Dr Louise Hull presented the facts about Endometriosis and its impact on fertility. Dr Louise Hull has worked in fertility services since she graduated as a doctor 15 years ago. She became Obstetrician and Gynaecologist (FRANZCOG) after gaining clinical experience in New Zealand and Cambridge and Somerset in the UK. Louise has a strong interest in reproductive medicine and has worked in IVF units in New Zealand, England and Australia, including Bourn Hall, the fertility centre where the first IVF baby was born. For more information about Dr Hull, please follow this link: http://www.fertilitysa.com.au/dr-m.-louise-hull-specialist.html

1. Endometriosis
and Infertility
Presented by
Dr Louise Hull

2. • What is endometriosis?
• How many women suffer from endometriosis?
• How do you know if you have endometriosis?
• How do you know if it will affect your fertility?
• What causes endometriosis?
• What causes fertility problems in endometriosis?
Questions about endometriosis?

3. The lining of the womb
grows outside the
uterine cavity
What is endometriosis?

4. What causes endometriosis?
Sampson’s theory
90% of women have retrograde menstruation but only 10%
develop endometriosis
Also genetic, immune, environmental and hormonal factors

5. What are the costs of Endometriosis?
In one year, on average a women with endometriosis will incur:
$2,898 in direct costs $12,330 in indirect costs
50% women have >17.6 days absenteeism /year
Kiejoff et al, 1987

6. What are the symptoms of endometriosis?
Endometriosis
Painful
periods
Difficulty
conceiving
Premenstrual spotting
Painful sex
Chronic pain
Heavy
periods

7. How do we diagnose endometriosis?

8. Laparoscopic surgery
Diagnostic laparoscopy
• Costly
• Requires anesthesia
• Is invasive
• Carries risks
1/3 of women that undertake
laparoscopy – do not have
endometriosis

9. Promising non- invasive diagnostic tests
Our research group at the university
Differences in microRNA profiles in women with
and without endometriosis
Other research groups are exploring proteins
and clinical parameters
Also MRI diagnostics

10. Does stage of endometriosis affect IVF outcomes?
Dmowski et al 2002

11. Can we predict fertility outcomes in women with
endometriosis?
579 women evaluated
and EFI formulated
Tested in an additional
222 women
Validated in a Dutch
population

12. Does endometriosis impact on fertility?
1. Prevalence is higher in women who have difficulty conceiving
-10% in general population vs 38% in women with infertility
2. Monthly pregnancy rate is reduced in endometriotic women
treated with donor sperm (12% vs 3.6%)
4. Poorer outcomes in IUI
-reduced pregnancy rates in FSH/IUI (11%)
-laparoscopic excision improved pregnancy rates in COH/IUI

13. What causes subfertility in endometriosis?

14. *
**
*
Adhesion and wounding
*
**
*
Inflammation
•*
•* *
*
*
* •*
•* *
Remodelling, healing and
blood vessel formation
Established lesion

15. The environment
The endometrial environment has
immune cells and other factors
that can stress eggs sperm and
embryos
Endometriotic peritoneal fluid
reduced fertility in animal models

16. Oxidative stress
Patient Number
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26
CumuluscellREDOX
(meanfluorescentpixels)
0
20
40
60
80
100
LOW
INTERMEDIATE
HIGH

17. Oocyte quality
Single embryo culture
Optimal lab handling and environment

18. Reduced ovarian reserve
Women with endometriosis have:
-lower day 3 FSH levels
-lower AMH levels
-reduced oocytes in cortical ovarian biopsies
-diminished response to FSH in IVF
Role of surgery
- surgically treated women have lower ovarian
reserve
- Postoperative decline in AMH levels

19. Preserving Fertility in Endometriosis
In young women undertaking surgery
consider discussing:
Measuring AMH and planning
pregnancy
Cryopreserving oocytes
Freezing ovarian tissue at excision of
endometrioma
At this stage little research re outcomes

20. Donor Studies: Egg versus Endometrium
Endometriosis recipients
(n=25)
Control recipients
(n=33)
LBR =28% LBR =27.2%
Diaz et al 2000
Fertity Sterility, 74,1: 31-34

21. Pregnancy outcomes for women with endometriosis
Swedish Cohort (Stephansson et al 2009)
8,922 women with endometriosis had
13090 singleton births
In a registry of >1.4 million singletons
Women with endometriosis had:
-increased risk of preterm birth
-increased rate of caesarean section

22. Consulting Clinic
345 Carrington Street
Adelaide SA 5000
Phone 8100 2900
e info@fertilitysa.com.au
w www.fertilitysa.com.au