Endometriosis and

Dr. Sharda Jain / Dr. Jyoti Agarwal

…Caring Hearts, Healing hands

INFERTILITY an update

Katrina Kaif

Queen Visctoria

Hillary Clinton

Marilyn Monroe

Endometrios is a full of m

ystery

•Diagnostic Dilemma•Debilitating Disease•Progressive Disease•Disease with “No Cure”

A Gynaecologist’s Dilemma

Prevalence of Endometriosis

176 million women with endometriosis during the prime years of their lives…

1 in 10 women suffer from endometriosis

Rogers et al, Reprod Sci 2009;16:335-346World Bank, Population Projection Tables by Country and Group, 2010

Most of whom have not been diagnosed & treated!!!

Adamson et al. J of Endometriosis 2010;2:3-6

Prevalence of endometriosis in India

“5% girls below 18 who complained of dysmenorrhea are affected by endometriosis”

Kolkata SurveyEndometriosis Society, India

at least 26 million Indian women between the ages of 18 and 35 were afflicted by endometriosis

2007 surveyDr P Das

MahapatraEndometriosis Society of

India

Endometriosis begins at early age

Nnoaham et al, Global Study of women`s Health

Getting to know the woman with endometriosis

Nnoaham et al, J of Endometriosis 2009;1:36-45

Not a life-style diseaseNo prevention

Endometriosis is a challenging disease and requires decision making at every stage by

the clinician & the patient

Endometriosis at ALL stages has a negative impact on infertility

More severe is

the disease , lesser is the fecundity

Important Facts• 25-50% of infertile

women have endometriosis

• 30-50% of women with endometriosis are infertile

• Infertile women are 6-8 times more likely to have endometriosis than fertile women

Endometriosis and Infertility

Guidelines to manage infertility in patients of endometriosis

ASRMASRM

ESHRE Guidelines Jan 2014Human Reproduction vol.0 pg 1-13 2014

Why do we need these guidelines

???

Even today endometriosis remains an enigma full of mystery

“There is much , that is still not understood and the condition continues to arise interest and controversies”.

Robert W. Shaw

“ “ He who knows endometriosis He who knows endometriosis knows Gynaecology ”knows Gynaecology ”

Sir William Osler

There is a BIG Tussle between Laproscopists and IVF specialists about

management of infertility in patients of endometriosis

Aim is to help Gynaecologists make their own decision

Query 1 Are hormonal therapies effective

for infertility associated with endometriosis ??

Stage I (Minimal) Stage II (Mild)

Stage III (Moderate) Stage IV (Severe)

Classification of EndometriosisREVISED

AFS

SCORE

REVISED

AFS

SCORE

Hormonal therapy and infertility Suppression of ovarian function by means

of hormonal contraceptives , progestagens GnRH analogues or danazol to improve fertility in patients with minimal or mild endometriosis is NOT effective and hence should not be offered for this indication alone .

Evidence does not comment on more severe disease

(Hughes et al., 2007). A

Big Question 2 Is Surgery effective for infertility

associated with endometriosis ??

Infertile women with Stage I/II endometriosis

Evidence recommends that clinicians should perform operative laparoscopy (excision and adhesiolysis ) rather than performing diagnostic laparoscopy only to increase pregnancy rates

(Nowroozi , 1987; Jacobson , 2010).

Women with Stage III/IV Endometriosis So far no RCT,s comparing the reproductive outcome after surgery and after expectant management is available but

2 cohort studies have shown better pregnancy rate after surgery so

Clinicians can consider operative laparoscopy,instead of expectant management,

to increase spontaneous pregnancy rate(Nezhat et al., 1989; Vercellini et al.,2006). B

Effectiveness of Surgical techniques

Big Question

Effectiveness of Surgical techniques

Guidelines recommend that in infertile patients with chocolate cyst clinicians should perform excision of the endometrioma capsule, instead of drainage and electrocoagulation to increase spontaneous pregnancy rates .

(Hart et al., 2008) A

why excision and not ablation ?Cyst wall excision provids greater improvement

– Spontaneous pregnancy rates– Dysmenorrhea and deep-dyspareunia–Recurrence and repeat surgery– Allows histo-pathological examination

Coagulation/ laser vaporization without excision is associated with increase risk of cyst recurrence.

ASRM Practice Guidelines 2013

Possibility of occult malignancy to be kept in mind

MOST IMPORTANT !!!!

surgery must be complete & performed by a qualified gynae surgeon with experience in dealing with endometriosis.

Other techniques• Clinicians may consider CO2 laser vaporization of

endometriosis, instead of monopolar electrocoagulation, as laser vaporization is associated with higher cumulative spontaneous pregnancy rates .

• Unfortunately cost has been a big factor to prevent

widespread availability of co2 laser

(Chang et al., 1997).

Counselling ….. Two concerns

Ovarian Reserve Recurrence

Decision to proceed with surgery should be considered very carefully ,especially if the

women has had previous ovarian surgery

Is hormonal therapy effective as an

adjunct to surgical therapy for

treatment of infertility?

