European Journal of Obstetrics & Gynecology and Reproductive Biology 181 (2014) 130–134

Contents lists available at ScienceDirect

European Journal of Obstetrics & Gynecology and Reproductive Biology journal homepage: www.elsevier.com/locate/ejogrb

IVF outcome in women with accidental contamination of follicular fluid with endometrioma content Laura Benaglia a,*, Lucia Cardellicchio a,b, Cristina Guarneri a, Alessio Paffoni a, Liliana Restelli a, Edgardo Somigliana a, Luigi Fedele a,b a b

Obstet-Gynecol Dept., Fondazione Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy Universita` degli Studi di Milano, Milan, Italy

A R T I C L E I N F O

A B S T R A C T

Article history: Received 12 February 2014 Received in revised form 24 July 2014 Accepted 29 July 2014

Objective: To evaluate whether accidental contamination of follicular fluid with endometrioma content during oocytes retrieval affects IVF outcome. Study design: We set up a retrospective review of women undergoing IVF in our infertility unit during a four years period. Cases were 19 women with ovarian endometriomas who had an accidental aspiration of the endometrioma content during oocyte retrieval. Controls (n = 38) were the two subsequent agematched women with endometriomas who underwent an uncomplicated oocyte retrieval. The main outcome was to evaluate the clinical pregnancy rate in cases and in controls. Results: Accidental aspiration of endometrioma content occurred in 19 out of 314 women (6.1%, 95%CI: 3.8–9.1%). The number of embryos and top quality embryos was significantly higher in exposed women (3.1  2.0 versus 1.7  1.2 and 1.9  1.5 versus 1.1  1.1, respectively) but the chances of pregnancy were lower. The adjusted RRs of clinical pregnancy and live birth were 0.63 (95%CI: 0.49–0.87, p = 0.005) and 0.60 (95%CI: 0.51–086, p = 0.003), respectively. Conclusion: Accidental contamination of the follicular fluid with endometrioma content is an uncommon but possible event. This situation may affect IVF outcome but does not justify systematic surgical removal before the cycle. ß 2014 Elsevier Ireland Ltd. All rights reserved.

Keywords: Endometrioma IVF Oocyte

Introduction There is consistent evidence demonstrating that surgical excision of ovarian endometriomas damages the ovarian reserve [1–11]. Accordingly, there is a now growing consensus that ovarian endometriomas should not be systematically removed in asymptomatic women before IVF [1–3]. However, the expectant management strategy exposes women with ovarian endometriomas to some risks. They include the possibility of missing an occult early stage malignancy, the development of a pelvic abscess due to the infection of the endometrioma content, the progression of endometriotic lesions, the risk of causing the rupture of the endometriomas, difficulties during oocyte retrieval, increased obstetric complications and the possible follicular fluid contamination with endometrioma content [1,12–15]. Overall, these complications are deemed rare and of scanty clinical relevance. However, evidence supporting this view is mostly insufficient.

* Corresponding author. Tel.: +39 02 55034303; fax: +39 02 55034302. E-mail address: [email protected] (L. Benaglia). http://dx.doi.org/10.1016/j.ejogrb.2014.07.036 0301-2115/ß 2014 Elsevier Ireland Ltd. All rights reserved.

In this study, we focussed on one of these complications, i.e. the potential detrimental effect of follicular fluid contamination with endometrioma content during oocytes retrieval. Even though there is a general consensus that these cysts should not be punctured, accidental aspiration cannot be always avoided and actually seldom occurs [3,16]. Contamination of follicular fluid with the endometriotic fluid may be harmful to the oocytes since the endometriomas contain a plethora of substances that may be toxic [17–22]. However, the available evidence on this potentially detrimental effect is scanty and controversial [23–25]. In an in vivo study in mice, Piromlertamorn et al. observed that the brief exposure of the oocytes to the endometrioma content did not influence the embryo development up to the stage of blastocyst but lowered the chances to reach the stage of hatched blastocyst [25]. Evidence from the two small clinical contributions is contradictory. Suwajanakorn et al. reported a lower fertilization rate and a lower pregnancy rate in women who had an accidental follicular fluid contamination [23] whereas Khamsi et al. failed to document any significant impact [24]. In order to shed more light on this issue, we reviewed oocytes retrieval in women with ovarian endometriomas over a four years

