Endometriosis is conventionally defined as the presence of
tissue lesions or nodules that are histologically similar to
the endometrium, but are present at sites outside the uterus.It is a chronic, often recurring disease of complex and unclear aetiology. Endometriosis is a highly variable condition in terms of age and mode of presentation, range of symptoms, anatomical sites, response to treatment and likelihood of recurrence.
This document discusses endometriosis and its impact on fertility and IVF outcomes. It provides information on diagnosing and treating endometriosis, including:
- Laparoscopy is the gold standard for diagnosing endometriosis. Surgical excision of endometriomas and deep endometriosis can improve pain and fertility outcomes.
- For subfertility, treatment depends on factors like disease severity, pain levels, and reproductive plans. IVF is an option if conservative treatments fail.
- Studies show endometriosis may reduce ovarian response and increase IVF cancellation rates. However, it does not significantly impact live birth, pregnancy, or miscarriage rates compared to other infertility factors
This document discusses whether surgery improves fertility outcomes for women with endometriosis. It reviews several studies that have looked at IVF success rates and spontaneous pregnancy rates after surgery for mild versus severe endometriosis. The document also presents unpublished data from a study of 261 women who underwent laparoscopic excision for stage III/IV endometriosis, finding a 79.7% spontaneous pregnancy rate. It concludes that while surgery is generally recommended for stage I/II endometriosis, the role of surgery for stage III/IV endometriosis remains controversial in improving fertility outcomes due to a lack of large, prospective studies.
PANEL DISCUSSION ON ENDOMETRIOSIS RELATED INFERTILITY (EVIDENCE BASED)Lifecare Centre
PANEL DISCUSSION ON ENDOMETRIOSIS RELATED INFERTILITY (EVIDENCE BASED)
MODERATOR
DR SHARDA JAIN
DR JYOTI AGARWAL
DR ILA GUPTA
UMA RAI
RAJ BOKARIA
JYOTI AGARWAL
JYOTI BHASKER
RENU CHAWLA
DIPTI NABH
VANDANA GUPTA
This document discusses emerging treatments for endometriosis. It begins by outlining the limitations of current treatments, such as being suppressive rather than curative, interfering with fertility, and having limited effectiveness for certain disease phenotypes. The document then examines the criteria for an ideal endometriosis medication and evaluates several emerging hormonal and non-hormonal treatments. These include gonadotropin-releasing hormone antagonists, selective progesterone receptor modulators, aromatase inhibitors, immunomodulators, and other agents. For many of the treatments, human and animal studies are summarized that demonstrate reductions in pain, lesion size, or other beneficial outcomes for endometriosis.
This document discusses controversies in aesthetic gynecology procedures. It begins by defining aesthetic gynecology as procedures that alter female genital appearance or structure for non-medical reasons. The document then outlines the increasing popularity of these procedures in recent years. It notes both opponents and proponents of these procedures and their differing views on issues like patient autonomy and lack of evidence. The document concludes by summarizing various medical organizations' ethical guidelines, which state that the safety and effectiveness of many aesthetic gynecology procedures have not been established and caution is warranted.
This document discusses new frontiers in the management of endometriosis. It provides background on the history and diagnosis of endometriosis. Pain and infertility are identified as the main clinical features. Diagnosis involves ultrasound, MRI, laparoscopy and the Endometriosis Fertility Index staging system. Current medical treatment options discussed include NSAIDs, estro-progestins, progestins, danazol, and gonadotropin-releasing hormone analogues. Investigational options mentioned are aromatase inhibitors, anti-angiogenic drugs, and immunomodulators. The ideal treatment is described as one that is curative, treats both pain and fertility, and has an acceptable safety profile.
This document discusses endometriosis and its impact on fertility and IVF outcomes. It provides information on diagnosing and treating endometriosis, including:
- Laparoscopy is the gold standard for diagnosing endometriosis. Surgical excision of endometriomas and deep endometriosis can improve pain and fertility outcomes.
- For subfertility, treatment depends on factors like disease severity, pain levels, and reproductive plans. IVF is an option if conservative treatments fail.
- Studies show endometriosis may reduce ovarian response and increase IVF cancellation rates. However, it does not significantly impact live birth, pregnancy, or miscarriage rates compared to other infertility factors
This document discusses whether surgery improves fertility outcomes for women with endometriosis. It reviews several studies that have looked at IVF success rates and spontaneous pregnancy rates after surgery for mild versus severe endometriosis. The document also presents unpublished data from a study of 261 women who underwent laparoscopic excision for stage III/IV endometriosis, finding a 79.7% spontaneous pregnancy rate. It concludes that while surgery is generally recommended for stage I/II endometriosis, the role of surgery for stage III/IV endometriosis remains controversial in improving fertility outcomes due to a lack of large, prospective studies.
PANEL DISCUSSION ON ENDOMETRIOSIS RELATED INFERTILITY (EVIDENCE BASED)Lifecare Centre
PANEL DISCUSSION ON ENDOMETRIOSIS RELATED INFERTILITY (EVIDENCE BASED)
MODERATOR
DR SHARDA JAIN
DR JYOTI AGARWAL
DR ILA GUPTA
UMA RAI
RAJ BOKARIA
JYOTI AGARWAL
JYOTI BHASKER
RENU CHAWLA
DIPTI NABH
VANDANA GUPTA
This document discusses emerging treatments for endometriosis. It begins by outlining the limitations of current treatments, such as being suppressive rather than curative, interfering with fertility, and having limited effectiveness for certain disease phenotypes. The document then examines the criteria for an ideal endometriosis medication and evaluates several emerging hormonal and non-hormonal treatments. These include gonadotropin-releasing hormone antagonists, selective progesterone receptor modulators, aromatase inhibitors, immunomodulators, and other agents. For many of the treatments, human and animal studies are summarized that demonstrate reductions in pain, lesion size, or other beneficial outcomes for endometriosis.
This document discusses controversies in aesthetic gynecology procedures. It begins by defining aesthetic gynecology as procedures that alter female genital appearance or structure for non-medical reasons. The document then outlines the increasing popularity of these procedures in recent years. It notes both opponents and proponents of these procedures and their differing views on issues like patient autonomy and lack of evidence. The document concludes by summarizing various medical organizations' ethical guidelines, which state that the safety and effectiveness of many aesthetic gynecology procedures have not been established and caution is warranted.
This document discusses new frontiers in the management of endometriosis. It provides background on the history and diagnosis of endometriosis. Pain and infertility are identified as the main clinical features. Diagnosis involves ultrasound, MRI, laparoscopy and the Endometriosis Fertility Index staging system. Current medical treatment options discussed include NSAIDs, estro-progestins, progestins, danazol, and gonadotropin-releasing hormone analogues. Investigational options mentioned are aromatase inhibitors, anti-angiogenic drugs, and immunomodulators. The ideal treatment is described as one that is curative, treats both pain and fertility, and has an acceptable safety profile.
Endometriosis An Enigmatic Disease, DR. SHARDA JAIN Dr. Jyoti Agarwal Dr. Jyo...Lifecare Centre
ENDOMETRIOSIS STILL AN ENIGMATIC DISEASE
Endometriosis: The Pain That Keeps on Giving
“Endometriosis remains a riddle wrapped in a mystery inside an enigma”
This document discusses how evidence-based medicine is changing attitudes in gynecologic practice. It provides an example of a randomized controlled trial comparing two ovarian induction protocols for intrauterine insemination. The trial found that using clomiphene citrate along with human menopausal gonadotropin reduced the rate of premature luteinizing hormone surges compared to human menopausal gonadotropin alone, with no significant differences in clinical pregnancy rates. The document outlines how evidence from randomized trials, prognostic models, economic analyses and other studies can inform clinical decision-making and change practices in gynecology.
Dr. Laxmi Shrikhande has had an illustrious career in obstetrics and gynecology. She has held numerous leadership positions including Chairperson for ICOG, national corresponding editor, and founder and president of various medical organizations. She has received several awards for her contributions to women's health. Her career highlights include over 450 guest lectures, 31 national publications, and sensitizing over 200,000 adolescents on health issues. She currently serves as the medical director of Shrikhande Fertility Clinic in Nagpur, Maharashtra.
Uterine fibroids and endometrial polyps are common lesions in the female genital tract, and often they are asymptomatic. However, if the lesions are occupying and distorting the uterine cavity, they may cause symptoms such as abnormal uterine bleeding, subfertility and pregnancy losses. This review will discuss the impact of uterine cavity fibroids and polyps on subfertility and pregnancy losses and whether the removal of these lesions will improve reproductive outcome.
This document discusses heterotopic pregnancy, which is defined as a simultaneous pregnancy where one embryo implants in the uterus and another implants outside the uterus, usually in a fallopian tube. The incidence is about 1 in 30,000 for natural conceptions but higher with ART. Risk factors include ART, damage to the fallopian tubes, and prior tubal surgery. Diagnosis can be challenging as symptoms mimic other conditions, but ultrasound may reveal an adnexal mass or free fluid. Treatment depends on the location and stability of the patient, ranging from medical management to surgery. Outcomes include risk of miscarriage of the intrauterine pregnancy as well as maternal morbidity if not diagnosed and treated promptly.
This document discusses adolescent endometriosis (AE), noting that it is a common condition with many unanswered questions. AE can involve lesions of all stages of severity, from minimal to severe. While some reports have found only early stage lesions in AE, more recent studies show a significant portion have advanced stage disease. AE seems to have a progressive natural course. Risk factors include early menarche, family history, and mullerian anomalies. Common symptoms are pain, which is often resistant to medical therapy, and pelvic masses seen on ultrasound. Laparoscopy is the gold standard for diagnosis but often shows atypical lesions. Treatment involves medications, with surgery as an option for persistent or severe cases. Recurrence is a
Uterus (womb) as an organ is pivotal not only to giving birth, but also to the overall well-being of women and their physical, emotional, and sexual health.
