Ls,infertility 2007

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  • Pregnancy rates observed after laparoscopic excision of endometriomas. Diamonds represent percentage point estimates and horizontal lines represent 95% CIs. Modified from Jones and Sutton (2002), with permission.
  • Pregnancy and implantation rates were significantly lower in the groups of patients with intramural and
    submucosal fibroids, even when there was no deformation of the uterine cavity. Pregnancy and implantation rates were not
    influenced by the presence of subserosal fibroids. Surgical or medical treatment should be considered in infertile patients
    who have intramural and/or submucosal fibroids before resorting to ART treatment.
  • In women with IM fibroids, no significant differences are seen.
    Even if IM fibroids do indeed decrease fertility (and this is far from conclusive), it is not a given that their removal will reverse the process and normalize fertility or even be beneficial to the patient. There are several excellent reasons for avoiding myomectomy in the infertile woman with IM myomas. Abdominal or laparoscopic myomectomy can be associated with significant morbidity, including infection, damage to internal organs, and risk of blood or blood product transfusions. Also of concern for the infertile woman is the
    high rate of postoperative adhesion formation, especially with myomectomies performed through posterior uterine incisions. Add to these the risks of uterine rupture during pregnancy and increased likelihood of cesarean section, and there are many reasons to be wary of myomectomy when the indications are unclear.
  • Ls,infertility 2007

    1. 1.   
    2. 2. Optimal use of infertility diagnostic tests &  treatments The ESHRE Capri Workshop Group Guidelines for evaluation of infertility: Year: 2000            Tests: • Semen analysis • Mid-Luteal - P • Assessment of tubal patency • LS should be reserved as a further diagnostic procedure   or in combination with endoscopic surgery • Diagnostic laparoscopy recognized but questioned for  absolute necessity Human Reprod  Vol;15 No:3 pp.723-32,2000
    3. 3. Last Ten Years What has changed in the last 10 years  with the usage of Laparoscopy for diagnostic  and therapeutic purposes? Can we define to what extend we need  to perform Laparoscopy for  fertility         investigation?
    4. 4. Infertility - Laparoscopy (L/S) It is generally accepted that diagnostic-LS is gold  standard in diagnosing:  Tubal pathology,          Endometriosis,           Adnexial adhesions,          Other intra-abdominal causes of infertility Tanahatoe SJ, et al. Hum. Reprod (18) 1:8-11, 2003 Bosteels J.et al. Hum Reprod.Update, vol.13,No.5pp447-485,2007
    5. 5. Advantages and disadvantages of  diagnostic laparoscopy ADVANTAGES DISADVANTAGES •See and treat •Combine with HS •Day care surgery •Cost affectivity ? •Need for GA •Complications •Adhesion formation •Performance of   procedures that  unnecessary or not proven to  benefit the patient    
    6. 6. Is Laparoscopy outdated? • When considering the relationship between  Laparoscopy and Infertility with the advantages  mentioned earlier, it is not possible to think that  Laparoscopy is entirely an outdated procedure. • However nowadays it should be questioned to  what extent Laparascopy is effective for  Infertility investigation in the areas of diagnostic  and therapeutic purposes
    7. 7. Is Laparoscopy outdated? • Understanding the position of Laparoscopy in   infertility investigation should be considered  within the scope of Evidence Based Medicine  datas.  • This assessment can explain the up-to-date  position of Laparoscopy.  • As a result, the effectiveness and the strength of  Laparoscopy will be investigated in different  topics and various parameters based on the  current evidence available for us.