L. Benaglia et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 181 (2014) 130–134

period with the primary aim to evaluate IVF outcome in women who had an accidental contamination of the follicular fluid with endometrioma content. Our ultimate aim was to evaluate whether this potential complication may affect the chances of success and justify surgery prior to enter an IVF cycle. Materials and methods Women who underwent oocyte retrieval at the infertility unit of our Department between January 2009 and December 2012 were retrospectively reviewed. We firstly identified women with one or more endometriomas at the time of oocyte retrieval. We then selected as cases those who had accidental contamination of follicular fluid with endometrioma content. This event was ascertained based on both clinical and biological charts. In our unit, the accidental aspiration of an endometrioma was systematically reported by the physician performing the oocyte retrieval and confirmed by the biologist who described the presence of chocolate-like fluid at stereo-microscopic evaluation. More specifically, the biological diagnosis of follicular fluid contamination was based on the observation of a fluid with turbid dark-brown appearance containing many fine black particles [24]. Controls corresponded to the two subsequent age-matched women with endometriomas who underwent an uneventful oocyte aspiration. Women failing to retrieve oocytes were excluded from both study groups. All women referring to our unit routinely provided an informed consent for their clinical data to be used for researches purposes. The local institutional review board approved the study. Women with endometriomas selected for IVF were monitored and managed according to a standardized clinical protocol [10,14]. The regimen used and the dose of gonadotropins was determined on an individual basis according to data from previous IVF cycles, age, hormonal tests and antral follicle count (AFC). The patients underwent serial transvaginal ultrasound starting on day 5–6 of ovarian hyperstimulation. When three or more leading follicles with a mean diameter >18 mm were visualized, human chorionic gonadotropin (hCG) was administered subcutaneously. Oocyte retrieval was performed transvaginally 36 h after the hCG injection. Ceftriaxone 1–2 g was administered intravenously 30– 60 min before the intervention and continued intramuscularly for three days after oocytes retrieval. Oocytes retrieval was performed using a single lumen 17 ga needle and flushing was not performed. Several follicles could be aspirated in each test tube. The needle was routinely flushed with oocyte culture media between the right ovary and the left ovary. All efforts were made to avoid endometrioma puncture. When this accidentally occurred, aspiration was immediately interrupted, the needle was flushed with oocyte culture media and then the follicular aspiration was continued and completed. Oocytes obtained from tubes contaminated with endometrioma content and uncontaminated ones were handled similarly. Specifically, oocyte–cumulus complexes were immediately separated from follicular fluid, washed and transferred to a 1-ml IVF medium (Quinn’s Advantage Protein Plus fertilization medium; Sage, Trumbull, Conn., USA). Following a 3-h incubation at 37 8C in an atmosphere of 5% CO2, standard IVF or ICSI were performed. Each embryo was cultured separately. Embryo transfer was generally performed 72 h after the oocyte collection. Embryo transfer at 48 h could be done in cases where less than three embryos were available. In some but not all cases (this was not a stringent policy in our laboratory), it was specifically recorded for every oocyte whether it was or was not exposed to the contaminated follicular fluid. High quality embryos were defined as embryos types 1 and 2 according to the grading scheme proposed by Veeck [26]. Clinical pregnancy was defined as the ultrasonographic demonstration of

