The document is a lecture on the treatment of endometriosis-associated infertility according to 2022 ESHRE guidelines. It discusses various treatment options including medical treatment with hormonal therapies, surgery, assisted reproductive technologies (ART), and fertility preservation. Key recommendations include that ovarian suppression should not be used to improve fertility. Surgery and ART may be considered depending on the stage of endometriosis and patient factors. Extensive counseling is recommended when discussing fertility preservation options.

1. 3/15/2022
ABOUBAKR ELNASHAR
You can get this lecture and 500 lecture from:
1.My scientific page on Face book: Aboubakr
Elnashar Lectures.
https://www.facebook.com/groups/2277448840913
51/
2.Slide share web site
3.elnashar53@hotmail.com
4.My clinic: Elthawra St. Mansura
TREATMENT OF
ENDOMETRIOSIS-ASSOCIATED INFERTILITY
ESHRE guidelines 2022
Prof. ABOUBAKR ELNASHAR
Benha university Hospital, Egypt
ABOUBAKRELNASHAR
ABOUBAKRELNASHAR
CONTENTS
I. DIAGNOSIS OF ENDOMETRIOSIS
II. TREATMENT OF ENDOMETRIOSIS-ASSOCIATED PAIN
III. TREATMENT OF ENDOMETRIOSIS-ASSOCIATED
INFERTILITY
IV. IMPACT OF ENDOMETRIOSIS ON PREGNANCY AND PREGNANCY OUTCOME
V. ENDOMETRIOSIS RECURRENCE
VI. ENDOMETRIOSIS AND ADOLESCENCE
VII. ENDOMETRIOSIS AND MENOPAUSE
VIII.EXTRAPELVIC ENDOMETRIOSIS
IX. ASYMPTOMATIC ENDOMETRIOSIS
X. PRIMARY PREVENTION OF ENDOMETRIOSIS
XI. ENDOMETRIOSIS AND CANCER
ABOUBAKRELNASHAR
 Recommendations either ‘‘strong’’ or ‘‘weak” according to the GRADE
approach,
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DIAGNOSIS OF ENDOMETRIOSIS
 Symptoms
 Cyclical & non-cyclical:
 Dysmenorrhea,
 Deep dyspareunia ,
 Infertility
 Dysuria
 Dyschezia
 Painful rectal bleeding or
haematuria,
 shoulder tip pain,
 catamenial pneumothorax,
cyclical cough/haemoptysis/
chest pain, cyclical scar swelling
and pain, fatigue. GPP
ABOUBAKRELNASHAR
3/15/2022
 Diary/questionnaire/app
 No evidence that a symptom reduces the time to diagnosis or
leads to earlier diagnosis
 Potential benefit in
 completing the traditional history
 pain
 Other symptoms. GDG STATEMENT
 Clinical examination, including vaginal examination
 should be considered to identify
 deep nodules or
 endometriomas in patients with suspected endometriosis
 Diagnostic accuracy is low.⊕Strong recommendation
ABOUBAKRELNASHAR
 Investigation
 Biomarkers: not to be used.⊕⊕⊕ Strong recommendation
1. Imaging (US or MRI):
 Should be considered even if the clinical
examination is normal.⊕⊕ Strong recommendation
 Negative finding does not exclude endometriosis,
particularly superficial peritoneal disease ⊕⊕Strong
recommendation
ABOUBAKRELNASHAR
 Justification:
 For endometrioma & DIE: TVS & MRI have a similar
or slightly better specificity & sensitivity than
laparoscopy
 For superficial disease: imaging modalities have
inferior diagnostic value compared to laparoscopy
(Wykes, et al., 2004).
 Dedicated TVS in experienced hands (also MRI)
 can replace laparoscopy
 the gold standard for the diagnosis of
endometrioma & DIE in the pelvis
ABOUBAKRELNASHAR
2. Laparoscopy is considered for the diagnosis &TT in
1. Patients with negative imaging results
2. Empirical TT was unsuccessful or inappropriate GPP
 Endometriotic lesions is confirmed by histology although
negative histology does not entirely rule out the disease GPP
 Justification:
 The benefits of laparoscopy need to be weighed up
against its risks (Bafort, et al., 2020, Byrne, et al., 2018b, Chapron, et
al., 1998).
 Expensive, invasive& associated with morbidity mortality.
 Direct, photographic& histological proof of lesions: an
important psychological factor for women
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 2-step approach
 Can be considered
 endometriosis is suspected
 imaging results are negative
 not trying to conceive
 TVS followed by empirical TT
 oral contraceptive pill or progestogens(Kuznetsov, et
al., 2017).
 If symptoms improve: endometriosis is presumed
the main underlying condition, although other
clinical causes can coexist.
ABOUBAKRELNASHAR
 Women suspected of endometriosis
 Diagnostic laparoscopy and
 Imaging combined with empirical TT
 Can be considered
 No evidence of superiority of either approach:
 Pros & cons should be discussed with the
patient. GDG STATEMENT
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2. 3/15/2022
TREATMENT OF ENDOMETRIOSIS-ASSOCIATED
INFERTILITY
 LINES OF TREATMENT
I. IUI & OS
II. SURGERY
III. IVF
IV. FERTILITY PRESERVATION
 Medical
 Non medical
ABOUBAKRELNASHAR
 Medical treatment
 Ovarian suppression Should not be prescribed to
improve fertility ⊕⊕Strong recommendation
 Justification:
 Based on the results of the Cochrane review, suppression of ovarian
function (by means of danazol, GnRH agonists, progestogens, OCP)
to improve fertility is not effective and should not be offered for this
indication alone
 Pentoxifylline, other anti-inflammatory drugs or
letrozole outside ovulation-induction: should not
prescribed to improve natural pregnancy rates
⊕Strong recommendation
ABOUBAKRELNASHAR
 Justification
 As endometriosis is associated with inflammation.
