1. Endometriosis can negatively impact ovarian reserve by damaging follicles through inflammation, fibrosis, and reduced vascularization caused by the disease itself or surgery to remove endometriotic cysts. 2. Anti-Mullerian hormone (AMH) levels tend to be lower in women with endometriosis, with more severe reductions seen with bilateral disease, larger cysts, more fibrosis, and longer disease duration. 3. When considering surgery or fertility treatments for endometriosis patients with low ovarian reserve, factors like the woman's age, infertility duration, pelvic pain levels, recurrence risk, and ovarian reserve markers must be evaluated individually to optimize outcomes while preserving future fertility potential.

1. Endometriosis with low AMH.
How to deal with it
PROF. ROKEYA BEGUM
Advisor
Dept. of Obs and Gynecology USTC.
Director
Surgiscope fertility centre
Chittagong.

2. Endometriosis is a….
Disease of theories and debates

3. Endometriosis….
i) Defined as the presence of endometrial tissue (gland/stroma) outside the
uterus.
ii) Prevalence is 7-15% of reproductive age women .
iii) 70 million of women are affected with endometriosis 30% of these women
are infertile.
iv) Estrogen dependent
- Rare before menarche and after menopause.
- Not in male
v) Progressive disease
vi) Cure by pregnancy

4. Sites of Endometriosis…
i) Peritoneum
ii) Ovaries
iii) Rectovaginal septum
iv) Urinary bladder
v) GI Tract

5. Ovarian function…
i) Hormone production
ii) Maintenance of follicular development
iii) Reservoir of dormant oocyte.

6. Pathogenesis of ovarian endometriosis is still a matter of debate.
- Superficial ovarian endometriosis.
- Accumulation and activation of pelvic macrophage.
Local inflammatory response, fibrosis of cortical tissue damage of dormant primordial follicle
Progression of formation of endometriotic lesion in superficial ovarian cortex
Provoke invagination of ovarian superficial endometriosis facilitates cyst formation.
The cyst wall of endometriosis may show various degree of haemosiderin laden macrophages.
Cyst wall show dense fibrosis adjacent to normal ovarian time.

7. The multipotent stem cells which can form endometriotic
lesion and further progression of stem cell derived lesion via
tissue remodelling may be modulated by ovarian steriod
hormone and local inflammation.
Accumulation and trafficking of these stem cells can be
stimulated by oestradiol and immune cells.
Local immune cells such as in variant natural killer T (NKT)
cells may be involved in pathogenesis of endometriosis.

8. Ovarian steroid hormone production
The direct effects of endometriosis on ovarian steroid hormone production
are unclear.
Altered follicular development can result in decreased hormone production
lower level of oestrogen and progesterone have been noted in serum and
urine .
Impairment of ovulatory process causes LUFS. The causal relationship
between endometriosis and LUFS are unclear and controversial.

9. Oocyte quality…
Oocyte maturity can be affected by inflammatory intrafollicular
environment. The presence of intrafollicular oxidative stress in
patients with endometriosis is an event that is directly linked to
reduced oocyte quality and infertility.
Oxidative stress brought by hemorrhagic chocolate fluids in
endometriosis may spread to surrounding normal ovarian tissue.
Assessment of quality of follicle in clinical setting is not straight
forward.

10. Quantity…
Ovarian reserve is a term concerning the quality and quantity of
ovarian follicles remains at certain time points.
Ovarian reserve may refer to the quantity of remaining primordial
follicles are formed in the course of ovarian development in foetal life
than they maintain dormancy until they are activated in later
reproductive life.

11. Presence of ovarian endometriosis on ovarian
reserve-
1.Adjacent ovarian tissue is morphologically altered but not functionally.
2.Compression by cyst hamper circulation and causes follicular loss.
3. Inflammatory reaction causes follicular damage.
4. Impaired vascularization.
5.High concentration of iron in cyst mediates the production of reactive
oxygen species. Reactive oxygen species (ROS) along with transforming
growth factor  is potent inducer of tissue fibrosis which causes follicular
loss. Reactive oxygen species (ROS) is responsible for progressive ovarian
tissue damage.

13. Ovarian reserve tests

14. Assessment of ovarian reserve in endometriosis has to
be done by-
• Serum Antimullerian hormone (AMH)
• Serum Follicle stimulating hormone (FSH)
• Antral follicle count (AFC)
FSH and AFC have limitation-
• FSH – higher intercycle variation
• AFC – Not accurate with endometrioma.

15. Indeed in two large Cohot studies shown women
with history of endometriosis related infertility
are reported to experience menopause earlier
than women without endometriosis.

