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The Management of Recurrent Endometriosis

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Title: Endoscopic Treatment of Endometriosis in infertile patient Author: Gazi YILDIRIM Last modified by: cihat unlu Created Date: 11/13/2007 7:33:03 PM – PowerPoint PPT presentation

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Title: The Management of Recurrent Endometriosis


1
The Management of Recurrent Endometriosis
  • Prof. Cihat ÜNLÜ, M.D.
  • Acibadem University Hospital, Department of
    Obstetrics Gynecology, Istanbul/TURKEY
  • President of the Turkish-German Gynecology
    Association (TAJEV)
  • Editor of the Journal of the Turkish-German
    Gynecology Association (JTGGA)

2
Disclosure
  • No financial relationships to disclose.

3
Recurrence Definitions
  • Reoperation because of reappearanceof symptoms
  • Ultrasonography
  • Second laparoscopy at the end of thesecond year
  • Ultrasonographic evidence and theneed for
    reoperation due to pains
  • Presence of clinical and/orbiopsy-proven
    endometriosis atlaparoscopy or as the presence of
    anendometriotic cyst on ultrasound
    withcytological confirmation
  • Recurrence of 1 symptom (urgency,frequency and
    pain at micturition) ofmoderate-to-severe
    intensity
  • Clinical examinationUltrasonographic exam during
    theproliferative phase of the menstrualCycle
  • Evaluation of symptoms, pelvicexamination,
    transvaginalultrasonography and renal ultrasound
  • Detection of cysts 2 cm byUltrasonography
  • Presence of endometrioma 2 cm asdetected by
    ultrasonography
  • Exacerbated symptoms 3 monthsafter surgery plus
    at least one of (i)reappearance of disappeared
    positivepelvic characteristics followingsurgery
    (ii) ultrasonography and (iii)arise of serum
    CA125 following fall
  • The presence of ovarian cysts morethan 3 cm in
    diameter with a typicalaspect detected by
    ultrasonography
  • For two consecutive menstrual cycles
  • Not clearly defined
  • Either pain or ultrasonographicEvidence
  • Pain evaluated by visual analog scale(VAS)
  • Symptom recurrence
  • Clinical exam, ultrasound, CA-125,second look
    laparoscopy based onclinical finding
  • The sum of pain score (total pelvicsymptom score)
    7

4
36 month cumulative recurrence rates according to
disease stage
From Vercellini et al. Human Reprod 2006
5
From Vercellini et al. RBM Online 2010
6
More Radical Many Intervention
Endometrioma Surgery
Less Radical
  • Recurrence

7
Endometrioma recurrence
  • More common when the endometrioma is removed
    piecemeal and the tissue planes are scarred
  • More common when the ovarian reserve is better

From Somigliana et al. AJOG 2011
8
The reported recurrence rate was high, estimated
as 21.5 at 2 years and
40-50 at 5 years. (23 years follow up)
9
Risk factors for Recurrence
10
Predictive factors for recurrence of
endometriotic lesions and pain
11
Recurrence Problems
  1. Impaired QoL (Pain)
  2. Infertility
  3. Asymptomatic Endometrioma

12
Impaired QoLPain
  1. Second Surgery
  2. Medical Supression
  3. Expectant Management

13
Impaired QoLSecond Surgery
  • Re-Excision
  • Pelvic Denervations
  • Presacral Neurectomy
  • LUNA
  • Hysterectomy

14
Re-Excision
  • Pain symptoms (42 women )
  • StageIV in 14
  • Stage III in 25
  • Stage I in 3
  • Follow-up of 42 months
  • Dysmenorrhea and deep dyspareunia reappeared in
    8 women
  • Non-cyclical pelvic pain in 7 women
  • A third operation was necessary in 6 women (14)
  • The symptoms recurrence rate when repeat
    laparotomy was performed specifically for pain is
    25