    8. 8. Laparoscopy for infertility • Diagnostic laparoscopy in otherwise unexplained infertility − Tubal patency − Before or  after IUI alter treatment decisions ? − Laparoscopy after failed IVF • Diagnostic&Therapeutic Fertility promoting laparoscopy in the  infertile couple – – – – – Endometriosis Myom Adhesion PCOS Hydrosalpinx
    9. 9. Tubal           pathology                        Tubal patency
    10. 10. HSG: Assessing the validity  of the evidence An ideal (or ‘‘gold standard’’) test for tubal disease  would correctly identify all women with tubal  disease. Medline search: 2813 articles retrieved, 19  original articles and meta-analysis fit for the  clinical problem (tubal patency)  No RCT and no Prospective cohort studies  investigating the validity of HSG in diagnosis  of tubal patency have been published.  Evers JLH. et al. Seminars in Reprod. Med. 21 (1):9-15 2003  Swart P. Mol.BW et al. Fertil Steril 1995; 64:486-491  
    11. 11.           Interpretation of the findings                            According 14 % normal prevalance of disease and                                          (HSG sensitivity: 0.65 Specificity:0.83)         Predictive value of tubal occlusion if HSG      abnormal is:                                        38 %                                This means:             Tubal occlusion is not confirmed at LS                       and  Tubes are open in as many as                                        62 %                  if  HSG suggests patent tubes,              Tubal occlusion is  highly unlikely : 6%
    12. 12. Comparison of HSG / LS as a predicting fertility  outcome  HSG: Two-sided occluded  LS: Normal (42% of patients)  FRR*: Slightly impaired (FRR:0.70)   HSG: Two-sided abnormal  LS: One or two –sided abnormal (23% of  patients)  FRR: Fertility prospects is strongly impaired  FRR (0.38 and 0.19 respectively)   Mol BWL Hum Reprod (14) 5:1237-1242, 1999
    13. 13. Recommendations - RCOG • Women who are not known to have comorbidities as:                               Pelvic inflamatory disease                                Previous ectopic pregnancy                               Endometriosis       should be offered     HSG …. strength of evidence:  B • Women thought to have co-morbidities should be  offered L/S so that tubal and other pelvic pathology can  be assessed at the same time ……… B • Tubal pathology detected at L/S has stronger effect on  future fertility than HSG.    Clinical Guideline for the NHS by NICE February 2004 p:48 RCOG press
    14. 14. Conclusion -Tubal Pathology- The prognostic significance of LS and HSG for fertility outcome • It is suggested that performing a diagnostic  LS after a two-sited occluded HSG is very  useful since it enables a division between  two groups with significantly different  fertility prospect. • LS can be delayed after normal HSG for at  least 10 months because of the very low  probability of only 5% that bilateral tubal  occlusion may be found.
    15. 15. Does diagnostic laparoscopy  before or      after IUI alter           treatment decisions ? -assessement&management-
    16. 16. Does diagnostic laparoscopy alters  treatment decisions ? Design: Retrospective Patient(s): Who had undergone diagnostic L/S after a normal  HSG and before IUI (n:495) Intervention(s): Diagnostic LS in infertility work up before IUI Results: Altered treatment desicion was 124 (25%) after LS      21 (4% ) had severe abnormalities that  resulted in a change  to IVF 8 (1.6%) and laparotomy 13(2.6%)     103 (21%) abnormalities, endometriosis stage I/II adhesions  were directly treated by LS  Conclusion(s): This study shows that:      Diagnostic-L/S alters treatment decision in 25% of patients  who would have been treated with IUI if this test had not  been performed. Tanahatoe SJ. Et. al. Fertil Steril 2003;79:361-6
    17. 17. Does diagnostic laparoscopy alters  treatment decicions ? Discussion:   Delaying L/S might probably lead to inappropriate treatment of IUI which  is expensive and stressful to patients.  Omiting L/S would probably lead to lower  pregnancy rates, longer times  to achieve pregnancy and more patients receiving IVF which is expensive.  IVF cycle is around 3.5 times higher than for stimulated    cycles of IUI and  5 times higher than a spontaneous IUI cycle   Given the low sensitivity of HSG, IVF may be chosen as an option for some  cases, leading to high rates of over treatmen  Diagnostic  L/S may be of considerable value, provided the change of  treatment decision effective. it is impossible to determine a possible  beneficial effect of LS –surgery on the cycle pregnancy rate or on the  Crude-PR. At least 1000 patients should have been included to show  difference of 10% in the cumulative ongoing-Pregnancy. Of course, this  finding(s)  justify further prospective studies to ascertain the role (if any).                                                  CONCLUSİON
    18. 18. •ENDOMETRİOSİS
    19. 19. •ENDOMETRİOSİS • Stage I-II • Mild-Moderate Endometriosis and Infertility
    20. 20. Two randomised studies (Marcoux  1997; Gruppo Italiano 1999) Two randomised studies directly addressed the  question of whether laparoscopic surgery  improved outcomes in patients with otherwise  unexplained infertility.
    21. 21. Meta-analysis also demonstrated an advantage of laparoscopic surgery when compared to  diagnostic laparoscopy only in terms of clinical pregnancy rates with an OR of 1.66 (95%Cl  1.09to 2.51) (437 participants, two trials, analysis) favouring laparoscopic surgery BUT,There are very few trials in this area and further trials are crucial.
