Endometriosis - PowerPoint PPT Presentation

Loading...

PPT – Endometriosis PowerPoint presentation | free to view - id: 732c42-OWVjM



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

Endometriosis

Description:

Infertility Treatment Levent M. SENTURK, M.D., Professor in Ob&Gyn Istanbul University Cerrahpasa School of Medicine Dept. of Ob&Gyn, Division of Reproductive ... – PowerPoint PPT presentation

Number of Views:205
Avg rating:3.0/5.0
Slides: 66
Provided by: Sent164
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Endometriosis


1
Endometriosis AdenomyosisInfertility Treatment
  • Levent M. SENTURK, M.D.,
  • Professor in ObGyn
  • Istanbul University Cerrahpasa School of Medicine
  • Dept. of ObGyn, Division of Reproductive
    Endocrinology, IVF Unit

2
(No Transcript)
3
(No Transcript)
4
BRANDI S. MCLEOD, and MATTHEW G. RETZLOFF, 2010
5
(No Transcript)
6
(No Transcript)
7
Prevalence of endometriosis according to stage
of disease in infertile and fertile women
8
Deep Endometriosis Symptoms
Pandis GK, 2010
9
Diagnosis of Endometriosis
  • History (The most important)
  • Symptoms
  • Physical Examination (not much help)
  • Serum Markers (Lacks sensitivity)
  • Ultrasound (of little value except endometrioma)
  • Magnetic Resonance Imaging (MRI) (a good guess!)
  • Other Imaging Modalities
  • immunoscintigraphy and positron emission
    tomography
  • Transvaginal Hydrolaparoscopy
  • Laparoscopic Visualization of the Pelvis (The
    gold standard)
  • Biopsy Preferable Over Visual Inspection
  • Novel Diagnostic Test

Rule out other Causes of Symptoms (The next most
important)
10
Endometriosis-associated infertility a decades
trend study of women from the Estrie Region of
Quebec, Canada
N 6845
INF
ENDO
EAI
KRYSTEL PARIS AZIZ ARIS, 2010
11
(No Transcript)
12
(No Transcript)
13
Effects of endometriosis on human reproduction
Dominique de Ziegler, 2010
14
Pathophysiology of Pain and Infertility
Associated with Endometriosis
Linda C. Giudice, 2010
15
Eijkemans et al., 2008
16
Collins JA , 1995
17
Cumulative conception rates with untreated
endometriosis related to disease grading,
compared with normal conception rate
N
Minor
Moderate Severe
Kevin D. Jones, 2002
18
Fertility in women with minimal endometriosis
comparedwith normal women was assessed by means
of a donor insemination program in unstimulated
cycles
N 51
N 24
Roberto Matorras 2010
19
Success in intrauterine insemination the role of
etiology
  • A total of 1,171 cycles among 532 infertile
    couples were retrospectively studied and the
    impact of different prognostic factors on
    pregnancy rate in five different etiology
    subgroups was analyzed.
  • Results. The pregnancy rate/cycle was highest
    (19.2) among women with anovulatory infertility
    and lowest (11.9) in endometriosis based
    infertility.

Katja Ahinko-Hakamaa 2007
20
EndometriosisCOH IUI
  • Treatment with intra-uterine insemination (IUI)
    improves fertility in minimal-mild endometriosis
    IUI with ovarian stimulation is effective but the
    role of unstimulated IUI is uncertain (Tummon et
    al., 1997).
  • Evidence A, Level 1b 
  • No RCTs exist for COHIUI for moderate-severe
    endometriosis.
  • ?COHIUI should be limited to 3-4 cycles
  • ESHRE Guidelines, Recommedation grade A ,
    evidence level 1b

21
(No Transcript)
22
2010
To develop a clinical tool that predicts
pregnancy rates (PRs) in patients with surgically
documented endometriosis who attempt non-IVF
conception.
23
(No Transcript)
24
(No Transcript)
25
Decreased anti-Mullerian hormone and altered
ovarian follicular cohort in infertile patients
with minimal/mild endometriosis
p0.004
N17
N17
EE
CC
Nadiane Albuquerque Lemos, 2009
26
Anti mullerian hormone serum levels in women with
endometriosisA casecontrol study
  • 909 patients undergoing in vitro fertilisation/
    intracytoplasmic sperm injection (IVF/ICSI)
    treatment or consulting our specific
    endometriosis unit.
  • Mean AMH serum level was significantly lower in
    the study than in the control group (2.752.0
    ng/ml vs. 3.462.30 ng/ml, p 0.001).
  • In women with mild endometriosis (rAFS I-II), the
    mean AMH level was almost equal to the control
    group (3.281.93 ng/ml vs. 3.442.06 ng/ml p
    0.61).
  • A significant difference in mean AMH serum level
    was found between women with severe endometriosis
    (rAFS III-IV) and the control group (2.381.83
    ng/ml vs. 3.582.46 ng/ml p 0.0001).

