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Endometriosis and infertility
• The hypothesis that endometriosis
causes infertility or a decrease in
fecundity remains co...
Endometriosis and infertility: a
committee opinion.
The Practice Committee of the
American Society for
Reproductive Medici...
A paradox !
•1. Need to do a
laparoscopy to make a
diagnosis of
endometriosis
•2. No need to do
laparoscopy routinely
for all infertile couples
Routine laparoscopy
• Laparoscopy in infertile woman,
simply to confirm or rule out the
disease is not warranted.
• Endome...
Routine laparoscopy
• The benefit of laparoscopic treatment of
minimal or mild endometriosis is
insufficient to recommend ...
No laparoscopy ? Won’t we
miss the diagnosis ?
• Yes, we will
• So, what ?
• We don’t treat a diagnosis, we treat the
infe...
Routine laparoscopy
• Does not change treatment options - or
outcome !
• Burning endometriosis lesions, and
cutting adhesi...
Harm Caused
• Misdiagnosis - corpus luteum vs
endometriosis
• Burning or excising chocolate cyst reduces
ovarian reserve
•...
Medical treatment does not
improve pregnancy rates
• In infertile women with endometriosis,
clinicians should not prescrib...
Changing paradigm
• PAST
• Removal of lesions is a
priority.
• It is a gynecological
lesion
• Recurrence means
incomplete ...
Principles of care
• Ovarian reserve should be assessed
before intervention.
• Endometriosis surgery should be avoided
in ...
Principles of care
• Don’t just treat the lesions !
• Need to factor in:
• Female age
• Duration of infertility
• Pelvic p...
Endometrioma diagnosed on
ultrasound
Ovarian Endometriomas
Justification for doing laparoscopic
ovarian cystectomy
• Confirm the diagnosis histologically
• Reduces risk of recurrenc...
IVF and endometriosis
• Embryo implantation is not affected
in patients with endometriosis.
• The presence of severe
endom...
• Although the presence of bilateral
endometriomas at the time of IVF affects
responsiveness to hyperstimulation, the qual...
Ultrasound guided cyst aspiration
prior to IVF
• Safe and effective
• Temporary solution – good
enough
• If she gets pregn...
Minimally invasive !
• Ethanol sclerotherapy of ovarian
endometrioma: a safe and effective
minimal invasive procedure.
Pre...
New treatment option
• Sclerotherapy in the management of
ovarian endometrioma: systematic
review and meta-analysis. Cohen...
Take home messages
• Routine diagnostic laparoscopy not indicated
for infertile women
• Medical therapy of endometriosis h...
The elephant in the room
• None of us will change what we are
doing!
• We all have our personal prejudices
Trigger happy doctor
• We like doing things - " Itchy " fingers
• Feel good - for yourself, because you did
something
• Pa...
Why it’s easy to fool
doctors
• Personal experience - Small numbers, no
controls, no followup
• Patients change doctors. O...
Experts are biased – and often
wrong !
• Eminence based medicine - "my
experience" - which is plagued with
problems
• Expe...
Trust your own eyes !
• Minimal endometriosis is a very common
incidental finding
• No clinical relevance
• Look for it ca...
IVF vs Endoscopy
• Do both !
• Gynecologist and Ivf specialist refer
patients to each other !
• Both are happy - only lose...
Overtreating endometriosis
Overtreating endometriosis
Overtreating endometriosis
Overtreating endometriosis
Overtreating endometriosis
Overtreating endometriosis
Overtreating endometriosis
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Overtreating endometriosis

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Why do gynecologists and infertility specialists provide the wrong treatment to infertile women with endometriosis ?