    22. 22. Mild-Moderate Endometriosis and Infertility • The experimental event rate is 26% versus a control event rate of 18%. • The absolute benefit increase of 8% translates into a number needed to treat (NNT) of 12 laparoscopies should be performed to obtain one additional pregnancy compared with treatment abstention) • This estimate should be doubled or tripled considering that preoperative identification of subjects with stage I–II disease is unfeasible, and that only one-third to one-half of the women undergoing laparoscopy for unexplained infertility actually have the condition.
    23. 23. International Guidelines
    24. 24. CONCLUSİON FURTHER TRİALS Further trials should carefully address the methods of randomisation and blinding The interpretation of the outcomes of any trial of this nature depends on these factors and they are crucial.
    25. 25. ENDOMETRİOSİS stage III-IV
    26. 26. Surgery for ovarian disease (ASRM stage III-IV) • (ESHRE) guidelines for the diagnosis and treatment of endometriosis (Kennedy et al., 2005), it has been pointed out that • ‘No RCT or meta-analysis are available to answer the question whether surgical excision of moderate–severe endometriosis enhances pregnancy rates’.
    27. 27. International Guidelines
    28. 28. CONCLUSİON FURTHER TRİALS Further trials should carefully address the methods of randomisation and blinding The interpretation of the outcomes of any trial of this nature depends on these factors and they are crucial.
    29. 29. ENDOMETRİOSİS Endometriotic cystsENDOMETRİOMA
    30. 30. Pregnancy rates observed after laparoscopic excision of endometriomas. Very different outcomes have been reported in uncontrolled studies evaluating the impact of laparoscopic treatment of ovarian endometriotic cysts on post-operative reproductive performance. Pregnancy rates vary from 30% (Marrs, 1991) to 67% (Beretta et al., 1998), with an overall weighted mean of about 50%. This is most likely an overestimate due to multiple confounding factors, including selection bias (inclusion of women who did not try to conceive preoperatively and that are not necessarily infertile) Few authors indicate how many patients achieved a pregnancy postoperatively by means of IVF. In these cases it is questionable to attribute success exclusively to laparoscopy. Vercellini P et al. Hum. Reprod. 2009;24:254-269
    31. 31. Endometrioma: Excision vs Ablation Spontaneous conception Overview of RCTs comparing vaporization/coagulation with excision of ovarian endometriotic cysts. NNT= 2.7 2006 Vercellini P et al. Hum. Reprod. 2009;24:254-269 © The Author 2008. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please email: journals.permissions@ oxf ordj our nals .org Accordingly, the potential absolute benefit increase over background pregnancy rate 12 months after surgery in women with patent tubes could be hypothetically estimated to not greater than 25%. Based on this estimate, the NNT would be 4. Vercellini et al. Hum Reprood Advance Access October 23,2008
    32. 32. International Guidelines
    33. 33. Conclusion Ablation of endometriotic lesions plus adhesiolysis to improve fertility in minimal-mild endometriosis is effective compared to diagnostic LS alone……A Women with moderate or severe endometriosis should be offered surgical treatment because it improves the chance of pregnancy……………………………….B A Directly based on level 1 evidence B Directly based on level 2 evidence or extrapolated recommendation from level 1 evidence Conservative surgery may be indicated in women with infertility and endometriotic ovarian cysts (stage III/IV) also because of the need for histological examination to rule out early ovarian cancer. RCTs are badly needed to clarify whether and how much, surgery for endometriomas improves the reproductive prognosis of infertile women.
    34. 34. ENDOMETRIOSIS Recurrent Endometriosis
    35. 35. • After repeat conservative surgery for infertility, the pregnancy rate is almost half the rate obtained after primary surgery. • More data are needed to define the best therapeutic option in women with recurrent endometriosis, in terms of pain relief, pregnancy rate and patient compliance.
    36. 36. International Guidelines After repeat conservative surgery for infertility, the pregnancy rate is almost half the rate obtained after primary surgery.
    37. 37. Conclusion More data are needed to define the best therapeutic option in women with recurrent endometriosis, in terms of pain relief, pregnancy rate and patient compliance.
