Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6...
-
Upload
ethelbert-barnett -
Category
Documents
-
view
220 -
download
4
Transcript of Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6...
![Page 1: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/1.jpg)
Can we really treat endometriosis?
Johannes L.H. Evers, Maastricht, NetherlandsBelek, Turkey, 6 October 2011,
Annual Congress of the Turkish Society of Reproductive
Medicine
![Page 2: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/2.jpg)
Objectives
To investigate the following hypotheses:
1. We understand endometriosis2. Endometriosis is a progressive
disease3. We can treat endometriosis4. We have good evidence for all of this
Belek, Turkey, 6 October 2011
![Page 3: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/3.jpg)
Evidence-based medicineis the integration of(patho)physiologicalmechanisms and theoutcome of top-qualityclinical research
Belek, Turkey, 6 October 2011
David Sackett
![Page 4: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/4.jpg)
Preface
Belek, Turkey, 6 October 2011
![Page 5: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/5.jpg)
![Page 6: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/6.jpg)
![Page 7: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/7.jpg)
Hypothesis 1
Measles is the disease
The spots are the symptoms
Endometriosis
Belek, Turkey, 6 October 2011
![Page 8: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/8.jpg)
You cannot cure the disease by removing the symptoms
Hypothesis 2
Belek, Turkey, 6 October 2011
![Page 9: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/9.jpg)
2 ımportant pıtfalls
When to perform Second Look Laparoscopy?
How to deal wıth spontaneous progressıon/regressıon?
![Page 10: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/10.jpg)
6 months drug treatment
0
2
4
6
8
10
12
14
16
18
20
# implants
Danazol x 6 monthsEvers, Fertil Steril,1985
Belek, Turkey, 6 October 2011
Number of implants
FLL
SLL
SLL+2
![Page 11: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/11.jpg)
Placebo group- better 5/17 (29%)- same 4/17 (24%)- worse 8/17 (47%)
Br Med J. 1987 January 31; 294(6567): 272–274. E J Thomas and I D Cooke
![Page 12: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/12.jpg)
Preamble
Endometriosis is a dynamic process
Belek, Turkey, 6 October 2011
![Page 13: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/13.jpg)
Preamble
Endometriosis is a dynamic processLesions come and lesions go
Belek, Turkey, 6 October 2011
![Page 14: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/14.jpg)
Preamble
Endometriosis is a dynamic processLesions come and lesions goThis depends on:
Aggression: reflux menstruationDefense: peritoneal immune system
Belek, Turkey, 6 October 2011
![Page 15: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/15.jpg)
Preamble
Endometriosis is a dynamic processLesions come and lesions goThis depends on:
Aggression: reflux menstruationDefense: peritoneal immune system
How can we modulate this process?
Belek, Turkey, 6 October 2011
![Page 16: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/16.jpg)
Surgery Drugs
Belek, Turkey, 6 October 2011
![Page 17: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/17.jpg)
Surgery
Belek, Turkey, 6 October 2011
![Page 18: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/18.jpg)
. . ..
..
.. ..
..
![Page 19: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/19.jpg)
. . ..
..
.. ..
..
![Page 20: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/20.jpg)
. . ..
..
.. ..
..
![Page 21: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/21.jpg)
. . ..
..
.. ..
..
![Page 22: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/22.jpg)
. . ..
..
.. ..
..
![Page 23: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/23.jpg)
. . ..
..
.. ..
..
![Page 24: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/24.jpg)
. . ..
..
.. ..
..
![Page 25: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/25.jpg)
. . ..
..
.. ..
..
![Page 26: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/26.jpg)
. . ..
..
.. ..
..
![Page 27: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/27.jpg)
Drugs
Belek, Turkey, 6 October 2011
![Page 28: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/28.jpg)
. . ..
..
.. ..
..
![Page 29: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/29.jpg)
. . ..
..
.. ..
..
![Page 30: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/30.jpg)
. . ..
..
.. ..
..
![Page 31: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/31.jpg)
. . ..
..
.. ..
..
![Page 32: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/32.jpg)
. . ..
..
.. ..
..
![Page 33: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/33.jpg)
. . ..
..
.. ..
..
![Page 34: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/34.jpg)
. . ..
..
.. ..
..
![Page 35: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/35.jpg)
. . ..
..
.. ..
..
![Page 36: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/36.jpg)
. . ..
..
.. ..
..
![Page 37: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/37.jpg)
. . ..
..
.. ..
..
. . ..
..
.. ..
..
surg
ery
![Page 38: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/38.jpg)
. . ..
..
.. ..
..
. . ..
..
.. ..
..
. . ..
..
.. ..
..
![Page 39: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/39.jpg)
. . ..
..
.. ..
..
. . ..
..
.. ..
..
. . ..
..
.. ..
..
. . ..
..
.. ..
..
drugs
![Page 40: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/40.jpg)
. . ..
..
.. ..
..
. . ..
..
.. ..
..
. . ..
..
.. ..
..
. . ..
..
.. ..
..
. . ..
..
.. ..
..
