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

1. PANEL DISCUSSION ON
ENDOMETRIOSIS RELATED
INFERTILITY (EVIDENCE BASED)
MODERATOR
DR SHARDA JAIN
DR JYOTI AGARWAL
DR ILA GUPTA

2. PANNELISTS
• UMA RAI
• RAJ BOKARIA
• JYOTI AGARWAL
• JYOTI BHASKER
• RENU CHAWLA
• DIPTI NABH
• VANDANA GUPTA
9TH
AUGUST
2018

3. How do we know what is the
Evidence available in Literature for
management
GRADE OF RECOMMENDATIONS
A: Meta-analysis or multiple RCT (of high quality)
B: Meta-analysis or multiple RCT (of moderate quality)
Single RCT, large non-RCT(s) or case control/cohort
studies (of high quality)
C :Single RCT, large non-RCT(s) or
case control/cohort studies (of moderate quality)
D :Non-analytic studies or case reports / case series (of
high or moderate quality)
GPP :Good practice point, based on expert opinion

4. Plenty of Guidelines to manage infertility in
patients of endometriosis
ASRM
ESHRE Guidelines Jan 2014
Human Reproduction vol.0 pg 1-13 2014

5. WHY SO MANY Guidelines ON
ENDOMETRIOSIS??
1. RCOG: Evidence-based Clinical, 1999
2. Endometriosis and infertility. ASRM, 2004.
3. ACOG. Endometriosis in adolescents, 2005.
4. ESHRE guideline for the diagnosis and
treatment of endometriosis, 2005.
5. Endometriosis and infertility. ASRM, 2006 .
6. Endometriosis: diagnosis and management. SOGC, 2010
7. Fertility: Assessment and Treatment for People
with Fertility Problems. NICE, 2013.
ESHRE guideline: management of women with endometriosis, 2014

6. Why do we need
these guidelines
???

7. Even today endometriosis remains an
enigma full of mystery &
Gynaecologists are confused

8. ASRM has stated that,
“Endometriosis should be viewed as a
chronic disease that requires a life-long
management plan with the goal of
maximizing the use of medical treatment
and avoiding repeated surgical procedures.”
Fertil & Steril, 2008
Why This request
:recurrence-high/ decrease in ovarian reserve
REQUEST

9. OBJECTIVES of this panel discussion
Review
ESRH: 2014 EB guideline(Paradigm Shift )
Review Literature: 2015 and 2018
Diagnosis : -Define role of diagnostic laparoscopy
• Treatment
1. Hormonal ?-only for PAIN
2. Surgery - exact role
3. ART IUI + COS
4. IVF – ICSI
 CASES & Conclusion

10. ENDOMETRIOSIS-AN ENIGMA
• Endometriosis is defined as the presence of
endometrial-like tissue outside the uterus, which
induces a chronic, inflammatory reaction
(Kennedy, et al., 2005). Its USP..can be summed
up in 4 lines.
• DIAGNOSTIC DELEMMA…Takes 5 to 7 yrs
• DEBILITATING Disease
• PROGRESSIVE Disease
• NO CURE Today

11. 3 Main Types
• 1.PERITONEAL: 1-2cm, red, blue, black or
white
• 2.ENDOMETRIOMA: chocolate cyst
• 3.D. I. E: penetrate the bowel, bladder and
vaginal wall including nerves

12. PREVALANCE
• The exact prevalence of
endometriosis is unknown but
estimates are that around 10% of the
general female population & up to
50% in infertile women have
Endometriosis
Eskenazi and Warner, 1997;, Meuleman, et al., 2009

13. HOW DOES ENDOMETRIOSIS CAUSE
INFERTILITY
FACT :Nearly 50% require Treament.
Still unclear ,but following are possible explanation
I.Anatomic distortion
II.Tubal occlusion
III.Oocyte quality / ovarian function
IV.Endometrial receptivity
I & II mainly due to Adhesions
associated with advanced disease

14. A comprehensive fertility assessment is therefore
necessary
a) Age
b) Male factor
c) Tubal patency + Hydrosalpinges
d) Ovarian reserve
e) Uterine cavity assessment
THE GYNAECOLOGISTS NEED TO MAKE A DECISION EITHER
FOR SURGERY OR ART OR BOTH TO INCREASE THE CHANCE
OF PREGNANCY.

15. DIAGNOSIS

16. DIAGNOSTICLAPAROSCOPY
Laparoscopy +BIOPSY + HPE : gold standard for diagnosis
Negative diagnostic laparoscopy: highly
accurate for excluding endometriosis
Positive laparoscopy:Is
of limited value if NO Biopsy
is taken
(Wykes et al., 2004).