    38. 38. MYOMECTOMY Intramural (IM): Subserosal (SS):
    39. 39. Effect of intramural, subserosal, and submucosal fibroids on the outcome of assisted reproductive technology treatment Eldar-Geva Tet al. Fertil Steril. 1998 Oct;70(4):687-91
    40. 40. Effect of myomectomy on fertility: -intramural fibroids- . Pritts EA, Parker WH, Olive DL Fibroids and infertility: An updated systematic review of the evidence. Fertil Steril. 2009 Apr;91(4):121523.
    41. 41. There are several excellent reasons for avoiding myomectomy in the infertile woman with IM myomas.  Abdominal or laparoscopic myomectomy can be associated with significant morbidity, including infection, damage to internal organs, risk of blood or blood product transfusions. Also of concern for the infertile woman is the high rate of postoperative adhesion formation, especially with myomectomies performed through posterior uterine incisions  Add to these the risks of uterine rupture during pregnancy and increased likelihood of cesarean section, and there are many reasons to be wary of myomectomy when the indications are unclear.  Pritts EA, Parker WH, Olive DL Fibroids and infertility: An updated systematic review of the evidence. Fertil Steril. 2009 Apr;91(4):1215-23.
    42. 42. The only randomised controlled study that met with the Cochrane inclusion criteria was probably underpowered to look at fertility outcomes.
    43. 43. Implications for practice It is not identified any randomized controlled trial evidence to suggest that myomectomy improves fertility efficacy as indicated by clinical pregnancy rate or live birth rate, although there are many retrospective observational studies that suggest this. There was no evidence identified to suggest there is a difference in the clinical pregnancy rate or live birth rate between the different surgical modalities available to remove fibroids. There were some non fertility benefits of removal via laparoscopy including shorter hospital stay, less febrile illness and asmaller drop in preoperative haemoglobin concentration when compared to laparotomy.
    44. 44. Conclusions Infertility increasing effect of Laparoscopic Myomectomy when compared with the Laparotomic Myomectomy is not proven. There were some non fertility benefits of removal via laparoscopy including shorter hospital stay, less febrile illness and asmaller drop in pre-operative haemoglobin concentration when compared to laparotomy.
    45. 45. ADHESIONS
    46. 46. Recommendations - RCOG • Women who are not known to have co-morbidities as: • Pelvic inflamatory disease • Previous ectopic pregnancy • Endometriosis should be offered HSG strength of evidence: B • Women thought to have co-morbidities should be offered L/S so that tubal and other pelvic pathology can be assessed at the same time B • Tubal pathology detected at L/S has stronger effect on future fertility than HSG. RCOG - Clinical Guideline February 2004 p:48
    47. 47. Adhesions Case-controlled studies usually claim that adhesiolysis increases the pregnancy rate in a certain period of time. However, randomized controlled trials have shown that laparoscopic adhesiolysis following pelvic reproductivesurgery does not have a significant impact on the odds ratio of pregnancy, live birth, ectopic pregnancy and miscarriage. Thus adhesiolysis does not seem to be a primary option in the treatment of an infertile couple. Tulandi T, Collins JA, Burrows E, et al. Am .J .Obstet Gynecol 1990; 162:354–357.