OMAR SHEBL, 2009
27
(No Transcript)
28
(No Transcript)
29
(No Transcript)
30
(No Transcript)
31
(No Transcript)
32
A comparison of histopathologic findings of
ovariantissue inadvertently excised with
endometrioma andother kinds of benign ovarian
cyst in patientsundergoing laparoscopy versus
laparotomy
The surgical approach had no statistically
significant impact on conservation of ovarian
reserves. The nature of the ovarian cyst played a
greater role in the quality and quantity of the
excised ovarian tissue
Saeed Alborzi, 2009
33
Excision of endometriotic cyst wall may cause
lossof functional ovarian tissue
N46
Umut Dilek, 2006
34
The impact of electrocoagulation on ovarian
reserve after laparoscopic excision of ovarian
cysts a prospective clinical study of 191
patients
  • 191 patients with benign ovarian cysts undergoing
    ovarian cystectomy.
  • When comparing the bipolar group and ultrasonic
    scalpel group (L/S) with the suture (L/T) group,
    a statistically significant increase of the mean
    FSH value was found in bilateral-cyst patients at
    1-, 3-, 6-, and 12-month follow-up evaluations
    and in unilateral-cyst patients at the 1-month
    follow-up evaluation.
  • Statistically significant decreases of basal
    antral follicle number and mean ovarian diameter
    were found during the 3-, 6-, 12-month follow-up
    evaluations as well as statistically significant
    decreases of peak systolic velocity at all of the
    follow-up evaluations.
  • Conclusion(s) Bi-polar electrocoagulation after
    laparoscopic excision of ovarian cysts is
    associated with a statistically significant
    reduction in ovarian reserve, which is partly a
    consequence of the damage to the ovarian vascular
    system.

Chang-Zhong Li, 2009
35
Analysis of risk factors for the removalof
normal ovarian tissue during laparoscopic
cystectomy for ovarian endometriosis
  • A total of 121 patients who had histologically
    confirmed ovarian endometriosis and 56 control
    patients who had other histologically confirmed
    benign cysts were included
  • Normal ovarian tissue adjacent to the cyst wall
    was detected in 71 patients (58.7) with
    endometriosis, whereas normal ovarian tissue was
    removed from only three patients (5.4) with
    other benign cysts.
  • A significant factor that was independently
    associated with the removal of normal ovarian
    tissue with ovarian endometriosis was
    pre-operative medical treatment

Sachiko Matsuzak,2009
36
IVF-ICSI outcome in women operatedfor bilateral
endometriomas
  • 68 cases (bilat. cystectomy) - 136 controls
  • the number of follicles (p0.006), oocytes
    retrieved (p0.024) and embryos obtained
    (p0.024) were significantly lower.
  • The clinical pregnancy rate per started cycle in
    cases and controls was 7 and 19 (p0.037)
  • CONCLUSIONS IVF outcome is significantly
    impaired in women operated on for bilateral
    ovarian endometriomas.

Edgardo Somigliana1, 2008
37
NS
38
P aivi Harkki, 2010
39
Effects of (unilateral) ovarian endometrioma on
the number of oocytes retrieved for IVF81 women
with unilateral endometrioma who underwent their
first IVF cycle
Benny Almog, 2010
Conclusion(s) The presence of ovarian
endometrioma in a controlled ovarian
hyperstimulation cycle for IVF treatment is not
associated with a reduced number of oocytes
retrieved from the affected ovary
40
(No Transcript)
41
(No Transcript)
42
(No Transcript)
43
Spontaneous Pregnancy After 1? surgery
236/577 (41) Spontaneous Pregnancy After 2?
surgery 28/124 (23)
44
Sp. Pregnancy following L/T 12 47 (27) Sp.
Pregnancy following L/S 22 42 (25)
45
Results of studies comparing IVF-ET with
second-line surgery in infertile women with
recurrent moderate to severe endometriosis
P. Vercellini , 2009
46
(No Transcript)
47