16. Endometriosis patients suffers from…
1. Pain
2. Infertility
3. Menstrual disturbances
4. Lump in lower abdomen
5. Quality of life
6. Negative influence on sexual function
7. Inter personal relationship.

17. Endometriosis is associated with infertility..
Fertility reduction is subjective choice and
women could be informed but absolutely must
not be terrorized leading to unnecessary stress
and intervention.

18. Treatment of endometriosis is individualized
1. Medical
2. Surgical
3. ART alone or combination

19. * Medical treatment :
- long term suppression
- Reduces pain
- Reduced growth of lesion
- Protect ovarian function
1. GnRh agonist
2. Dienogest

20. • Medical treatment suppresses general and
peripheral oestrogen production result in better
treatment outcome in ART cycle.
• Reduction of endometriosis activity may
restore endometrial receptivity as well as
maintenance of ovarian reserve.

21. 1. GnRh agonist -
a. Reduce cyst size
b. Reduction of hyper vascularization and inflammation.
c. Reduction of cyst wall thickness.
d. Absence of corpus luteum or follicle.
e. Facilitation of surgery
f. Reduction of adhesion

22. Recommendation
GnRh
1. Prior to IVF
2.Prior to surgery

23. 2. Dienogest -
Acts on multiple receptors
a) Oestrogen
b) Androgen
c) Gluco corticoid
d) Mineralo corticoid
Dienogest has little impact on the metabolic parameter and
having a significant impact on endometriotic lesion locally.

24. Dienogest has -
a. anti inflammatory
b. Modulation of proinflammatory cytokine and chemokine
production-which mediates via progesterone receptor.
It is questionable whether dienogest can improve the clinical
outcome if use before IVF or surgery.

25. Surgery indicated in
i) large endometrioma > 4cm
ii) Extensive pelvic endometriosis
iii) Prior IVF
iv) Failure to hormone therapy

26. Surgical treatment-
Conservative surgery
1. Excision
2. Drainage
3. Ablation

27. Aim of surgery
Reconstruction of normal pelvic anatomy to achieve an
excellent tubo-ovarian relationship and removed all visible disease .
Laparoscopy is preferred over laparotomy.
Ovarian tissue was present in cyst wall
- 65% laparoscopy stripping
- 80% laparotomy.

28. All ovarian cyst are not created equal
Ovarian tissue removed
Well defined Capsule
Dermoid 6%
Serious cyst adenoma
Mucinous cyst adenoma
Endometrioma
54-69%
(Margin of the ovarian tissue)
The structural difference among different ovarian cysts yield
different amounts of adjacent ovarian tissue when they are
removed.

29. Endometriosis is a false cyst and its cyst wall is
the same as the ovarian cortex.
Therefore unsafe removal of pseudo cyst may
damage the ovary and interfere with future
fertility.

30. Laparoscopy is Gold standard.
Ongoing pregnancy rate increased in infertile
women with endometriosis after laparoscopy.
Chance of pregnancy increased from 38-71%
cases.

31. Benefits of surgery…
a. Decreased inflammations in pelvis.
b. Decreased toxicity to gametes.
c. Enhance uterine receptivity.

32. High recurrence rate versus potential harmful effects on
ovarian reserve make it difficult to select the most
effective treatment modality for endometriosis.
• Incomplete excision – recurrence high
• Excessive excision – reduced reserve

33. Recurrence of endometriosis:
The reported recurrence rate was high
=> 21.5% at 2 yrs
=> 40-50% at 5 yrs
Repeat surgery - 25%

34. Reduction of ovarian reserve due to-
a. Removal of healthy tissue during stripping.
b.Vascular injury to electrosurgical coagulation.
c. Inflammatory reaction.

35. Surgical technique for cystectomy-
1. Mobilisation of ovaries
2. During mobilisation cyst usually drain
on itself from the weakest point.
3. Cyst decompression by suction drainage.
4. Pitressin/vesopressin injection.
5. Cyst wall removed from normal ovarian tissue by traction and
counter traction.
6. Achieve complete haemostasis by suture not by bipolar current.

36. Three step techniques for ovarian endometrioma
1. Laparoscopic drainage
2. GnRh for 3 months
3. Laparoscopic Co2 laser vaporization.

37. The factors which determine the amount of loss of
follicles during surgery is dependent on many factors:
1. Use of electro cautery
2. Amount of inflammation
3. Number of pre existing follicle
4. Endometrioma is bilateral
5. Previous surgery
6. Expertise of surgery

38. Several cross section shows endometrioma had
lower ovarian reserve without surgery then
healthy women.
This decline is progressive in the absence
of any intervention and greater in
magnitude.