    48. 48. Implications for practice There is insufficient evidence to support the routine practice of postoperative hydrotubation or second-look laparoscopy with adhesiolysis following female pelvic reproductive surgery. Although no previous studies have shown the beneficial effects of adhesiolysis prior to IVF, laparoscopic adhesiolysis may have a role in assuring initial access to the ovaries during oocyte recovery and in improving subsequent attempts. To summarize, there is no evidence to show that surgical treatment of adhesions by laparoscopic interventionprior to ART is beneficial. Unfortunately there are no randomized controlled trials examining the outcomes of ART cycles in women who have had previous adhesiolysis compared with those who have not. Periovarian adhesions may constrict the ovarian blood Postoperative procedures for improving fertility following pelvic reproductive surgery Editorial Group: Cochrane Menstrual Disorders and Subfertility Group 1APR 2009 Published Online:
    49. 49. Implications for practice Does adhesiolysis increase the success rate in ART cycles? Does adhesiolysis have any beneficial effect on ectopic pregnancy in ART cycles? ? Unfortunately there are no randomized controlled trials examining the outcomes of ART cycles in women who have had previous adhesiolysis compared with those who have not. •Unfortunately there is no truly randomised studies examining second-look LS with adhesiolysis following pelvic reconstructive surgery. Periovarian adhesions may constrict the ovarian blood There is insufficient evidence to support the routine practice of post operative sec-look LS with adhesiolysis or hydrotubation for improving fertility Duffy JMN et al The Cochrane Library 2009,Issue 2
    50. 50. Conclusion-II Adhesions/ Adhesiolysis • Direct LS Observation is the most reliable method in diagnosis of adhesions. • However, in the infertility assessment LS is not a routine clinical practice to be the primary choice for the diagnosis of adhesions. • In this topic alternative diagnostic methods for tuboperitoneal infertility&adhesions ,should based on Medical history, Chlamydia screening, HSG • There is insufficient evidence to support the routine practice of post operative sec-look LS with adhesiolysis for improving fertility • Ablation of endometriotic lesions plus adhesiolysis to improve fertility in minimal-mild endometriosis is effective compared to diagnostic LS alone……A
    51. 51. Endoscopic Surgery and Tubal Infertility Hydrosalpinx
    52. 52. What is the place of endoscopic surgery Hydrosalpinx • • • before IVF cycles The presence of hydrosalpinx is associated with early pregnancy loss and poor implantation and pregnancy rates, probably due to alteration in endometrial receptivity……….Evidence level 2b A systematic review of three RCTs showed that tubal surgery such as laparoscopic salpingectomy significantly increased live birth rate (OR 2.13; 95% CI 1.24 to 3.65) and pregnancy rate (OR 1.75; 95% CI 1.07 to 2.86) in women with hydrosalpinges before IVF when compared with no treatment. ………..Evidence level 1a Women with hydrosalpinges should be offered salpingectomy, preferably by laparoscopy, before in vitro fertilisation treatment because this improves the chance of a live birth ………..A Bosteels J. Et al. Human reprod Update, Vol.13,No.5 pp477-85,2007 , Johnson NP et al Cochrane database issue:3,2000 , Strandel A Human Reprod Update 2000;6:387-95
    53. 53. Authors’ conclusions Laparoscopic salpingectomy should be considered for all women with hydrosalpinges prior to IVF treatment. Currently unilateralsalpingectomy for a unilateral hydrosalpinx (bilateral salpingectomy for bilateral hydrosalpinges) should be recommended, although this requires further evaluation. Further randomised trials are required to assess other surgical treatments for hydrosalpinx, such as salpingostomy, tubal occlusion or needle drainage of a hydrosalpinx at oocyte retrieval. The role of surgery for tubal disease in the absence of a hydrosalpinx is unclear and merits further evaluation. Removing blocked or diseased fallopian tubes before in vitro fertilisation (IVF) can increase pregnancy rates for women on the IVF program
    54. 54. Authors’ conclusions Before commencing an ART cycle •If the patient has bilateral visible hydrosalpinges on hysterosalpingography or ultrasonography, a previous ectopicpregnancy, and endometrial fluid collection during previous COH, a laparoscopy should be performed in order to consider salpingectomy.
    55. 55. Polycystic ovary syndrome - LOD
    56. 56. Polycystic ovary syndrome LOD There was no evidence of a difference in the live birth rate and miscarriage rate in women with clomipheneresistant PCOS undergoing LOD compared to gonadotrophin treatment. The reduction in multiple pregnancy rates in women undergoing LOD makes this option attractive. However, there are ongoing concerns about long-term effects of LOD on ovarian function.
    57. 57. Polycystic ovary syndrome LOD LOD cannot be recommended as a first line treatment for women with PCOS undergoing IVF-ET. This treatment should be reserved for women who have previously had at least one treatment cycle abandoned for risk of OHSS, and then after a thorough discussion of the procedure with the patient.chance of pregnancy following ART cycles. However,few clinical situations fit these criteria. Current evidence advocates laparoscopy and salpingectomy for visible hydrosalpinx before starting ART cycles. In addition,laparoscopy may be used to replace transposed ovaries. Finally, it could be considered performing LOD for PCOS patients who repeatedly suffer from severe OHSS.
    58. 58. Conclusions LOD cannot be recommended as a first line treatment for women with PCOS undergoing IVFET. It could be considered performing LOD for PCOS patients who repeatedly suffer from severe OHSS.
