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MANAGEMENT OF ENDOMETRIOSIS ASSOCIATED INFERTILITY STATE OF THE ART!

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... or radical and extensive surgery ... (CYSTECTOMY OR DRAINAGE AND ELECTROCOAGULATION OF THE CYST WALL) !? *2 RCTs of laparoscopic surgery of cyst ... – PowerPoint PPT presentation

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Title: MANAGEMENT OF ENDOMETRIOSIS ASSOCIATED INFERTILITY STATE OF THE ART!


1
MANAGEMENT OF ENDOMETRIOSIS ASSOCIATED
INFERTILITYSTATE OF THE ART!
  • ISSAM LEBBI
  • MD,PhD
  • Ob-Gyn Fertility Private Clinic
  • Dream Center,Montplaisir,Tunis
  • Tunisia


  • SGOM session

  • On 13th
    TJOD , May 12th, 2015

2
LAPAROSCOPY PERMIT THE DIAGNOSIS !
  • NORMAL
  • HYSTERO-SALPINGOGRAPHY
  • IN LAPAROSCOPICALLY
  • DIAGNOSED ENDOMETRIOSIS
  • DONNEZ 19.2
  • RICE 45.5
  • WOOD 42
  • LEBBI 27

3
LAPAROSCOPY PERMIT THE TREATMENT !
  • IN LAPAROSCOPY
  • ENDOMETRIOSIC LESIONS
    LAPAROSCOPIC TREATMENT
  • IN THE SAME OPERATIVE TIME
  • Why ?
  • Laparoscopic treatment of stage 1 and 2 improve
    significantly the spontaneous
  • pregnancy rates 30.7 Vs 17.7


  • Marcoux J Maheux R,NEJM.1997
  • Surgery improve fertility in stage 3 and 4

  • Farquhar
    C, Curr.Opinion Gyn Obs.1998

4
BUT THE INTEREST OF LAPAROSCOPY IN
ENDOMETRIOSIS STILL HIGHLY DISCUSSED
  • No comparative randomised studies with ART
    techniques
  • Operative risks and morbidity of laparoscopy
  • Wich surgical procedure ?
  • minimal surgery (coagulation) or radical and
    extensive surgery (large
  • excision experience and expertise of the
    operator)
  • Benefit /cost of laparoscopy

5
THE INTEREST OF LAPAROSCOPY IN ENDOMETRIOSIS
INFERTILITY /- ENDOMETRIOSIC CLINICS AND/OR
PARACLINICS SYMPTOMS (PROBABLY STAGE 3 4 asrm)
!
LAPAROSCOPY /- SURGERY LIMITED TO PERITONEUM OR
EXTENSIVE ?? (EL3)
6
SURGERY OF ENDOMETRIOSIS ALONE OR BEFORE IVF-ET
IMPROVE THE RESULTS OF INFERTILITY !
  • Retrospective study
  • 29 operated patients AFTER IVF-ET FAILURE
  • 22 pregnancies ( 76 )
  • -15 without IVF-ET ( 52 68 of
    pregnancies)
  • -7 by IVF/ICSI ( 24 32 of pregnancies)

  • Littman E Nezhat C,Fertil
    Steril.2005
  • Retrospective study
  • 107 infertile patients treated by laparoscopy
    for endometriosis
  • Follow-up 1 to 11 years
  • 40 spontaneous pregnancies after surgery 34,4
  • 67 IVF-ET after surgery Pregnancy rate 56,1
    (significant)
  • The higher pregnancy rate after surgery is at 6
    MONTHS 23,2

  • Coccia M,Eur J Obstet Gynecol Reprod
    Biol.2008

7
SURGERY OF THE ADVANCED STAGES AND DEEP
INFILTRATIVE ENDOMETRIOSIS (DIE)
  • DOES EXTENSIVE LAPAROSCOPIC EXCISION OF DIE
    IMPROVE SPONTANEOUS
  • AND IVF-ET PREGNANCY RATES ?
  • Yes
  • -Prospective cohort study of 179 women with DIE
  • Gr A 105 IVF without surgery
  • Gr B 64 extensive surgery before IVF
  • -The odds ratio of achieving a pregnancy were
    2.45 time greater in Gr B than in
  • Gr A 41 Versus 24,p0.001
    Bianchi PH, J Minim Invasive Gynecol.2009

8
SURGERY OF ENDOMETRIOMAS
  • Q1-EXCISIONAL SURGERY OR ABLATIVE SURGERY
    (CYSTECTOMY OR DRAINAGE AND
  • ELECTROCOAGULATION OF THE CYST WALL) !?
  • 2 RCTs of laparoscopic surgery of cyst (sizegt3
    cm)
  • exisional surgery (Cystectomy) provides more
    favourable oucome with regard to
  • -The reccurence of endometrioma
  • -The reccurence of pain
  • -The subsequent spontaneous pregnancy rate
  • -BUT,in case of a subsequent ART (IIU OR
    IVF-ET)
  •  INSUFFISANT EVIDENCE EXISTS TO DETERMINE THE
    BEST SURGICAL APPROACH 

  • Hart R,Cochrane
    Database Sys Rev.2008
  • RCTs showed that the excision technique is
    associated with higher pregnancy rate and a
  • lower rate of reccurence although it may
    determine severe injury to the ovarian
  • reserve.
    Somigliana
    E,Placenta.2011
  • Q2-DOES PRESENT ENDOMETRIOMAS REDUCE IVF OUTCOME
  • DOES LAPAROSCOPIC SURGERY OF ENDOMETRIOMAS
    BEFORE IVF IMPROVE IVF RESULTS ?
  • 1Women with endometriomas have a higher
    cancellation rate, a similar pregnancy,
  • implantation and delivery rate.Endometrioma
    does not reduce IVF outcome.

9
SURGERY OF ENDOMETRIOSISASSOCIATED
INFERTILITY IT IS A PLEA FOR RESEARCH   

Somigliana E,Placenta .2011
  • The purported benefit of surgery may be
    overvalued (uncontrolled studies)
  • The overal increase in post-operative pregnancy
    rates is estimated between
  • 10 25
  • The role of surgery before,after or as an
    alternative to IVF needs clarification.

  • Vercellini P,Hum
    Reprod.2009
  • Surgery improves the chance of concieving in the
    12-18 months afterwards the
  • extension of the disease to the ovaries may
    reduce the ovarian response to C.O.S
  • in IVF-ET
  • Surgery of endometriomas can reduce ovarian
    response to C.O.S in IVF-ET but is
  • not associated with reduced oocyte quality or
    ART outcome
  • Pre-ART oral contraception improve ART outcome
    particularly if
  • endometriomas are present at time of retrieval.

  • De Ziegler
    D, Minerva Ginecol.2011

10
THE MEDICAL TREATMENTS !?
11
A PROPOSAL OF A PRAGMATIC APPROACH
Agegt35years Poor Ovarian Reserve(AMH) EMMERGENCY
ART
INFERTILITY /- ENDOMETRIOSIC CLINICS AND/OR
PARACLINICS SYMPTOMS
NO
LAPAROSCOPY /- SURGERY LIMITED TO PERITONEUM OR
EXTENSIVE ?? (EL3)
ALTERED TUBES ABNORMAL SPERM
YES
NO
EXPECTATIVE FOR12-18 MONTHS
OP x 6 to 10 weeks GnRh Analogs ? 2 To 3 Months
IVF-ET
OVARIAN STIMULATION IUI ? 6 à 14 CYCLES (EL3)
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