1. UOG Journal Club: September 2014 Impact of endometriosis and its staging on assisted reproduction outcome: systematic review and meta-analysis M.A.P. Barbosa, D. M. Teixeira, P.A.A.S. Navarro, R.A. Ferriani, C. O. Nastri, W. P. Martins Volume 44, Issue 3, Date: September 2014, Pages 261-278 Journal Club slides prepared by Ligita Jokubkiene (UOG Editor for Trainees)

2. Impact of endometriosis and its staging on assisted reproduction outcome: systematic review and meta-analysis Barbosa et al., UOG 2014 Does presence of endometriosis affect the outcome of assisted reproductive techniques (ART)? Does severity of endometriosis affect the outcome of ART? Endometriosis affects: 6-10% of women of fertile age 35-50% women with subfertility, pelvic pain or both Endometriosis treatment: Impact of medical/surgical treatment on fertility is controversial

3. Impact of endometriosis and its staging on assisted reproduction outcome: systematic review and meta-analysis Barbosa et al., UOG 2014 Aim To evaluate whether the presence or severity of endometriosis affects the reproductive outcomes of women undergoing assisted reproductive techniques

4. Impact of endometriosis and its staging on assisted reproduction outcome: systematic review and meta-analysis Barbosa et al., UOG 2014 Inclusion criteria Any study with data on ART outcomes* in women undergoing ART with and without a previous diagnosis of endometriosis Studies comparing ART outcomes with different stages of endometriosis *Live birth, clinical pregnancy, miscarriage, number of oocytes retreived

5. Impact of endometriosis and its staging on assisted reproduction outcome: systematic review and meta-analysis Barbosa et al., UOG 2014 Data extracted from studies Study characteristics (design, aims, time period, inclusion and exclusion criteria) Intervention and setting Ovulation induction protocol Severity of endometriosis Endometriosis treatment before ART

6. Impact of endometriosis and its staging on assisted reproduction outcome: systematic review and meta-analysis Barbosa et al., UOG 2014 Main outcomes Primary outcome: Live birth Secondary outcome: Clinical pregnancy Additional outcomes: Miscarriage Number of oocytes retreived Quality of evidence of studies analyzed by Newcastle-Ottawa scale http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp

7. Impact of endometriosis and its staging on assisted reproduction outcome: systematic review and meta-analysis Effect of disease 20167 with endometriosis compared with 121931 women without endometriosis Barbosa et al., UOG 2014 Effect of severity 1703 women with Stage III/IV compared with 2227 women with Stage I/II endometriosis

8. Impact of endometriosis and its staging on assisted reproduction outcome: systematic review and meta-analysis Barbosa et al., UOG 2014 Results: endometriosis vs control Higher miscarriage risk for women with endometriosis Lower number of retrieved oocytes in women with endometriosis

9. Impact of endometriosis and its staging on assisted reproduction outcome: systematic review and meta-analysis Barbosa et al., UOG 2014 Results: Stage I/II vs Stage III/IV risk comparison Lower number of retreived oocytes in women with Stage III/IV endometriosis vs Stage I/II

10. Impact of endometriosis and its staging on assisted reproduction outcome: systematic review and meta-analysis Barbosa et al., UOG 2014 Conclusions Women undergoing ART have the same chance of achieving clinical pregnancy and live birth irrespective of the absence/presence or severity of endometriosis

11. Impact of endometriosis and its staging on assisted reproduction outcome: systematic review and meta-analysis Barbosa et al., UOG 2014 Conclusions Fewer oocytes are retrieved from women with endometriosis vs no endometriosis Fewer oocytes are retrieved from women with Stage III/IV endometriosis vs Stage I/II Possible higher risk for miscarriage in women with endometriosis

12. Discussion points Should endometriosis be treated prior to commencing ART treatment in order to improve pregnancy rate? Do women with endometriosis have lower chance of live birth compared to women with other causes of infertility? Do women with advanced stage endometriosis have lower chances of live birth? What are the mechanisms that affect the chances of achieving a live birth in women with endometriosis? What adverse ART outcomes are more likely in women with endometriosis?