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Laparoscopy 2


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Laparoscopy 2

  1. 1. Does surgery for endometriosis improve fertility outcomes? Lakshmi Ravikanti Fellow in Endoscopy and Infertility Waikato Hospital & Fertility Associates Hamilton Acknowledgment: Mr V P Singh
  2. 2. Burden of Endometriosis <ul><li>20-50% of all women with infertility </li></ul>
  3. 3. 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
  4. 4. 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
  5. 5. 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
  6. 6. Management options for endometriosis related infertility <ul><li>Expectant </li></ul><ul><li>Surgical resection/ablation </li></ul><ul><li>Combined surgical and medical therapy </li></ul><ul><li>COH +/- IUI </li></ul><ul><li>IVF/ICSI </li></ul>
  7. 7. Expectant management IVF Vs expectant management Soliman et al, Fertil Steril 1993; 59:1239
  8. 8. Endometriosis & COH/IUI Tummon IS et al: Fertil Steril 1997;68: 8-12
  9. 9. Surgery improves the likelihood of spontaneous conception <ul><li>Meta-analysis </li></ul><ul><li>Not controlled for stage </li></ul><ul><li>Crude pregnancy rate 38% higher than medical therapy or expectant management </li></ul><ul><li>Meta-analysis </li></ul><ul><li>Common OR 2.67 in favour of surgery compared to medical treatment or expectant management </li></ul>Adamson GD et al, Am J Obstet Gynecol 1994; 171:1488 Hughes EG et al, Fertil Steril; 1993;59:963
  10. 10. ENDO-CAN <ul><li>341 infertile women with min (stage 1) and mild (stage 2 )endometriosis </li></ul><ul><li>Group 1- Laparoscopy only </li></ul><ul><li>Group 2- Laparoscopic ablation/resection </li></ul><ul><li>36 week follow up </li></ul>
  11. 11. 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? <ul><li>Surgery is the standard approach </li></ul><ul><li>Very few controlled studies </li></ul><ul><li>Lack of description of duration of follow up and fecundity rates </li></ul><ul><li>Differences in surgical technique </li></ul><ul><li>Complete or partial excision </li></ul><ul><li>Increasing recognition of “atypical” lesions </li></ul>
  12. 12. Fertility outcomes after surgery for stage III / IV Endometriosis (unpublished data) 79.7% 20.3% Total no of cases- 261
  13. 14. Fertility outcomes after Laparoscopic excision of grade 3 & 4 endometriosis
  14. 15. Additional Procedures required & Complications <ul><li>Additional Procedure required </li></ul><ul><ul><ul><li>Elective bowel resection 13 </li></ul></ul></ul><ul><ul><ul><li>Partial bladder resection 1 </li></ul></ul></ul><ul><li>Complications </li></ul><ul><ul><ul><li>Intraop rectal serosal damage 1 </li></ul></ul></ul><ul><ul><ul><li>Abd wall Haematoma 1 </li></ul></ul></ul><ul><ul><ul><li>Small bowel Obst 1 </li></ul></ul></ul><ul><ul><ul><li>Laparotomy for prim Haemorrhage 1 </li></ul></ul></ul>
  15. 16. Summary of outcomes <ul><li>Pain relief (Visual Analogue Scale) – 78% </li></ul><ul><li>Spontaneous pregnancy rates- 36% </li></ul><ul><li>Complications- 2% </li></ul>
  16. 17. Mrs J Y <ul><li>34 years </li></ul><ul><li>Primary infertility 4 years </li></ul><ul><li>Regular periods, mild dysmenorrhoea, no dyschezia, no dyspareunia, semenalysis normal </li></ul><ul><li>Diagnostic laparoscopy- AFS Stage 3 endometriosis, tubes normal </li></ul><ul><li>TVS- 3 cm endometrioma left ovary </li></ul><ul><li>Do you proceed to IUI, do IVF or surgical treatment of endometriosis </li></ul>
  17. 18. <ul><li>~ 30% spontaneous conception </li></ul><ul><li>Lower risk of ovarian/pelvic abscess with OPU? </li></ul><ul><li>Oocyte Quality improved? </li></ul><ul><li>Risk of surgery </li></ul><ul><li>IVF conception rates 45% with one cycle and 70% with 2 cycles </li></ul><ul><li>Cost </li></ul><ul><li>Psychological impact </li></ul><ul><li>Avoids potential surgical complications </li></ul>Surgery IVF
  18. 19. Mrs PC <ul><li>38 years </li></ul><ul><li>1 infertility 2 years </li></ul><ul><li>Regular periods, severe dysmenorrhoea, mild dyspareunia, no dyschezia </li></ul><ul><li>PV- nodularity in POD </li></ul><ul><li>TVS- endometrioma right ovary 4 cm, left ovary 2 cm endometrioma </li></ul><ul><li>Do you perform IUI, IVF or offer laparoscopy? </li></ul>
  19. 20. First Laparoscopy
  20. 21. Wide excision of deep endometriosis from vagina
  21. 22. Excision of D I E from rectum
  22. 23. Removal of specimen
  23. 24. Excision completed
  24. 25. Suturing of vaginal opening
  25. 27. Follow up <ul><li>Asymptomatic at 3 month follow up </li></ul><ul><li>Pregnant at 6 months </li></ul><ul><li>NVD of a baby boy </li></ul><ul><li>Remains asymptomatic 6 months postpartum </li></ul>
  26. 28. Conclusion <ul><li>Management of endometriosis related infertility is complex </li></ul><ul><li>Surgical treatment of stage I & II endometriosis should be undertaken at the time of initial assessment </li></ul><ul><li>Surgical excision of infertility related to stage III&IV endometriosis in absence of pain symptoms remains c ontroversial in absence of reliable prospective studies. </li></ul>
  27. 29. THANK YOU