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Overtreating endometriosis

  1. 1. Endometriosis and infertility • The hypothesis that endometriosis causes infertility or a decrease in fecundity remains controversial. • Whereas evidence demonstrates an association between endometriosis and infertility, a causal relationship has not been clearly established.
  2. 2. Endometriosis and infertility: a committee opinion. The Practice Committee of the American Society for Reproductive Medicine. Sept 2012
  3. 3. A paradox ! •1. Need to do a laparoscopy to make a diagnosis of endometriosis
  4. 4. •2. No need to do laparoscopy routinely for all infertile couples
  5. 5. Routine laparoscopy • Laparoscopy in infertile woman, simply to confirm or rule out the disease is not warranted. • Endometriosis and infertility: a committee opinion. The Practice Committee of the American Society for Reproductive Medicine. ASRM, 2012
  6. 6. Routine laparoscopy • The benefit of laparoscopic treatment of minimal or mild endometriosis is insufficient to recommend laparoscopy solely to increase the likelihood of pregnancy. • Endometriosis and infertility: a committee opinion . The Practice Committee of the American Society for Reproductive Medicine. ASRM, 2012
  7. 7. No laparoscopy ? Won’t we miss the diagnosis ? • Yes, we will • So, what ? • We don’t treat a diagnosis, we treat the infertile couple ! • Treating mild endometriosis , either with medical therapy or operative laparoscopy, does not improve fertility
  8. 8. Routine laparoscopy • Does not change treatment options - or outcome ! • Burning endometriosis lesions, and cutting adhesions are fun , but “treating” these doesn't improve fertility – and can actually reduce it • Post hoc, ergo propter hoc fallacy - Patients get pregnant after the laparoscopy and doctor is happy to take the credit
  9. 9. Harm Caused • Misdiagnosis - corpus luteum vs endometriosis • Burning or excising chocolate cyst reduces ovarian reserve • Overtreatment – patient “treated” with Lupron after the surgery • Wastes time – you tell the patient, you have now been treated, so you can get pregnant on your own • Don't cut and burn just because you can !
  10. 10. Medical treatment does not improve pregnancy rates • In infertile women with endometriosis, clinicians should not prescribe hormonal treatment for suppression of ovarian function to improve fertility. • ESHRE guideline: management of women with endometriosis. Human Reproduction, Volume 29, Issue 3, 1 March 2014, Pages 400– 412,
  11. 11. Changing paradigm • PAST • Removal of lesions is a priority. • It is a gynecological lesion • Recurrence means incomplete primary surgery • ART had low pregnancy rates • PRESENT • Preservation of ovarian function is a priority. • It is an inflammatory syndrome • Recurrence means persistent offending factor • ART is safe and effective
  12. 12. Principles of care • Ovarian reserve should be assessed before intervention. • Endometriosis surgery should be avoided in women with diminished ovarian reserve who should be offered ART straightaway. • ART is the best option in women with recurrent endometriosis
  13. 13. Principles of care • Don’t just treat the lesions ! • Need to factor in: • Female age • Duration of infertility • Pelvic pain
  14. 14. Endometrioma diagnosed on ultrasound
  15. 15. Ovarian Endometriomas
  16. 16. Justification for doing laparoscopic ovarian cystectomy • Confirm the diagnosis histologically • Reduces risk of recurrence over fulguration • Reduce the risk of infection at IVF • Improves access to follicles • Improves IVF pregnancy rate ( because endometriosis fluid is “toxic “ to eggs)
  17. 17. IVF and endometriosis • Embryo implantation is not affected in patients with endometriosis. • The presence of severe endometriosis or bilateral ovarian endometrioma does not lower implantation rates.
  18. 18. • Although the presence of bilateral endometriomas at the time of IVF affects responsiveness to hyperstimulation, the quality of the oocytes retrieved and the chances of pregnancy are not affected. • Benaglia L Bermejo ASomigliana E Faulisi SRagni G Fedele L Garcia-Velasco JA In vitro fertilization outcome in women with unoperated bilateral endometriomasFertil Steril 2013 99 6 1714-1719
  19. 19. Ultrasound guided cyst aspiration prior to IVF • Safe and effective • Temporary solution – good enough • If she gets pregnant in the IVF cycle, problem is resolved !
  20. 20. Minimally invasive ! • Ethanol sclerotherapy of ovarian endometrioma: a safe and effective minimal invasive procedure. Preliminary results. Eur J Obstet Gynecol Reprod Biol 2015 Apr;187:25-9. Dr Garcia-Teiedor A
  21. 21. New treatment option • Sclerotherapy in the management of ovarian endometrioma: systematic review and meta-analysis. Cohen A, Almog B, Tulandi T. Fertile Steril, 2017 Jul;108(1):117-124. • Using ethanol as a sclerosant
  22. 22. Take home messages • Routine diagnostic laparoscopy not indicated for infertile women • Medical therapy of endometriosis has no role in improving fertility • In minimal to mild disease, ovulation induction and IUI is first line therapy. • IVF is the final common pathway for having a baby
  23. 23. The elephant in the room • None of us will change what we are doing! • We all have our personal prejudices
  24. 24. Trigger happy doctor • We like doing things - " Itchy " fingers • Feel good - for yourself, because you did something • Patient is happy – she feels you have "diagnosed" the problem and have treated it • Can charge more
  25. 25. Why it’s easy to fool doctors • Personal experience - Small numbers, no controls, no followup • Patients change doctors. Only the success stories come back with chocolates ! • Reinforces your bias – the easiest person to fool in the world is yourself
  26. 26. Experts are biased – and often wrong ! • Eminence based medicine - "my experience" - which is plagued with problems • Experts fudge numbers – they lie ! • Sponsored by pharma companies and medical device manufacturers who want to sell their products
  27. 27. Trust your own eyes ! • Minimal endometriosis is a very common incidental finding • No clinical relevance • Look for it carefully in patients undergoing lap TL • You will find it in nearly every woman you put a scope into if you are meticulous
  28. 28. IVF vs Endoscopy • Do both ! • Gynecologist and Ivf specialist refer patients to each other ! • Both are happy - only loser is the patient

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