Treatment of endometriosis associated infertility

An evidence based approachABOUBAKR ELNASHARBenha university, Egypt

ABOUBAKR ELNASHAR

EB Guidelines1. RCOG: Evidence-based Clinical, 19992. Endometriosis and infertility. ASRM, 2004.3. ACOG. Endometriosis in adolescents, 2005.4. ESHRE guideline for the diagnosis and

treatment of endometriosis, 2005.5. Endometriosis and infertility. ASRM, 2006 .6. Endometriosis: diagnosis and management.

SOGC, 2010 7. Fertility: Assessment and Treatment for People

with Fertility Problems. NICE, 2013.8. ESHRE guideline: management of women

with endometriosis, 2014

ABOUBAKR ELNASHAR

OBJECTIVESReview

ESRH: 2014 EB guidelineLiterature: 2015 and 2016

Diagnosis Treatment

1. Hormonal2. Nutritional supplements, complementary and

alternative treatments3. Surgery4. IUI and COS5. ART

Conclusion

ABOUBAKR ELNASHAR

ESRH 2014 EB guidelineGrade of recommendations based onA: Meta-analysis or multiple RCT (of high quality)B: Meta-analysis or multiple RCT (of moderate quality)Single RCT, large non-RCT(s) or case control/cohort studies (of high quality)C Single RCT, large non-RCT(s) or case control/cohort studies (of moderate quality)DNon-analytic studies or case reports / case series (of high or moderate quality)GPP Good practice point, based on experts’ opinion

ABOUBAKR ELNASHAR

I. DIAGNOSISLaparoscopywith biopsy and histology: gold standard for diagnosisNegative diagnostic laparoscopy: highly accurate

for excluding endometriosis Positive laparoscopy:

less informativeof limited value when used without taking biopsies (Wykes et al., 2004).To obtain tissue for histology in women undergoing surgery for endometrioma and/or deep infiltrating disease

{exclude rare instances of malignancy}{GPP}

ABOUBAKR ELNASHAR

Histopathologic confirmationnecessary for the diagnosis of endometriosis{Definition: ectopic endometrial stroma and glands}(Berker, Seval, 2015)

ABOUBAKR ELNASHAR

II. TREATMENT1. Hormonal therapies

No needFor suppression of ovarian function to improve fertility(Hughes et al., 2007).{A}hormonal contraceptives,ProgestagensGnRH analogues or Danazolto improve fertility in minimal to mild endometriosis is not effective and should not be offered for this indication alone. The published evidence does not comment on more severe disease (Hughes et al., 2007).

ABOUBAKR ELNASHAR

2. Nutritional supplements, complementary and alternative

treatmentsNo evidence for a beneficial effect(GPP)

ABOUBAKR ELNASHAR

3. Surgery

Stage I/II:•Operative laparoscopy:excision or ablation of the endometriosis lesionsadhesiolysisrather than•Diagnostic laparoscopy only, to increase PR(Nowroozi et al., 1987; Jacobson et al., 2010).{A}

ABOUBAKR ELNASHAR

CO2 laser vaporization of endometriosis, instead of monopolar electrocoagulation{higher cumulative spontaneous PR }(Chang et al., 1997).{C}

ABOUBAKR ELNASHAR

EndometriomaExcision of the capsule, instead of drainage and electrocoagulation of the endometrioma wall{increase spontaneous PR}(Hart et al., 2008).{A}Counseling:

Risks of reduced ovarian function after surgery and the possible loss of the ovary.

The decision to proceed with surgery should be considered carefully if the woman has had previous ovarian surgery.{GPP}

ABOUBAKR ELNASHAR

Stage III/IVOperative laparoscopy, instead of expectant management: increase spontaneous PR (Nezhat et al., 1989; Vercellini et al.,2006). {B}Crude spontaneous pregnancy rates of (Olive et al., 1985; Nezhat et al., 1989; Vercellini et al., 2006).

After expectant management

After operative laparoscopy

Stage

33% 52-68% III0% 57-69% IV

ABOUBAKR ELNASHAR

Operative Laparoscopy (Jozwiak et al, 2015)

an efficient method most effective particularly at stage III.

The period for expectant management after a surgical procedure should last 6 months.

