Endometriosis and Infertility: Surgery or ART? · Endometriosis and Infertility: Surgery or ART?...

Université Paris‐Descartes, Hôpital Cochin, Paris, France

Charlers ChapronBruno Borghese

Hervé Foulot

Antoine Bouret

Paul Mazurk

Guillaume Pierre

Marie Christine Lafay

Fouzia Decupere

François X. Aubriot

Dominique de ZieglerVanessa Gayet

Pietro Santulli

Paul Pirtea

Blandine Boquet

Aurélie Vincent

Bander Kuttbi

François Aubriot

Ann Marszalek

Endometriosis and Infertility: Surgery or ART?

DisclosureOn the advisory board of IBSA pharmaceuticalsSeventure Inc.

Holds equity interests in:Ultrast Inc.

Medical treatment of endometriosis

Surgical treatment of endometriosis

Surgery and ovarian reserve

Endometriosis and ART

Endometriosis and endometrial receptivity

Practical management









de Ziegler D, Borghese B, Chapron C. The Lancet 2010;376:730‐8..



All treatments are contraceptive

1. Pelvic pain2. Recurrence after surgery

Equally Effective

Inneffective

1. Fertility after surgery2. Enhancing fertility










At all stages of OSIS, Sx provides 50% chances on conceiving naturally in 12‐18 months.


Ressection of endometriomas


Ressection of recto‐vaginal endometriosis


Sx w/ & w/o post‐op medical treatment


Colorectal surgery does not hamper the benefit of endometriosis surgery









Retrospective measurement of AMH in 927 women with and without OSIS. No difference seen.

n = 514(E) + 413(C)

Streuli I et al. Hum Reprod. 2012;27:3294‐303


AFCEffect of Sx

AFCEffect of Non‐exis Sx

AFCEffect of OMAVs other side

AFCOperated OMAVs other side



0

10

20

30

n=68 n=1360

n=68 n=1360

PR/ sarting cycle


Kalalau BeachKauai, Hi

GnRH‐a

COS #1 COS #2

OR #1

GnRH‐a

OR #2

P4 P4

ET

E2


GnRH‐a

COS #1 COS #2

OR #1

GnRH‐a

OR #2

P4 P4

ET

E20

2

4

6

p = NS


GnRH‐a

COS #1 COS #2

OR #1

GnRH‐a

OR #2

P4 P4

ET

E2

0

0.5

1

1.5

p = NS







DiagnosisAdenomyosisEndometriomasManagement Endometriosis and endometria



Ultrasound Obstet Gynecol. 2015;46:730‐6


Ultrasound Obstet Gynecol. 2015;46:730‐6

Fertil Steril 2016;105:1421‐31.

Fertil Steril 2016;105:1421‐31.

FS 2015;103:1252‐60.


Fertil Steril 2016






DiagnosisAdenomyosisEndometriomasManagement Endometriosis and endometria




ART and Adenomyosis

ART, Adenomyosis & miscarriages

ART, Adenomyosis & long or short protocol

ART, Adenomyosis: MRI vs. US



Fecundity: likelyhood of spont preg

DiagnosisAdenomyosisEndometriomasManagement






Endometriosis and endometria



400,059 cycles reported during 2008–2010, 347,185 cycles after excluding donor, gestational carrier, and banking cycles.

39,356 initiated cycles with endometriosis, (11%)o Of these, 14,053 cycles (4%) isolated endometriosis (Endometriosis Only), o 25,303 cycles (7%) in endometriosis and additional diagnosis (Endometriosis Plus).


Conclusion Endometriosis, when associated with other alterations in the reproductive tract (either

as a result of progression or by chance) has the lowest chance. In contrast, for the minority of women who have endometriosis in isolation, the live

birth rate is similar or slightly higher compared with other diagnostic groups.






Endometriosis and endometria

DiagnosisAdenomyosisEndometriomasManagement


Impact of ARTRisk of complication

Fertil Steril 2016;105;978‐87.