This document provides guidelines for the diagnosis and management of endometriosis. It discusses the symptoms of endometriosis and recommends laparoscopy with biopsy as the gold standard for diagnosis. For treatment of pain, it recommends initially treating empirically with adequate analgesia, hormonal contraceptives, progestagens, or GnRH agonists. It provides details on the use of various hormonal options like combined oral contraceptives, progestins, and aromatase inhibitors to reduce endometriosis-associated pain.
The document discusses unexplained infertility, providing definitions and discussing prevalence, causes, diagnosis, and treatment options. It notes that unexplained infertility affects 10-20% of couples and can cause psychological distress. Potential causes are discussed but many are uncertain and found in fertile couples. Diagnosis involves ruling out known causes through standard investigations. Treatment aims to increase monthly pregnancy rates and options discussed include expectant management, ovulation induction, IUI, IVF, and alternative therapies like letrozole, with success rates provided for each option.
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.
Uterine-Sparing Surgery for Adenomyosis Prof. Aboubakr ElnasharAboubakr Elnashar
This document discusses uterine-sparing surgery for adenomyosis to improve fertility. It describes how adenomyosis can negatively impact fertility and IVF success rates. There are two types of uterine-sparing surgery discussed - complete excision (adenomyomectomy) for localized adenomyosis and partial excision (cytoreductive surgery) for diffuse adenomyosis. The techniques, indications, complications, and outcomes of these surgeries are examined, including improved fertility and pregnancy rates compared to hormonal therapies. However, risks like uterine rupture during subsequent pregnancy must be considered. Overall, the document concludes uterine-sparing surgery is a feasible option for improving fertility in qualified patients with adenomyosis, but it requires
Management Of Endometriosis Related Infertility By Dr. Abayomi Ajayiabayomi ajayi
1) Endometriosis affects 10% of women and can cause infertility in 30-50% of cases. It involves the growth of endometrial tissue outside the uterus and comes in three main types.
2) The exact ways endometriosis causes infertility are unclear but likely involve anatomical distortion, tubal occlusion, reduced oocyte quality, and impaired endometrial receptivity.
3) Treatment options for endometriosis-related infertility include surgery, assisted reproductive technologies (ART) like IUI or IVF, and medical therapies like danazol or GnRH agonists, though medicines alone do not improve pregnancy rates. A comprehensive fertility assessment is needed to determine the best individual approach.
The document discusses how obesity can cause abnormalities in menstrual cycle length, regularity, and amount of bleeding, as well as disorders like oligomenorrhea and amenorrhea, due to changes in hormone levels and increased risk of conditions like PCOS. Menstrual irregularities and heavy menstrual bleeding are more prevalent in obese women. The pathophysiology involves effects of obesity on hormones like leptin, estrogen, insulin, and testosterone that can impact menarche, menopause, and endometrial health.
1. The document discusses emerging treatments for endometriosis, including levonorgestrel-releasing intrauterine devices (LNG-IUD), gonadotropin-releasing hormone antagonists (GnRHan), aromatase inhibitors (AIs), selective estrogen receptor modulators (SERMs), and progesterone antagonists.
2. It finds that LNG-IUD is effective for pain control and reduction in endometriosis lesions. GnRHan provide immediate hormone suppression with fewer side effects than agonists. AIs reduce estrogen levels through multiple pathways and show promise when combined with other drugs, though require further research. SERMs and progesterone antagonists aim to block estrogen and progesterone's
Endometrioma and how it affects IVF outcome : modified procedure with encoura...Mohamed Walaa El Deeb
1) Endometriomas are common in women with endometriosis and infertility, affecting up to 50% of subfertile women. Surgical removal carries risks of reducing ovarian reserve.
2) A meta-analysis found no significant difference in ovarian response or pregnancy rates between surgery vs no treatment prior to IVF. However, large endometriomas over 4cm may interfere with oocyte retrieval.
3) The authors propose a modified aspiration technique for large, recurrent endometriomas as an alternative to repeated surgery. Preliminary results show encouraging pregnancy rates without complications. Larger studies are still needed.
The document discusses a case of a 32-year-old woman presenting with primary infertility of 1.5 years. Ultrasound findings show adenomyosis. Adenomyosis can be associated with infertility, decreased chance of pregnancy, and increased risk of abortion. Treatment options discussed include clomiphene, letrozole, IUI with ovarian stimulation, and IVF. For patients with failed IVF, conservative surgery to treat adenomyosis may improve fertility outcomes, especially for those under age 39. The best treatment approach depends on factors like age, prior treatment failures, and desire for future pregnancies.
Endometriosis an overview by dr. sharda Jain, Dr. Jyoti Agarwal , Dr. Jy...Lifecare Centre
Endometriosis :An Overview
Presented in Endometriosis update in Delhi June (2016) Hotel Leela
EB Guidelines
RCOG: Evidence-based Clinical, 1999
Endometriosis and infertility. ASRM, 2004.
ACOG. Endometriosis in adolescents, 2005.
ESHRE guideline for the diagnosis and treatment of endometriosis, 2005.
Endometriosis and infertility. ASRM, 2006.
Endometriosis: diagnosis and management.
Fertility: Assessment and Treatment for People with Fertility Problems. NICE, 2013.
ESHRE guideline: management of women with endometriosis,2014.
Endometriosis An Enigmatic Disease, DR. SHARDA JAIN Dr. Jyoti Agarwal Dr. Jyo...Lifecare Centre
ENDOMETRIOSIS STILL AN ENIGMATIC DISEASE
Endometriosis: The Pain That Keeps on Giving
“Endometriosis remains a riddle wrapped in a mystery inside an enigma”
This document discusses how evidence-based medicine is changing attitudes in gynecologic practice. It provides an example of a randomized controlled trial comparing two ovarian induction protocols for intrauterine insemination. The trial found that using clomiphene citrate along with human menopausal gonadotropin reduced the rate of premature luteinizing hormone surges compared to human menopausal gonadotropin alone, with no significant differences in clinical pregnancy rates. The document outlines how evidence from randomized trials, prognostic models, economic analyses and other studies can inform clinical decision-making and change practices in gynecology.
Dr. Laxmi Shrikhande has had an illustrious career in obstetrics and gynecology. She has held numerous leadership positions including Chairperson for ICOG, national corresponding editor, and founder and president of various medical organizations. She has received several awards for her contributions to women's health. Her career highlights include over 450 guest lectures, 31 national publications, and sensitizing over 200,000 adolescents on health issues. She currently serves as the medical director of Shrikhande Fertility Clinic in Nagpur, Maharashtra.
Uterine fibroids and endometrial polyps are common lesions in the female genital tract, and often they are asymptomatic. However, if the lesions are occupying and distorting the uterine cavity, they may cause symptoms such as abnormal uterine bleeding, subfertility and pregnancy losses. This review will discuss the impact of uterine cavity fibroids and polyps on subfertility and pregnancy losses and whether the removal of these lesions will improve reproductive outcome.
This document discusses heterotopic pregnancy, which is defined as a simultaneous pregnancy where one embryo implants in the uterus and another implants outside the uterus, usually in a fallopian tube. The incidence is about 1 in 30,000 for natural conceptions but higher with ART. Risk factors include ART, damage to the fallopian tubes, and prior tubal surgery. Diagnosis can be challenging as symptoms mimic other conditions, but ultrasound may reveal an adnexal mass or free fluid. Treatment depends on the location and stability of the patient, ranging from medical management to surgery. Outcomes include risk of miscarriage of the intrauterine pregnancy as well as maternal morbidity if not diagnosed and treated promptly.
This document discusses adolescent endometriosis (AE), noting that it is a common condition with many unanswered questions. AE can involve lesions of all stages of severity, from minimal to severe. While some reports have found only early stage lesions in AE, more recent studies show a significant portion have advanced stage disease. AE seems to have a progressive natural course. Risk factors include early menarche, family history, and mullerian anomalies. Common symptoms are pain, which is often resistant to medical therapy, and pelvic masses seen on ultrasound. Laparoscopy is the gold standard for diagnosis but often shows atypical lesions. Treatment involves medications, with surgery as an option for persistent or severe cases. Recurrence is a
Uterus (womb) as an organ is pivotal not only to giving birth, but also to the overall well-being of women and their physical, emotional, and sexual health.
This document provides guidelines for the diagnosis and management of endometriosis. It discusses the symptoms of endometriosis and recommends laparoscopy with biopsy as the gold standard for diagnosis. For treatment of pain, it recommends initially treating empirically with adequate analgesia, hormonal contraceptives, progestagens, or GnRH agonists. It provides details on the use of various hormonal options like combined oral contraceptives, progestins, and aromatase inhibitors to reduce endometriosis-associated pain.
The document discusses unexplained infertility, providing definitions and discussing prevalence, causes, diagnosis, and treatment options. It notes that unexplained infertility affects 10-20% of couples and can cause psychological distress. Potential causes are discussed but many are uncertain and found in fertile couples. Diagnosis involves ruling out known causes through standard investigations. Treatment aims to increase monthly pregnancy rates and options discussed include expectant management, ovulation induction, IUI, IVF, and alternative therapies like letrozole, with success rates provided for each option.
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.
Uterine-Sparing Surgery for Adenomyosis Prof. Aboubakr ElnasharAboubakr Elnashar
This document discusses uterine-sparing surgery for adenomyosis to improve fertility. It describes how adenomyosis can negatively impact fertility and IVF success rates. There are two types of uterine-sparing surgery discussed - complete excision (adenomyomectomy) for localized adenomyosis and partial excision (cytoreductive surgery) for diffuse adenomyosis. The techniques, indications, complications, and outcomes of these surgeries are examined, including improved fertility and pregnancy rates compared to hormonal therapies. However, risks like uterine rupture during subsequent pregnancy must be considered. Overall, the document concludes uterine-sparing surgery is a feasible option for improving fertility in qualified patients with adenomyosis, but it requires
Management Of Endometriosis Related Infertility By Dr. Abayomi Ajayiabayomi ajayi
1) Endometriosis affects 10% of women and can cause infertility in 30-50% of cases. It involves the growth of endometrial tissue outside the uterus and comes in three main types.