    59. 59. The role of Laparoscopic Treatment of Endometriosis in patients who have Failed In Vitro Fertilization
    60. 60. Laparoscopy in Patients with Failed IVF + Laparoscopy No laparoscopy 29 35 34.75 35 NS 2.25 2.4 NS Pregnancy rate 22/29 13/35 <.01 Spontaneous pregnancy rate 13/29 2/35 <.01 Number of patients (n) Average Age Average no. of failed IVF cycles Fertility and Sterility Volume 84, Issue 6 , December 2005, Pages 1587-1588 p-value
    61. 61. Conception rates 25 22 20 15 13 11 10 7 7 Spontaneous OI/IUI IVF No conception 5 2 0 Study group 2 0 Control group Eva Litman, MD,Amin Milki, MD,Linda Giudice, MD,Lynn Westphal, MD,Ruth Lathi,MD,Bulent Berker, MD,Camran Nezhat, MD.Fertility and Sterility Volume 84, Issue 6 , December 2005, Pages 1587-1588
    62. 62. Conception rates by endometriosis stage Stage n total n conceived Conception % I 4 4 100 II 6 5 83 III 6 5 83 IV 13 8 62 Eva Litman, MD,Amin Milki, MD,Linda Giudice, MD,Lynn Westphal, MD,Ruth Lathi,MD,Bulent Berker, MD,Camran Nezhat, MD.Fertility and Sterility Volume 84, Issue 6 , December 2005, Pages 1587-1588
    63. 63. LS after failed IVF Eva Litman, MD,Amin Milki, MD,Linda Giudice, MD,Lynn Westphal, MD,Ruth Lathi,MD,Bulent Berker, MD,Camran Nezhat, MD.Fertility and Sterility Volume 84, Issue 6 , December 2005, Pages 1587-1588
    64. 64. Infertility - Laparoscopy (L/S) It is generally accepted that diagnostic-LS is gold standard in diagnosing:     Tubal pathology Other intra-abdominal causes of infertility: Endometriosis, Adnexial adhesions Tanahatoe SJ, et al. Hum. Reprod (18) 1:8-11, 2003 Bosteels J.et al. Hum Reprod.Update, vol.13,No.5pp447-485,2007
    65. 65. Findings at diagnostic laparoscopy in women with otherwise unexplained infertility Finding Endometriosis Adhesions Tubal occlusion Treatment related to improvement of fertility Unknown Unknown Yes/No Alters management Yes/No Yes/No Yes
    66. 66. Conclusions Diagnostic laparoscopy is not an integral part of infertility evaluation The place of diagnostic laparoscopy prior to and after failed IUI/IVF is not clear The benefit of therapeutic laparoscopy for endometriosis is not established The benefit of therapeutic laparoscopy for IM myomas is not established The removal of the SM myomas enhance the rates of conception and live births. SS fibroids do not affect fertility or spontaneous abortion. Myomas that distort the uterine cavity adversely affect fertility both spontaneous and during IVF treatment. Therapeutic laparoscopy is indicated for removal of hydrosalpinges The benefit of therapeutic laparoscopy for adhesion is not well established. ART & LS are not mutually exclusive, but coexisting & complimentary tretment.
    67. 67. Removal of endometriomas before in vitro fertilization does not improve fertility outcomes: a matched, case-control study Juan A. Garcia-Velasco, M.D., Neal G. Mahutte, M.D., José Corona, M.D., Victor Zúñiga, M.D., Juan Gilés, M.D., Aydin Arici, M.D., and Antonio Pellicer, M.D. Fertility and Sterility, vol. 81, no. 5, May 2004
    68. 68. Conclusion Management Mild- MinimalEndometriosis Whether or not minimal and mild Endometriosis should be treated in case of infertility still remains aseemingly never –ending discussion There still is a need for further RCT in order to solve this issue but it may be hard to convince ethical committees and even harder to recruit pat,ente ,in view of the current level of evidence. ESHRE Guideline.Hum Reprod. Vol.20,No.10 pp .2698-2704,2005 Bosteels J. Et al. Human reprod Update, Vol.13,No.5 pp477-85,2007
    69. 69. Conclusion Mild- MinimalEndometriosis • Ablation of endometriotic lesions plus adhesiolysis to improve fertility in minimalmild endometriosis is effective compared with diagnostic LS-alone….A ……..Evidence Level 1a Clinical guidelinefor the NHS by NICE,RCOG Press,2004 ESHRE Guideline.Hum Reprod. Vol.20,No.10 pp .2698-2704,2005 RCOG Guideline.No.24,2006
