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Managing Endometriosis-Associated Infertility: State of the Art

This comprehensive review discusses laparoscopic diagnosis and treatment of endometriosis for improved fertility outcomes. It explores the efficacy of surgery at different stages and deep infiltrative endometriosis, providing insights and recommendations. The text highlights the significance of laparoscopic techniques before or after IVF-ET procedures and addresses the impact of surgery on ovarian reserve and ART outcomes. Additionally, the pragmatic approach to medical treatments is outlined for various infertility scenarios. The content emphasizes the need for further research and clarifications in managing endometriosis-associated infertility.

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Managing Endometriosis-Associated Infertility: State of the Art

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  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 ! *Retrospectivestudy *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 & NezhatC,FertilSteril.2005 *Retrospectivestudy *107 infertile patients treated by laparoscopy for endometriosis *Follow-up: 1 to 11 years *40 spontaneouspregnanciesaftersurgery : 34,4 % *67 IVF-ET aftersurgery: Pregnancy rate = 56,1% (significant) *The higherpregnancy rate aftersurgeryisat6 MONTHS =23,2% CocciaM,Eur J ObstetGynecolReprodBiol.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%,p=0.001 Bianchi PH, J Minim Invasive Gynecol.2009

  8. 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 (size>3 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 ? 1*Women with endometriomas have a higher cancellation rate, a similar pregnancy, implantation and delivery rate.Endometrioma does not reduce IVF outcome. 2*Lower AFC and higher gonadotropin doses. Surgery of Omas before IVF does not improve IVF outcome. Bongioanni F, Reprod Biol Endocrinol.2011

  9. 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 Age>35years PoorOvarian 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 GnRhAnalogs 2 To 3 Months IVF-ET OVARIAN STIMULATION + IUI  6 à 14 CYCLES (EL3)

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