17. {Definition: ectopic endometrial stroma and glands}
(Berker, Seval, 2015)
HPE necessary for the diagnosis of endometriosis
To obtain tissue for histology in women undergoing surgery for
endometrioma and/or
deep infiltrating disease {exclude rare instances of malignancy} (GPP}
Histopathology Examination

18. TREATMENT

19. CURRENTLY AVAILABE TREATMENT of
ENDOMETRIOSIS irrespective of AGE
MEDICAL
• Danazol
• GnRh a
• OCP
• Progestogens
• DIENOGEST
• SURGERY
• Diag.Laparoscopy
• Open surgery
• Operative LAP
Deep infiltrative E
Big chocolate cyst
IUI / IVF /ICSI /SURROGACY

20. S
u
r
g
e
r
y
TREATMENT OF INFERTILITY
RELATED TO
ENDOMETRIOSIS
A
R
T Most appropriate treatment is still
controversial but we have some tools in our
armamentarium
Medical therapy though useful in alleviating pain .
Drugs e.g. danazol, GnRHa and progestogens have
not been shown to enhance pregnancy rates

21. TREATMENT
Hormonal therapies
ABOUBAKR ELNASHAR
No need
For suppression of ovarian function to
improve fertility
(Hughes et al.,
2007).{AEVIDENCE}
hormonal contraceptives,
Progestagens
GnRH analogues or
Danazol
to improve fertility in minimal to mild endometriosis is
not effective and should not be offered for this
indication alone. The published evidence does not
comment on more severe disease
(Hughes et al., 2007).

22. RULE I

23. OOCYTE QUALITY

26. ENDOMETRIOMAS—Paradigm shift
--

27. •Rapid growth
•Suspicious features on Ultra sound
•Painful symptoms attributable to mass
•Potential rupture in pregnancy
•Inability to access follicles in normal ovarian
tissue
BIG QUESTION ?
TOUCH & NOT TO TOUCH

28. What is the place of Surgery??
Stage I/II
As such surgery is NOT Needed
•Operative laparoscopy:if at all done for PAIN
excision or
ablation of the endometriosis lesions
adhesiolysis
rather than
•Diagnostic laparoscopy only, to increase PR
(Nowroozi et al., 1987; Jacobson et al., 2010).{A}

29. What is the place of Surgery??
CO2 LASER VAPORIZATION of
endometriosisI is BETTER, instead of monopolar
electrocoagulation
{higher cumulative spontaneous PR }
(Chang et al., 1997).{C}

32. Endometrioma
• Excision of the capsule, instead of drainage and
electrocoagulation of the endometrioma wall
• {increase spontaneous PR}
• (Hart et al., 2008).{A}
• Counselingis very very important:
• Risks of reduced ovarian function after surgery
and the possible loss of the ovary.
• Recurrence Rate is high

33. H/o previous surgery
• The decision to proceed with surgery
should be considered carefully if the
woman has had previous ovarian
surgery. {GPP}

34. ENDOMETRIOSIS Stage III/IV
ABOUBAKR ELNASHAR
• Operative laparoscopy, instead of expectant
management: increase spontaneous PR
(Nezhat et al., 1989; Vercellini et al.,2006). {B}
• Crude spontaneous pregnancy rates of
(Olive et al., 1985; Nezhat et al., 1989; Vercellini et al., 2006).
Stage After operative
laparoscopy
After expectant
management
III 52-68% 33%
IV 57-69% 0%

35. Conclusion
Operative Laparoscopy in 3 & 4STAGE
• an efficient method
most effective particularly at stage III.
(Jozwiak et al, 2015)
The period for expectant management after a
surgical procedure should last 6 months only.

37. OVULATION INDUCTION

38. NO MEDICAL TREATMENT IF WOMEN
WANTS CHILD
• IN INFERTILE WOMEN WITH
ENDOMETRIOSIS, the PANEL recommends
clinicians not to prescribe adjunctive
hormonal treatment before OR after surgery
to improve spontaneous pregnancy rates, as
suitable evidence is lacking.

39. case 1
HAEMORRAGIC CYST OF 3X4 CM
• 26 YRS OLD.,MARRIED FOR 3 YRS,NO
CONTRACEPTIVE USED.
• HAS MILD DYMENORROEA,
• WANTS TO CONCEIVE,
• SEMEN NORMAL
• ONE CYCLE FOLLICLE MONITOING—OVULATED
• CBC /VIRAL MARKERS /URINE ROUTINE
/RUBELLA IgG –NORMAL.