131

an intrauterine gestational sac containing a viable embryo 4–5 weeks after embryo transfer. The diagnosis of the endometriotic cysts was performed by ultrasound and had to be documented on at least two occasions and at least two menstrual cycles apart. More specifically, ovarian endometrioma was defined as a roundshaped cystic mass with a minimum diameter of 1 cm, with thick walls, regular margins, homogeneous low echogenic fluid content with scattered internal echoes, and without papillary proliferations [27]. Women carrying atypical lesions, i.e. cysts whose sonographic appearance was compatible but not distinctive of endometriosis were excluded. The diameter of the endometriomas was calculated as the mean of three perpendicular diameters. Analysis of the data was carried out with the Statistics Package for Social Sciences (SPSS 18.0, Chicago, IL, USA). The main aim of the study was to compare IVF outcome in women who did and did not have follicular fluid contamination. Moreover, an intra-patient comparison of contaminated and uncontaminated oocytes was performed when data from both gametes populations was recorded separately. Data were compared using unpaired Student’s t-test, non-parametric Mann–Whitney test, non-parametric Wilcoxon paired test, Chi-square test or Fisher’s exact test as appropriate. A multivariate linear regression model was used to assess the adjusted relative risk (RR) of pregnancy and live birth. It included baseline variables known to influence the chances of success, i.e. smoking, BMI, parity, previous surgery for mono or bilateral endometriomas, previous IVF–ICSI cycles, bilaterality of the endometriomas at the time of the cycle, serum FSH, serum AMH, AFC, regimen of ovarian hyperstimulation used, total dose of gonadotropins used, total number of oocytes retrieved and the in vitro technique used (FIVET versus ICSI). A p-value 0.05 was considered statistically significant. Results Accidental aspiration of endometrioma content occurred in 19 out of 314 women with ovarian endometriomas who underwent oocyte retrieval (6.1%, 95%CI: 3.8–9.1%). None developed pelvic inflammatory disease after the oocyte retrieval. These 19 cases were matched to 38 controls. Baseline characteristics of the two study groups are shown in Table 1. No statistically significant difference was observed. The characteristics of the IVF–ICSI cycles in the two study groups are summarized in Table 2. We detected a statistically significant higher number of fertilized oocytes, embryos obtained and top quality embryos in women who had follicular fluid contamination. The chances of pregnancy and live birth did not significantly differ at univariate analysis (Table 2). The crude RRs were 0.88 (95%CI: 0.69–1.12, p = 0.28) and 0.90 (95%CI: 0.73–1.12, p = 0.33), respectively. In contrast, the multivariate analyses detected a significantly lower chance of success in exposed women. The adjusted RRs of pregnancy and live birth were 0.63 (95%CI: 0.49–0.87, p = 0.005) and 0.60 (95%CI: 0.51–086, p = 0.003), respectively. In nine of the 19 cases, it was not possible to unequivocally discern oocytes that did and did not enter in contact with the contaminated follicular fluid. In contrast, in the remaining ten women, data on oocyte competence and embryo development in exposed and unexposed oocytes could be retrieved. Specifically we could compare the fertilization process and embryo development in 19 exposed and unexposed 48 oocytes. The fertilization rate, the cleavage stage rate and the rate of high quality embryo were 89% and 69% (p = 0.06), 68% and 48% (p = 0.07) and 47% and 23% (p = 0.04), respectively. The chances of being chosen for embryo transfer was higher for embryos originating from exposed oocytes (47% versus 19%, p = 0.03). Three women were transferred exclusively embryos originating from exposed oocytes and one got a twin pregnancy (two embryos out of eight implanted). Four

132

L. Benaglia et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 181 (2014) 130–134

Table 1 Baseline characteristics of cases and controls. Characteristics

Cases (n = 19)

Controls (n = 38)

p

Age (years) BMI (kg/m2) Current smoking Previous deliveries Duration of infertility (months) Concomitant male factor of infertility Previous excision of endometriomas No Unilateral Bilateral Previous IVF cycles None 1 2 Day 3 serum FSH (IU/ml) Serum AMH (ng/ml) Total AFC Endometriomas at the time of IVF Laterality Unilateral Bilateral Number of lesions 1 2 Mean diameter (mm)a

