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Laparoscopy  2
 

Laparoscopy 2

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    Laparoscopy  2 Laparoscopy 2 Presentation Transcript

    • Does surgery for endometriosis improve fertility outcomes? Lakshmi Ravikanti Fellow in Endoscopy and Infertility Waikato Hospital & Fertility Associates Hamilton Acknowledgment: Mr V P Singh
    • Burden of Endometriosis
      • 20-50% of all women with infertility
    • Is IVF outcome affected in Endometriosis? Endometriosis Vs Tubal – OR 0.56 Severe endometriosis Vs mild endometriosis-OR 0.60 Barnhart et al.FertilSteril.2002
    • Endometrial Receptivity or Oocyte Quality? Diaz et al. FertilSteril.2000 Healthy Oocyte Donors Healthy recipients Recipients with Endometriosis III-IV No significant difference in implantation rates or live birth rates Sibling Oocytes Uterine receptivity is NOT impaired
    • Endometrial Receptivity or Oocyte Quality? Simon C et al. HumRep 1994 Oocyte donors with endometriosis Vs Oocyte donors without endometriosis Significantly lower pregnancy rates from donors with endometriosis So it is likely to be the Oocyte Quality
    • Management options for endometriosis related infertility
      • Expectant
      • Surgical resection/ablation
      • Combined surgical and medical therapy
      • COH +/- IUI
      • IVF/ICSI
    • Expectant management IVF Vs expectant management Soliman et al, Fertil Steril 1993; 59:1239
    • Endometriosis & COH/IUI Tummon IS et al: Fertil Steril 1997;68: 8-12
    • Surgery improves the likelihood of spontaneous conception
      • Meta-analysis
      • Not controlled for stage
      • Crude pregnancy rate 38% higher than medical therapy or expectant management
      • Meta-analysis
      • Common OR 2.67 in favour of surgery compared to medical treatment or expectant management
      Adamson GD et al, Am J Obstet Gynecol 1994; 171:1488 Hughes EG et al, Fertil Steril; 1993;59:963
    • ENDO-CAN
      • 341 infertile women with min (stage 1) and mild (stage 2 )endometriosis
      • Group 1- Laparoscopy only
      • Group 2- Laparoscopic ablation/resection
      • 36 week follow up
    • So we know that surgery for endometriosis related infertility is useful for stage 1 & 2 but what about stage 3 & 4? Is it worth the risk?
      • Surgery is the standard approach
      • Very few controlled studies
      • Lack of description of duration of follow up and fecundity rates
      • Differences in surgical technique
      • Complete or partial excision
      • Increasing recognition of “atypical” lesions
    • Fertility outcomes after surgery for stage III / IV Endometriosis (unpublished data) 79.7% 20.3% Total no of cases- 261
    •  
    • Fertility outcomes after Laparoscopic excision of grade 3 & 4 endometriosis
    • Additional Procedures required & Complications
      • Additional Procedure required
          • Elective bowel resection 13
          • Partial bladder resection 1
      • Complications
          • Intraop rectal serosal damage 1
          • Abd wall Haematoma 1
          • Small bowel Obst 1
          • Laparotomy for prim Haemorrhage 1
    • Summary of outcomes
      • Pain relief (Visual Analogue Scale) – 78%
      • Spontaneous pregnancy rates- 36%
      • Complications- 2%
    • Mrs J Y
      • 34 years
      • Primary infertility 4 years
      • Regular periods, mild dysmenorrhoea, no dyschezia, no dyspareunia, semenalysis normal
      • Diagnostic laparoscopy- AFS Stage 3 endometriosis, tubes normal
      • TVS- 3 cm endometrioma left ovary
      • Do you proceed to IUI, do IVF or surgical treatment of endometriosis
      • ~ 30% spontaneous conception
      • Lower risk of ovarian/pelvic abscess with OPU?
      • Oocyte Quality improved?
      • Risk of surgery
      • IVF conception rates 45% with one cycle and 70% with 2 cycles
      • Cost
      • Psychological impact
      • Avoids potential surgical complications
      Surgery IVF
    • Mrs PC
      • 38 years
      • 1 infertility 2 years
      • Regular periods, severe dysmenorrhoea, mild dyspareunia, no dyschezia
      • PV- nodularity in POD
      • TVS- endometrioma right ovary 4 cm, left ovary 2 cm endometrioma
      • Do you perform IUI, IVF or offer laparoscopy?
    • First Laparoscopy
    • Wide excision of deep endometriosis from vagina
    • Excision of D I E from rectum
    • Removal of specimen
    • Excision completed
    • Suturing of vaginal opening
    •  
    • Follow up
      • Asymptomatic at 3 month follow up
      • Pregnant at 6 months
      • NVD of a baby boy
      • Remains asymptomatic 6 months postpartum
    • Conclusion
      • Management of endometriosis related infertility is complex
      • Surgical treatment of stage I & II endometriosis should be undertaken at the time of initial assessment
      • Surgical excision of infertility related to stage III&IV endometriosis in absence of pain symptoms remains c ontroversial in absence of reliable prospective studies.
    • THANK YOU