MANAGEMENT OF ENDOMETRIOSIS ASSOCIATED INFERTILITY

STATE OF THE ART!

ISSAM LEBBI

MD,PhD

Ob-Gyn & Fertility Private ClinicDream Center,Montplaisir,Tunis

Tunisia

SGOM session

On 13th TJOD , May 12th, 2015

LAPAROSCOPY PERMIT THE DIAGNOSIS !

NORMAL HYSTERO-SALPINGOGRAPHY IN LAPAROSCOPICALLYDIAGNOSED ENDOMETRIOSIS*DONNEZ : 19.2 %*RICE : 45.5 %*WOOD : 42 %*LEBBI : 27 %

LAPAROSCOPY PERMIT THE TREATMENT !

IN LAPAROSCOPY:ENDOMETRIOSIC LESIONS LAPAROSCOPIC

TREATMENTIN 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

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

THE INTEREST OF LAPAROSCOPY IN ENDOMETRIOSIS

INFERTILITY +/- ENDOMETRIOSIC CLINICS AND/OR PARACLINICS INFERTILITY +/- ENDOMETRIOSIC CLINICS AND/OR PARACLINICS SYMPTOMSSYMPTOMS

(PROBABLY STAGE 3 & 4 asrm) !(PROBABLY STAGE 3 & 4 asrm) !

LAPAROSCOPY +/- SURGERY LAPAROSCOPY +/- SURGERY LIMITED TO PERITONEUM OR EXTENSIVE ?? (EL3)LIMITED TO PERITONEUM OR EXTENSIVE ?? (EL3)

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

SURGERY OF THE ADVANCED STAGES AND DEEP

INFILTRATIVE ENDOMETRIOSIS (DIE)

DOES EXTENSIVE LAPAROSCOPIC EXCISION OF DIE IMPROVE SPONTANEOUSAND 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%,p=0.001 Bianchi PH, J Minim Invasive

Gynecol.2009

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 (size>3 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 ?1*Women with endometriomas have a higher cancellation rate, a similar pregnancy, implantation and delivery rate.Endometrioma does not reduce IVF outcome.2*Lower AFC and higher gonadotropin doses. Surgery of Omas before IVF does not improve IVF outcome. Bongioanni F, Reprod Biol Endocrinol.2011

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

THE MEDICAL TREATMENTS !?

A PROPOSAL OF A PRAGMATIC APPROACH

INFERTILITY +/- ENDOMETRIOSIC INFERTILITY +/- ENDOMETRIOSIC CLINICS AND/OR PARACLINICS CLINICS AND/OR PARACLINICS

SYMPTOMSSYMPTOMS

LAPAROSCOPY +/- SURGERY LAPAROSCOPY +/- SURGERY LIMITED TO PERITONEUM OR LIMITED TO PERITONEUM OR

EXTENSIVE ?? (EL3)EXTENSIVE ?? (EL3)

ALTERED TUBESALTERED TUBES ABNORMAL ABNORMAL

SPERMSPERM

YESYES NONO

OP x 6 to 10 OP x 6 to 10 weeksweeksGnRh GnRh

Analogs Analogs 2 2 To 3 MonthsTo 3 Months

IVF-IVF-ETET

EXPECTATIVE FOREXPECTATIVE FOR12-18 12-18 MONTHS MONTHS

OVARIAN STIMULATION + IUI OVARIAN STIMULATION + IUI 6 à 14 CYCLES (EL3)6 à 14 CYCLES (EL3)

Age>35yearAge>35yearssPoor Poor Ovarian Ovarian Reserve(AMReserve(AMH)H)EMMERGENEMMERGENCY ARTCY ART

NNOO