![Page 41: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/41.jpg)
HypothesisEndometriosis is a dynamic process
You can remove the implants by surgeryOccult implants will remain, and grow
You can inactivate (hide) implants by drugsThey will regrow after the end of therapy
Belek, Turkey, 6 October 2011
![Page 42: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/42.jpg)
1Pain
![Page 43: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/43.jpg)
Surgery Drugs
Belek, Turkey, 6 October 2011
![Page 44: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/44.jpg)
RCT
cohort
case control
interventional
observational
validity
Hierarchy of major study designs
cross-sectional
case reports / case series
Belek, Turkey, 6 October 2011
![Page 45: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/45.jpg)
Drugs
Belek, Turkey, 6 October 2011
![Page 46: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/46.jpg)
Endometriosis : pelvic paindrug - placebo
0
2
4
6
8
10
12
Start 3 months 6 months follow-up
danazol
placebo
MPA
OC
GnRHa
GnRHa+
Medical treatment
Belek, Turkey, 6 October 2011
![Page 47: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/47.jpg)
Surgery
Belek, Turkey, 6 October 2011
![Page 48: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/48.jpg)
Endometriosis : pelvic painLUNA + ablation
0
2
4
6
8
10
12
Start 3 months 6 months
Surgery
Controls
Sutton, 1997
Belek, Turkey, 6 October 2011
![Page 49: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/49.jpg)
Endometriosis : pelvic painLUNA + ablation
0
2
4
6
8
10
12
Start 3 months 6 months
Surgery
Controls
Sutton, 1997
Belek, Turkey, 6 October 2011
![Page 50: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/50.jpg)
Improvement pain
Abbott et al, 2004F&S 82: 878-84
Belek, Turkey, 6 October 2011
![Page 51: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/51.jpg)
Long term follow-up of pain surgery
Belek, Turkey, 6 October 2011
Abbott et al. 2003
VAS score
![Page 52: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/52.jpg)
Number Needed to Treat
Pain relief surgery 36/52 = 69 %
Pain relief controls 13/50 = 26 %
ARI 43 %
NNT 3
95 % Confidence Interval 2 – 6
Belek, Turkey, 6 October 2011
Sutton, 1997Abbott, 2004
![Page 53: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/53.jpg)
Pain conclusion Medical treatment works Surgical treatment works
Medical treatment will only suppress endometriosis temporarily
Surgical treatment will only remove visible lesions
Belek, Turkey, 6 October 2011
![Page 54: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/54.jpg)
2 Infertility
![Page 55: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/55.jpg)
Surgery Drugs
Belek, Turkey, 6 October 2011
![Page 56: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/56.jpg)
Drugs
Belek, Turkey, 6 October 2011
![Page 57: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/57.jpg)
Ovulation suppression for endometriosis
24 trials Drugs vs OR 95% CIOR pregnancy drugs versus placebo or no treatment
Placebo 0.79 0.54-1.14
No treatment
0.80 0.51-1.24Hughes et al, Cochrane 2007
Belek, Turkey, 6 October 2011
![Page 58: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/58.jpg)
Ovulation suppression for endometriosis
24 trials Drugs vs OR 95% CIOR pregnancy drugs versus placebo or no treatment
Placebo 0.79 0.54-1.14
No treatment
0.80 0.51-1.24Hughes et al, Cochrane 2007
Belek, Turkey, 6 October 2011
AUTHORS' CONCLUSIONS: There is no evidence of benefit in the use of ovulation suppression in subfertile women with endometriosis who wish to conceive.
![Page 59: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/59.jpg)
Surgery
Belek, Turkey, 6 October 2011
![Page 60: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/60.jpg)
Grading endometriosis
Type Clinical findings
Complicated ImplantsAdhesionsCysts
Simple Implants
Occult ---
Belek, Turkey, 6 October 2011
![Page 61: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/61.jpg)
Grading endometriosis
Type Clinical findings
Complicated ImplantsAdhesionsCysts
Simple Implants
Occult ---
Belek, Turkey, 6 October 2011
![Page 62: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/62.jpg)
Grading endometriosis
Type Clinical findings
Complicated ImplantsAdhesionsCysts
Simple Implants
Occult ---
Belek, Turkey, 6 October 2011
![Page 63: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/63.jpg)
Grading endometriosis
Type Clinical findings
Complicated ImplantsAdhesionsCysts
Simple Implants
Occult ---
Belek, Turkey, 6 October 2011
![Page 64: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/64.jpg)
2Does endometriosis affect fertility?
2 questions:
Belek, Turkey, 6 October 2011
![Page 65: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/65.jpg)
2Does endometriosis affect fertility?
If so, will treatment restore fertility?
2 questions:
Belek, Turkey, 6 October 2011
![Page 66: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/66.jpg)
RCT
cohort
case control
interventional
observational
validity
Hierarchy of major study designs
cross-sectional
case reports / case series
Belek, Turkey, 6 October 2011
![Page 67: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/67.jpg)
The best option: RCTSow - at random - endometrium in
peritoneal cavity of one group of healthy female volunteers and not in the other, and compare fertility
(cf. Ridley JH, Edwards IK: Experimental endometriosis in the human Am J Obstet Gynecol 76: 783-790, 1958)
Belek, Turkey, 6 October 2011
![Page 68: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/68.jpg)
RCT
cohort
case control
interventional
observational
validity
Hierarchy of major study designs
cross-sectional
case reports / case series
Belek, Turkey, 6 October 2011
![Page 69: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/69.jpg)
Prospective cohort study
20 years follow-up: live birth rates
unselectedyoungwomen
Belek, Turkey, 6 October 2011
![Page 70: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/70.jpg)
women withunexplainedsubfertility
Prospective cohort study
10 years untreated follow-up: live birth rates
? ? ??