2) The exact ways endometriosis causes infertility are unclear but likely involve anatomical distortion, tubal occlusion, reduced oocyte quality, and impaired endometrial receptivity.
3) Treatment options for endometriosis-related infertility include surgery, assisted reproductive technologies (ART) like IUI or IVF, and medical therapies like danazol or GnRH agonists, though medicines alone do not improve pregnancy rates. A comprehensive fertility assessment is needed to determine the best individual approach.
The document discusses how obesity can cause abnormalities in menstrual cycle length, regularity, and amount of bleeding, as well as disorders like oligomenorrhea and amenorrhea, due to changes in hormone levels and increased risk of conditions like PCOS. Menstrual irregularities and heavy menstrual bleeding are more prevalent in obese women. The pathophysiology involves effects of obesity on hormones like leptin, estrogen, insulin, and testosterone that can impact menarche, menopause, and endometrial health.
1. The document discusses emerging treatments for endometriosis, including levonorgestrel-releasing intrauterine devices (LNG-IUD), gonadotropin-releasing hormone antagonists (GnRHan), aromatase inhibitors (AIs), selective estrogen receptor modulators (SERMs), and progesterone antagonists.
2. It finds that LNG-IUD is effective for pain control and reduction in endometriosis lesions. GnRHan provide immediate hormone suppression with fewer side effects than agonists. AIs reduce estrogen levels through multiple pathways and show promise when combined with other drugs, though require further research. SERMs and progesterone antagonists aim to block estrogen and progesterone's
Endometrioma and how it affects IVF outcome : modified procedure with encoura...Mohamed Walaa El Deeb
1) Endometriomas are common in women with endometriosis and infertility, affecting up to 50% of subfertile women. Surgical removal carries risks of reducing ovarian reserve.
2) A meta-analysis found no significant difference in ovarian response or pregnancy rates between surgery vs no treatment prior to IVF. However, large endometriomas over 4cm may interfere with oocyte retrieval.
3) The authors propose a modified aspiration technique for large, recurrent endometriomas as an alternative to repeated surgery. Preliminary results show encouraging pregnancy rates without complications. Larger studies are still needed.
The document discusses a case of a 32-year-old woman presenting with primary infertility of 1.5 years. Ultrasound findings show adenomyosis. Adenomyosis can be associated with infertility, decreased chance of pregnancy, and increased risk of abortion. Treatment options discussed include clomiphene, letrozole, IUI with ovarian stimulation, and IVF. For patients with failed IVF, conservative surgery to treat adenomyosis may improve fertility outcomes, especially for those under age 39. The best treatment approach depends on factors like age, prior treatment failures, and desire for future pregnancies.
Endometriosis an overview by dr. sharda Jain, Dr. Jyoti Agarwal , Dr. Jy...Lifecare Centre
Endometriosis :An Overview
Presented in Endometriosis update in Delhi June (2016) Hotel Leela
EB Guidelines
RCOG: Evidence-based Clinical, 1999
Endometriosis and infertility. ASRM, 2004.
ACOG. Endometriosis in adolescents, 2005.
ESHRE guideline for the diagnosis and treatment of endometriosis, 2005.
Endometriosis and infertility. ASRM, 2006.
Endometriosis: diagnosis and management.
Fertility: Assessment and Treatment for People with Fertility Problems. NICE, 2013.
ESHRE guideline: management of women with endometriosis,2014.
This document provides biographical information about Dr. Narendra Malhotra, an obstetrician and gynecologist from India. It lists his professional roles and accomplishments, which include being president of FOGSI, dean of ICMU, director of the Ian Donald School of Ultrasound, and editor of several medical books and journals. It also provides contact information for Malhotra Hospitals in Agra, India, where Dr. Malhotra practices and serves as a consultant for IVF procedures in several other cities.
This document discusses endometriosis, including its pathogenesis, medical interventions, and changing treatment paradigms. It presents the case of a 25-year old woman with worsening pelvic pain and notes 80 ongoing clinical trials on the topic. New insights into biomarkers have led to newer medical treatments. While surgery was traditionally prioritized, endometriosis is now viewed primarily as a medical disease, with medical treatment preferred for superficial disease and surgery as back-up. The effectiveness of medical treatments like GnRH agonists and IUDs for pain and improved fertility with GnRH agonists prior to ART are summarized.
WHAT IS AN EVIDENCE-BASED APPROACH? - Jonathan Potter (OECD)OECD CFE
This seminar will focus on how countries can establish a policy framework to enable effective local action using an evidence-based approach, choosing between different measures when resources are scarce. The latest evidence from OECD countries on ‘what works’ and ‘what doesn’t’ will be considered, with participants sharing their own experiences from their perspectives as policy makers, researchers, practitioners and social entrepreneurs.
Clinical reasoning in infertility treatment involves considering biological knowledge, social factors, and evidence-based medicine, but evidence is often insufficient to support diagnostic tests and many treatment modalities. Evaluating evidence for infertility treatments presents challenges including type I and II errors, confounding factors, biases in study selection and data collection, and determining clinical relevance from statistical significance.
Evidence based medicine in management of varicocele 2015Ahmad Motawi
1) Varicocele is the abnormal dilation of the veins within the scrotum that drain blood from the testicles. It is a common cause of male infertility.
2) Treatment options for varicocele include open surgical repair, laparoscopic surgery, and percutaneous embolization or sclerotherapy.
3) Microsurgical repair has a lower recurrence rate compared to open techniques. Meta-analyses show varicocele repair improves semen quality and pregnancy rates for men with a palpable varicocele and abnormal semen parameters.
1. Prognostic models can help predict the chances of conceiving naturally, conceiving with interventions like IUI or IVF, and the chances of live birth from IVF.
2. Key factors in these models include female age, duration of infertility, cause of infertility, ovarian reserve tests, and data from previous treatment cycles.
3. Existing prediction models have been shown to have good discrimination and calibration for outcomes like IUI or IVF success, though individual patient preferences must also be considered in treatment decisions.
Common algorithm of the management of InfertilityRupal Shah
The document outlines Dr. Rupal N Shah's qualifications and experience in reproductive medicine and infertility treatment. It then discusses common algorithms and guidelines for managing infertility, including initial investigations, treatment options based on factors like age and ovarian reserve, and when to pursue assisted reproductive technologies like IUI or IVF. The goal is to present practical concepts and best clinical management options based on local perspectives.
Best Clinical Practice Guidelines Ever Produced on Management of EndometriosisLifecare Centre
This document provides guidelines for the management of endometriosis. It addresses key questions regarding symptoms, diagnosis, treatment of pain, and prevention. Some main points covered include:
- Common symptoms associated with endometriosis include dysmenorrhea, pelvic pain, and infertility.
- Laparoscopy with histological examination is the gold standard for diagnosis but can have a delay of 4-10 years.
- Hormonal therapies, analgesics, and surgery are effective treatments for painful symptoms. For surgery, laparoscopy is preferred over laparotomy when possible.
- Secondary prevention with hormonal contraceptives after surgery may help reduce recurrence of disease and pain.
Optimizing Embryo Transfer in IVF Cyclesemubilisim
1. Embryo transfer is the rate-limiting step in IVF and successful embryo transfer depends on uterine receptivity, embryo quality, and the transfer procedure itself.
2. Factors that can negatively impact embryo transfer include disruption of the endometrium, induction of uterine contractions, deposition of embryos in a suboptimal location, and damage to embryos during the process. Difficult transfers are associated with lower pregnancy and implantation rates.
3. Ultrasound guidance during embryo transfer can help reduce difficult transfers, detect if the catheter is properly loaded in the uterine cavity, and position embryos more accurately. Operator experience also impacts success, with trainees achieving comparable results to experienced staff after 50 or more transfers.
how to investigate infertile couples? there are endless number of tests: How evidence based diagnosis would help us in this issue? this talk try to answer such questions?
EVIDENCE BASED PRACTICAL TIPS FOR LUTEAL PHASE SUPPORT BY DR SHASHWAT JANIDR SHASHWAT JANI
This document provides evidence-based practical tips for luteal phase support. It summarizes various diagnostic criteria and treatments for luteal phase deficiency, including progesterone, hCG, and estrogen. While no single diagnostic test is definitive, vaginal progesterone is widely considered the most effective treatment due to its direct delivery to the endometrium. Progesterone supplementation is recommended over hCG to prevent ovarian hyperstimulation syndrome.
Optimizing male infertility treatment in ART- Dr Parul Katiyar, Max Hospitals...Dr Parul Katiyar
Male factor itself is responsible for infertility in approx 30-40% couples and contributes to infertility in another approx 20%. In many men having normal sperm parameters on semenogrom,
sperms do not function in a manner necessary for fertility and can still cause infertility. This often goes undetected unless specifically sought for. This presentation presents a clinical approach to male factor infertility, specifically related to functional aspects of male fertility.
This document discusses evidence-based infertility treatment and includes the following key points:
- It introduces evidence-based medicine (EBM) and describes how clinical practice is transitioning from experience-oriented to evidence-based.
- It provides examples of models for creating medical evidence, including randomized controlled trials (RCTs) and systematic reviews. An RCT studying a novel gonadotropin protocol is summarized.
- Economic evaluations are discussed as a model, using Markov modeling to compare costs and outcomes of fertility drug options.
- The concept of prognosis modeling to estimate natural conception chances and IVF success is explained.