    70. 70. Conclusion Mild- MinimalEndometriosis • When LS is performed,the surgeon should consider safetly ablating or excising visible lesions of endometriosis • In women with stage I/II endometriosis-associated infertility, expectant management or superovulation/IUI after LS can be considered for younger patients. • Women ≥ 35 should be treated with superovulation/IUI or IVF-ET. • In women with stage III/IV endometriosis-associated infertility, conservative therapy with LS and possible LT are indicated. ASRM Fertil Steril 2004;81(5):1441-6
    71. 71. Conclusion -Managementmoderate-severe Endometriosis • No RCT or meta-analyses are avaible to answer the question.Based upon three studies there seems to be a negative correlation between the stage of Endometriosis and the spt –CPR after surgical removal of Endom. But statistical significance was only reached in one study Adamson GD et al.Fertil Steril.1993;59:35-44 ,Guzick DS et al.Fertil Steril.1997;67:822-9 Osuga Y et al. Gynecol Obstet Invest.2002;53(Suppl 1):33-9 ,RCOG Guideline.No.24,2006
    72. 72. Conclusion -Managementmoderate-severe Endometriosis • Does surgery for moderate- severe disease improve pregnancy rates ? • The role of surgery in improving pregnancy rates for moderate-severe disease is uncertain……..B ………Evidence Level 3 • Postoperative medical treatment does not improve pregnancy rates in women with moderate to severe endometriosis and is not recommended….A Clinical guidelinefor the NHS by NICE,RCOG Press,2004 ,ESHRE Guideline.Hum Reprod . Vol.20,No.10 pp . 2698-2704,2005 ,RCOG Guideline.No.24,2006
    73. 73. Conclusion -ManagementEndometrioma • LS-cystectomy for ovarian endometriomas> 4 cm diameter improves fertility compared to drainage and coagulation ……A ……..Evidence Level 1b • Coagulation or Laser vaporization of Endometriomas without excision of the pseudo- capsula is associated with a significantly increased risk of cyst recurrence……A ……..Evidence Level 1b • Subsequent spontaneus pregnancy rates in women who were previously sub fertile are also improved with this treatment……A ……..Evidence Level 1a Hart RJ. et al,Cochrane database 2005, issue 3 ,RCOG Guideline.No.24,2006
    74. 74. Conclusions The benefit of therapeutic laparoscopy for endometriosis is not established Surgery recommedation&Minimal/mild Endometriosis: ESHRE-2005: Limited benefit ASRM-2006: Small benefit RCOG-2006:Demonstrated benefit
    75. 75. Conclusions • A number needed to treat (NNT) of 12 laparoscopies should be performed to obtain one additional pregnancy compared with treatment abstention) • This estimate should be doubled or tripled considering that preoperative identification of subjects with stage I–II disease is unfeasible • Endometriosis prevalance .30-50% • NNT:12X2-12X3 =24-36 (30) • Diagnostic laparoscopy is not an integral part of infertility evaluation • Women with minimal or mild endometriosis who undergo laparoscopy should be offered surgical ablation or resection of endometriosis plus laparoscopic adhesiolysis because this improves the chance of pregnancy………………………. A
    76. 76. Infertility treatment: the viability of the Laparoscopic view • ART & LS are not mutually exclusive, but coexisting & complimentary tretment. • For disease conditions contrubuting to infertility in addition to other concomitant or potantial morbidity ,LS represent a more comprehensive approach. Fertil Steril 2008 ;89:461-4 by ASRM
    77. 77. Recommendation: • If minimal or mild endometriosis is diagnosed by L/S, surgical treatment is recommended but if pregnancy does not occur, patients should be treated in the same way as couples with unexplained infertility. Sutter DP Best practice and research Clin. Obstet Gynecol 2006:1-18
    78. 78. • no RCT or meta-analysis are available to answer the question whether surgical excision of moderate–severe endometriosis enhances pregnancy rates’.
    79. 79. – 22 out of 29 patient (76%) achieved pregnancy – 15 of the 29 patients conceived without further IVF therapy – >60% of patients with Stage IV endometriosis, conceived, spontaneously or with additional IVF Eva Litman, MD,Amin Milki, MD,Linda Giudice, MD,Lynn Westphal, MD,Ruth Lathi,MD,Bulent Berker, MD,Camran Nezhat, MD.Fertility and Sterility Volume 84, Issue 6 , December 2005, Pages 1587-1588

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