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ENDOMETRIOSIS AND INFERTILITY
LOOKING AT THE EVIDENCE
JOHN C. PETROZZA
CHIEF, DIVISION OF REPRODUCTIVE MEDICINE & IVF
CO-DIRECTOR, MGH INTEGRATED FIBROID PROGRAM
MASSACHUSETTS GENERAL HOSPITAL
DISCLOSURE
• NONE
ENDOMETRIOSIS AND INFERTILITY
Normal
fecundity
20%
Endometriosis
2-10%
Idiopathic
4-5%
ASRM Comm, Fertil Steril, 2004Berube, Fertil Steril, 1998
MILD/MINIMAL ENDOMETRIOSIS AND INFERTILITY
• TOXIC EFFECT ON GAMETES, EMBRYOS, TUBAL MOTILITY
• ABNORMAL CYTOKINE LEVELS IN FOLLICULAR FLUID
• INCREASED GRANULOSA CELL APOPTOSIS
• ENHANCED MACROPHAGE PHAGOCYTOSIS OF SPERM
• REDUCED FERTILIZATION WITH ART
• IMPAIRED IMPLANTATION AND ENDOMETRIAL RECEPTIVITY Shifren, JCEM, 1996Carlberg, Hum Reprod, 2000Nakahara, Fertil Steril, 1997Muscato, AJOG, 1982Cahill, JARG, 1997Burney, Endocrin, 2007
MODERATE/SEVERE ENDOMETRIOSIS AND INFERTILITY
Impairment of
oocyte release
Tubal obstruction
or mobility
restriction
Impaired sperm
migration
Dunselman, Hum Reprod, 2014
MEDICAL TREATMENTSPONTANEOUS CONCEPTION
Ovarian suppression vs placebo
No difference
Surgery + ovarian suppression vs placebo
No difference
STAGE I/II ENDOMETRIOSISSURGICAL TREATMENT
SPONTANEOUS CONCEPTION
• ADHESIOLYSIS
• EXCISION OF LESIONS WITH CO2 LASER
• CLINICAL PREGNANCY RATE:• OR 1.64
• 95% CI 1.05 – 2.57
Dunselman, Hum Reprod, 2014Marcoux, NEJM, 1997Chang, JAAGL, 1997
STAGE III/IV ENDOMETRIOSISSURGICAL TREATMENT
SPONTANEOUS CONCEPTION
• CLINICAL PREGNANCY RATE:
CONTROL SURGERY
• STAGE III 33% 57-69%
• STAGE IV 0% 52-68%
Koch, Aust NZ J Obstet Gyn, 2012Adamson, AJOG, 1994Dunselman, Hum Reprod, 2014
STAGE III/IV ENDOMETRIOSISSURGICAL TREATMENT
SPONTANEOUS CONCEPTION
• RE-OPERATIVE CLINICAL PREGNANCY RATE:
1ST PROCEDURE 2ND PROCEDURE
40% 22%
Vercellini, Fertil Steril, 2009Koch, Aust N Z J Obstet Gyn, 2012
ENDOMETRIOMASSPONTANEOUS PREGNANCY
• EXCISE
• DRAINAGE AND ABLATION
Donnez, Fertil Steril, 2010
STAGE I/II ENDOMETRIOSISCOH/IUI
119
33.6
49
16.3
NUMBER OF PATIENTS PREGNANCY RATE %
Outcomes of COH/IUI
Unexplained I/II Endometriosis
Hughes, Hum Reprod, 1997
STAGE I/II ENDOMETRIOSISIVF
Fertilization Rate Implantation Rate
Clinical Pregnancy
Live Birth
Stage I/II 7% No difference No difference No difference
Stage II/IV No difference 21% 21% No difference
Harb, BJOG, 2013
Rates are compared to controls – IVF in women without endometriosis
ENDOMETRIOMASIVF
• STUDIES VARY ON RESULTS
• RISKS: INFECTION, CYST RUPTURE, DETRIMENTAL
TO OOCYTES, OVARIAN FAILURE
• SURGERY MAY REMOVE NORMAL OVARIAN TISSUE
• OPTIONS:
• LAPAROSCOPY WITH OVARIAN
CYSTECTOMY
• LAPAROSCOPY WITH PARTIAL CYSTECTOMY
AND ABLATION OF REMAINING CYST WALL
• CYST DRAINAGE
• TRANSVAGINAL CYST ASPIRATION +/- SCLEROSIS
Suzuki, Fertil Steril, 2005Donnez, Front Biosc, 2012Pal, JARG, 1998Sacha, Karmon, Petrozza, Obstst Gynecol Int J, 2018
ENDOMETRIOSISIVF/COH
• MEDICAL PRETREATMENT
• GNRH AGONIST THERAPY X 3-4 MONTHS PRE-IVF MAY INCREASE PREGNANCY RATES
4-FOLD
• OCPS X 3-4 MONTHS MAY BE JUST AS BENEFICIAL
• IVF DOES NOT INCREASE RECURRENCE RATE OR SYMPTOMS
Sallam, Cochrane Database Syst Rev, 2006
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