- In closing, it briefly touches on other topics like using cabergoline
Doctors aim to provide their infertile couples with the best care. This can only be done if we follow evidence from clinical trials and accepting patient preferences
This document discusses the importance of evidence-based fertility practice. It provides examples of how evidence-based medicine involves asking answerable clinical questions, acquiring the best evidence to answer those questions, and appraising the validity and applicability of the evidence. The document gives examples of evaluating studies on using metformin for PCOS and triggering ovulation with HCG. It emphasizes integrating the best available evidence with clinical expertise and patient values and preferences.
Endometriosis is a condition where endometrial tissue grows outside the uterus, often resulting in pelvic pain and infertility. Key points:
- It is most common in women of reproductive age and is characterized by dysfunctional uterine tissue implants in the pelvis that cause pain, especially during periods.
- Diagnosis requires laparoscopy to visualize the implants. Treatment depends on severity and reproductive plans, and may include expectant care, hormonal therapies like oral contraceptives to induce pseudopregnancy, or surgery to remove implants and adhesions.
- Hormonal therapies aim to suppress menstruation and the ectopic endometrial tissue through continuous combination estrogen-progestin pills,
Endometrial cancer in a woman undergoing hysteroscopy for recurrent ivf failurecare women scentre
An unsuspected endometrial cancer was found in a 38-year-old woman undergoing hysteroscopy due to repeated failures of in vitro fertilization. The hysteroscopy revealed a small polyp, which was biopsied and found to be endometrial atypia. Further testing showed it was actually endometrial cancer. This case highlights that endometrial cancer can potentially be found in young women with recurrent IVF failure undergoing hysteroscopy. It also raises questions about whether undetected cancers could impact fertility treatment outcomes.
Adenomyosis, is a defined mass of cells within the uterine wall, is characterized as ectopic endometrial tissue within the myometrium in the uterus.
In adenomyosis, a series of immune responses is activated, including changes in both cellular and humoral immunity.
To know related details refer doctors answer --> https://www.icliniq.com/qa/adenomyosis/can-i-conceive-with-adenomyosis
This document discusses the management of infertility in women with endometriosis. It covers topics such as the relationship between endometriosis and infertility, guidelines for treatment, the pathophysiology of endometriosis-related infertility, diagnosing endometriosis, medical and surgical treatment options, assisted reproduction techniques for endometriosis patients, and specific considerations for deep endometriosis, endometriomas, and unexplained infertility. Treatment aims to relieve symptoms, remove or destroy endometrial lesions, and potentially improve fertility outcomes through methods like laparoscopic surgery, hormonal therapies, IUI, and IVF. However, the evidence on most effective approaches is still limited.
This document provides an overview of endometriosis, including its definition, pathology, clinical diagnosis, differential diagnosis, relationship to endometrial cancer and menopause, etiologies and theories, and treatment options. Key points include that endometriosis is the growth of endometrial tissue outside the uterus, which can cause pelvic pain and infertility. Diagnosis involves physical exam and laparoscopy with biopsy. Treatment involves medications like danazol or GnRH agonists to suppress hormones, or surgery to remove endometrial lesions and adhesions. Recurrence is common without continued treatment.
International Journal of Pharmaceutical Science Invention (IJPSI) inventionjournals
International Journal of Pharmaceutical Science Invention (IJPSI) is an international journal intended for professionals and researchers in all fields of Pahrmaceutical Science. IJPSI publishes research articles and reviews within the whole field Pharmacy and Pharmaceutical Science, new teaching methods, assessment, validation and the impact of new technologies and it will continue to provide information on the latest trends and developments in this ever-expanding subject. The publications of papers are selected through double peer reviewed to ensure originality, relevance, and readability. The articles published in our journal can be accessed online
This document provides an overview of basic infertility investigations. It defines primary and secondary infertility and discusses the most common causes of infertility including female factors like ovulation disorders, tubal abnormalities, and uterine issues as well as male factors. It outlines the initial tests that should be performed on both partners to investigate infertility including testing for ovulation, evaluating male factor issues, and assessing tubal patency. Physical exams, histories, and occasionally laparoscopy/hysteroscopy are important initial steps in the evaluation process. The goal of initial investigations is to identify treatable causes of infertility for the couple.
May occur very early on during the attachment or migration stages (No objective evidence e.g. –ve hCG)
May also occur at a later stage (+ve hCG) but process becomes disrupted
Definition: Refers to the failure of the embryo to reach a stage when an intrauterine gestational sac is recognized by ultrasonography.
Implantation failure can apply to patients undergoing ART and patients trying to conceive without any fertility treatment.
It is a separate entity from RPL
Orvieto et al - 3 failed IVF-ET cycles with good quality embryos transferred .
Zeyneloglu et al. - 3 unsuccessful IVF specifically with two embryos of high quality
Simon and Laufer - embryo & endometrium can both play an active role in RIF
Coughlan et al. suggest a more complete working definition taking into account maternal age, number of embryos transferred, and number of cycles completed.
They define RIF as the failure of clinical pregnancy after 4 good quality embryo transfers, with at least three fresh or frozen IVF cycles, and in women under the age of 40
RIF is a complex problem with a wide variety of etiologies / mechanisms/ treatment options.
Recommendations vary depending on the source of their problem. Perhaps the best and yet most complex answer is personalized medicine, a personal approach to each patient depending on her unique set of characteristics.
It would help to establish a set of standardized tests to use, in order to do a preliminary evaluation on each patient, which would then hopefully direct the approach of treatment for each individual couple.
This can be implemented when we have well designed studies that will help us to establish new protocols.
Diagnosis and classification of tubal factor infertilitySanjay Makwana
This document discusses tubal factor infertility (TFI), including causes such as damage from injury or pelvic inflammatory disease. It evaluates various diagnostic tests for TFI like hysterosalpingography (HSG), laparoscopy, and chlamydial antibody testing. Treatment options discussed include expectant management, antibiotics, tubal surgery like cannulation or anastomosis, and IVF. The evidence for different approaches is limited, with no randomized controlled trials directly comparing treatments. The conclusion is that IVF is generally the best treatment for older patients or more severe TFI, while surgery may be considered for milder cases or proximal tubal obstruction.
Endometrial Receptivity in eutopic endometrium in endometriosisMediana Sutopo L
This document summarizes evidence that endometrial receptivity is not affected in patients with endometriosis. Several studies using IVF cycles and egg donation programs found no differences in implantation rates between endometriosis patients and healthy women. Additionally, an analysis of 238 endometrial receptivity genes using the endometrial receptivity analysis tool found no differences in gene expression profiles between endometriosis stages and healthy controls. The data indicates that endometrial receptivity is similar in women with and without endometriosis and is independent of the stage of endometriosis. Any effects of endometriosis on fertility outcomes appear to be related to oocyte and embryo quality rather than endometrial factors.
When more is not better: The 10 ‘Don’ts’ in Endometriosis ManagementAhmed Al Amely
This document outlines 10 recommendations ("don'ts") for the management of endometriosis:
1) Do not suggest laparoscopy for superficial peritoneal endometriosis in infertile women without pain symptoms.
2) Do not recommend controlled ovarian stimulation and IUI for endometriosis-related infertility at any stage.
3) Do not remove small ovarian endometriomas solely to improve IVF success in infertile patients.
4) Do not remove uncomplicated deep lesions in asymptomatic women or those where medical treatment is effective.
5) Do not systematically request additional diagnostic tests for known non-subocclusive colorectal endometriosis responding to treatment.
Endometriosis is a disease where endometrial tissue grows outside the uterus, most commonly on the ovaries, fallopian tubes, and peritoneum. It typically affects women during their reproductive years and some of the main symptoms include painful periods, pain with intercourse, and infertility. Diagnosis involves a combination of clinical examination, imaging like ultrasound, and laparoscopy which remains the gold standard for direct visualization and biopsy of suspicious lesions. Common signs seen at laparoscopy include powder burn-like black or blue lesions on the pelvic organs and peritoneum.
Unexplained infertility refers to the inability to conceive after one year despite routine investigations showing no abnormalities. While the causes are uncertain, treatments aim to increase monthly pregnancy rates and include expectant management, clomiphene citrate, gonadotropins, IUI, IVF, and lifestyle changes. Couples with unexplained infertility have higher risks of obstetric complications and should follow a progressive treatment plan based on factors like duration of infertility and age.
Unexplained infertility refers to the inability to conceive after one year despite routine investigations showing no abnormalities. While the causes are uncertain, treatments aim to increase monthly pregnancy rates and include expectant management, clomiphene citrate, gonadotropins, IUI, IVF, and lifestyle changes. Couples with unexplained infertility have higher risks of obstetric complications and should follow a progressive treatment plan based on factors like duration of infertility and age.
As an intern doctor in Gyne department , this presentation outlines the steps of assessment of an infertile couple including history taking , examinations and relevant investigations and imagings .
1) Laparoscopic ablation of minimal or mild endometriosis in women with subfertility aims to increase pregnancy rates but evidence from randomized trials is limited and inconclusive.
2) Two randomized trials found slightly higher pregnancy rates with ablation but the number needed to treat was high at 8 women to achieve one additional pregnancy.
3) A prospective cohort study found no significant difference in fecundity rates between women with minimal/mild endometriosis and unexplained infertility.
Endometriosis in the peri menopause/ post menopauseArunSharma10
Post menopausal endometriosis
Endometriosis during menopause
Endometriosis in menopause
Endometriosis after menopause
Endometriosis
Endometriosis and cancer
Is endometriosis a problem of reproductive years only?
