Can endometriosis cause secondary ovarian failure?

Endometriosis and Secondary Ovarian Failure

Endometriosis can cause secondary ovarian failure through both direct damage to ovarian tissue and inflammatory processes that diminish ovarian reserve over time. 1

Mechanisms of Ovarian Damage in Endometriosis

• Endometriosis causes a sustained reduction of ovarian reserve through physical mechanisms and inflammatory reactions, resulting in reactive oxygen species production and tissue fibrosis 2
• The severity of endometriosis correlates with the degree of ovarian reserve reduction 2
• Endometriosis can lead to diminished ovarian reserve even without surgical interventions due to the damaging effect of the pathological process on follicle reservoir 3
• Recent bidirectional Mendelian randomization studies have established a significant causal relationship between endometriosis and primary ovarian failure (OR=1.348,95% CI 1.050-1.731, P=0.019) 1

Clinical Evidence and Presentation

• Endometriosis affects at least one-third of women with infertility and up to 10% of reproductive-aged women 4
• Women with endometriosis may present with reduced ovarian reserve markers, including:
  • Decreased antral follicle counts 4
  • Ovarian volume <3 cm³ 4
  • <5 antral follicles present, suggesting diminished ovarian reserve 4
• The risk for compromised ovarian reserve is especially high in young patients with:
  • Bilateral endometriomas 3
  • History of repeated surgical interventions 3
  • Severe endometriosis requiring extensive treatment 3

Diagnostic Considerations

• Transvaginal ultrasound (TVUS) can be used to monitor follicle development, perform antral follicle counts, and measure ovarian volume to assess ovarian reserve 4
• MRI can detect endometriomas with high sensitivity (82-90%) and specificity (91-98%) when TVUS findings are indeterminate 4
• Laparoscopy remains the standard for both diagnosis and staging of endometriosis, especially for detecting small endometrial implants not well visualized on imaging 4

Impact on Fertility and Treatment Implications

• Surgical treatment of endometriosis can further reduce ovarian reserve during the resection of endometriotic tissue 2
• Up to 44% of women experience symptom recurrence within one year after surgery for endometriosis, potentially leading to progressive ovarian damage 5, 6
• In cases of severe endometriosis with diminishing ovarian reserve, fertility preservation techniques should be considered before extensive surgical intervention 3
• When treating endometriosis-associated infertility, clinicians should consider that ovarian reserve can be reduced both by the disease itself and by surgical treatment 2

Prevention Strategies

• Multistep surgical techniques have been proposed to minimize the reduction of ovarian reserve during endometriosis treatment 2
• Early diagnosis and management of endometriosis may help prevent progression to secondary ovarian failure 1
• Fertility preservation options should be discussed with patients diagnosed with severe endometriosis, especially those designated for extensive ovarian surgical intervention 3

Clinical Implications

• The bidirectional relationship between endometriosis and ovarian failure suggests that managing endometriosis may help prevent secondary ovarian failure 1
• Personalized counseling should be offered to all patients with endometriosis, taking into account age, extent of ovarian involvement, current ovarian reserve, and previous/planned surgeries 3