Candiani GB, Fedele L, Vercellini P, Bianchi S,
Di Nola G. Repetitive conservativesurgery for
recurrence of endometriosis. Obstet Gynecol
1991774214.
15
Repetetive Surgery for Pelvic Pain
2nd Surgery
3rd Surgery
Berlando N, Curr Opin Obstet Gynecol 2010,
16
Re-Excision
  • 81 women re-operated, 60 months
  • Laparotomy
    (n 41) Laparoscopy(n 40)
  • Stage IV..14.. 11
  • Stage III ..25..
    21
  • Stage II..0...2
  • Stage I 2...6
  • Dysmenorrhea..22(7/32)29(
    10/35)
  • Deep dyspareunia.. 30(7/23).2
    5(4/16)
  • Pelvic pain...............
    35(9/26)..................... 32(7/22)

Busacca M, Fedele L, Bianchi S, et al. Surgical
treatment of recurrent endometriosislaparotomy
versus laparoscopy. Hum Reprod 19981322714.
17
Re-Excision
  • Recurrence rate (5-year cumulative pain)
  • After the first surgical procedure 20
  • After the second procedure 17

Fedele L, Bianchi S, Zanconato G, et al.
Laparoscopic excision of recurrent
endometriomas long-term outcome and comparison
with primary surgery. Fertil Steril 2006856949.
18
Re-Excision
The effect of repetitive laparoscopic surgery on
pain is similar to that observed after first-line
surgery.
19
Ovarian surgery for bilateral endometriomas
influences age at menopause
Patients who had been operated on for bilateral
endometriomas have an increased risk of POF.
20
Surgery plus PSN vs Surgery Alone
Berlando N, Curr Opin Obstet Gynecol 2010,
21
Presacral Neurectomy

  • Conservative surgery Conservative

  • plus PSN
    surgery

  • (n63)
    (n63)
  • Dysmenorrhea cure rate
  • 6-month follow-up 87 .57
  • 12-month follow-up 60...................
    .................86
  • 24-month follow-up .83..................
    .................53
  • At the end of the study period, the frequency and
    severity of deep dyspareunia and non-menstrual
    pain were also significantly lower in women from
    the PSN those in conservative.
  • 11 women who underwent PSN referred long-term
    complaints such as de-novo constipation (n
    9,15) and urinary urgency (n 3, 5).

Zullo F, Palomba S, Zupi E, et al. Am J Obstet
Gynecol 2003189510. Zullo F, Palomba S, Zupi
E, et al. J AmAssoc Gynecol Laparosc 200411238.
22
Presacral neurectomy
From Berlanda et al. Curr Opin Obstet Gynecol
2010
23
Addition of pelvic denervation
  • PSN has been reported as an effective procedure
    in reducing pain recurrences in women undergoing
    first-line surgical treatment of endometriosis
  • Although no data are available in women with
    recurrent endometriosis, it might be argued that
    women with recurrent pain are those in whom the
    greatest surgical effort should be made in order
    to cure the disease, including therefore PSN

24
Limitations of PSN
  • Effective in reducing midline pain only, whereas
    lateral, adnexal pain is not influenced
  • Denervation of bowel and bladder might cause
    constipation and urinary dysfunction
  • It must be performed by an experienced surgeon
    because it is carried out in a complex anatomic
    area and great care must be taken to avoid
    damaging the right ureter as well as major and
    midsacral vessels

25
LUNA

  • Conservative surgery Conservative

  • plus LUNA
    surgery

  • (n78)
    (n78)
  • Dysmenorrhea recurrence rate
  • 12-month follow-up 29 ..27
  • 24-month follow-up 36...................
    .................32
  • 68 of 90 (75) patients in the LUNA group and
  • 67 of 90 (75) patients in the conservative
    surgery only group were satisfied at 1 year.

Vercellini P et al Fertil Steril 2003803109.
26
Hysterectomy
  • Young patients?????????????????
  • Ovaries???????????????????????
  • Symptomatic endometriosis in 29 women
  • Ovarian tissue
    was preserved Both ovaries removed

  • n 29
    n109
  • Recurrent pain 18 (62)........
    11 (10)
  • Required reoperation. 9
    (31)...4 (3.7)
  • Patients who underwent hysterectomy with ovarian
    conservation had
  • 6.1 times greater risk of developing recurrent
    pain and
  • 8.1 times greater risk of re-operation.