Explanation for endometriosis after menopause
Prevalence of endometriosis
Coelomic metaplasia theory
Estrogen threshold theory
HRT and post menopausal endometriosis
Tamoxifen & postmenopausal endometriosis
Laparoscopy is useful for diagnosing various gynecologic disorders that cause chronic pelvic pain, including endometriosis, adhesions, ovarian cysts, and pelvic inflammatory disease. It allows for direct visualization of the pelvic organs and structures. While laparoscopy may not find a cause in some cases, abnormalities are detected through laparoscopy in approximately 60% of patients who have undergone other diagnostic evaluations. Laparoscopy is also used therapeutically to treat conditions like ectopic pregnancies and tubo-ovarian abscesses.
Similar to Evidence linked treatment for endometriosis-associated infertility (20)
Movement disorders: A complication of chronic hyperglycemia? A case reportApollo Hospitals
A 77-year-old man presented with bilateral choreic movements that had developed over the past month. He had a history of poorly controlled type 2 diabetes. At admission, he was found to have severe hyperglycemia without ketosis. A CT scan showed hyperdensity in the putamen and lenticular nucleus. Treatment with insulin, haloperidol, and glycemic control led to regression of the choreic movements within 4 days. Chorea secondary to nonketotic hyperglycemia is a rare complication of uncontrolled diabetes that is usually reversible with normalization of blood glucose levels and neuroleptic treatment. The pathophysiology is thought to involve metabolic disturbances from hyperglycemia impairing neurotransmission in basal ganglia structures and
Malignant Mixed Mullerian Tumor – Case Reports and Review ArticleApollo Hospitals
Malignant mixed mullerian tumors are very rare genital tumors. They are biphasic neoplasms composed of an admixture of malignant epithelial and mesenchymal elements. In descending order of frequency they originate in the uterus, ovaries, fallopian tubes, cervix and vagina. Also they arise denovo from peritoneum. They are highly aggressive and tend to occur in postmenopausal low parity women. Because of rarity, there is as such no treatment guidelines available. Multimodality treatment in the form of radical surgery followed by adjuvant chemotherapy or radiotherapy or combined chemoradiation gives a better prognosis & outcome. Two case reports of such tumors, one from ovary and other from penitoneum are presented along with the review of literature.
Intra-Fetal Laser Ablation of Umbilical Vessels in Acardiac Twin with Success...Apollo Hospitals
This case report describes the successful treatment of an acardiac twin (TRAP sequence) via intra-fetal laser ablation of the umbilical vessels. The patient was a 26 year old pregnant woman at 18 weeks gestation with twins, one normal (Twin A) and one acardiac (Twin B). By 26 weeks, Twin A showed signs of cardiac failure so laser ablation was performed to interrupt blood flow from Twin B to A. This minimally invasive procedure used an Nd: YAG laser to coagulate the vessels under ultrasound guidance. The pregnancy continued successfully, with Twin A delivered via c-section at 35 weeks in good condition. This report demonstrates that intra-fetal laser ablation can safely
Improved Patient Satisfaction At Apollo – A Case StudyApollo Hospitals
1) Indraprastha Apollo Hospital utilized patient satisfaction surveys called Voice of Customer (VOC) tools to identify ways to improve various hospital departments and services.
2) Factors that contributed to an increasing trend in VOC scores over 1.5 years included leadership commitment to quality improvement, improved efficiency, superior clinical care, soft skills enhancement for staff, and improved patient information and complaint resolution.
3) Through consistent efforts such as staff training, improved processes, and addressing issues identified in VOC surveys, Apollo Hospitals achieved higher than target patient satisfaction scores, creating loyal patients with memorable hospital experiences.
Breast Cancer in Young Women and its Impact on Reproductive FunctionApollo Hospitals
Breast cancer is the most common cancer in women in developed countries. Chemotherapy for breast cancer is likely to negatively impact on reproductive function. We review current treatment; effects on reproductive function; breastfeeding and management of menopausal symptoms following breast cancer.
Turner syndrome (gonadal dysgenesis) is one of the most common chromosomal abnormalities occuring 1 in 2500 to 1 in 3000 live-born girls. It is an important cause of short stature in girls and primary amenorrhea in young women that is usually caused by loss of part or all of an X chromosome. This review briefly summarises the current knowledge about the syndrome and the management strategies.
Due to pregnancy thyroid economy is affected with changes in iodine metabolism, TBG and development of maternal goiter. The incidence of hypothyroidism in pregnancy is quite common with autoimmune hypothyroidism being the most important cause. Overt as well as subclinical hypothyroidism has a varied impact on maternal and neonatal outcome. After multiple studies also, routine screening in pregnancy for hypothyroidism can still not be recommended. Management mainly comprises of dosage adjustments as soon as pregnancy is diagnosed based on results of thyroid function tests. The aim should be to keep FT4 at the upper end of normal range.
Growth Hormone Deficiency (GHD) can persist from childhood or be newly acquired. Confirmation through stimulation testing is usually required unless there is a proven genetic/structural lesion persistent from childhood. Growth harmone (GH) therapy offers benefits in body composition, exercise capacity, skeletal integrity, and quality of life measures and is most likely to benefit those patients who have more severe GHD. The risks of GH treatment are low. GH dosing regimens should be individualized. The final decision to treat adults with GHD requires thoughtful clinical judgment with a careful evaluation of the benefits and risks specific to the individual.
Advances in the management of thalassemia have led to marked improvements in the life span and quality of life of children and young adults. This poses new challenges for the treating physicians. There is now increasing recognition that thalassemics have impaired bone health which is multifactorial in etiology. This paper aims to highlight the factors that predispose these patients to osteoporosis and suggests measures to minimise the impact on bone health.
A 34-year-old woman presented with accidental ingestion of mercury that was used in her household to preserve grains. She experienced abdominal radiopaque shadows on X-ray that cleared after two days. Mercury poisoning can result from inhalation, ingestion, or absorption and affects the neurological, gastrointestinal, and renal systems. Diagnosis involves determining exposure history and elevated mercury levels in blood and urine. Supportive treatment includes removal of contaminated materials, irrigation, activated charcoal, chelation agents, and hemodialysis in severe cases.
Laparoscopic Excision of Foregut Duplication Cyst of StomachApollo Hospitals
Retroperitoneal gastric duplication cysts lined by ciliated columnar epithelium are extremely rare lesions and its presentation during adulthood is a diagnostic challenge for treating clinicians. This entity often resembles cystic pancreatic neoplasm, retroperitoneal cystic lesions and sometimes as an adrenal cystic neoplasm. Correct diagnosis on the basis of radiological investigation is difficult and histopathologic analysis. We report a case of gastric duplication cyst in a 16year old girl that mimicked as a retroperitoneal /pancreatic /adrenal cystic lesion and was successfully managed by laparoscopy.
Occupational Blood Borne Infections: Prevention is Better than CureApollo Hospitals
Viral infections like HIV, hepatitis Band C virus pose a big risk to the contacts of individuals with high risk behaviour as well as to the attending health care workers. Blood, semen, vaginal and other potentially infectious materials can transmit the infection to the susceptible contacts. Universal precautions should be strictly implemented during clinical examination, laboratory work and surgical procedures to prevent transmission to the health care providers. Health care workers should receive vaccination for hepatitis B infection. An inadvertent exposure should be managed with proper first aid and infectivity of the source and severity of exposure should be assessed. Severity of exposure is based on the nature and area of exposed surface, mode of injury and volume of infective material. Post-exposure prophylaxis (PEP) should be started as soon as possible after a proper counseling about the effectiveness of post-exposure prophylaxis, side effects and risk of carrying the infection to his familial contacts and its prevention.
Evaluation of Red Cell Hemolysis in Packed Red Cells During Processing and St...Apollo Hospitals
Storage of red cells causes a progressive increase in hemolysis. Inspite of the use of additive solutions for storage and filters for leucoreduction some amount of hemolysis is still inevitable. The extent of hemolysis however should not exceed the permissible threshold for hemolysis even on the 42nd day of storage.
Efficacy and safety of dexamethasone cyclophosphamide pulse therapy in the tr...Apollo Hospitals
Various drugs used to treat pemphigus can cause remission, but none can provide permanent remission as relapses are common. With the introduction of DCP in pemphigus in 1984, patients started being in prolonged/permanent remission. This study was done to compare the efficacy of DCP to oral corticosteroids and cyclophosphamide in combination.
Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS)Apollo Hospitals
This case report describes a 24-year-old man who presented with fever, rash, abdominal pain, and vomiting. He had been taking carbamazepine for seizures. His symptoms and lab results met the criteria for Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS), also known as drug hypersensitivity syndrome. DRESS is caused by certain drugs and is characterized by fever, rash, eosinophilia, and involvement of internal organs like the liver or lungs. Carbamazepine was withdrawn and steroids were started, leading to improvement. The report reviews the characteristics, diagnosis, and treatment of DRESS, noting it is important to identify the causative drug and avoid re-
Difficult Laparoscopic Cholecystectomy-When and Where is the Need to Convert?Apollo Hospitals
Laparoscopic cholecystectomy has now become the treatment of choice for the gall bladder stone. With increasing experience, surgeon has started to take more difficult cases which were considered relative contra indications for laparoscopic removal of gall bladder few years back.
We conducted this study at our hospital and included all laparoscopic cholecystectomy done from May'08 to January'10. Total time taken in surgery, conversion rate and complication rate were analysed. Factors making laparoscopic cholecystectomy difficult were also analysed. We defined difficult laparoscopic cholecystectomy when we found -dense fibrotic adhesions in and around Callot's triangle, gangrenous gall bladder, empyma, large stone impacted at gall bladder neck, contracted gall bladder, Mirrizi's syndrome, h/o biliary pancreatitis, CBD stones, acute cholecystitis of <72 hrs duration.
Out of 206 cases done during above period, 56 cases were considered difficult. Only two cases were converted to open.
With growing experience and technical advancement surgery can be completed in most of the difficult cases. This is important because recently it is shown in literature that laparoscopic cholecystectomy is associated with less morbidity than open method irrespective of duration of the surgery.
