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 The document also presents unpublished data from a study of 261 women who underwent laparoscopic excision for stage III/IV endometriosis, finding a 79.7% spontaneous pregnancy rate.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.

1. Does surgery for endometriosis improve fertility outcomes? Lakshmi Ravikanti Fellow in Endoscopy and Infertility Waikato Hospital & Fertility Associates Hamilton Acknowledgment: Mr V P Singh

2. Burden of Endometriosis 20-50% of all women with infertility

3. Is IVF outcome affected in Endometriosis? Endometriosis Vs Tubal – OR 0.56 Severe endometriosis Vs mild endometriosis-OR 0.60 Barnhart et al.FertilSteril.2002

4. Endometrial Receptivity or Oocyte Quality? Diaz et al. FertilSteril.2000 Healthy Oocyte Donors Healthy recipients Recipients with Endometriosis III-IV No significant difference in implantation rates or live birth rates Sibling Oocytes Uterine receptivity is NOT impaired

5. Endometrial Receptivity or Oocyte Quality? Simon C et al. HumRep 1994 Oocyte donors with endometriosis Vs Oocyte donors without endometriosis Significantly lower pregnancy rates from donors with endometriosis So it is likely to be the Oocyte Quality

6. Management options for endometriosis related infertility Expectant Surgical resection/ablation Combined surgical and medical therapy COH +/- IUI IVF/ICSI

7. Expectant management IVF Vs expectant management Soliman et al, Fertil Steril 1993; 59:1239

8. Endometriosis & COH/IUI Tummon IS et al: Fertil Steril 1997;68: 8-12

9. Surgery improves the likelihood of spontaneous conception Meta-analysis Not controlled for stage Crude pregnancy rate 38% higher than medical therapy or expectant management Meta-analysis Common OR 2.67 in favour of surgery compared to medical treatment or expectant management Adamson GD et al, Am J Obstet Gynecol 1994; 171:1488 Hughes EG et al, Fertil Steril; 1993;59:963

10. ENDO-CAN 341 infertile women with min (stage 1) and mild (stage 2 )endometriosis Group 1- Laparoscopy only Group 2- Laparoscopic ablation/resection 36 week follow up

11. So we know that surgery for endometriosis related infertility is useful for stage 1 & 2 but what about stage 3 & 4? Is it worth the risk? Surgery is the standard approach Very few controlled studies Lack of description of duration of follow up and fecundity rates Differences in surgical technique Complete or partial excision Increasing recognition of “atypical” lesions

12. Fertility outcomes after surgery for stage III / IV Endometriosis (unpublished data) 79.7% 20.3% Total no of cases- 261

14. Fertility outcomes after Laparoscopic excision of grade 3 & 4 endometriosis

15. Additional Procedures required & Complications Additional Procedure required Elective bowel resection 13 Partial bladder resection 1 Complications Intraop rectal serosal damage 1 Abd wall Haematoma 1 Small bowel Obst 1 Laparotomy for prim Haemorrhage 1

16. Summary of outcomes Pain relief (Visual Analogue Scale) – 78% Spontaneous pregnancy rates- 36% Complications- 2%

17. Mrs J Y 34 years Primary infertility 4 years Regular periods, mild dysmenorrhoea, no dyschezia, no dyspareunia, semenalysis normal Diagnostic laparoscopy- AFS Stage 3 endometriosis, tubes normal TVS- 3 cm endometrioma left ovary Do you proceed to IUI, do IVF or surgical treatment of endometriosis

18. ~ 30% spontaneous conception Lower risk of ovarian/pelvic abscess with OPU? Oocyte Quality improved? Risk of surgery IVF conception rates 45% with one cycle and 70% with 2 cycles Cost Psychological impact Avoids potential surgical complications Surgery IVF

19. Mrs PC 38 years 1 infertility 2 years Regular periods, severe dysmenorrhoea, mild dyspareunia, no dyschezia PV- nodularity in POD TVS- endometrioma right ovary 4 cm, left ovary 2 cm endometrioma Do you perform IUI, IVF or offer laparoscopy?

20. First Laparoscopy

21. Wide excision of deep endometriosis from vagina

22. Excision of D I E from rectum

23. Removal of specimen

24. Excision completed

25. Suturing of vaginal opening

27. Follow up Asymptomatic at 3 month follow up Pregnant at 6 months NVD of a baby boy Remains asymptomatic 6 months postpartum

28. Conclusion Management of endometriosis related infertility is complex Surgical treatment of stage I & II endometriosis should be undertaken at the time of initial assessment Surgical excision of infertility related to stage III&IV endometriosis in absence of pain symptoms remains c ontroversial in absence of reliable prospective studies.

29. THANK YOU