients have postoperative complications: four rectovaginal fistula, two anastomotic leakage, two pelvic abscess and one postoperative bleeding. At a median follow-up of 23 months after surgery (range, 12-56 months), 91 women had a live birth (44.9%; 95% C.I., 38.0%-56.1%). The live-birth rate was significantly higher in patients who underwent IVF/ICSI than in those who underwent surgery (p = 0.047). The time to conception that resulted in live birth was significantly shorter in patients who underwent IVF/ICSI (mean ± SD, 11.9 ± 7.6 months) than in those who underwent surgery (18.5 ± 8.1 months; p = 0.037). Six months after surgery or first IVF/ICSI cycle, there was a higher improvement of pain (p &lt; 0.001) and intestinal symptoms (p &lt; 0.001) in women surgically treated. No bowel endometriosis-related complication occurred during pregnancy. There was no difference in perinatal outcomes between the two groups.

Limitations, reasons for caution
The nonrandom allocation to treatments and the relatively small sample sized limits the strength of our results.

Wider implications of the findings
IVF/ICSI is associated with a higher live birth rate and a shorter time to conceive than surgery. The disadvantages of IVF/ICSI are potential endometriosis-related complications during the procedure and persistence of symptoms. Surgery improves symptoms but it has a higher risk of postoperative complications, which may negatively impact spontaneous conception.

Trial registration number
CE Liguria - ID 10766 - n. 394 (Approval: 10/2020)