ENDOMETRIOSIS AND INFERTILITY

LOOKING AT THE EVIDENCE

JOHN C. PETROZZA

CHIEF, DIVISION OF REPRODUCTIVE MEDICINE & IVF

CO-DIRECTOR, MGH INTEGRATED FIBROID PROGRAM

MASSACHUSETTS GENERAL HOSPITAL

DISCLOSURE

• NONE

ENDOMETRIOSIS AND INFERTILITY

Normal

fecundity

20%

Endometriosis

2-10%

Idiopathic

4-5%

ASRM Comm, Fertil Steril, 2004Berube, Fertil Steril, 1998

MILD/MINIMAL ENDOMETRIOSIS AND INFERTILITY

• TOXIC EFFECT ON GAMETES, EMBRYOS, TUBAL MOTILITY

• ABNORMAL CYTOKINE LEVELS IN FOLLICULAR FLUID

• INCREASED GRANULOSA CELL APOPTOSIS

• ENHANCED MACROPHAGE PHAGOCYTOSIS OF SPERM

• REDUCED FERTILIZATION WITH ART

• IMPAIRED IMPLANTATION AND ENDOMETRIAL RECEPTIVITY Shifren, JCEM, 1996Carlberg, Hum Reprod, 2000Nakahara, Fertil Steril, 1997Muscato, AJOG, 1982Cahill, JARG, 1997Burney, Endocrin, 2007

MODERATE/SEVERE ENDOMETRIOSIS AND INFERTILITY

Impairment of

oocyte release

Tubal obstruction

or mobility

restriction

Impaired sperm

migration

Dunselman, Hum Reprod, 2014

MEDICAL TREATMENTSPONTANEOUS CONCEPTION

Ovarian suppression vs placebo

No difference

Surgery + ovarian suppression vs placebo

No difference

STAGE I/II ENDOMETRIOSISSURGICAL TREATMENT

SPONTANEOUS CONCEPTION

• ADHESIOLYSIS

• EXCISION OF LESIONS WITH CO2 LASER

• CLINICAL PREGNANCY RATE:• OR 1.64

• 95% CI 1.05 – 2.57

Dunselman, Hum Reprod, 2014Marcoux, NEJM, 1997Chang, JAAGL, 1997

STAGE III/IV ENDOMETRIOSISSURGICAL TREATMENT

SPONTANEOUS CONCEPTION

• CLINICAL PREGNANCY RATE:

CONTROL SURGERY

• STAGE III 33% 57-69%

• STAGE IV 0% 52-68%

Koch, Aust NZ J Obstet Gyn, 2012Adamson, AJOG, 1994Dunselman, Hum Reprod, 2014

STAGE III/IV ENDOMETRIOSISSURGICAL TREATMENT

SPONTANEOUS CONCEPTION

• RE-OPERATIVE CLINICAL PREGNANCY RATE:

1ST PROCEDURE 2ND PROCEDURE

40% 22%

Vercellini, Fertil Steril, 2009Koch, Aust N Z J Obstet Gyn, 2012

ENDOMETRIOMASSPONTANEOUS PREGNANCY

• EXCISE

• DRAINAGE AND ABLATION

Donnez, Fertil Steril, 2010

STAGE I/II ENDOMETRIOSISCOH/IUI

119

33.6

49

16.3

NUMBER OF PATIENTS PREGNANCY RATE %

Outcomes of COH/IUI

Unexplained I/II Endometriosis

Hughes, Hum Reprod, 1997

STAGE I/II ENDOMETRIOSISIVF

Fertilization Rate Implantation Rate

Clinical Pregnancy

Live Birth

Stage I/II 7% No difference No difference No difference

Stage II/IV No difference 21% 21% No difference

Harb, BJOG, 2013

Rates are compared to controls – IVF in women without endometriosis

ENDOMETRIOMASIVF

• STUDIES VARY ON RESULTS

• RISKS: INFECTION, CYST RUPTURE, DETRIMENTAL

TO OOCYTES, OVARIAN FAILURE

• SURGERY MAY REMOVE NORMAL OVARIAN TISSUE

• OPTIONS:

• LAPAROSCOPY WITH OVARIAN

CYSTECTOMY

• LAPAROSCOPY WITH PARTIAL CYSTECTOMY

AND ABLATION OF REMAINING CYST WALL

• CYST DRAINAGE

• TRANSVAGINAL CYST ASPIRATION +/- SCLEROSIS

Suzuki, Fertil Steril, 2005Donnez, Front Biosc, 2012Pal, JARG, 1998Sacha, Karmon, Petrozza, Obstst Gynecol Int J, 2018

ENDOMETRIOSISIVF/COH

• MEDICAL PRETREATMENT

• GNRH AGONIST THERAPY X 3-4 MONTHS PRE-IVF MAY INCREASE PREGNANCY RATES

4-FOLD

• OCPS X 3-4 MONTHS MAY BE JUST AS BENEFICIAL

• IVF DOES NOT INCREASE RECURRENCE RATE OR SYMPTOMS

Sallam, Cochrane Database Syst Rev, 2006