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  1. 1. Endometriosis and infertility Dr. Jyoti Agarwal Dr. Sharda Jain Dr. Jyoti Agarwal Dr. Jyoti Bhaskar …Caring Hearts, Healing hands
  2. 2. Katrina Kaif Queen Visctoria Hillary Clinton Marilyn Monroe
  3. 3. Endometriosis is a challenging disease and requires decision making at every stage by the clinician & the patient
  4. 4. Endometriosis at ALL stages has a negative impact on infertility More severe is the disease , lesser is the fecundity
  5. 5. Important Facts • 25-50% of infertile women have endometriosis • 30-50% of women with endometriosis are infertile • Infertile women are 6-8 times more likely to have endometriosis than fertile women Endometriosis and Infertility
  6. 6. Guidelines to manage infertility in patients of endometriosis ASRM ESHRE Guidelines Jan 2014 Human Reproduction vol.0 pg 1-13 2014
  7. 7. Why do we need these guidelines ???
  8. 8. Even today endometriosis remains an enigma full of mystery
  9. 9. “There is much , that is still not understood and the condition continues to arise interest and controversies”. Robert W. Shaw “ He who knows endometriosis knows Gynaecology ” Sir William Osler
  10. 10. Tussle between laproscopists and IVF specialists about management of infertility in patients of endometriosis Aim is to help Gynaecologists make their own decision.
  11. 11. Query 1 Are hormonal therapies effective for infertility associated with endometriosis ??
  12. 12. Stage I (Minimal) Stage II (Mild) Stage III (Moderate) Stage IV (Severe) Classification of Endometriosis R E V I S E D A F S S C O R E R E V I S E D A F S S C O R E
  13. 13. Hormonal therapy and infertility Suppression of ovarian function by means of hormonal contraceptives , progestagens GnRH analogues or danazol to improve fertility in patients with minimal or mild endometriosis is NOT effective and hence should not be offered for this indication alone . Evidence does not comment on more severe disease (Hughes et al., 2007). A
  14. 14. Big Question 2 Is Surgery effective for infertility associated with endometriosis ??
  15. 15. Infertile women with Stage I/II endometriosis Evidence recommends that clinicians should perform operative laparoscopy (excision and adhesiolysis ) rather than performing diagnostic laparoscopy only to increase pregnancy rates (Nowroozi , 1987; Jacobson , 2010).
  16. 16. Women with Stage III/IV Endometriosis So far no RCT,s comparing the reproductive outcome after surgery and after expectant management is available but 2 cohort studies have shown better pregnancy rate after surgery so Clinicians can consider operative laparoscopy, instead of expectant management, to increase spontaneous pregnancy rate (Nezhat et al., 1989; Vercellini et al.,2006). B
  17. 17. Effectiveness of Surgical techniques Big Question
  18. 18. Effectiveness of Surgical techniques Guidelines recommend that in infertile patients with chocolate cyst clinicians should perform excision of the endometrioma capsule, instead of drainage and electrocoagulation to increase spontaneous pregnancy rates . (Hart et al., 2008) A
  19. 19. why excision and not ablation ? Cyst wall excision provids greater improvement – Spontaneous pregnancy rates – Dysmenorrhea and deep-dyspareunia –Recurrence and repeat surgery – Allows histo-pathological examination Coagulation/ laser vaporization without excision is associated with increase risk of cyst recurrence. ASRM Practice Guidelines 2013 Possibility of occult malignancy to be kept in mind
  20. 20. MOST IMPORTANT !!!! surgery must be complete & performed by a qualified gynae surgeon with experience in dealing with endometriosis.
  21. 21. Other techniques • Clinicians may consider CO2 laser vaporization of endometriosis, instead of monopolar electrocoagulation, as laser vaporization is associated with higher cumulative spontaneous pregnancy rates . • Unfortunately cost has been a big factor to prevent widespread availability of co2 laser (Chang et al., 1997).
  22. 22. Counselling ….. Two concerns Ovarian Reserve Recurrence Decision to proceed with surgery should be considered very carefully ,especially if the women has had previous ovarian surgery
  23. 23. Is hormonal therapy effective as an adjunct to surgical therapy for treatment of infertility? Question 3
  24. 24. Endometriosis: Medical In minimal or mild endometriosis it does not enhance fertility and hence should not be offered Surgical Offered in minimal or mild and moderate to severe endometriosis Medical treatment is not effective Rather delays fertility restoration
  25. 25. • In infertile women with endometriosis, clinicians should not prescribe adjunctive hormonal treatment before or after surgery to improve spontaneous pregnancy rates (Furness et al., 2004). A But clinicians should not withhold hormonal treatment for pain in symptomatic women in the waiting period before undergoing surgery or medically assisted reproduction . GPP
  26. 26. Is ART needed in women with Endometriosis ???
  27. 27. ART …. Not complementary but needed
  28. 28. Objective is the baby Dictum is to send the patient for ART earlier than late
  29. 29. IUI in endometriosis Live Birth Rate is 5.6 times higher in couples with minimal to mild endometriosis after COS with gonadotrophins and IUI as compared to couples after expectant management .