40. COH + IUI
• In infertile women with endometrioma larger
than 3 cm there is no evidence that
cystectomy prior to treatment with assisted
reproductive technologies improves
pregnancy rates.
(Benschop, et al., 2010, Donnez, et al., 2001,
Hart, et al., 2008). Evidence A
No surgery

41. IUI + COH is indicated, may be
beneficial in minimal/mild stages.
3-4 cycles
(ESHRE GUIDELINES for the diagnosis and treatment of
endometriosis 2008)
INFERTILITY TREATMENTIN
STAGE I & II

42. CASE II
• WOMEN aged 26 yrs, Married for over 2 yrs,
• BMI 26
• Having RT chocolate cyst of 10 cm & Left
ovary has haemorragic cyst of 3 by 3 cms.
• She presented with severe PAIN in emergency
in Tertiary care Hospital
• CA 125 68,CBC/KFT /LFT /VIRAL MARKERS
• BLD SUGARS /TSH --NORMAL
• MOTHER HAD TREATMENT OF PULMONARY TB
& HAS HYPOTHROIDISM

43. SURGERY..OVARIAN CYSTECTOMY
Was done on both sides. Rest clean pelvis
TUBES –patent on chromotubation.
Getting discharged
• IF NO BORDERLINE MALIGNANCY.. DIENOGEST for atleast
12 weeks suggested
What is role of Medical Treatment in this case of
B/L endometriomas ?
OR Surgery is indicated??

44. C O H + I U I should be PLANNED
AFTER H.P.E. REPORT
• NO MEDICAL TREATMENT AFTER SURGERY IF
SHE WANTS CHILD.
• IF SHE DOES NOT WANT CHILD –MEDICAL
TREAMENT CAN BE GIVEN

45. IVF represents the most efficient and successful
means of achieving conception.
Indications
a) Tubal function is compromised
b) Presence of male factor
c) Age factor ≥ 38 years
d) Other treatment failed
e) Advanced disease (stage iii & iv)
Frequently associated with Adhesions,
endometriomas and tubal occlusion
PLACE OF IVF-ICSI

46. a) Increased gonadotropins needed and duration of
stimulation
b) Reduced oocytes number and quality
c) Cycle cancellation higher
d) ? ICSI may give better results
e) Reduced fertilization rates
f) Reduced implantation rates
g) Pregnancy outcome poorer in advanced disease
particularly with significant ovarian involvement
(endometrioma) or prior ovarian surgery
WHAT IS SPECIFIC observations of
IVF IN ENDOMETRIOSIS

47. SUMMARY of I V F TREATMENT
When IVF is indicated
1. Counselling:
a) May need to do multiple cycles for egg/embryo
pooling + FET as number of oocytes retrieved might
be reduced especially if advanced disease or multiple
previous surgeries
b) Risk of cycle cancellation
2) Increased dosage of gonadotropins
3) Agonist or antagonist can be used but long long
protocol yields BEST results
4) Endometrioma do not need to be removed unless
indicated

48. 2) Avoid PUNCTURING endometriomas at
OPU to reduce risk of pelvic
infection/abscess
3) Consider prolonged down regulation before
FET especially in advanced disease
or
previous failed cycle due to implantation
failure
4) Frozen embryo transfer

49. ENDOMETRIOMA & I V F
• In women with endometrioma,
clinicians may use antibiotic prophylaxis
at the time of oocyte retrieval, although
the risk of ovarian abscess following
follicle aspiration is low (Benaglia, et al.,
2008).

51. IMPACT OF IVF ON ENDOMETRIOSIS
PROGRESSION

52. CAN ANYTHING BE DONE TO MINIMIZE THE
DETRIMENTAL EFFECT OF ENDOMETRIOSIS ON
OOCYTE QUALITY?
GnRH agonist was touted to help improve
clinical pregnancy rate
? Ovarian/endometrial effect; unexplained

53. REPEATED SURGICAL EXCISION SHOULD BE AVOIDED as
large body of evidence suggest a negative impact on ovarian
reserve and response to gonadotropins
PRE-IVF SURGERY WAS ALSO TRIED
The logic was to minimize the effect of peritoneal implants or their secretory
products might
have on oocyte quality, embryo development or implantation.
No obvious improvement in outcome with pre-surgical resection __________
EXCISION VS ABLATION

54. CASE 4
• CASE OF ENDOMETRIMA..5 CMS IN 25 YEARS
OLD WOMEN –NOT WANTING TO HAVE CHILD.
• CA 125 45
• REST NORMAL.
• TREATMENT--DIENOGEST IS THE
CHOICE OF PANELISTS
• WHY NO SURGERY ?

55. NO SURGERY NEEDED IN THIS
CASE.
MEDICAL TREAMENT WITH
DIENOGEST IS ENOUGH .
NEEDS FOLLOW UP

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