Deep vein thrombosis prophylaxis in a tertiary care center: An observational ...Apollo Hospitals
Deep vein thrombosis (DVT) is a major health problem with substantial mortality and morbidity in medically ill patients. Prevention of DVT by risk factor stratification and subsequent antithrombotic prophylaxis in moderate- to severe-risk category patients is the most rational means of reducing morbidity and mortality.
This document describes two cases of unusual manifestations of dengue fever. Case 1 is a 40-year-old man who presented with fever, headache, body aches, and a rash who developed hepatitis, thrombocytopenia, and respiratory distress from dengue hemorrhagic fever. Case 2 is a 24-year-old man who presented with fever and was found to have an intraocular hemorrhage, retinal detachment, ARDS, myocarditis, and hepatitis, also from dengue hemorrhagic fever. The document then reviews atypical neurological and gastrointestinal manifestations that have been reported with dengue infection.
A 71-year-old male presented in ENT department with dysphagia for last three weeks, more to solids than liquids. He had a hard bony bulge in the posterior pharyngeal wall on palpation and hence was referred for an Orthopaedic opinion. Lateral radiograph of the cervical spine revealed diffuse ossification of the anterior longitudinal ligament. This ossification was extending almost half the width of the cervical body from its anterior body at C1 and C2 vertebra level.
This document discusses pediatric liver transplantation. It begins by stating that pediatric liver transplantation is now an established treatment for end-stage liver failure from various causes, with excellent results due to improved immunosuppressive regimens, surgical techniques, and intensive care. It then discusses the historical development of liver transplantation, including the first attempts in the 1960s and key innovations like cyclosporine in the 1980s. The most common indications for pediatric liver transplantation are discussed as extrahepatic biliary atresia and acute liver failure. The document provides an overview of the pre-transplant evaluation process and post-transplant medical management and immunosuppression. It notes that living-related transplantation has helped address the shortage of donor l
Selective alpha1 blockers are Prazosin, Terazosin, Doxazosin, Tamsulosin and Silodosin majorly used to treat BPH, also hypertension, PTSD, Raynaud's phenomenon, CHF
Can Traditional Chinese Medicine Treat Blocked Fallopian Tubes.pptxFFragrant
There are many traditional Chinese medicine therapies to treat blocked fallopian tubes. And herbal medicine Fuyan Pill is one of the more effective choices.
This presentation gives information on the pharmacology of Prostaglandins, Thromboxanes and Leukotrienes i.e. Eicosanoids. Eicosanoids are signaling molecules derived from polyunsaturated fatty acids like arachidonic acid. They are involved in complex control over inflammation, immunity, and the central nervous system. Eicosanoids are synthesized through the enzymatic oxidation of fatty acids by cyclooxygenase and lipoxygenase enzymes. They have short half-lives and act locally through autocrine and paracrine signaling.
PGx Analysis in VarSeq: A User’s PerspectiveGolden Helix
Since our release of the PGx capabilities in VarSeq, we’ve had a few months to gather some insights from various use cases. Some users approach PGx workflows by means of array genotyping or what seems to be a growing trend of adding the star allele calling to the existing NGS pipeline for whole genome data. Luckily, both approaches are supported with the VarSeq software platform. The genotyping method being used will also dictate what the scope of the tertiary analysis will be. For example, are your PGx reports a standalone pipeline or would your lab’s goal be to handle a dual-purpose workflow and report on PGx + Diagnostic findings.
The purpose of this webcast is to:
Discuss and demonstrate the approaches with array and NGS genotyping methods for star allele calling to prep for downstream analysis.
Following genotyping, explore alternative tertiary workflow concepts in VarSeq to handle PGx reporting.
Moreover, we will include insights users will need to consider when validating their PGx workflow for all possible star alleles and options you have for automating your PGx analysis for large number of samples. Please join us for a session dedicated to the application of star allele genotyping and subsequent PGx workflows in our VarSeq software.
Nano-gold for Cancer Therapy chemistry investigatory projectSIVAVINAYAKPK
chemistry investigatory project
The development of nanogold-based cancer therapy could revolutionize oncology by providing a more targeted, less invasive treatment option. This project contributes to the growing body of research aimed at harnessing nanotechnology for medical applications, paving the way for future clinical trials and potential commercial applications.
Cancer remains one of the leading causes of death worldwide, prompting the need for innovative treatment methods. Nanotechnology offers promising new approaches, including the use of gold nanoparticles (nanogold) for targeted cancer therapy. Nanogold particles possess unique physical and chemical properties that make them suitable for drug delivery, imaging, and photothermal therapy.
Storyboard on Acne-Innovative Learning-M. pharm. (2nd sem.) CosmeticsMuskanShingari
Acne is a common skin condition that occurs when hair follicles become clogged with oil and dead skin cells. It typically manifests as pimples, blackheads, or whiteheads, often on the face, chest, shoulders, or back. Acne can range from mild to severe and may cause emotional distress and scarring in some cases.
**Causes:**
1. **Excess Oil Production:** Hormonal changes during adolescence or certain times in adulthood can increase sebum (oil) production, leading to clogged pores.
2. **Clogged Pores:** When dead skin cells and oil block hair follicles, bacteria (usually Propionibacterium acnes) can thrive, causing inflammation and acne lesions.
3. **Hormonal Factors:** Fluctuations in hormone levels, such as during puberty, menstrual cycles, pregnancy, or certain medical conditions, can contribute to acne.
4. **Genetics:** A family history of acne can increase the likelihood of developing the condition.
**Types of Acne:**
- **Whiteheads:** Closed plugged pores.
- **Blackheads:** Open plugged pores with a dark surface.
- **Papules:** Small red, tender bumps.
- **Pustules:** Pimples with pus at their tips.
- **Nodules:** Large, solid, painful lumps beneath the surface.
- **Cysts:** Painful, pus-filled lumps beneath the surface that can cause scarring.
**Treatment:**
Treatment depends on the severity and type of acne but may include:
- **Topical Treatments:** Such as benzoyl peroxide, salicylic acid, or retinoids to reduce bacteria and unclog pores.
- **Oral Medications:** Antibiotics or oral contraceptives for hormonal acne.
- **Procedures:** Such as chemical peels, extraction of comedones, or light therapy for more severe cases.
**Prevention and Management:**
- **Cleanse:** Regularly wash skin with a gentle cleanser.
- **Moisturize:** Use non-comedogenic moisturizers to keep skin hydrated without clogging pores.
- **Avoid Irritants:** Such as harsh cosmetics or excessive scrubbing.
- **Sun Protection:** Use sunscreen to prevent exacerbation of acne scars and inflammation.
Acne treatment can take time, and consistency in skincare routines and treatments is crucial. Consulting a dermatologist can help tailor a treatment plan that suits individual needs and reduces the risk of scarring or long-term skin damage.
Fexofenadine is sold under the brand name Allegra.
It is a selective peripheral H1 blocker. It is classified as a second-generation antihistamine because it is less able to pass the blood–brain barrier and causes lesser sedation, as compared to first-generation antihistamines.
It is on the World Health Organization's List of Essential Medicines. Fexofenadine has been manufactured in generic form since 2011.
The biomechanics of running involves the study of the mechanical principles underlying running movements. It includes the analysis of the running gait cycle, which consists of the stance phase (foot contact to push-off) and the swing phase (foot lift-off to next contact). Key aspects include kinematics (joint angles and movements, stride length and frequency) and kinetics (forces involved in running, including ground reaction and muscle forces). Understanding these factors helps in improving running performance, optimizing technique, and preventing injuries.
Applications of NMR in Protein Structure Prediction.pptxAnagha R Anil
This presentation explores the pivotal role of Nuclear Magnetic Resonance (NMR) spectroscopy in predicting protein structures. It delves into the methodologies, advancements, and applications of NMR in determining the three-dimensional configurations of proteins, which is crucial for understanding their function and interactions.
Milan J. Anadkat, MD, and Dale V. Reisner discuss generalized pustular psoriasis in this CME activity titled "Supporting Patient-Centered Care in Generalized Pustular Psoriasis: Communications Strategies to Improve Shared Decision-Making." For the full presentation, please visit us at www.peervoice.com/HUM870.
The Children are very vulnerable to get affected with respiratory disease.
In our country, the respiratory Disease conditions are consider as major cause for mortality and Morbidity in Child.
3. Treatment for endometriosis-associated infertility
after donor as well as husband’s sperm insemination in
women with minimal to mild endometriosis when
compared to these with a normal pelvis have been shown
in various others studies.7
Reduced pregnancy rates have been reported in women
with endometriosis undergoing In Vitro Fertilization
(IVF). Barnhart et al (2002) in a meta-analysis of 22 published studies concluded that pregnancy rate is almost
half in these women when compared with tubal factor
infertility.8
Donor oocytes from women with endometriosis have
been reported to yield lower pregnancy rates that those
from the healthy donors.9
Review Article
185
- Increased progesterone concentration in follicular
fluid
- Increased concentration of IL-6, IL-Ib, IL-8
- Increased expression of the TNFa in the cultured
granulosa cells
- Lower levels of cortisol
- Lower concentrations of IGFBP-I
- Lower levels of HCG receptors in granulosa cells
- Increased rate of apoptosis in granulosa cells mediated by elevated concentrations of soluble Fas ligand
in serum and peritoneal fluid.
EFFECT ON ENDOMETRIAL RECEPTIVITY
PATHOGENIC MECHANISM IN ENDOMETRIOSIS-ASSOCIATED INFERTILITY
The exact cause of infertility remains elusive and controversial. The possible mechanisms may be anatomical
disruption or physiological-hormonal, chemical or immunological alterations. All aspects of reproductive
process e oocyte development, ovulation process, fertilization, embryo quality and implantation have been reported to
be adversely affected by endometriosis.10 Several cytokines, interleukins, oxidative stress markers, cellular adhesion markers and immunomodulators are being
investigated to decode the mysterious role of endometriosis
in causing infertility. The current literature suggests a multifactorial mechanism.