Endometrioma and IVF
Laparoscopic ovarian cystectomy is recommended if an ovarian endometrioma 4 cm in diameter, is present to confirm the diagnosis histologically reduce the risk of infection improve access to follicles and possibly improve ovarian response. The woman should be counselled regarding the risks of reduced ovarian function after surgery and the loss of the ovary. The decision should be reconsidered if she has had previous ovarian surgery.
GPP
http//guidelines.endometriosis.org
48
(No Transcript)
49
Endometriosis-associated infertility surgery
andIVF, a comprehensive therapeutic approach
825 patients, 2001-2008, observational study
Pedro N Barri, 2010
50
Does Controlled Ovarian Hyperstimulationin Women
with a History of EndometriosisInfluence
Recurrence Rate?
  • Retrospective cohort study of 592 patients
    submitted to laparoscopy for endometriosis, 177
    with infertility-related endometriosis who
    underwent a periodic ultrasound follow-up after
    laparoscopy were selected.
  • Women who started ART after laparoscopy (n90)
    were compared with the control group, who did not
    undergo ART (n87).
  • Recurrence of endometriosis was defined as the
    presence of endometriotic lesions observed
    through TV-US.
  • During a long-term TV-US follow-up (115 years),
    40 (22.6) recurrences were observed.
  • Patients submitted to ART showed a cumulative
    recurrence rate similar to that of the control
    group (28.6 and 37.9 respectively, p0.471)

(28.6 vs. 37.9, p0.471)
Maria Elisabetta Coccia, 2010
51
SART-2005
52
SART-2006
53
SART-2007
54
Endometriosis-GnRHa
  • Pain
  • After operation for the prevention
  • Before IVF
  • Empirical

55
(No Transcript)
56
Pathophysiology of Pain and Infertility
Associated with Endometriosis
Linda C. Giudice, 2010
57
(No Transcript)
58
Three randomised controlled trials (with 165
women) were included
59
GnRH agonist vs no agonist before IVF(Clinical
pregnancy rate per woman)
Sallam et al, Cochrane Database Syst Rev
25(1)CD004635, 2006
N165
Live birth rate OR 9.19, (95 CI 1.08 to
78.22) Clinical pregnancy rate OR 4.28, (95 CI
2.00 to 9.15) CONCLUSIONS The administration of
GnRH agonists for a period of three to six months
prior to IVF or ICSI in women with endometriosis
increases the odds of clinical pregnancy by
fourfold. Data regarding adverse effects of this
therapy on the mother or fetus are not available
at present.
60
(No Transcript)
61
(No Transcript)
62
Use of oral contraceptives in women
withendometriosis before assisted reproduction
treatment improves outcomes
  • In women with endometriosis, including those with
    endometriomas, 6 to 8 weeks of continuous use of
    oral contraception (OC) before assisted
    reproduction treatment (ART) maintains ART
    outcomes comparable with the outcomes of
    age-matched controls without endometriosis.
  • In contrast, ART outcomes are markedly
    compromised in endometriosis patients who are not
    pretreated with OC.
  • Ovarian responsiveness to stimulation was not
    altered by 6 to 8 weeks use of pre-ART OC,
    including in poor responders with endometriomas
  • Our data indicate that 6 to 8 weeks of continuous
    OC use before ART not only improves outcomes in
    endometriosis but possibly is as effective as 3
    months of GnRH-agonist treatment before ART

Dominique de Ziegler, 2010
63
Deep Endometriosis Symptoms
Pandis GK, 2010
64
Deep endometriosis Excisional surgeryPregnancy
rates
Vercellini et al., Hum Reprod (2009)
65
(No Transcript)
66
Fertility and clinical outcome after bowel
resection in infertile women with endometriosis
  • 62 infertile women who underwent laparoscopic
    excision of endometriosis with segmental bowel
    resection performed for severe intestinal
    symptoms.
  • Among women younger than 30 years trying to
    conceive spontaneously, the cumulative pregnancy
    rate was 58 and the cumulative pregnancy rate
    was 45 in those aged 3034 years.

Anna Stepniewska, 2010
67
Results of first in vitro fertilization cyclein
women with colorectal endometriosiscompared with
those with tubal or malefactor infertility
Emmanuelle Mathieu dArgent, 2010
68
Deep endometrisois Complications
Vercellini et al., Hum Reprod (2009)
69
Endometrioma ve oosit toplanmasi
  • Hacim artmasi
  • Enfeksiyon, abse
  • Akut abdomen
  • Toksik etki
  • Malignite

70
Endometrioma and oocyte retrievalinduced pelvic
abscess a clinical concern or an exceptional
complication
  • The authors evaluated the risk of developing a
    pelvic abscess in a series of 214 in vitro
    fertilization cycles that were performed in women
    with endometriomas. This complication was never
    recorded, indicating that its risk is very low
    (0.0 95 confidence interval, 0.01.7).
  • Literature
  • nine cases were described. Prophylactic
    antibiotics have been administered in at least
    eight cases. The endometrioma was punctured at
    the time of oocyte retrieval in at least six
    cases.

