MANAGEMENT OF ENDOMETRIOSIS ASSOCIATED INFERTILITY STATE OF THE ART!

1
MANAGEMENT OF ENDOMETRIOSIS ASSOCIATED
INFERTILITYSTATE OF THE ART!

• ISSAM LEBBI
• MD,PhD
• Ob-Gyn Fertility Private Clinic
• Dream Center,Montplaisir,Tunis
• Tunisia
• 
  
• 
  SGOM session
• 
  On 13th
  TJOD , May 12th, 2015

2
LAPAROSCOPY PERMIT THE DIAGNOSIS !

• NORMAL
• HYSTERO-SALPINGOGRAPHY
• IN LAPAROSCOPICALLY
• DIAGNOSED ENDOMETRIOSIS
• DONNEZ 19.2
• RICE 45.5
• WOOD 42
• LEBBI 27

3
LAPAROSCOPY PERMIT THE TREATMENT !

• IN LAPAROSCOPY
• ENDOMETRIOSIC LESIONS
  LAPAROSCOPIC TREATMENT
• IN THE SAME OPERATIVE TIME
• Why ?
• Laparoscopic treatment of stage 1 and 2 improve
  significantly the spontaneous
• pregnancy rates 30.7 Vs 17.7
• 
  
  Marcoux J Maheux R,NEJM.1997
• Surgery improve fertility in stage 3 and 4
• 
  Farquhar
  C, Curr.Opinion Gyn Obs.1998

4
BUT THE INTEREST OF LAPAROSCOPY IN
ENDOMETRIOSIS STILL HIGHLY DISCUSSED

• No comparative randomised studies with ART
  techniques
• Operative risks and morbidity of laparoscopy
• Wich surgical procedure ?
• minimal surgery (coagulation) or radical and
  extensive surgery (large
• excision experience and expertise of the
  operator)
• Benefit /cost of laparoscopy

5
THE INTEREST OF LAPAROSCOPY IN ENDOMETRIOSIS
INFERTILITY /- ENDOMETRIOSIC CLINICS AND/OR
PARACLINICS SYMPTOMS (PROBABLY STAGE 3 4 asrm)
!
LAPAROSCOPY /- SURGERY LIMITED TO PERITONEUM OR
EXTENSIVE ?? (EL3)
6
SURGERY OF ENDOMETRIOSIS ALONE OR BEFORE IVF-ET
IMPROVE THE RESULTS OF INFERTILITY !

• Retrospective study
• 29 operated patients AFTER IVF-ET FAILURE
• 22 pregnancies ( 76 )
• -15 without IVF-ET ( 52 68 of
  pregnancies)
• -7 by IVF/ICSI ( 24 32 of pregnancies)
• 
  Littman E Nezhat C,Fertil
  Steril.2005
• Retrospective study
• 107 infertile patients treated by laparoscopy
  for endometriosis
• Follow-up 1 to 11 years
• 40 spontaneous pregnancies after surgery 34,4
  
• 67 IVF-ET after surgery Pregnancy rate 56,1
  (significant)
• The higher pregnancy rate after surgery is at 6
  MONTHS 23,2
• 
  Coccia M,Eur J Obstet Gynecol Reprod
  Biol.2008

7
SURGERY OF THE ADVANCED STAGES AND DEEP
INFILTRATIVE ENDOMETRIOSIS (DIE)

• DOES EXTENSIVE LAPAROSCOPIC EXCISION OF DIE
  IMPROVE SPONTANEOUS
• AND IVF-ET PREGNANCY RATES ?
• Yes
• -Prospective cohort study of 179 women with DIE
• Gr A 105 IVF without surgery
• Gr B 64 extensive surgery before IVF
• -The odds ratio of achieving a pregnancy were
  2.45 time greater in Gr B than in
• Gr A 41 Versus 24,p0.001
  Bianchi PH, J Minim Invasive Gynecol.2009

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SURGERY OF ENDOMETRIOMAS

• Q1-EXCISIONAL SURGERY OR ABLATIVE SURGERY
  (CYSTECTOMY OR DRAINAGE AND
• ELECTROCOAGULATION OF THE CYST WALL) !?
• 2 RCTs of laparoscopic surgery of cyst (sizegt3
  cm)
• exisional surgery (Cystectomy) provides more
  favourable oucome with regard to
• -The reccurence of endometrioma
• -The reccurence of pain
• -The subsequent spontaneous pregnancy rate
• -BUT,in case of a subsequent ART (IIU OR
  IVF-ET)
•  INSUFFISANT EVIDENCE EXISTS TO DETERMINE THE
  BEST SURGICAL APPROACH 
• 
  Hart R,Cochrane
  Database Sys Rev.2008
• RCTs showed that the excision technique is
  associated with higher pregnancy rate and a
• lower rate of reccurence although it may
  determine severe injury to the ovarian
• reserve.
  Somigliana
  E,Placenta.2011
• Q2-DOES PRESENT ENDOMETRIOMAS REDUCE IVF OUTCOME
  
• DOES LAPAROSCOPIC SURGERY OF ENDOMETRIOMAS
  BEFORE IVF IMPROVE IVF RESULTS ?
• 1Women with endometriomas have a higher
  cancellation rate, a similar pregnancy,
• implantation and delivery rate.Endometrioma
  does not reduce IVF outcome.

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SURGERY OF ENDOMETRIOSISASSOCIATED
INFERTILITY IT IS A PLEA FOR RESEARCH   

Somigliana E,Placenta .2011

• The purported benefit of surgery may be
  overvalued (uncontrolled studies)
• The overal increase in post-operative pregnancy
  rates is estimated between
• 10 25
• The role of surgery before,after or as an
  alternative to IVF needs clarification.
  
• 
  Vercellini P,Hum
  Reprod.2009
• Surgery improves the chance of concieving in the
  12-18 months afterwards the
• extension of the disease to the ovaries may
  reduce the ovarian response to C.O.S
• in IVF-ET
• Surgery of endometriomas can reduce ovarian
  response to C.O.S in IVF-ET but is
• not associated with reduced oocyte quality or
  ART outcome
• Pre-ART oral contraception improve ART outcome
  particularly if
• endometriomas are present at time of retrieval.
• 
  De Ziegler
  D, Minerva Ginecol.2011

10
THE MEDICAL TREATMENTS !?
11
A PROPOSAL OF A PRAGMATIC APPROACH
Agegt35years Poor Ovarian Reserve(AMH) EMMERGENCY
ART
INFERTILITY /- ENDOMETRIOSIC CLINICS AND/OR
PARACLINICS SYMPTOMS
NO
LAPAROSCOPY /- SURGERY LIMITED TO PERITONEUM OR
EXTENSIVE ?? (EL3)
ALTERED TUBES ABNORMAL SPERM
YES
NO
EXPECTATIVE FOR12-18 MONTHS
OP x 6 to 10 weeks GnRh Analogs ? 2 To 3 Months
IVF-ET
OVARIAN STIMULATION IUI ? 6 à 14 CYCLES (EL3)