POSSIBLE CAUSES OF REDUCED FERTILITY
IN WOMEN WITH ENDOMETRIOSIS
(i) Tubal adhesions
(ii) Impaired gamete interaction
(iii) Reduced functional ovarian tissue (ovarian reserve) by
endometriosis or surgery
(iv) Poor quality of oocytes
(v) Impaired fertilization
(vi) Lower quality embryos with a reduced ability to
implant
(vii) Impaired implantation
POOR QUALITY OF OOCYTES
Several investigators have reported altered follicular environment in women with endometriosis and linked this to
poor quality oocytes. Few of these reported markers are11,12:
Pellicer et al (2001)9 published a cross-over oocyte donation study and concluded that it is the oocyte quality and
not endometrial receptivity, that plays a role in diminished
pregnancy rates in women with endometriosis. However,
a study analyzing a cohort of 170 oocyte donors reported
no significant effects but a trend for reduced pregnancy
rates in recipient cycles if the donor had endometriosis
and a trend for reduced implantation rates in recipients
with endometriosis, suggesting a potential mild effect of
endometriosis on both the uterine environment and the
quality of the oocyte.13
There is increasing evidence to support the hypotheses
that endometriosis is primarily an “endometrial” disease.
Multiple functional and microanatomical abnormalities
have been demonstrated within endometrium. The key
functional anomalies appear to be the expression of intracellular adhesions molecules, the presence of local aromatase enzyme activity, decreased apoptosis, increased
angiogenesis and increased neurogenesis.1
The available data suggests that both-development of
oocytes & embryos and endometrial receptivity can be
compromised in women with endometriosis.
DIAGNOSIS OF ENDOMETRIOSIS IN INFERTILE WOMEN
- The most common presenting complaints include
chronic pelvic pain, dysmenorrhoea, dyspareunia, dyschezia (pain on defecation) and low back pain. On
physical examination localized pelvic tenderness with
or without a mass/nodularity is often demonstrable.
Uterus may be fixed and retroverted due to adhesions.
- Pelvic transvaginal ultrasound although limited
by its non-specificity, is very useful in detecting
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endometriomas (chocolate cyst) and in monitoring its
size in response to therapy.
- CT scan and MRI pelvis are other non-surgical diagnostic tools used to identify the presence and the
extent of deeply infiltrating lesions. These are especially useful in detecting bowel and ureteric
involvement.
- The “gold standard” for diagnosis remains direct visualization of endometrial lesions using laparoscopy,
ideally with histopathological confirmation by biopsy
of excised endometriotic tissue. Classic lesions are
red, blue-black powder burn appearance, white or
non-pigmented patches.
- Serum CA 125 levels may be elevated in endometriosis. However, the test’s performance in diagnosing
all disease stages is limited with an estimated sensitivity of only 28% and specificity of 90%. Compared
with laparoscopy, measuring serum CA 125 levels,
has no value as a diagnostic tool (Grade A
recommendation).
STAGING OF ENDOMETRIOSIS
Although various classification systems have been
proposed to standardise the criteria for severity of symptoms, no system so far has received universal acceptance.
Based on revised American Society for Reproductive Medicine (ASRM)14 (Fig. 1) endometriosis can be classified into
four different stages:
Stage
Stage
Stage
Stage
I (minimal)
II (mild)
III (moderate)
IV (severe)
1e5 (Revised ASRM scoring system)
6e15
16e40
>40
EVIDENCE-BASED TREATMENT OF
ENDOMETRIOSIS-ASSOCIATED
INFERTILITY
A number of treatment options are available to treat infertility in women with endometriosis.
(i) Expectant management
(ii) Medical therapy
(iii) Surgical treatment
(iv) Combined medical and surgical therapy
(v) Controlled ovarian stimulation (COS) with or without
Intrauterine Insemination (IUI)
(vi) Assisted reproduction techniques
Verma
EVIDENCE-BASED MEDICINE
Grade A recommendation is based on good evidence obtained from meta-analysis of randomized controlled trials
(RCT) e Evidence level Ia or at least one RCT e Evidence
level IB.15
Grade B recommendation is based on well controlled
clinical studies (CT, cohort, case-control) but no RCT
(Evidence levels IIa, IIb and III).
Grade C recommendation is based primarily on
consensus and expert opinion (evidence level IV).
Good practice point e Based on clinical experience of
the guideline development group.
PROBLEMS IN THE EVALUATION OF TREATMENT OPTIONS FOR ENDOMETRIOSISASSOCIATED INFERTILITY
- Any management should be compared to expectant
management
- The monthly fecundity rate (MFR) is more meaningful than the pregnancy rate (PR)
- Few studies are controlled
- Few studies report the fecundity rate
- Techniques/skills differ
- Recognition of “atypical” lesions
Expectant management in endometriosis
The fecundity defined as the probability of a woman
achieving pregnancy in a given month, ranges from 0.15
to 0.20 in normal couples and 0.02 to 0.10 in untreated
women with endometriosis.16
It is well known that monthly fecundity is lower in
women with endometriosis than in women without this
condition. The reduced fertility rates are shown in Table 1.17
As some women especially with mild to moderate endometriosis will conceive spontaneously, when comparing the
effectiveness of any therapy for infertility, this needs to
be considered.
Medical therapies
The medical treatment of endometriosis involves suppressing oestrogen/progesterone levels to prevent cyclical
changes and menstruation. Depending upon their mode of
action these agents can be classified under 3 categories
(Table 2).18 Although these medical therapies are helpful
in reducing the severity of pain and menstrual disorders
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Table 1 Spontaneous
endometriosis.17
Degree of
endometriosis
Mild
Moderate
Severe
All cases
conception
in
women
Verma
with
Cumulative pregnancy rate (CPR)
Monthly fecundity
rate (MFR)
52.9%
25%
0%
24.4%
5.7%
3.2%
0%
3.1%
Table 3 Cumulative pregnancy rates following ovarian
suppression for endometriosis (CPR).5
associated with endometriosis, these are not shown to be
effective in the treatment of infertility.
The value of ovarian suppression with danazol, medroxyprogesterone acetate or gestrinone versus placebo/no treatment has been assessed in a Cochrane review.16 The odds
ratio for pregnancy following ovulation suppression versus
placebo or no treatment was 0.74 (95% CI 0.48e1.15).
These data were statistically homogeneous, despite the
use of a variety of suppression agents. The odds ratio for
pregnancy following all agents versus danazol, the most
commonly used agent prior to the advent of GnRH
agonists, was 1.3 (95% CI 0.97e1.76).
Commonly used ovulation suppression agents have been
known to cause significant adverse effects such as weight
gain, hot flushes and bone loss.
Clearly, there is no evidence to support the use of
ovarian suppression agents in the treatment of endometriosis-associated infertility (Table 3). More harm than good
may result from treatment, because of adverse effects and
the lost opportunity to conceive.
Recommendations
Suppression of ovarian function to improve fertility in minimalemild endometriosis is not effective and should not be
offered for this indication alone. There is no evidence of its
effectiveness in more severe disease either (Grade A
Recommendation).7,15
No
therapy
Thomas et al., 1987 (RCT)
(Gestrinone)
Bayer et al., 1988 (RCT)
(Danazol)
Telimaa et al., 1988 (RCT)
(Danazol)
Telimaa et al., 1988 (RCT)
(MPA)
Fedele et al., 1992 (RCT)
(Buserelin)
Ovarian
suppression
P
value
24%
25%
NS
57.4%
37.2%
NS
46%
33%
NS
46%
42%
NS
61%
37%
NS
Surgical management
When endometriosis causes mechanical distortion of the
pelvis, surgery is usually indicated to restore the normal
pelvic anatomy. However, no RCTs are available to give
a definitive answer whether surgery enhances the pregnancy rates.
Laparoscopy is the preferred surgical approach due to
40% lower risks than that of laparotomy.19 The goal of
surgery is to remove endometriotic lesions as much as
possible, restore normal anatomy with adhesiolysis and
optimize ovarian and tubal preservation and integrity. Excision or cystectomy is preferred over fenestration, drainage
or ablation of the cyst lining for the treatment of an ovarian
endometriomas.
There are several power sources used in endoscopic
surgery such as electrocautery (mono or bipolar), CO2 laser,
Fibre lasers (KTP, argon, Nd YAG), diode laser, Harmonic
scalpel or Helica thermal coagulator. No significant difference in pregnancy rates using different power source has
been reported.19 Use of adhesion-prevention adjuncts may
Table 2 Medical therapy for endometriosis.18
Suppression of ovulation/oestrogen
Oral contraceptive pill
Danazol
Gestrinone
Direct action on endometriotic deposits
Progesterone antagonists (Mifepristone, Onapristone)
SPRMs (Selective Progesterone Receptor Modulators) e
Asoprisnil
SERMs (Selective Oestrogen Receptor Modulators) e
Raloxifene
Aromatase inhibitors (Letrozole, Anastrozole)
(GnRH) Gonadotrophin releasing
hormone
agonists or antagonists
Aromatase inhibitors
ER ligands (Estrogen Receptor beta agonists)
Progestogen & (Medroxyprogesterone Angiogenesis inhibitors
etc.)
Immunomodulation
Inflammatory modulators
Matrix metallo-proteinase inhibitors
(MMP)
Anti TNF Alfa Therapy (Pentoxi-fylline
etc.)
