Why do gynecologists and infertility specialists provide the wrong treatment to infertile women with endometriosis ?

2. Endometriosis and infertility
• The hypothesis that endometriosis
causes infertility or a decrease in
fecundity remains controversial.
• Whereas evidence demonstrates an
association between endometriosis
and infertility, a causal relationship
has not been clearly established.

3. Endometriosis and infertility: a
committee opinion.
The Practice Committee of the
American Society for
Reproductive Medicine. Sept
2012

4. A paradox !
•1. Need to do a
laparoscopy to make a
diagnosis of
endometriosis

5. •2. No need to do
laparoscopy routinely
for all infertile couples

6. Routine laparoscopy
• Laparoscopy in infertile woman,
simply to confirm or rule out the
disease is not warranted.
• Endometriosis and infertility: a
committee opinion. The Practice
Committee of the American Society
for Reproductive Medicine. ASRM,
2012

7. Routine laparoscopy
• The benefit of laparoscopic treatment of
minimal or mild endometriosis is
insufficient to recommend laparoscopy
solely to increase the likelihood of
pregnancy.
• Endometriosis and infertility: a
committee opinion . The Practice
Committee of the American Society for
Reproductive Medicine. ASRM, 2012

8. No laparoscopy ? Won’t we
miss the diagnosis ?
• Yes, we will
• So, what ?
• We don’t treat a diagnosis, we treat the
infertile couple !
• Treating mild endometriosis , either with
medical therapy or operative
laparoscopy, does not improve fertility

9. Routine laparoscopy
• Does not change treatment options - or
outcome !
• Burning endometriosis lesions, and
cutting adhesions are fun , but “treating”
these doesn't improve fertility – and can
actually reduce it
• Post hoc, ergo propter hoc fallacy -
Patients get pregnant after the
laparoscopy and doctor is happy to take
the credit

10. Harm Caused
• Misdiagnosis - corpus luteum vs
endometriosis
• Burning or excising chocolate cyst reduces
ovarian reserve
• Overtreatment – patient “treated” with
Lupron after the surgery
• Wastes time – you tell the patient, you have
now been treated, so you can get pregnant on
your own
• Don't cut and burn just because you can !

12. Medical treatment does not
improve pregnancy rates
• In infertile women with endometriosis,
clinicians should not prescribe hormonal
treatment for suppression of ovarian function
to improve fertility.
• ESHRE guideline: management of women
with endometriosis. Human Reproduction,
Volume 29, Issue 3, 1 March 2014, Pages 400–
412,

13. Changing paradigm
• PAST
• Removal of lesions is a
priority.
• It is a gynecological
lesion
• Recurrence means
incomplete primary
surgery
• ART had low pregnancy
rates
• PRESENT
• Preservation of ovarian
function is a priority.
• It is an inflammatory
syndrome
• Recurrence means
persistent offending
factor
• ART is safe and
effective

14. Principles of care
• Ovarian reserve should be assessed
before intervention.
• Endometriosis surgery should be avoided
in women with diminished ovarian
reserve who should be offered ART
straightaway.
• ART is the best option in women with
recurrent endometriosis

15. Principles of care
• Don’t just treat the lesions !
• Need to factor in:
• Female age
• Duration of infertility
• Pelvic pain

16. Endometrioma diagnosed on
ultrasound

17. Ovarian Endometriomas

18. Justification for doing laparoscopic
ovarian cystectomy
• Confirm the diagnosis histologically
• Reduces risk of recurrence over
fulguration
• Reduce the risk of infection at IVF
• Improves access to follicles
• Improves IVF pregnancy rate ( because
endometriosis fluid is “toxic “ to eggs)

19. IVF and endometriosis
• Embryo implantation is not affected
in patients with endometriosis.
• The presence of severe
endometriosis or bilateral ovarian
endometrioma does not lower
implantation rates.

20. • Although the presence of bilateral
endometriomas at the time of IVF affects
responsiveness to hyperstimulation, the quality
of the oocytes retrieved and the chances of
pregnancy are not affected.
• Benaglia L Bermejo ASomigliana E Faulisi SRagni
G Fedele L Garcia-Velasco JA In vitro fertilization
outcome in women with unoperated bilateral
endometriomasFertil Steril 2013 99 6 1714-1719

21. Ultrasound guided cyst aspiration
prior to IVF
• Safe and effective
• Temporary solution – good
enough
• If she gets pregnant in the IVF
cycle, problem is resolved !

22. Minimally invasive !
• Ethanol sclerotherapy of ovarian
endometrioma: a safe and effective
minimal invasive procedure.
Preliminary results. Eur J Obstet
Gynecol Reprod Biol 2015
Apr;187:25-9. Dr Garcia-Teiedor A

23. New treatment option
• Sclerotherapy in the management of
ovarian endometrioma: systematic
review and meta-analysis. Cohen A,
Almog B, Tulandi T. Fertile Steril,
2017 Jul;108(1):117-124.
• Using ethanol as a sclerosant

24. Take home messages
• Routine diagnostic laparoscopy not indicated
for infertile women
• Medical therapy of endometriosis has no role
in improving fertility
• In minimal to mild disease, ovulation
induction and IUI is first line therapy.
• IVF is the final common pathway for having
a baby

25. The elephant in the room
• None of us will change what we are
doing!
• We all have our personal prejudices

28. Trigger happy doctor
• We like doing things - " Itchy " fingers
• Feel good - for yourself, because you did
something
• Patient is happy – she feels you have
"diagnosed" the problem and have
treated it
• Can charge more

29. Why it’s easy to fool
doctors
• Personal experience - Small numbers, no
controls, no followup
• Patients change doctors. Only the
success stories come back with
chocolates !
• Reinforces your bias – the easiest person
to fool in the world is yourself

30. Experts are biased – and often
wrong !
• Eminence based medicine - "my
experience" - which is plagued with
problems
• Experts fudge numbers – they lie !
• Sponsored by pharma companies and
medical device manufacturers who want
to sell their products

31. Trust your own eyes !
• Minimal endometriosis is a very common
incidental finding
• No clinical relevance
• Look for it carefully in patients
undergoing lap TL
• You will find it in nearly every woman
you put a scope into if you are
meticulous

32. IVF vs Endoscopy
• Do both !
• Gynecologist and Ivf specialist refer
patients to each other !
• Both are happy - only loser is the
patient