Laura Benaglia, 2008
71
Preterm birth, ovarian endometriomata, and
assisted reproduction technologies
Shavi Fernando, 2009
72
Adenomyosis
  • A benign disorder, characterized with the
    presence of glandular and stromal endometrial
    tissue in myometrium

73
Adenomyosis
  • Myometrial location
  • Diffuse
  • Focal
  • Adenomyotic cyst
  • Adenomyoma

74
AdenomyosisEpidemiology
  • 20 of women.
  • (J Minim Invasive Gynecol 2009 16622625)
  • More frequently seen in women with endometriosis.
  • More frequently seen in women with low BMI.
  • (Hum Reprod 2010 2513251334)

75
AdenomyosisSymptoms
  • Dysmenorrhea (66 vs 42)
  • Chronic pelvic pain (53 vs 21)
  • Menorrhagia
  • Infertility

Fertil Steril 20109412238
76
AdenomyosisDiagnosis - US
  • Globular uterus
  • Asymmetric thickening of anterior and/or
    posterior uterus wall
  • Difficulty in distunguishing the
    endometrial-myometrial junction
  • Focal or diffuse heterogenous myometrial
    echogenity
  • Myometrial cyst
  • Increased vascularity

77
3D TV-US Normal Uterus
  • Minimum JZ
  • Maximum JZ
  • Total myometrial thickness

78
3D TV-US Adenomyosis
79
3D TV-US Adenomyosis
80
AdenomyosisDiagnosis - MRI
T2
T1
81
AdenomyosisDiagnosis - MRI
82
AdenomyomaDiagnosis - MRI
83
  • Retrospective study in 74 infertile patients with
    surgically proven endometriosis
  • The diagnosis of adenomyosis was based on
    transvaginal ultrasound criteria
  • All patients were pretreated with long-term (?3
    months) GnRH-agonist prior to IVF/ICSI.
  • Endometriosis rASRM stages III-IV adenomyosis

84
  • mean dosage of FSH used was 208IU
  • the mean number of oocytes retrieved was 8.73
  • the mean number of embryos obtained was 3.86
  • the mean number of embryos transferred was 1.6
  • a mean fertilization rate of 43.6
  • a mean implantation rate of 26.3
  • a mean miscarriage rate of 24.3
  • and a clinical pregnancy rate (?12 gw) of 31.7

85
  • No significant differences were found for any of
    the IVF/ICSI outcomes between women with and
    without adenomyosis.
  • CONCLUSIONS Adenomyosis had no adverse effects
    on IVF/ICSI outcomes in infertile women with
    proven endometriosis who were pretreated with
    long-term GnRH-agonist.

86
Algorithm for management of infertility
associated with endometriosis
Dominique de Ziegler, 2010
87
Endometriosis - InfertilityQA
  • Does stage I-II endometriosis cause infertility
    ?
  • Yes
  • Is COH IUI effective in EA infertility?
  • Yes in I-II / Data is not sufficient for III-IV
  • Does endometriosis decrease ovarian reserve?
  • Yes
  • Does deep endometriosis cause infertility?
  • Yes, probably
  • Does endometriosis cause pregnancy loss?
  • No

88
Endometriosis - InfertilityQA
  • Does endometriosis decrease IVF success?
  • No (???for St IV ? ovarian reserve)
  • Endometrioma and infertility?
  • Not related
  • Surgery for endometrioma before IVF?
  • Not effective (May decrease ovarian reserve)
  • Does IVF treatment increase endometriosis
    recurrence rate?
  • No
  • Role of surgery after an unsuccessful IVF cycle
  • Not effective except few cases

89
Endometriosis - InfertilityQA
  • GnRHa use before IVF in endometriosis?
  • May be helpful, more studies are needed
  • Management of recurrent endometrioma (IVF vs
    surgery)?
  • IVF
  • Which protocol?
  • No difference
  • Adenomyosis ART?
  • Had no adverse effect on IVF/ICSI outcomes
About PowerShow.com