36.7  3.6 20.4  2.2 2 (10%) 0 (0%) 42  19 8 (42%)

37.0  3.5 21.1  3.0 4 (10%) 2 (5%) 41  16 18 (47%)

0.71 0.39 1.00 0.55 0.87 0.78 0.17

14 (74%) 3 (16%) 2 (10%)

18 (47%) 12 (32%) 8 (21%) 0.09

4 (21%) 8 (42%) 7 (37%) 9.3  3.6 1.9  1.8 8.1  4.5

19 (50%) 12 (32%) 7 (18%) 7.7  2.6 2.3  1.8 7.3  4.5

0.07 0.54 0.57 1.00

15 (79%) 4 (21%)

30 (79%) 8 (21%)

12 (63%) 7 (37%) 20.9  8.5

28 (74%) 10 (26%) 19.7  6.1

0.54

0.66

Data is reported as mean  SD or number (%). a If more than one endometrioma per woman was present, data refers to the larger one.

women were transferred exclusively embryos from unexposed oocytes and two got pregnant (three embryos out of seven implanted). Comment Accidental contamination of the follicular fluid with ovarian endometrioma content is an uncommon but possible complication of oocytes retrieval. In our experience, despite a policy aimed at avoiding the puncture of the endometriomas, this event occurred in 6.1% (95%CI: 3.8–9.1%) of women with this form of endometriosis. There is few previous data on the incidence of this

complication in the literature. To our knowledge, this rate was specifically reported in only one previous study of our group [16]. This study was performed in the same setting but referred to a different study period (2004–2006). The frequency of follicular fluid contamination was lower (six cases out of 214 oocyte retrievals, corresponding to 2.8%, 95%CI: 1.1%–5.6%) but overall consistent with our current data. The 95%CIs indeed overlap. In this study, we failed to document a detrimental impact on the fertilization process and embryo development in women who had follicular fluid contamination with endometrioma content. The fertilization rate, the cleavage rate and the rate of high quality embryos did not differ between women who did and did not have

Table 2 Characteristics of the IVF–ICSI cycles in cases and in controls. Characteristics Protocol of ovarian stimulation Long protocol Protocol with GnRH antagonists Other Total amount of gonadotropins used (IU) Duration of stimulation (days) Number of follicles >10 mm at hCG administration In vitro fertilization technique used IVF ICSI Number of oocyte retrieved Number of oocytes used Number of fertilized oocytes Fertilization rate Number of cleavage embryos obtained Cleavage rate Number of high quality embryos (type 1 and 2) Rate of high quality embryos Number of embryo transfers not performed Number of embryos transferreda Clinical pregnancy (CPR) per oocyte retrieval Number of embryos implanted (IR) Number of live births (LBR) per oocyte retrieval

Cases (n = 19)

Controls (n = 38)

6 (32%) 11 (58%) 2 (10%) 3110  1645 10.4  2.1 3.7  2.1

18 (47%) 12 (32%) 8 (21%) 3075  1796 10.2  2.5 3.4  3.4

8 (42%) 11 (58%) 7.6  4.4 5.2  3.3 3.7  2.4 83% (67–100%) 3.1  2.0 67% (57–85%) 1.9  1.5 39% (17–69%) 2 (11%) 2.1  0.9 3 (16%) 5 (15%) 2 (11%)

7 (18%) 31 (82%) 6.5  4.4 3.7  2.8 2.2  1.5 63% (48–100%) 1.7  1.2 50% (29–100%) 1.1  1.1 33 (0–50%) 7 (17%) 1.7  0.7 11 (29%) 12 (22%) 8 (21%)

p 0.15

Data is reported as mean  SD or number (%) or median (IQR) as appropriate. CPR: clinical pregnancy rate. IR: implantation rate. LBR: live birth rate. a Data refers to women who underwent embryo transfer (17 cases and 31 controls).