Belek, Turkey, 6 October 2011
![Page 71: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/71.jpg)
The second best option, rephrased
Study spontaneous PR in untreated controls of RCT’s Compare to PR in women with unexplained subfertility
Belek, Turkey, 6 October 2011
![Page 72: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/72.jpg)
Spontaneous PR in RCT Controls
Pats Pregn PR
Thomas,’87 17 4 24%
Bayer,’88 36 17 47%
Telimaa,’88a 14 6 43%
Telimaa,’88b 14 6 43%
Fedele,’92 36 17 47%
Overton,’94 18 7 39%
RCT’s medical treatment
Belek, Turkey, 6 October 2011
![Page 73: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/73.jpg)
Spontaneous PR in RCT Controls
Pats Pregn PR
Endocan,’97 169 29 17%
GISE,’99 45 13 29%
RCT’s surgical treatment
Belek, Turkey, 6 October 2011
![Page 74: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/74.jpg)
Spontaneous PR in RCT Controls
Pats Pregn PR
Medical 135 57 42%
Surgical 214 42 20%
2 RCT’s surgical treatment6 RCT’s medical treatment
![Page 75: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/75.jpg)
Spontaneous PR in RCT Controls
Pats Pregn PR
Medical 135 57 42%
Surgical 214 42 20%
weighted average 28%
95%CI 24-34%
2 RCT’s surgical treatment6 RCT’s medical treatment
![Page 76: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/76.jpg)
Spontaneous pregnancy rates
Pats
Pregn
PR
Present review Endometriosis 349 99 28%
Adamson,1996 Endometriosis 1063 360 34%
Taylor & Collins,1992
Unexplained subfertility
2026 669 33%
Adamson, WCE Yokohama, 1996Taylor & Collins, Unexplained Infertility, 1992
![Page 77: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/77.jpg)
surgery
Belek, Turkey, 6 October 2011
![Page 78: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/78.jpg)
ENDOCAN – 1997 Canada172 surgery169 controls29% PR surgery17% PR controls
Removal of lesions + lysis of adhesions
GISE – 1999 Italy51 surgery49 controls20% PR surgery22% PR controls
Removal of lesions + lysis of adhesions
Belek, Turkey, 6 October 2011
![Page 79: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/79.jpg)
Jacobson TZ, Barlow DH, Koninckx PR, Olive D, Farquhar C. Laparoscopic surgery for subfertility associated with endometriosis (Cochrane Review). In: The Cochrane Library, Issue 2, 2003. Oxford: Update Software.
Jacobson et al. 2003
Belek, Turkey, 6 October 2011
![Page 80: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/80.jpg)
Number Needed to Treat
PR surgery 60/223 = 26.9 %
PR controls 39/214 = 18.2 %
ARI 8.7 %
NNT 12
95 % Confidence Interval 6 - 111
Belek, Turkey, 6 October 2011
![Page 81: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/81.jpg)
Can we treat Endometriosis?
Evidence for drug effect Pain: ovulation suppression works Subfertility: no effect
Evidence for surgery effect Pain: NNT 3 (95% CI 2 – 6)
Subfertility: NNT 12 (95% CI 6 – 111)
![Page 82: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/82.jpg)
![Page 83: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/83.jpg)
![Page 84: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/84.jpg)
Control & treated pats
0
5
10
15
20
25
30
35
40
45
50
FedeleBayerTelimaa aTelimaa bOvertonGISEThomas-Endocan CEndocan EC E
Untreated controls, 7 RCTs Endocan
Belek, Turkey, 6 October 2011
![Page 85: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/85.jpg)
Control & treated pats
0
5
10
15
20
25
30
35
40
45
50
FedeleBayerTelimaa aTelimaa bOvertonGISEThomas-Endocan CEndocan EC E
Untreated controls, 7 RCTs Endocan
Belek, Turkey, 6 October 2011
![Page 86: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/86.jpg)
Control & treated pats
0
5
10
15
20
25
30
35
40
45
50
FedeleBayerTelimaa aTelimaa bOvertonGISEThomas-Endocan CEndocan EC E
Untreated controls, 7 RCTs Endocan
Belek, Turkey, 6 October 2011
![Page 87: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/87.jpg)
Hummelshoj 01/2006www.endometriosis.ca
![Page 88: Can we really treat endometriosis? Johannes L.H. Evers, Maastricht, Netherlands Belek, Turkey, 6 October 2011, Annual Congress of the Turkish Society of.](https://reader035.fdocuments.in/reader035/viewer/2022062423/56649f175503460f94c2eb50/html5/thumbnails/88.jpg)