endometriosis and infertility
TRANSCRIPT
Endometriosis & Infertility
Dr. Marwan AlhalabiAssistant Professorin Faculty of medicineDamascus University
And
Orient Hospital assisted Reproduction center Damascus – Syria
Endometriosis
Disease of theories and questions
n Peritoneal endometriosisn Ovarian endometriosisn Rectovaginal septum
endometriosis are
3 DIFFERENT ENTITIES
Pathogenesis
RED BALCK WHITE
Pathogenesis
Pathogenesis
Pathogenesis
Types
Types
Types
HOW MIGHT ENDOMETRIOSISRESULT IN INFERTILITY
* Mechanical effects * Endocrine abnormalities
-Attenuated LH Surge- LUF - Luteal Phase defect
* Peritoneal Fluid abnormalities - Prostanoids - Cytokines - Growth Factors - Interleukins …. ets.
* Immune System abnormalities * Oocytes defects * Increased Miscarriage rate
Diagnosis of Endometriosis
Confirmed by Laparoscopy : The Key.Indication : Infertility & Pain ,…..
Mild and minimal endometriosis associated infertility
n Laparoscopic destruction :
– Diathermy ( bi-polar)
– Vaporization
– Ablation (Marcoux etal, 1997)
n Expectant Management (Italian Study, 1999)
Mild and minimal endometriosis associated infertility
n 2RCTs showed : that repeat laparoscopy after 6 -12 month of treatment with placebo in women with early endometriosis : – 50% of endometrial deposits were
deteriorated .– 17% unchanged .– 33% resolved spontaneously .
(cooke and thomes , 2000)
Laparoscopy treatment of endometriosis Benefits
n Decreased inflammation in the Pelvis.
n Decreased Toxicity to embryos and gametes .
n Enhanced uterine receptivity .
Mild and minimal endometriosis associated infertility
Conclusion We strongly support the view that :Visible endometriosis Must be removed at the time of surgery .
Laparoscopic destruction (first line)
If Red + Black
If Black only
GnRHa(Three Month) Donnez et al, 2004
Mild and minimal endometriosis associated infertility
Types of conservative surgery
n Drainage alone (Fayez and Vogel, 1991)
n Resection of the site of invagination (Brosens, 1996)
n Destruction of the internal cyst wall (CO2 laser or
bi-polar) (Donnez and Nisolle , 1990)
n Cystectomy (Canis et al, 1989)
Small Endometrioma <3 cm
n Adhesiolysis . n Drainage . n Destruction of the cyst wall .
n Cystectomy ?
Large Endometrioma >3 cm
n Two step procedure (donnez et al, 1990)
1) * Drainage by wide opening and rinsing Adhesiolysis and free mobilization of ovary
* biopsy* Destruction of peritoneal lesions .
2) GnRH against ( 3 Month ) 3) Second look laparoscopy for internal wall
vaporization ( destruction ) .
Large Endometrioma >3 cm
n Cystectomy (canis et al, 1989)
– Risk of bleeding – “chocolate”
luteal cysts (30%) – Risk of POF– Recurrence
(incomplete surgery)
Advantage of pre-operative GnRH agonist
1- Reduction of cyst size .2- Reduction of hypervascularization and
inflammation .3- Reduction of cyst wall thickness .4- Absence of corpus luteum or follicles .5- Facilitation of surgery .6- Reduction of adhesions .
Very Large Endometrioma > 15 cm
Very Large Endomerioma > 15 cm
A. Laparoscopic drainage .Wide opening – biopsy .
B. GnRH agonist 3 month .C. Transvaginal echography and ovarian
endometrioma puncture under echographic control .
D. GnRH agonist 2 month ( + Tibolone ? ) E. Second-look laparoscopy and vaporization
(destruction of the cyst wall)
GnRH agonist 5 months
Ovarian Endometriosis
Conclusion : Destruction of the ovarian cyst wall proved to be effective .• Low recurrence rate ( 6% ).• High pregnancy rate (>50%). • Minimal destruction of normal ovarian
cortex ( as proved by IVF study, Donnez et al, 2001)
Post operative management of endometriosis n Waiting 12 – 18 month
? (simple Treatment )n MOH + IUI n IVF : depend on
– Age (OR)– Sperm – Period – Adhesions – Finance .
The Potential Risk of Endometrioma and IVF
n No RCTs.n Rupture by enlargement during
the stimulation .n Puncture – drainage :
Ovarian abscess.n Acute evolution during Pregnancy .n Acute evolution after IVF failure .n Toxic effects .n Risk of Malignancy n Effect on ovarian reserve ??
Conclusion 1
Treatment options for all grades of endometriosis associated infertility should include surgery .
Conclusion 2
Laparoscopic surgery of endometriosis improves fertility (minimal-mild)
Conclusion 3
MOH and IUI was found to be effective in infertility associated endometriosis with patent tubes
Conclusion 4
IVF is an effective treatment in advanced endometriosis, however, there are controversial data, concerning it’s outcome.
Conclusion
IVF should be adviseddirectly in :
– Sperm Abnormality – Age > 38 ( Low OR ) – Tubal Injury .– Infertility > 8 years ? – Recurrent Endometriosis.
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Conclusion
n The role of ovarian endometriomas on outcome of ART is not clear .
n Laparotomy if necessary n Importance of biopsy .
Endometriosis
Disease of theories and questions
S. AL SAMAWI MD. Gyn. Obs.A. TAHA MD. Gyn. Obs.H. HAMAD MD. Gyn. Obs.M. ABDUL WAHED MD. Gyn. Obs.Z. IDLBI Senior BiologistN. ABO HASSAN AndrolgistF. RAHMEH AndrolgistW. DAWOOD BiologistN. ASSAF BiologistF. HAMAD Administration ManagerA. ALKHATEB M.D Micro BiologistR. ALKHATEB MD. Gyn. Obs. Ph. D.
Acknowledgement
Thank You