Namnoum AB et al. Fertil Steril199564898902.
27
Removal of the ovaries at definitive surgery
28
Reoperation rates-definitive vs conservative
surgery
Surgery Reoperation rate
Definitive with removal of the ovaries
Definitive with ovarian conservation 2.89
Conservative surgery 6.16
29
Impaired QoLMedical Suppression
30
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31
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32
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33
Recurrent EndometriosisAromatase Inhibitors
  • Good case reports
  • No randomized controlled studies

Lall Seal S, Kamilya G, Mukherji J, De A, Ghosh
D, Majhi AK. Aromatase inhibitors in recurrent
ovarian endometriomas report of five cases with
literature review. Fertil Steril. 2011
Jan95(1)291.e15-8.
34
Recurrent EndometriosisGnRH Analogues
Sesti F, Capozzolo T, Pietropolli A, Marziali M,
Bollea MR, Piccione E. Recurrence rate of
endometrioma after laparoscopic cystectomy a
comparative randomized trial between
post-operative hormonal suppression treatment or
dietary therapy vs. placebo. Eur J Obstet
Gynecol Reprod Biol. 2009 Nov147(1)72-7.
35
Recurrent EndometriosisGnRH Analogues
  • A 6-month course of hormonal suppression
    treatment or dietary therapy after laparoscopic
    cystectomy had no significant effect on the
    recurrence rate of ovarian endometriosis when
    compared with surgery plus placebo.
  • So, treatment of endometrioma can be carried out
    exclusively by laparoscopic cystectomy without
    post-operative therapy, if a complete excision of
    ovarian endometriosis has been assured.

Sesti F, Capozzolo T, Pietropolli A, Marziali M,
Bollea MR, Piccione E. Recurrence rate of
endometrioma after laparoscopic cystectomy a
comparative randomized trial between
post-operative hormonal suppression treatment or
dietary therapy vs. placebo. Eur J Obstet
Gynecol Reprod Biol. 2009 Nov147(1)72-7.
36
Recurrence Problems
  • Impaired QoL-Pain
  • Infertility
  • Asymptomatic Endometrioma

37
Recurrent EndometriosisInfertility
  • 2nd Surgery
  • Medical Therapy
  • Medical Therapy ART
  • ART
  • KOH
  • KOH IUI
  • ICSI-ET

38
Pregnancy rates after second-line surgical
treatment for infertility in women with recurrent
endometriosis
Recurrent EndometriosisInfertility/2nd Surgery
The mean conception rate among women undergoing
repetitive surgery for recurrent endometriosis
associated with infertility was 26, whereas the
overall crude pregnancy rate after a primary
procedure was 41.
Berlando N, Current Opinion in Obstetrics and
Gynecology 2010, 22320325
39
Acta Obstet Gynecol Scand 2009
LAPAROTOMY
LAPAROSCOPY
40
Recurrent EndometriosisInfertility/2nd Surgery
Spontaneous Pregnancy After 1? surgery
236/577 (41) Spontaneous Pregnancy After 2?
surgery 28/124 (23)
Vercellini P, Somigliana E, Viganò P, De Matteis
S, Barbara G, Fedele L. The effect of
second-line surgery on reproductive performance
of women with recurrent endometriosis a
systematic review. Acta Obstet Gynecol Scand.
200988(10)1074-82.
41
Recurrent EndometriosisInfertility/2nd Surgery
Sp. Pregnancy following L/T 12 47 (27) Sp.
Pregnancy following L/S 22 42 (25)
Vercellini P, Somigliana E, Viganò P, De Matteis
S, Barbara G, Fedele L. The effect of
second-line surgery on reproductive performance
of women with recurrent endometriosis a
systematic review. Acta Obstet Gynecol Scand.
200988(10)1074-82.
42
TVUSG Guided Aspiration
  • Agostini A et al, Eur J Obstet Gynecol Rep Biol,
    2007

43
Repeat surgery for infertility
  • Repeat surgery for infertility is associated with
    low pregnancy rates
  • This is mainly due to affected ovarian reserve
  • When there is no risk of malignancy and no pain
    IVF should be preferred over surgery in these
    patients