Question 3

Endometriosis: Medical

In minimal or mildendometriosis it does not enhance fertility and hence should not be offered

Surgical

Offered in minimal or mild and moderate to severe endometriosis

Medical treatment is not effective Rather delays fertility restoration

• In infertile women with endometriosis, clinicians should not prescribe adjunctive hormonal treatment before or after surgery to improve spontaneous pregnancy rates (Furness et al., 2004).

A But clinicians should not withhold hormonal treatment for pain in symptomatic women in the

waiting period before undergoing surgery or medically assisted reproduction .

GPP

Is ART needed in women with

Endometriosis???

ART …. Not complementary but needed

Objective is the baby

Dictum is to send the patient for ART earlier than late

IUI in endometriosis Live Birth Rate is 5.6 times higher in

couples with minimal to mild endometriosis after COS with gonadotrophins and IUI as compared to couples after expectant management .

Recommendation ......for IUI In women with stage I/II endometriosis, Clinicians may perform IUI with

controlled ovarian stimulation• instead of expectant management &• instead of IUI alone .

C

Definitely refer for ART a little earlier

IUI improves fertility with superovulation .

Role of unstimulated IUI is uncertain

IVF is appropriate where IUI fails

Recommendations for ART

IVF is the treatment of choice if

Tubal function is compromised There is male factor infertility Other treatments have failed Stage 3 -4 endometriosis

What’s different ???

IVF in Endometriosis

Issues to be considered

Remember ….. Endometriosis has decreased per cycle

conception rates in comparison with male factor and unexplained infertility .

Recurrence rates of endometriosis does not increase after COH for IVF - ICSI

Ultra long protocol and ICSI is Rx of choice for endometriosis

If patient is for IVF ......

Is medical therapy effective as an adjunct to ART for

endometriosis-associated infertility ???

Answer is …. Clinicians can prescribe GnRH agonists for a

period of 3–6 months prior to ART to improve clinical pregnancy rates in infertile women with endometriosis.

Down regulation for 3-6 months with a GnRH agonist (depot preparation) increases the odds of clinical pregnancy by more than 4 fold.

(sallam et al.,2006 ) B

Should surgery be performed prior to treatment with ART to improve

reproductive outcome?

Does Surgery improves success ??

In women with Stage I / II endometriosis undergoing laparoscopy prior to ART,

clinicians may consider the complete surgical removal of endometriosis to improve live birth rate, although the benefit is not well established .

(Opoien et;al 2011) C

Laparascopy should NOT be performed prior to ART in all women with the only aim to diagnose and subsequently treat endometriosis in order to improve the result of the ART treatment .

Remember ….• Benefit of laparoscopy in minimal or mild

endometriosis is insufficient to recommend laparoscopy solely to increase pregnancy rates.

• Laparoscopy in infertile woman, simply to confirm or rule out the disease is

not warranted.

ASRM COMMITTEE REPORT 2012

Surgical Rx 17 – 44 % of patients with endometriosis

develops ENDOMETRIOMA which affects ART outcome

Female age, duration of infertility, stage of disease, pelvic pain should be considered

while formulating a treatment plan.

Women with stage 3- 4 endometriosis

Women with chocolate cyst larger than 3 cm there is NO evidence that cystectomy prior to treatment with ART improves pregnancy rates . ( A ) Consider cystectomy prior to ART ONLY to improve • endometriosis-associated pain or• difficulty in oocyte retrival (GPP)

Role of ultrasound guided cyst aspiration

TVS aspiration offers a nonsurgical approach

TO DRAIN OR NOT TO DRAIN• Satistically reproductive outcome with or

without cyst aspiration is NOT different.

• If more than 4 cm , aspiration may be better than surgery , (especially in recurrent cases)

Bigger & Recurrent cysts are drained before stimulation

Deep infiltrating endometriosis

The effectiveness of surgical excision is NOT well established with regard to reproductive outcome.

However, these women often suffer from pain, requesting surgical treatment.

C

What to do in Recurrent endometriosis ??

Hum reprod 2009

IVF – ICSI is a better option

experiences & strategy

• On laparoscopy , even small deposits seen are fulgurated & thus managed aggressively .

• Generally , laparoscopy is reserved for chocolate cyst of more than 4 cm in size.

• Small chocolate cysts with short period of infertility , COH & IUI is tried for 3- 4 cycles before taking up for laparoscopy .

• For chocolate cysts cystectomy is done , but sometimes there may be technical difficulties then removal of the cyst lining as much as possible is done , along with fulguration of the rest.

Tips from……• Do a complete surgery.• Do not cauterize excessively.• Adhesions preventing barriers have a role.

• Medical management: improves pain, not fertility• Surgical management improves both pain and infertility

Success depends upon the residual disease left behind

To conclude …….• Medical Rx has no role in

improving fertility

• In minimal to mild disease, ovulation induction and IUI is first line therapy.

• Laparoscopic Sx with removal of all endometriotic implants and IVF –ICSI with long long protocol is the treatment of choice for moderate to severe disease.

So friends…..

Take a step in the right direction ….

ASRM 2012

ENDOMETRIENDOMETRIOSIS & INFERTILITYOSIS & INFERTILITY

He/ She who knows Endometriosis knows Gynaecology

Thank youThank you

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