Stimulation protocols for Severe Endometriosis- is there any difference?

Endometriosis, being an estrogen-dependent condition, can lead to subfertility in women. Those facing difficulty achieving pregnancy goals may need assistance from assisted reproductive technology (ART). Due to the challenges posed by endometriosis in natural conception, assisted reproductive technologies like IVF and ICSI. Objective of the study: This study aimed to compare ART outcomes in women with endometriosis following the three distinct groups of protocols undergoing various treatment modalities, namely the progestin-primed ovarian Stimulation protocol, GnRH agonist long protocol, and Combined Oral Contraceptives (OCPs). This investigation aims to enhance our understanding of how different stimulation protocols may influence ART outcomes Methodology: This is a cross-sectional study between March 2019 to March 2023. The study collected data from 126 infertile women diagnosed with endometriosis, who were undergoing their first intracytoplasmic sperm injection (ICSI) cycle at MHRT Hospital and Research Center, Hyderabad, Telangana India. Patients in each group were classified into three Protocols ie-GnRH agonist Long Protocol, Progestins primed Ovarian Stimulation, and Combined Oral Contraceptives. The outcomes of the ICSI program were evaluated Result: The findings from our study suggest that women with endometriosis undergoing ICSI experience improved reproductive outcomes when subjected to prolonged downregulation with GnRH agonist long protocol, Progestin primed Ovarian Stimulation and Combined Oral Contraceptives before initiating ovarian stimulation. Notably, the clinical pregnancy rate is notably higher at GnRH agonist long Protocol 57.5% compared to the alternative protocols: PPOS at 34.2 % and Combined Oral Contraceptives at 40.54 %. The groups subjected to extended pituitary downregulation with GnRH agonists long protocol demonstrated superior clinical pregnancy and live birth rates compared to those following the PPOS and Combined Oral Contraceptives. Our segmented IVF approach, including FET cycles, revealed a higher live birth rate in the GnRH agonist protocol compared to the PPOS and Combined Oral Contraceptives. Conclusion:  This study demonstrates that GnRH agonists' long protocol demonstrated superior clinical pregnancy and live birth rates compared to those following the PPOS and Combined Oral Contraceptives. Better clinical outcomes were observed in the GnRH agonist long protocol group when compared to the PPOS and Combined Oral Contraceptive group.