0.94 0.69 0.73 0.11

0.37 0.10 0.02 0.47 0.01 0.27 0.03 0.24 0.25 0.18 0.34 0.16 0.47

L. Benaglia et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 181 (2014) 130–134

follicular fluid contamination. Our data even suggests a paradoxical trend for an improved fertilization process and embryo development in exposed cases. Indeed, the number of embryos obtained and the number of high quality embryos was significantly higher among exposed cases despite a similar number of developed follicles and oocytes retrieved. This possibility was confirmed in the subgroup analysis on women for whom the fertilization process and embryo development could be evaluated separately for the oocytes that were and were not exposed to the endometrioma content. Indeed, when analyzing these oocytes, the rate of high quality embryo and the chances of being chosen for embryo transfer were higher for those obtained from contaminated follicular fluid. On the other hand, this biological positive evidence markedly contrasts with the clinical data. The chances of pregnancy and live birth were lower in exposed women. This reduction did not reach statistical significance at univariate analysis but becomes significant using a multivariate evaluation. A relative mean reduction of 37% and 40% was actually observed for clinical pregnancy rate and live birth rate, respectively. Noteworthy, the magnitude of this effect may be under-estimated given that, in a consistent proportion of women, embryos obtained from uncontaminated follicles were transferred. A detrimental effect of follicular fluid contamination with endometriomas content could be expected. These cysts contain a plethora of factors and some of them are expected to be toxic for the oocytes [17–28]. Explaining the conflicting information emerging from our findings, i.e. the potential toxicity of the endometrioma content, the lack of any detrimental impact on embryo development (if not a beneficial effect) and the reduced pregnancy rate is conversely demanding. Of possible interest here is that exposure of oocytes to a sublethal stress may be paradoxically beneficial, at least in the earlier phases of embryo development [29–34]. In animal models, the transient exposure of oocytes to hydrostatic pressure, hyperosmotic milieu, hydrogen peroxide (H2O2) or heat stress may indeed improve embryo development [29–33]. We herein hypothesize that a similar effect may occur in oocytes briefly exposed to endometrioma content. This would explain the improved embryo development observed in our study. On the other hand, the long term effects of this exposure may be detrimental. Our study has some strengths (we included a control group and we performed a multivariate analysis), has but also some limitations. First, the sample size is small. In this regard, it has however to be pointed out that we focused on a rare complication. Noteworthy, there is now a general consensus that endometriomas should not be punctured during oocytes retrieval and it is thus not surprising that this complication actually seldom occurred. Moreover, it has also to be underlined that the ultimate aim of our study was to clarify whether the possibility of accidental endometrioma contamination may justify the systematic surgical removal of these cysts prior to IVF. We were thus interested on both the frequency of the event and on its consequences and only marked difference between exposed and unexposed women would have been of interest. Overall, our study provided valuable information on this point. A 40% reduction in live birth rate (thus from 21% to 12.6%) due to a complication occurring in 6.1% of cases would turn into a number of women need to be treated to have one additional live birth of 195. Second, the study is retrospective and in nine out of 19 women we were not able to retrieve independent data per each oocyte. Even if this inaccuracy does not affect the overall clinical message emerging from our analysis, it reduces the power of the study on the part specifically focusing on oocyte competence. Finally, despite the use of a multivariate analysis, the study was obviously not randomized and we cannot thus fully rule out some confounders. Future in vitro studies using eggs donated for research to fertilize in experimental situations with or without

133

endometriotic fluid are needed to draw definite conclusions on a causal relationship. Our results have some potential clinical implications. In particular, they emphasize the importance of avoiding endometriomas puncture during oocytes retrieval. When contamination accidentally occurs, aspiration should be immediately interrupted and the needle should be flushed with oocyte culture media or replaced prior to continue the follicular aspiration. Moreover, oocyte–cumulus complexes should be promptly separated from the follicular fluid and washed. We also suggest to handle oocytes that were and were not exposed to endometriomas content separately and to favour the transfer of those originating from uncontaminated follicular fluid. Finally, in order to prevent concomitant exposure of several oocytes, one should consider using one test tube for each follicle when performing oocytes retrieval in women with endometriomas. On the other hand, it has to be emphasized that, given the rarity of the event and the relatively modest impact on the liver birth rate, fear about this complication does not justify systematic surgical removal of endometriomas prior to IVF.