ABOUBAKR ELNASHAR

Hormonal treatment Before surgery to improve spontaneous PR:No{evidence is lacking}(GPP)For painYes(GPP)After surgery to improve spontaneous PRNo (Furness et al., 2004).{A}

ABOUBAKR ELNASHAR

4. IUI WITH COS instead of expectant managementIn Stage I/II {increases LBR}(Tummon et al., 1997).{C}

In Stage I/II within 6 months after surgical TT{PR are similar to those achieved in unexplained infertility }(Werbrouck et al., 2006). {C}

ABOUBAKR ELNASHAR

5. ART Indicationstubal function is compromisedmale factor infertilityother treatments have failed.{GPP}after surgery{cumulative endometriosis recurrence rates are not increased after COS for IVF/ICSI}(D’Hooghe et al., 2006; Benaglia et al., 2010;Coccia et al., 2010; Benaglia et al., 2011). {C}

ABOUBAKR ELNASHAR

Going straight to IVF. (Polat et al, 2015)Age ≥38 y infertility is long lasting.

Semen characteristicstubal status that is incompatible with natural conception

IVFbypasses the distortion of pelvic anatomyremoves gametes from a hostile peritoneal

environment.

ABOUBAKR ELNASHAR

Surgery before ARTIn Stage I/IIlaparoscopy for complete removal of endometriosis to improve LBR, although the benefit is not well established (Opoien et al., 2011). {C}

ABOUBAKR ELNASHAR

In I/IIsurgical excision or ablation of endometriosis is recommended as first line with doubling PR (Rizk et al, 2015) In patients who failed to conceive spontaneously after surgery: ART is more effective than repeat surgery.

ABOUBAKR ELNASHAR

Surgical resection of nonovarian disease has not been consistently shown to improve outcomes with the possible exception of resection of deeply invasive disease, although the data is limited.(Surrey, 2015)

ABOUBAKR ELNASHAR

Endometrioma Counsel women regarding the risks of reduced ovarian function after surgery and the possible loss of the ovary. {A}The decision to proceed with surgery should be considered carefully if the woman has had previous ovarian surgery.Cystectomy to

improve endometriosis-associated pain or accessibility of follicles.

{GPP}Cystectomy for endometrioma larger than 3 cm: no evidence for improvement PR (Donnez et al., 2001; Hart et al., 2008; Benschop et al.,2010).{A}

ABOUBAKR ELNASHAR

Endometriomas > 4 cm should be removed(Rizk et al, 2015)

Precycle resection of endometriomas: does not have benefitshould only be performed for gynecologic

indications.deleterious impact on ovarian reserve and

response.(Surrey, 2015)

ABOUBAKR ELNASHAR

Although endometriomas can be detrimental to the ovarian reserve, surgical therapy may further lower a woman's ovarian reserve. (Keyhan et al, 2015)

Presence of an endometrioma does not appear to adversely affect IVF outcomes

Surgical excision of endometriomas does not improve IVF outcomes.(Kaponis et al, 2015; Keyhan et al, 2015)

ABOUBAKR ELNASHAR

o Surgery or expectant management. (Keyhan et al, 2015)Symptomsageovarian reservesize and laterality of the cystprior surgical treatmentlevel of suspicion for malignancy.

Proceeding directly to in IVF≥38diminished ovarian reservebilateral endometriomas prior surgical treatment.

ABOUBAKR ELNASHAR

Indications for Resection of a Suspected Endometrioma prior to IVF (Surrey et al, 2015)(i) Rapid growth,(ii) Suspicious features noted on ultrasound,(iii) Painful symptoms that can be attributed to the mass(iv) Potential for rupture in pregnancy,(v) Inability to access follicles in normal ovarian tissue.

ABOUBAKR ELNASHAR

Deep endometriosisThe effectiveness of surgical excision isnot well established with regard to reproductive outcome (Bianchi et al.,2009; Papaleo et al., 2011).{C}

laparoscopic excision of deep endometriosis enhances PR, by both spontaneous conception and ART. (Surrey, 2015 ; Centeni et al, 2016)

ABOUBAKR ELNASHAR

The therapeutic decision should be based on clinical historyinstrumental findingspain symptomsrisks of pregnancy complicationswoman's wishes.

(Somigliana et al, 2015)

ABOUBAKR ELNASHAR

GnRHa for a period of 3–6 months prior to treatment with ART: improve PR (Sallam et al., 2006). {B}A benefit (which did not reach clinical significance)only when fresh and cryopreserved embryo transfers were combined. (Houwen et al, 2014)

Significant benefit was noted only among patients stages III and IV(Rickes et al, 2002)

ABOUBAKR ELNASHAR

At Oocyte retrivealAntibiotic prophylaxis although the risk of ovarian abscess following follicle aspiration is low (Benaglia et al., 2008).{D}

ABOUBAKR ELNASHAR

Conclusion

ABOUBAKR ELNASHAR

ABOUBAKR ELNASHAR

1.Aboubakr elnashar lectures:

270 lectures3702 members2. Slide share270 lectures1271 followers