The Impact Of Endometriosis On Infertility And It's Treatment - Dr. Abayomi Ajayi

THE IMPACT OF
ENDOMETRIOSIS ON
INFERTILITY AND IT’S
TREATMENT
By
Dr. Abayomi Ajayi
AFRH/IFFS Training Program
The Management of Infertility
and Assisted Conception.
Lagos

DISCLOSURES
Nothing to disclose
Thursday, 17th May 2018AFRH/IFFS Conference

OUTLINE
Introduction
Endometriosis and infertility
Effect of endometriosis on ART
Effect of ART on endometriosis
Pre-treatment before ART
Conclusion

INTRODUCTION: ENDOMETRIOSIS
A masquerade of
diseases
An inflammatory
oestrogen mediated
disorder
Endometrial tissue
fragments grow outside
the uterus

INTRODUCTION: ENDOMETRIOSIS
Affects over 176 million women worldwide
6 to 10% of women of reproductive age.
Much higher incidence in infertile women
25% of patients undergoing ART are affected and 20-40% of these
patients show ovarian endometriosis

INTRODUCTION CONTD: CAUSE
Unknown
A disease of theories
Retrograde
menstruation/Sampson’s
theory
Coelomic metaplasia
Lymphatic spread
Via pelvic veins
Surgical transplantation
Induction theory
Stem cell theory
Activation of mullerian cell at rest

INTRODUCTION CONTD: CAUSE
Sampson’s theory
›Most widely recognized & plausible.
›Based on the assumption that endometriosis is caused
by the seeding or implantation
›Supported by: Blood found in peritoneal cavity on
laparoscopy during menstruation in 75-90%(altered
peritoneal environment)
More in women with stenosis of internal OS
(Lancet, 2004

INTRODUCTION CONTD: SITES

INTRODUCTION: SYMPTOMS
No symptoms
Classical reproductive symptoms are:
Dysmenorrhoea 70%
Pelvic pain 40%
Infertility 35%
Dyspareunia 33%
Menstrual irregularities 15%
Other cyclic bleeding 1-2%

INTRODUCTION: SYMPTOMS
At Nordica we found the main
symptoms at presentation to be
dysmenorrhea (47, 73.8%).

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

30 to 50% are infertile
About half will require treatment
No indices to predict those that will require treatment for infertility
Reduced fecundity

HOW DOES ENDOMETRIOSIS CAUSE
INFERTILITY
Still unclear but the following are incriminated
I.Anatomic distortion
II.Tubal occlusion
III.Oocyte quality / ovarian function
IV.Endometrial receptivity

OOCYTE QUALITY

TREATMENT OF INFERTILITY RELATED TO
ENDOMETRIOSIS
Most appropriate treatment is still controversial but we have some tools in our
armamentarium
Surgery
ART
Medical therapy though useful in alleviating, if not eliminating symptoms of
endometriosis e.g. danazol, GnRHa and progestogens have not been shown to enhance
pregnancy rates

The clinician may need to make a decision either for surgery or ART or both to increase
the chance of pregnancy.
A comprehensive fertility assessment is therefore necessary
a) Age
b) Male factor
c) Tubal patency + Hydrosalpinges
d) Ovarian reserve
e) Uterine cavity assessment

Surgery may be considered for early stage disease especially less than 35 years +
Hydrosalpinges
Not diagnostic laparoscopy: avoid repeated surgery.
Surgery may improve spontaneous pregnancy rates in early stage disease
If 6-12 months→ ART

IUI + COH if indicated may be beneficial in minimal/mild stages.
50% reduction in pregnancy rates
3-4 cycles (ESHRE GUIDELINES for the diagnosis and treatment of
endometriosis 2008)

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)
Especially when associated with tubal occlusion

IMPACT OF ENDOMETRIOSIS ON IVF
OUTCOME
The issue is not yet resolved
Earlier studies showed poorer outcome in patients with
endometriosis

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

IMPACT OF IVF ON ENDOMETRIOSIS
PROGRESSION

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

Further research is probably needed as there are still no diagnostic markers to
predict the group of patient that will benefit from prolonged GnRH therapy

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
Repeated surgical excision should be avoided as large body of evidence suggest a
negative impact on ovarian reserve and response to gonadotropins

ENDOMETRIOMAS

Rapid growth
Suspicious features on Ultra sound
Painful symptoms attributable to mass
Potential rupture in pregnancy
Inability to access follicles in normal ovarian tissue

SUMMARY
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
4) Endometriomas do not need to be removed unless indicated

2) Avoid 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
Lessey et al: 64% restoration of β 3 integrin expression

Endometriosis-related infertility modern management
The gold standard
is
Individualized treatment

The Impact Of Endometriosis On Infertility And It's Treatment - Dr. Abayomi Ajayi

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