Condensation Accidental contamination of the follicular fluid with endometrioma may affect IVF outcome but does not justify systematic surgical removal before the cycle. References [1] Garcia-Velasco JA, Somigliana E. Management of endometriomas in women requiring IVF: to touch or not to touch. Hum Reprod 2009;24:496–501. [2] Somigliana E, Benaglia L, Vigano’ P, Candiani M, Vercellini P, Fedele L. Surgical measures for endometriosis-related infertility: a plea for research. Placenta 2011;32(Suppl 3):S238–42. [3] Ruiz-Flores FJ, Garcia-Velasco JA. Is there a benefit for surgery in endometrioma-associated infertility. Curr Opin Obstet Gynecol 2012;24:136–40. [4] Raffi F, Metwally M, Amer S. The impact of excision of ovarian endometrioma on ovarian reserve: a systematic review and meta-analysis. J Clin Endocrinol Metab 2012;97:3146–54. [5] Somigliana E, Berlanda N, Benaglia L, Vigano` P, Vercellini P, Fedele L. Surgical excision of endometriomas and ovarian reserve: a systematic review on serum antimu¨llerian hormone level modifications. Fertil Steril 2012;98:1531–8. [6] Gupta S, Agarwal A, Agarwal R, Loret de Mola JR. Impact of ovarian endometrioma on assisted reproduction outcomes. Reprod Biomed Online 2006;13: 349–60. [7] Demirol A, Guven S, Baykal C, Gurgan T. Effect of endometrioma cystectomy on IVF outcome: a prospective randomized study. Reprod Biomed Online 2006;12:639–43. [8] Benaglia L, Somigliana E, Iemmello R, Colpi E, Nicolosi AE, Ragni G. Endometrioma and oocyte retrieval-induced pelvic abscess: a clinical concern or an exceptional complication. Fertil Steril 2008;89:1263–6. [9] Busacca M, Riparini J, Somigliana E, et al. Postsurgical ovarian failure after laparoscopic excision of bilateral endometriomas. Am J Obstet Gynecol 2006;195:421–5. [10] Somigliana E, Arnoldi M, Benaglia L, Iemmello R, Nicolosi AE, Ragni G. IVF–ICSI outcome in women operated on for bilateral endometriomas. Hum Reprod 2008;23:1526–30. [11] Di Prospero F, Micucci G. Is operative laparoscopy safe in ovarian endometriosis? Reprod Biomed Online 2009;18:167. [12] Somigliana E, Vercellini P, Vigano´ P, Ragni G, Crosignani PG. Should endometriomas be treated before IVF–ICSI cycles. Hum Reprod Update 2006;12:57– 64. [13] Fernando S, Breheny S, Jaques AM, Halliday JL, Baker G, Healy D. Preterm birth, ovarian endometriomata, and assisted reproduction technologies. Fertil Steril 2009;91:325–30. [14] Benaglia L, Somigliana E, Vighi V, Ragni G, Vercellini P, Fedele L. Rate of severe ovarian damage following surgery for endometriomas. Hum Reprod 2010;25: 678–82. [15] Benaglia L, Somigliana E, Santi G, Scarduelli C, Ragni G, Fedele L. IVF and endometriosis-related symptom progression: insights from a prospective study. Hum Reprod 2011;26:2368–72. [16] Benaglia L, Bermejo A, Somigliana E, et al. Pregnancy outcome in women with endometriomas achieving pregnancy through IVF. Hum Reprod 2012;27: 1663–7. [17] Badawy SZ, Cuenca V, Kumar S, Holland J. Effects of chocolate cyst fluid on endometrioma cell growth in culture. Fertil Steril 1998;70:827–30.