  30. 30. Recommendation ......for IUI In women with stage I/II endometriosis, Clinicians may perform IUI with controlled ovarian stimulation • instead of expectant management & • instead of IUI alone . C
  31. 31. Definitely refer for ART a little earlier  IUI improves fertility with superovulation .  Role of unstimulated IUI is uncertain  IVF is appropriate where IUI fails
  32. 32. Recommendations for ART IVF is the treatment of choice if  Tubal function is compromised  There is male factor infertility  Other treatments have failed  Stage 3 -4 endometriosis
  33. 33. What’s different ??? IVF in Endometriosis
  34. 34. Issues to be considered Remember ….. Endometriosis has decreased per cycle conception rates in comparison with male factor and unexplained infertility . Recurrence rates of endometriosis does not increase after COH for IVF - ICSI Ultra long protocol and ICSI is Rx of choice for endometriosis
  35. 35. If patient is for IVF ...... Is medical therapy effective as an adjunct to ART for endometriosis-associated infertility ???
  36. 36. Answer is …. Clinicians can prescribe GnRH agonists for a period of 3–6 months prior to ART to improve clinical pregnancy rates in infertile women with endometriosis. Down regulation for 3-6 months with a GnRH agonist (depot preparation) increases the odds of clinical pregnancy by more than 4 fold. (sallam et al.,2006 ) B
  37. 37. Should surgery be performed prior to treatment with ART to improve reproductive outcome?
  38. 38. Does Surgery improves success ?? In women with Stage I / II endometriosis undergoing laparoscopy prior to ART, clinicians may consider the complete surgical removal of endometriosis to improve live birth rate, although the benefit is not well established . (Opoien et;al 2011) C
  39. 39. Laparascopy should NOT be performed prior to ART in all women with the only aim to diagnose and subsequently treat endometriosis in order to improve the result of the ART treatment .
  40. 40. Remember …. • Benefit of laparoscopy in minimal or mild endometriosis is insufficient to recommend laparoscopy solely to increase pregnancy rates. • Laparoscopy in infertile woman, simply to confirm or rule out the disease is not warranted. ASRM COMMITTEE REPORT 2012
  41. 41. Surgical Rx 17 – 44 % of patients with endometriosis develops endometrioma which affects ART outcome Female age, duration of infertility, stage of disease, pelvic pain should be considered while formulating a treatment plan.
  42. 42. Women with stage 3- 4 endometriosis Women with chocolate cyst larger than 3 cm there is NO evidence that cystectomy prior to treatment with ART improves pregnancy rates . ( A ) Consider cystectomy prior to ART ONLY to improve • endometriosis-associated pain or • difficulty in oocyte retrival (GPP)
  43. 43. Role of ultrasound guided cyst aspiration TVS aspiration offers a nonsurgical approach
  44. 44. TO DRAIN OR NOT TO DRAIN • Satistically reproductive outcome with or without cyst aspiration is NOT different. • If more than 4 cm , aspiration may be better than surgery , (especially in recurrent cases) Bigger & Recurrent cysts are drained before stimulation
  45. 45. Deep infiltrating endometriosis The effectiveness of surgical excision is NOT well established with regard to reproductive outcome. However, these women often suffer from pain, requesting surgical treatment. C
  46. 46. What to do in Recurrent endometriosis ?? Hum reprod 2009 IVF – ICSI is a better option
  47. 47. experiences & strategy Dr. Sharda Jain as our mentor • On laparoscopy , even small deposits seen are fulgrated & thus managed aggressively . • Generally , laparoscopy is reserved for chocolate cyst of more than 4 cm in size. • Small chocolate cysts with short period of infertility , COH & IUI is tried for 3- 4 cycles before taking up for laparoscopy . • For chocolate cysts cystectomy is done , but sometimes there may be technical difficulties then removal of the cyst lining as much as possible is done , along with fulgration of the rest.
  48. 48. Tips from…… • Do a complete surgery. • Do not cautarize excessively. • Adhesions preventing barriers have a role. • Medical management: improves pain, not fertility • Surgical management improves both pain and infertility Success depends upon the residual disease left behind
  49. 49. To conclude ……. • Medical Rx has no role in improving fertility • In minimal to mild disease, ovulation induction and IUI is first line therapy. • Laparoscopic Sx with removal of all endometriotic implants and IVF –ICSI with long long protocol is the treatment of choice for moderate to severe disease.
  50. 50. So friends….. Take a step in the right direction ….
  51. 51. He who knows Endometriosis knows Gynaecology Thank you
  52. 52. ASRM 2012 Younger women <35 years stg I/II • Expectant m/t • COS / IUI Older women >35 years stg I/II Aggressive tx COS / IUI or IVF Stg III/IV endometriosis- • Resection /ablation rather than drainage • If fail to conceive- IVF-ET ENDOMETRIOSIS & INFERTILITY
  53. 53. ADDRESS 11 Gagan Vihar, Near Karkari Morh Flyover, Delhi - 51 CONTACT US 9650588339, 011-22414049, WEBSITE : www.lifecarecentre.in www.drshardajain.com www.lifecareivf.com E-MAIL ID Sharda.lifecare@gmail.com Lifecarecentre21@gmail.com info@lifecareivf.com &