7. Treatment for endometriosis-associated infertility
help to reduce adhesion formation but improvement in
fertility is unknown.20
Recommendations
- Ablation of endometriotic lesions plus adhesiolysis to
improve fertility in minimalemild endometriosis is
effective compared with diagnostic laparoscopy alone
(Grade A Recommendation).
- The role of surgery in improving pregnancy rates for
moderate to severe disease is uncertain (Grade B
Recommendation).
- There is no universal consensus, but generally cystectomy for ovarian endometriomas is considered better
than drainage and coagulation (Grade A recommendation) and has less chance of recurrence.
Combined medical & surgical therapy
Surgery combined with pre and postoperative medical
therapy represents a growing field of drug application.
Theoretically, preoperative medication may reduce inflammation, vascularization, and implant size, making the
surgery faster, easier and less traumatic, and the potential
for complete eradication of the disease and decreased risk
of postoperative adhesions.
However, drawbacks of combined therapy include drug
costs, side effects, and temporary regression of endometrial
foci allowing escape from laparoscopic recognition and
ablation.21
Preoperative medical therapy
The preoperative use of medication may be useful for
reducing the severity of endometriosis. A prospective
multicenter clinical trial by Audebert et al21 reported reductions in severity with preoperative compared with postoperative GnRHa treatment, although surgical feasibility did not
differ significantly. Nasal application of GnRHa has
revealed decreased inflammation, vascularization, severity,
and endometrioma growth. However, in the absence of
convincing evidence of improvements in surgical feasibility
and in fertility rate, the use of preoperative medication is
controversial.
Postoperative medical therapy
Postoperative medical therapy is another option in
combined therapy, aiming to achieve resorption of residual
deposits that cannot be surgically removed, destruction of
microscopic implants, and reduction of disease dissemination in case of endometrioma rupture. Few studies have
evaluated the use of postoperative medical therapy with
Review Article
189
GnRHa. None of these studies reported increased fertility
rates with postoperative medication. ESHRE guidelines
conclude that postoperative danazol or GnRHa treatment
is not more effective than expectant management in
improving fertility for endometriosis-associated infertility
(Grade A recommendation, Evidence level 1b).7
Sandwich therapy
d
Medical-surgical-medical therapy
Recommendations
- Cochrane review 2007 documents no benefit of
hormonal suppression before or after surgery.16
- The opinion on pre-surgical medical therapy is
controversial.21 In some reports pre-surgical medical
therapy showed a significant improvement in pregnancy rates.22,23
- Post-surgical hormonal suppression has no beneficial
effect on pregnancy rates after surgery15 (Grade A
recommendation).
Combined ovarian stimulation (COS) with or
without Intrauterine Insemination (IUI)
- Several RTCs have shown significant higher clinical
pregnancy rates with COS & IUI treatment compared
to no treatment.7 However the presence of endometriosis is shown to reduce treatment effectiveness of IUI
by approximately half (OR 0.45), when compared
with similar treatment in disease-free women.24
- In general, repetitive COS þ IUI cycles show
a plateau effect after 3e4 cycles, therefore patients
must be counselled to switch to IVF after 3e4
cycles.7
- IUI plus gonadotrophins have been shown to significantly increase live birth rates in at least two RCTs.
One RCT2 reported 29% live birth rates with IUI
and gonadotrophins in comparison to 8% with no
treatment. The other cross-over RCT2 found that
alternate cycles of gonadotrophins plus IUI had
19% pregnancy rates versus 0% with IUI alone.
Recommendation
- Treatment with IUI improves fertility in minimal to
mild endometriosis. IUI with ovarian stimulation is
effective but the role of unstimulated IUI is uncertain
(Grade A recommendation).
8. 190
Apollo Medicine 2012 September; Vol. 9, No. 3
Assisted Reproduction Techniques (ART)
In Vitro Fertilization (IVF) is appropriate treatment, especially if tubal function is compromised, if there is also
male factor infertility and/or other treatments have failed
(Grade B recommendation). It represents an effective
means to bypass the hostile peritoneal environment and
anatomic distortion associated with endometriosis.
However, a meta-analysis of published studies suggests
that IVF pregnancy rates are lower in patients with endometriosis than in those with tubal infertility.8 The review
included 22 studies, consisting of 2377 cycles in women
with endometriosis and 4383 in women without the disease.
After adjusting for confounding variables, there was a 35%
reduction in the chance of achieving pregnancy (OR 0.63).
Other outcome parameters such as fertilization rate, implantation rate, mean number of oocytes retrieved and peak oestradiol concentrations were also significantly lower in
endometriosis group.
Although both GnRH antagonist and GnRH-analogue
protocols for IVF/ICSI are equally effective in terms of
implantation and clinical pregnancy rates, GnRH-analogue
may be preferred because of the availability of more M II
oocyts and embryos.25
Use of ultralong (3e6 months) prior to IVF in a group of
patients with significantly high proportion patients classified as moderate to severe endometriosis, showed higher
pregnancy rates23 (Grade A recommendation).
Verma
endometriomas 4 cm in diameter. Women should
be counselled regarding the risks of reduced ovarian
function after surgery.
- ESHERE guidelines 2008 e laparoscopic ovarian
cystectomy in patients with unilateral endometriomas
between 3 and 6 cm in diameter before IVF/ICSI can
decrease ovarian response without improving cycle
outcome e (Evidence level IB).
- As per the evidence available, there is no significant
difference in the clinical pregnancy rate by adopting
no intervention or medical or surgical option in
women with endometriomas.27
Based on above reports, there is insufficient evidence to
recommend surgical treatment of endometriomas before
IVF/ICSI cycles.
There are exceptions e such as pelvic pain (possibility
of intensifying during COHS), presence of hydrosalpings
and large endometriomas especially when doubts exist
about their exact nature, where surgery before ART should
be undertaken.28
Large randomized trials are needed. In the meantime
decisions need to be taken on a comprehensive and individualised basis.
Aspiration of endometrioma prior to IVF remains another
controversial issue. Traditionally it has been advised to avoid
aspiration due to risk of infection, however, Suganuma et al
(2002) compared the aspiration to surgery and no treatment
and found higher fertilization rate in aspiration group.29
SUMMARY
SURGERY FOR ENDOMETRIOMA-BEFORE
ART RECOMMENDED OR NOT?
The presence of an endometriotic cyst in women undergoing ART supposedly has a negative influence on the
results although the literature is far from consistent on
this point.7 The advantage of surgery has to be weighed
against the disadvantage of the loss of ovarian tissue containing follicles close to the cyst.
Recommendations
- NICE guidelines 20042 e if endometrioma 3 cm
with reasonable amount of normal ovarian stroma
and antral follicles e it should be left alone and
IVF carried out.
- ASRM-200626 e if bilateral large endometriomas
4 cm counsel for surgical excision prior to IVF/ICSI.
- RCOG Guidelines No 2415 e laparoscopic ovarian
cystectomy before IVF is recommended for
Based on currently available evidence, the stage wise treatment of endometriosis associated with infertility can be
summarized as given below:
Management of minimal to mild endometriosis
with infertility
- Ablation of endometriotic lesions plus adhesiolysis at
the time of diagnostic laparoscopy is recommended
(Grade A Recommendation).
- Suppression of ovarian function using drugs (OC
pills, progestational agents, danazol, GnRH agonists)
is of no benefit to infertile woman and delays potential conceptions (Grade A Recommendation).
- Considering age, ovarian reserve and excluding male
and tubal factors, option to try naturally for 3e6
cycles can be offered.
- Treatment with IUI is shown to improve fertility in
minimal to mild endometriosis. Therefore controlled
9. Treatment for endometriosis-associated infertility
ovarian Stimulation and IUI is recommended for 3e4
cycles. If there is still no conception e IVF/ICSI
should be advised.
- In older patients, reduced ovarian reserve or associated male/tubal factor e early resort to IVF/ICSI is
advised.
Management of moderate to severe endometriosis with infertility
- Medical therapy alone is ineffective in restoring the
fertility in women with endometriosis (Grade A
recommendation).
- The role of surgery in improving pregnancy rates for
moderate to severe disease is uncertain (Grade B
recommendation).
- Laparoscopic cystectomy for ovarian endometrioma
is better than drainage and coagulation (Grade A
recommendation). However, loss of normal ovarian
tissue should be minimized.
- Laparoscopy surgery to assess exact extent of the
disease and surgical excision (drainage and excision
of pseudo-cyst wall) as best as possible with ablation
and adhesiolysis should be considered.
- The role of preoperative hormonal therapy is
controversial.
- Postoperative hormonal treatment has no beneficial
effect on pregnancy rates after surgery (Grade A
recommendation).
- IVF is an effective treatment of infertility in these
women and this should be offered at an early stage
while ovarian reserve is still optimal. However,
patients must be counselled for lower rate of pregnancy as compared to non-disease IVF patients.
- Young patients with good ovarian reserve and no
male or tubal factor should be offered 2e3 cycles
of COS þ IUI before proceeding to IVF/ICSI.
Management of severe/deep infiltrating endometriosis or recurrent endometriosis following
previous surgery with infertility
- GnRH agonist depot for 3e6 months followed by IVF/
ICSI (Ultralong protocol) is shown to increase the rate
of clinical pregnancy (Grade A Recommendation).
CONCLUSION
Endometriosis is commonly associated with infertility. The
exact pathogenic mechanism remains elusive and current
Review Article
191
literature suggests a multifactorial mechanism. In the
absence of any clear understanding or cure for this enigmatic
medical disorder, it is important to be flexible in diagnostic
as well as therapeutic approach. Expectant management may
be a reasonable approach in younger patients with early
stage disease and a shorter duration of infertility. The couple
should be involved in decision making at all stages and treatment must be individualized taking into account all medical
and surgical therapeutic available options. Further RCTs are
necessary to find more conclusive answers and remedies to
treat this challenging disorder.
CONFLICTS OF INTEREST
The author has none to declare.
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