44
Is it possible to avoid repeat surgery for
endometriosis?
  • Refrain from operating early in the asymptomatic
    patient
  • Operation should be done by surgeons with
    expertise and training in endometriosis
    surgery-to preserve the ovarian reserve to
    remove DIE
  • Complete excision or destruction of all
    endometriosis lesions should be carried out
    although there is no randomized study showing the
    effectiveness of this approach
  • Postoperative suppressive treatment with OCPs or
    insertion of LNG IUD
  • Removal of the ovaries in women who have
    completed their family

45
Alternatives to surgery in recurrent endometriosis
  • Long term BCPs
  • Long term GnRHa with add back
  • LNG IUD
  • Aromatase inhibitors

46
Recurrent EndometriosisInfertility/Medical
Supressive Therapy
  • There is no evidence to support the use of
    ovarian suppression agents in the treatment of
    endometriosis-associated infertility.
  • More harm than good can be done by treatment,
    because of side-effects and the lost opportunity
    to conceive
  • The RCOG Guidelines N.24, 2000
  • ESHRE Guidelines 2005

47
Recurrent EndometriosisInfertility/2nd Surgery
NO DIFFERENCES
P. Vercellini , 2009
48
  • In patients with endometriosis-associated
    infertility, surgery followed by IVFET is more
    effective than surgery alone.
  • When patients fail to conceive spontaneously,
    after a maximum of 1 year from laparoscopic
    surgery, IVF should be suggested.

49
Recurrent EndometriosisInfertility/2nd Surgery
or ART
  • When reoperation is being considered with the
    specific aim of achieving conception, and not
    because severe symptoms or large cysts are
    present, the caring gynecologist should warn the
    patient that
  • the chances of pregnancy may be substantially
    lower than after the primary procedure and the
    role of IVF should be considered adequately as an
    alternative to repetitive surgery

50
Meta-analysis of Surgery vs No Surgery for
endometriomas before IVF
Tsoumpou et al, FS 2009
51
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52
Who have previously had one or more infertility
operations
DECISIONS AMONG INFERTILE WOMEN WITHENDOMETRIOSIS
  • IVF-ET is often a better therapeutic option than
    another surgical intervention, though this is
    another question that has not been addressed in
    any randomized trial.
  • If initial surgery fails to restore fertility in
    patients with moderate to severe endometriosis,
    IVF-ET is an effective alternative.
  • Current data are insufficient to estimate the
    effect of surgical treatment in addition to
    IVF-ET on the outcome of pregnancy in
    endometriosis associated infertility.

53
Recurrence Problems
  • Impaired QoL-Pain
  • Infertility
  • Asymptomatic Endometrioma

54
Endometriosis and ovarian cancer
  • There may be a link between endometriosis and
    ovarian cancer
  • x2 risk in women with endometriosis
  • x4 risk in women with endometriosis and
    infertility
  • The etiology of both diseases appears to be
    multifactorial with hormonal, genetic, and
    immunologic factors potentially playing a role

55
From the Ovarian Cancer Association Consortium
Lancet Oncology 2012
56
Conclusion-1Recurrent Endometrioma and Pain
  • Recommendation
  • Surgery Long term suppression
  • Only supression is not effective
  • Definitive surgerybased on patients requirements
  • LUNANot effective for pain
  • PSN Effective but creates new long term problems

57
Conclusion-2No Endometrioma and Pain
  • Recommendation
  • Long term suppression
  • OCP can be used
  • AI or GnRH Analogs can be used, need RCT
  • If there is DIE, first surgery then long term
    suppression

58
Conclusion-3Recurrent Endometrioma and
Infertility
  • Recommendation
  • ART
  • ART has the same effect in comparison with
    re-surgery
  • But
  • Every surgery increase the complications
  • Every surgery impaired the ovarian reserve
  • It seems that ART can be first recommendation

59
Conclusion-4Asymptomatic Endometrioma
  • Recommendation
  • Expectant Management
  • If there are strong evidence for malignancy then
    surgery can be recommended
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