Overtreating endometriosis

download Overtreating endometriosis

of 35

Embed Size (px)

Transcript of Overtreating endometriosis

  1. 1. Endometriosis and infertility The hypothesis that endometriosis causes infertility or a decrease in fecundity remains controversial. Whereas evidence demonstrates an association between endometriosis and infertility, a causal relationship has not been clearly established.
  2. 2. Endometriosis and infertility: a committee opinion. The Practice Committee of the American Society for Reproductive Medicine. Sept 2012
  3. 3. A paradox ! 1. Need to do a laparoscopy to make a diagnosis of endometriosis
  4. 4. 2. No need to do laparoscopy routinely for all infertile couples
  5. 5. Routine laparoscopy Laparoscopy in infertile woman, simply to confirm or rule out the disease is not warranted. Endometriosis and infertility: a committee opinion. The Practice Committee of the American Society for Reproductive Medicine. ASRM, 2012
  6. 6. Routine laparoscopy The benefit of laparoscopic treatment of minimal or mild endometriosis is insufficient to recommend laparoscopy solely to increase the likelihood of pregnancy. Endometriosis and infertility: a committee opinion . The Practice Committee of the American Society for Reproductive Medicine. ASRM, 2012
  7. 7. No laparoscopy ? Wont we miss the diagnosis ? Yes, we will So, what ? We dont treat a diagnosis, we treat the infertile couple ! Treating mild endometriosis , either with medical therapy or operative laparoscopy, does not improve fertility
  8. 8. Routine laparoscopy Does not change treatment options - or outcome ! Burning endometriosis lesions, and cutting adhesions are fun , but treating these doesn't improve fertility and can actually reduce it Post hoc, ergo propter hoc fallacy - Patients get pregnant after the laparoscopy and doctor is happy to take the credit
  9. 9. Harm Caused Misdiagnosis - corpus luteum vs endometriosis Burning or excising chocolate cyst reduces ovarian reserve Overtreatment patient treated with Lupron after the surgery Wastes time you tell the patient, you have now been treated, so you can get pregnant on your own Don't cut and burn just because you can !
  10. 10. Medical treatment does not improve pregnancy rates In infertile women with endometriosis, clinicians should not prescribe hormonal treatment for suppression of ovarian function to improve fertility. ESHRE guideline: management of women with endometriosis. Human Reproduction, Volume 29, Issue 3, 1 March 2014, Pages 400 412,
  11. 11. Changing paradigm PAST Removal of lesions is a priority. It is a gynecological lesion Recurrence means incomplete primary surgery ART had low pregnancy rates PRESENT Preservation of ovarian function is a priority. It is an inflammatory syndrome Recurrence means persistent offending factor ART is safe and effective
  12. 12. Principles of care Ovarian reserve should be assessed before intervention. Endometriosis surgery should be avoided in women with diminished ovarian reserve who should be offered ART straightaway. ART is the best option in women with recurrent endometriosis
  13. 13. Principles of care Dont just treat the lesions ! Need to factor in: Female age Duration of infertility Pelvic pain
  14. 14. Endometrioma diagnosed on ultrasound
  15. 15. Ovarian Endometriomas
  16. 16. Justification for doing laparoscopic ovarian cystectomy Confirm the diagnosis histologically Reduces risk of recurrence over fulguration Reduce the risk of infection at IVF Improves access to follicles Improves IVF pregnancy rate ( because endometriosis fluid is toxic to eggs)
  17. 17. IVF and endometriosis Embryo implantation is not affected in patients with endometriosis. The presence of severe endometriosis or bilateral ovarian endometrioma does not lower implantation rates.
  18. 18. Although the presence of bilateral endometriomas at the time of IVF affects responsiveness to hyperstimulation, the quality of the oocytes retrieved and the chances of pregnancy are not affected. Benaglia L Bermejo ASomigliana E Faulisi SRagni G Fedele L Garcia-Velasco JA In vitro fertilization outcome in women with unoperated bilateral endometriomasFertil Steril 2013 99 6 1714-1719
  19. 19. Ultrasound guided cyst aspiration prior to IVF Safe and effective Temporary solution good enough If she gets pregnant in the IVF cycle, problem is resolved !
  20. 20. Minimally invasive ! Ethanol sclerotherapy of ovarian endometrioma: a safe and effective minimal invasive procedure. Preliminary results. Eur J Obstet Gynecol Reprod Biol 2015 Apr;187:25-9. Dr Garcia-Teiedor A
  21. 21. New treatment option Sclerotherapy in the management of ovarian endometrioma: systematic review and meta-analysis. Cohen A, Almog B, Tulandi T. Fertile Steril, 2017 Jul;108(1):117-124. Using ethanol as a sclerosant
  22. 22. Take home messages Routine diagnostic laparoscopy not indicated for infertile women Medical therapy of endometriosis has no role in improving fertility In minimal to mild disease, ovulation induction and IUI is first line therapy. IVF is the final common pathway for having a baby
  23. 23. The elephant in the room None of us will change what we are doing! We all have our personal prejudices
  24. 24. Trigger happy doctor We like doing things - " Itchy " fingers Feel good - for yourself, because you did something Patient is happy she feels you have "diagnosed" the problem and have treated it Can charge more
  25. 25. Why its easy to fool doctors Personal experience - Small numbers, no controls, no followup Patients change doctors. Only the success stories come back with chocolates ! Reinforces your bias the easiest person to fool in the world is yourself
  26. 26. Experts are biased and often wrong ! Eminence based medicine - "my experience" - which is plagued with problems Experts fudge numbers they lie ! Sponsored by pharma companies and medical device manufacturers who want to sell their products
  27. 27. Trust your own eyes ! Minimal endometriosis is a very common incidental finding No clinical relevance Look for it carefully in patients undergoing lap TL You will find it in nearly every woman you put a scope into if you are meticulous
  28. 28. IVF vs Endoscopy Do both ! Gynecologist and Ivf specialist refer patients to each other ! Both are happy - only loser is the patient