134

L. Benaglia et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 181 (2014) 130–134

[18] Fasciani A, D’Ambrogio G, Bocci G, Monti M, Genazzani AR, Artini PG. High concentrations of the vascular endothelial growth factor and interleukin-8 in ovarian endometriomata. Mol Hum Reprod 2000;6:50–4. [19] Mizumoto H, Saito T, Ashihara K, et al. Expression of matrix metalloproteinases in ovarian endometriomas: immunohistochemical study and enzyme immunoassay. Life Sci 2002;71:259–73. [20] Darai E, Detchev R, Hugol D, Quang NT. Serum and cyst fluid levels of interleukin (IL)-6, IL-8 and tumour necrosis factor-alpha in women with endometriomas and benign and malignant cystic ovarian tumours. Hum Reprod 2003;18:1681–5. [21] Florio P, Reis Torres PB, et al. Plasma urocortin levels in the diagnosis of ovarian endometriosis. Obstet Gynecol 2007;110:594–600. [22] Yamaguchi K, Mandai M, Toyokuni S, et al. Contents of endometriotic cysts, especially the high concentration of free iron, are a possible cause of carcinogenesis in the cysts through the iron-induced persistent oxidative stress. Clin Cancer Res 2008;14:32–40. [23] Suwajanakorn S, Pruksananonda K, Sereepapong W, et al. Effects of contaminated endometriotic contents on quality of oocytes. J Med Assoc Thai 2001;84(Suppl 1):S371–6. [24] Khamsi F, Yavas Y, Lacanna IC, Roberge S, Endman M, Wong JC. Exposure of human oocytes to endometrioma fluid does not alter fertilization or early embryo development. J Assist Reprod Genet 2001;18:06–9. [25] Piromlertamorn W, Saeng-Anan U, Vutyavanich T. Effects of ovarian endometriotic fluid exposure on fertilization rate of mouse oocytes and subsequent embryo development. Reprod Biol Endocrinol 2013;11:4.

[26] Veeck LL. An atlas of human gametes and conceptuses. London: The Parthenon Publishing Group; 1988. 48. [27] Savelli L. Transvaginal sonography for the assessment of ovarian and pelvic endometriosis: how deep is our understanding. Ultrasound Obstet Gynecol 2009;33:497–501. [28] Devine PJ, Perreault SD, Luderer U. Roles of reactive oxygen species and antioxidants in ovarian toxicity. Biol Reprod 2012;86:27. [29] Pribenszky C, Vajta G, Molnar M, et al. Stress for stress tolerance? A fundamentally new approach in mammalian embryology. Biol Reprod 2010;83: 690–7. [30] Lin L, Du Y, Liu Y, et al. Elevated NaCl concentration improves cryotolerance and developmental competence of porcine oocytes. Reprod Biomed Online 2009;18:360–6. [31] Lin L, Kragh PM, Purup S, et al. Osmotic stress induced by sodium chloride sucrose or trehalose improves cryotolerance and developmental competence of porcine oocytes. Reprod Fertil Dev 2009;21:338–44. [32] Isom SC, Lai L, Prather RS, Rucker EB. Heat shock of porcine zygotes immediately after oocyte activation increases viability. Mol Reprod Dev 2009;76:548–54. [33] Vandaele L, Thys M, Bijttebier J, et al. Short-term exposure to hydrogen peroxide during oocyte maturation improves bovine embryo development. Reproduction 2010;139:505–11. [34] Lee MS, Liu CH, Lee TH, et al. Association of creatin kinase B and peroxiredoxin 2 expression with age and embryo quality in cumulus cells. J Assist Reprod Genet 2010;27:629–39.

IVF outcome in women with accidental contamination of follicular fluid with endometrioma content.

To evaluate whether accidental contamination of follicular fluid with endometrioma content during oocytes retrieval affects IVF outcome...
279KB Sizes 0 Downloads 7 Views