39. Ovarian reserve in endometriosis depends on-
a. Bilateral / unilateral disease.
b. Size of cyst
c. Severe adhesion
d. Fibrosis
e. Disease duration
f. Women’s age
g.Recurrence

40. • 30% AMH reduction – unilateral
• 44% AMH reduction – bilateral

41. Surgery ART
Age Young Old
Associated factor
- Male
- Tube
No Yes
Infertility duration Short Long
Ovarian reserve Satisfactory Reduced
Pelvic pain Severe Mild
Ovarian Endometrioma
bilateral
No Yes
Previous surgery No Yes
Adenomyomis No Yes

42. Anti mullerian hormone level in women with endometriosis.
A case-control study.
Object – To compare the Antimullarian hormone (AMH) level in
women with or without endometriosis.
Design – A case control study
Getting – Women’s general hospital, Lint, Austria.
Result – Mean AMH level was significantly lower in the study group
than in the control group (2.75 + 2.0mg/ml vs 3.46 + 2.30mg/ml P0.001)
OMAR SHEBL 2009.

43. Effect of ovarian endometrioma on the number of oocyte retrieved
for in vitro fertilization.
Objective – To evaluate the effects of ovarian endometrioma on the number of oocytes retrieved
for IVF.
Setting – University based tertiary medical center.
Patients – 81 women with unilateral endometrioma who under want first IVF cycle.
Main outcome measures –
The number of antral follicles and the retrieved oocyte in the ovary that contained endometrioma
were compared with those from contralaterd ovary results –Antral follicle count and number of
retrieved oocytes in these women were similar to those with no endometrionma.
Conclusion - The presence of ovarian endometrioma in a controlled ovarian hyper stimulation
cycle for IVF treatment is not associated with reduced number of oocytes retrieved from affected
ovary.
Benny Almog 2010

44. The impact of electrocoagulation on ovarian
reserve after laparoscopic excision of ovarian cyst .
Design-Prospective clinical study on 191 patients.
Objective- Bipolar, Ultrasonic scalpel and Suture.
Result- Significant reduction in ovarian reserve in bipolar.
Chang Zhong Li- 2009

45. Endometriosis patient should be assessed
individually and follow seven guidelines in order
to preserve fertility.

46. 1. Choosing the best surgical techniques.
Still not known which one is most effective.
Surgery can lead to reduction in ovarian reserve
i) Excessive stripping
ii) Disease itself
iii) Cauterization to stop bleeding
iv) Surgery induce inflammation
v) Cystectomy
vi) Bilateral
vii) Large endometriona

47. 2. Avoid unnecessary surgery
- No surgery if size less than 4cm
- No pain.

48. 3. Measure ovarian reserve before surgery.
a) Discussion of risks and benefits of surgery.
b) Allowing the surgery to optimize and individual treatment
modalities.
c) Aggressive nature of surgery should be avoided.
d) Fertility preservation should be offered.

49. 4. Emergency IVF before surgery
1. Older patient > 38yrs
2. Prolong infertility
3. Low AMH

50. 5. Use of GnRh analogues
i) Hypoestrogenic state
ii) Increase natural killer cell activity and diminished
embryotoxic effects of peritoneal fluid
iii) Ovarian parenchyma damage during the surgery seems to
be related to cyst diameter.
GnRh analogue is useful for both before surgery and IVF.

51. 6. Fertility preservation/Cryopreservation
i) Oocyte freezing
ii) Embryo freezing
iii) Ovarian cortical tissue freezing

52. Oocyte freezing
Survival rate 85%
Fertilization rate 75%
Pregnancy rate > 40%
Disadvantage
i) Zona hardening
ii) Chromosomal aneuploidy
iii) Karyotype abnormality
iv) Organ malfunction
v) Damage cytoskeleton

53. Ovarian cortical tissue cryopreservation
- Re implantation of cortical ovarian tissue into the pelvic cavity or
heterotopic site.
- When patient become disease free, the implanted tissue can be used
in IVF and ET procedure.
This method is associated with 25% follicle survival and is most successful
when patient is young.
Ovarian tissue cryopreservation
is still experimental although
pregnancies have been reported.

54. 7.Role of lifestyle changes in infertile patient with endometriosis-
i) Avoid late childhood obesity
ii) Avoid high trans fat
iii) Avoid caffeine
iv) Avoid alcohol

55. ART is a hope of ray for
Infertile patient with low AMH.
Conclusion