Different from reports of endometriosis flare during COH‐IUI COH‐IUI: Ovulation ART: No ovulation



HRU 2015;10:1‐14.


HRU 2015;10:1‐14.

Ovarian responsiveness to COS

Technical difficulties during oocyte retrieval

Infection of endometrioma

Follicular fluid contamination w/ endometrioma content

Progression of endometriosis

Pregnancy complications

Endometriomas and cancer

Risk of conservative management of women with endometriomas


Oocyte competence

HRU 2015;10:1‐14.


Oocyte competence








Reinblatt et al., 2011 Benaglia et al., 2013Reported that albeit lesser oocytes were retrieved in women w/ endometriomas, fert and good‐embryo rates were similar.


HRU 2015;10:1‐14.


Oocyte competence










22ds – 25wks

intervalAspirated

Padilla, 1993; Yaron et al., 1994; Younis et al., 1997; Den Boon et al., 1999; Matsunaga et al., 2003; Moini et al.,2005; Sharpe et al., 2006; Romero et al., 2013.

Overall, 14 cases described despite using prophylactic antibiotics in at least 11 cases. Endometrioma infectionfollowing oocyte retrieval can occur. Prophylactic ABmay reduce this risk but cannot abolish it. Cyst aspiration/puncture is a definite risk factor.


HRU 2015;10:1‐14.


Oocyte competence









HRU 2015;10:1‐14.


Oocyte competence








Missing an occult malignancy at IVF

Cancer development after IVF

Mostoufizadeh and Scully (1980): Ca in 8/950 operated endometriomas (0.8%, 95% CI: 0.4–1.6%)

Stern et al. (2001): 9/1000 (0.9%; 95% CI: 0.4–1.6%).

Overestimation, as are pathological findingsMost should have been picked up by imaging.

Complex issue concerning the rarity of ovarian cancer (lifetime risk of ~1%) and possible links of COS/ART and/infertility w/ ov cancer.


HRU 2015;10:1‐14.



Fertil Steril 2016 in press


Accident prevention:Proper management of risk: build your defenses

Risk in ARTPresents w/pain/shivering/WBCTT w/ IV AB


Accident prevention:Proper management of risk: build your defenses

Risk in ARTPresents w/pain/shivering/WBCTT w/ IV AB

Failed to improve (10/11)48h, Laparoscopy, drainageimproved and curedovary saved 10/10


Oocyte quantityOocyte quality



Surgery and ovarian rese





donor‐egg ART

reg. ART

37


37

donor‐egg ART

reg. ART

37


de Ziegler et al. Fertil Steril 2010;94:2796‐9.

poor responderspreserved outcome














Treatment before ART



Fallopian tubes

SurgeryProvide 6-18 mo

for spontaneous preg.

3

Ovarian reserveTime available for in vivo

1

InfertilityWork up

No COH‐IUI

Semen analysis2

Ovulation may flare disease

Fallopian tubes3


1

if not pregnant



IVF for severe male factor

IVF fortubal factor

Emergency I V F

2

3

1

InfertilityWork up

IVF / ICSI(3 months)

in principleNO surgery

Semen analysis2

Fallopian tubes



3


1

if not pregnant

IVF for severe male factor

IVF fortubal factor

Emergency I V F

2

3

1

InfertilityWork up

IVF / ICSI(3 months)

in principleNO surgery

Semen analysis2

• Pelvic pain• Hydrosalpinx• Large endometrioma

Université Paris‐Descartes, Hôpital Cochin, Paris, France

Charlers ChapronBruno Borghese

Hervé Foulot

Antoine Bouret

Paul Mazurk

Guillaume Pierre

Marie Christine Lafay

Fouzia Decupere

François X. Aubriot

Dominique de ZieglerVanessa Gayet

Pietro Santulli

Paul Pirtea

Blandine Boquet

Aurélie Vincent

Bander Kuttbi

François Aubriot

Ann Marszalek


Endometriosis and Infertility: Surgery or ART? · Endometriosis and Infertility: Surgery or ART?...

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