Pentoxifylline has anti‐inflammatory properties.
 SR show no benefit of pentoxifylline, postoperative
aromatase inhibitor (letrozole), or postoperative
GnRH agonist (triptorelin) to improve pregnancy
rates in women with endometriosis.
ABOUBAKRELNASHAR
 Non-medical management strategies for infertility
 Nutrition, Chinese medicine,
 Electrotherapy, acupuncture
 Physiotherapy, exercise, and psychological
interventions
 No clear evidence of benefit to increase the
chance of pregnancy.
 No recommendation can be made to support
any to increase fertility.
 The potential benefits and harms are unclear
GDG STATEMENT
ABOUBAKRELNASHAR
I. IUI with ovarian stimulation:
 rASRM stage I/II, instead of expectant
management or IUI alone, as it increases PR
⊕Weak recommendation
 could be considered in rASRM stage III/IV with
tubal patency Although the value is uncertain
⊕Weak recommendation
ABOUBAKRELNASHAR
II. SURGERY
 Should be guided by
 Presence or absence of pain symptoms
 Patient age and preferences
 History of previous surgery
 Presence of other infertility factors
 Ovarian reserve
 Estimated Endometriosis Fertility Index (EFI)
GPP
 Women should be counselled of their chances of
becoming pregnant after surgery.
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3/15/2022
ABOUBAKRELNASHAR
 Operative laparoscopy
 For rASRM stage I/II could be offered {improves the
rate of ongoing pregnancy} ⊕⊕Weak recommendation
 For endometrioma-associated infertility May be
considered {may increase their chance of natural
pregnancy}, although no data from comparative
studies exist ⊕ Weak recommendation
 For deep endometriosis: No convincing evidence
exists that it improves fertility
 May represent TT option in symptomatic patients
wishing to conceive ⊕Weak recommendation
ABOUBAKRELNASHAR
 Postoperative hormone suppression
 Should not be prescribed with the sole purpose to
enhance future pregnancy rates ⊕⊕Strong
recommendation
 may be offered for women who cannot attempt to
or decide not to conceive immediately after surgery
{does not negatively impact their fertility and
improves the immediate outcome of surgery for
pain} ⊕⊕ Weak recommendation
ABOUBAKRELNASHAR
III. ART
 Can be performed especially if
1. Tubal function is compromised
2. Male factor infertility
3. Low EFI and/or
4. Other treatments have failed ⊕⊕ Weak recommendation
 To identify patients that may benefit from ART after surgery
 EFI should be used as it is validated,
reproducible and cost-effective.
 Other fertility investigations such as their
partner’s sperm analysis GDG STATEMENT
ABOUBAKRELNASHAR
 Surgery prior ART
 rASRM stage I/II endometriosis: Not recommended as the
potential benefits are unclear ⊕⊕Strong recommendation
 Endometrioma
 Not recommended {no benefit& surgery is likely to have
a negative impact on ovarian reserve}. ⊕⊕Strong
recommendation
 can be considered to improve endometriosis-associated
pain or accessibility of follicles GPP
 Deep endometriosis: should be guided mainly by pain
symptoms& patient preference as its effectiveness on
reproductive outcome is uncertain due to lack of RCT
⊕Strong recommendation
ABOUBAKRELNASHAR
 Protocol
 Both GnRHan & agonist can be offered based on
patients’& physicians’ preferences as no difference
in PR or LBR ⊕ Weak recommendation
 The extended GnRHa is not recommended, as the
benefit is uncertain ⊕Strong recommendation
 Insufficient evidence to recommend prolonged
administration of COC/progestogens as a pre-TT to
ART to increase LPR ⊕ Weak recommendation
 The data are very limited and do not allow to draw any conclusion.
 This does not preclude use of OCP for planning purposes.
ABOUBAKRELNASHAR

3. 3/15/2022
 Oocyte retrieval
 In women with endometrioma, clinicians may use
antibiotic prophylaxis
 Although the risk of ovarian abscess formation
following follicle aspiration is low GPP
 Recurrence rates are not increased compared to
those women not undergoing ART ⊕⊕⊕ Weak
recommendation
ABOUBAKRELNASHAR
IV. Fertility Preservation (FP): oocyte cryopreservation
 In case of extensive ovarian endometriosis,
clinicians should discuss the pros & cons of FP
 The true benefit of FP is unknown ⊕ Strong recommendation
 FP may increase future chances of pregnancy of some
women
 FP is expensive& ±some clinical risks.
 Still many questions remain unanswered
 Cost effectiveness
 Criteria to select those women.
 Strong recommendation for counselling& information
provision.
ABOUBAKRELNASHAR
ABOUBAKRELNASHAR ABOUBAKR ELNASHAR
You can get this lecture and 500 lecture from:
1.My scientific page on Face book: Aboubakr
Elnashar Lectures.
https://www.facebook.com/groups/2277448840913
51/
2.Slide share web site
3.elnashar53@hotmail.com
4.My clinic: Elthawra St. Mansura