Endometriosis & Infertility

Dr. Marwan AlhalabiAssistant Professorin Faculty of medicineDamascus University

And

Orient Hospital assisted Reproduction center Damascus – Syria

Endometriosis

Disease of theories and questions

n Peritoneal endometriosisn Ovarian endometriosisn Rectovaginal septum

endometriosis are

3 DIFFERENT ENTITIES

Pathogenesis

RED BALCK WHITE

Pathogenesis

Pathogenesis

Pathogenesis

Types

Types

Types

HOW MIGHT ENDOMETRIOSISRESULT IN INFERTILITY

* Mechanical effects * Endocrine abnormalities

-Attenuated LH Surge- LUF - Luteal Phase defect

* Peritoneal Fluid abnormalities - Prostanoids - Cytokines - Growth Factors - Interleukins …. ets.

* Immune System abnormalities * Oocytes defects * Increased Miscarriage rate

Diagnosis of Endometriosis

Confirmed by Laparoscopy : The Key.Indication : Infertility & Pain ,…..

Mild and minimal endometriosis associated infertility

n Laparoscopic destruction :

– Diathermy ( bi-polar)

– Vaporization

– Ablation (Marcoux etal, 1997)

n Expectant Management (Italian Study, 1999)

Mild and minimal endometriosis associated infertility

n 2RCTs showed : that repeat laparoscopy after 6 -12 month of treatment with placebo in women with early endometriosis : – 50% of endometrial deposits were

deteriorated .– 17% unchanged .– 33% resolved spontaneously .

(cooke and thomes , 2000)

Laparoscopy treatment of endometriosis Benefits

n Decreased inflammation in the Pelvis.

n Decreased Toxicity to embryos and gametes .

n Enhanced uterine receptivity .

Mild and minimal endometriosis associated infertility

Conclusion We strongly support the view that :Visible endometriosis Must be removed at the time of surgery .

Laparoscopic destruction (first line)

If Red + Black

If Black only

GnRHa(Three Month) Donnez et al, 2004

Mild and minimal endometriosis associated infertility

Types of conservative surgery

n Drainage alone (Fayez and Vogel, 1991)

n Resection of the site of invagination (Brosens, 1996)

n Destruction of the internal cyst wall (CO2 laser or

bi-polar) (Donnez and Nisolle , 1990)

n Cystectomy (Canis et al, 1989)

Small Endometrioma <3 cm

n Adhesiolysis . n Drainage . n Destruction of the cyst wall .

n Cystectomy ?

Large Endometrioma >3 cm

n Two step procedure (donnez et al, 1990)

1) * Drainage by wide opening and rinsing Adhesiolysis and free mobilization of ovary

* biopsy* Destruction of peritoneal lesions .

2) GnRH against ( 3 Month ) 3) Second look laparoscopy for internal wall

vaporization ( destruction ) .

Large Endometrioma >3 cm

n Cystectomy (canis et al, 1989)

– Risk of bleeding – “chocolate”

luteal cysts (30%) – Risk of POF– Recurrence

(incomplete surgery)

Advantage of pre-operative GnRH agonist

1- Reduction of cyst size .2- Reduction of hypervascularization and

inflammation .3- Reduction of cyst wall thickness .4- Absence of corpus luteum or follicles .5- Facilitation of surgery .6- Reduction of adhesions .

Very Large Endometrioma > 15 cm

Very Large Endomerioma > 15 cm

A. Laparoscopic drainage .Wide opening – biopsy .

B. GnRH agonist 3 month .C. Transvaginal echography and ovarian

endometrioma puncture under echographic control .

D. GnRH agonist 2 month ( + Tibolone ? ) E. Second-look laparoscopy and vaporization

(destruction of the cyst wall)

GnRH agonist 5 months

Ovarian Endometriosis

Conclusion : Destruction of the ovarian cyst wall proved to be effective .• Low recurrence rate ( 6% ).• High pregnancy rate (>50%). • Minimal destruction of normal ovarian

cortex ( as proved by IVF study, Donnez et al, 2001)

Post operative management of endometriosis n Waiting 12 – 18 month

? (simple Treatment )n MOH + IUI n IVF : depend on

– Age (OR)– Sperm – Period – Adhesions – Finance .

The Potential Risk of Endometrioma and IVF

n No RCTs.n Rupture by enlargement during

the stimulation .n Puncture – drainage :

Ovarian abscess.n Acute evolution during Pregnancy .n Acute evolution after IVF failure .n Toxic effects .n Risk of Malignancy n Effect on ovarian reserve ??

Conclusion 1

Treatment options for all grades of endometriosis associated infertility should include surgery .

Conclusion 2

Laparoscopic surgery of endometriosis improves fertility (minimal-mild)

Conclusion 3

MOH and IUI was found to be effective in infertility associated endometriosis with patent tubes

Conclusion 4

IVF is an effective treatment in advanced endometriosis, however, there are controversial data, concerning it’s outcome.

Conclusion

IVF should be adviseddirectly in :

– Sperm Abnormality – Age > 38 ( Low OR ) – Tubal Injury .– Infertility > 8 years ? – Recurrent Endometriosis.

The linked image cannot be displayed. The file may have been moved, renamed, or deleted. Verify that the link points to the correct file and location.

Conclusion

n The role of ovarian endometriomas on outcome of ART is not clear .

n Laparotomy if necessary n Importance of biopsy .

Endometriosis

Disease of theories and questions

S. AL SAMAWI MD. Gyn. Obs.A. TAHA MD. Gyn. Obs.H. HAMAD MD. Gyn. Obs.M. ABDUL WAHED MD. Gyn. Obs.Z. IDLBI Senior BiologistN. ABO HASSAN AndrolgistF. RAHMEH AndrolgistW. DAWOOD BiologistN. ASSAF BiologistF. HAMAD Administration ManagerA. ALKHATEB M.D Micro BiologistR. ALKHATEB MD. Gyn. Obs. Ph. D.

Acknowledgement

Thank You