The Newer Concepts forReduced Surgery to preserve fertility in Endometriosis ENDOMETRIOSIS IS ENIGMA DIAGNOSTIC DILEMMA DEBILITATING DISEASE QOL PROGRESSIVE DISEASE RECURRENCE IS BIG PROBLEM NO FINAL VERDICT ON CAUSE NO PERMANENT CURE The exact prevalence of endometriosis is unknown, but estimates 10% in the general female population in India but up to 50% in infertile women

1. The Newer Concepts
for
Reduced Surgery to
preserve fertility in
Endometriosis Dr. Sharda Jain

2. ENDOMETRIOSIS IS ENIGMA
• DIAGNOSTIC DILEMMA
• DEBILITATING DISEASE QOL
• PROGRESSIVE DISEASE
• RECURRENCE IS BIG PROBLEM
• NO FINAL VERDICT ON CAUSE
• NO PERMANENT CURE
• The exact prevalence of endometriosis is unknown, but estimates 10% in the
general female population in India but up to 50% in infertile women

3. AFS, American Fertility Society.
1. Yovich. Med J Obstet Gynecol 2020;8:1130; 2. Tran et al. Gynecolog Surgery 2012;9:369‒373.
John A. Sampson
provided implantation
hypothesis of
endometriosis1
AFS endometriosis
staging2
Guidelines from
international societies
Histologic
confirmation
of endometriosis
is NOT
mandatory
Progression of Endometriosis Diagnosis Standards
2022

4. ESHRE, European Society of Human Reproduction and Embryology.
ESHRE: Endometriosis Guideline of European Society of Human Reproduction and Embryology. 2022.
ESHRE 2022 Guidelines
“Laparoscopy is no longer the
diagnostic gold standard and it is
now only recommended in patients
with negative imaging results and/or
where empirical treatment was
unsuccessful or inappropriate.”
Laparoscopy is no longer the diagnostic gold standard

5. Proprietary and confidential — do not distribute
It is a Significant Shift to more Traditional
Approaches Instead of LAPAROSCOPY
• Now focus on Non-Invasive Diagnostic Methods
• Does not require Laparoscopy for diagnosis.
• Good Gynaecologist should plan Medical
Management for Life
& follow Dictum for SURGERY once in life time / Bet
Caution against Repeated Surgeries .

6. Proprietary and confidential — do not distribute
MANTRA : Maximizing Medical treatment
optimized and individualized
Whether You & Your patient like it or not
 long-term medical management is
needed until seeking pregnancy
or, sometimes, menopause .
Endometriosis
Life Long Plan

7. Although many drugs are available for
endometriosis treatment, there is an unmet
need for a therapy that can preserve fertility
while mitigating the endometriosis
progression & associated pain.

8. Women with
endometriosis are
at risk of decreased
ovarian reserve and
ovarian tissue
damage which can
lead to:
Infertility
Premature ovarian
failure
Reduced response to
ovarian stimulation
Fertility Preservation should be the focus of
Endometriosis therapy in women of 18-40 yrs

9. Treatment option for Endometriosis
Surgical Medical
To destroy or prevent
the recurrence of
lesions
Adhesiolysis
DIE
Treatment
option for
Endometriosis

10. Features on Hysterolaparoscopy
• Number, location, and size of the endometriotic plaques, implants, lesions, and cysts are
determined and confirmed by histology although negative histology does not entirely
rule out the disease
Ovarian endometrioma is confirmed by histology or by presence of following features:
• Adhesions to pelvic side wall and/or broad ligament
• Endometriotic spots on ovarian surface
• Thick, tarry, and chocolate colored fluid inside the cyst

11. Features on Hysterolaparoscopy
Morphology of peritoneal and ovarian implants are characterized as
follows:
• Red (red, red-pink, and clear lesions)
• White (white, yellow-brown, and peritoneal defects)
• Black (black and blue lesions)

12. Need for Reduced Surgery to
preserve fertility

13. Infertility & Surgery : ONE & BEST
ESHRE, European Society of Human Reproduction and Embryology.
Becker CM, et al. Hum Reprod Open. 2022 Feb 26;2022(2):hoac009.
The decision to perform surgery should be guided by
the presence or absence of pain symptoms, patient
age and preferences, history of previous surgery,
presence of other infertility factors, ovarian reserve,
and estimated Endometriosis Fertility Index (EFI).
ESHRE
2022

14. 1. SOGC: Leyland et al. J Obstet Gynaecol Can 2010;37:S1–S32; 2. Busacca et al. Ital J Gynaecol Obstet 2018;30:7–21.
● Surgical management encompasses conservative and definitive procedures1
● Surgical management is indicated in the following groups:1,2
►Patients with pelvic pain who have not responded to medical therapy
►Patients who have declined medical therapy or have contraindications to
medical therapy
►Symptomatic patients with confirmed/suspected ovarian endometrioma of
>3 cm diameter or increasing volume
►Patients with functional organ damage (e.g. bowel sub-occlusion/occlusion,
urinary tract impairment with renal function involvement)
Surgery can be indicated for some women but decisions should consider
individual patient needs

15. 1. Duffy et al. Cochrane Database Syst Rev 2014.CD011031; 2. Guo. Hum Reprod Update 2009;15:441–461; 3.
Singh et al. J Obstet Gynaecol Can 2020;42:881–888;
● Systematic reviews of the literature
estimated the recurrence rate of
endometriosis to be 21.5% at 2 years and
40%–50% at 5 years,2 and
● Post-operative pain and pain recurrence
estimated to occur in 25%–34% and 16%–
29% of patients, respectively3
However…
Surgical excision of lesions shown to both improve pain and enhance fertility1

16. 1. 4. Busacca et al. Am J Obstet Gynecol 1999;180:519–523;
5. Koga et al. Hum Reprod 2006;21:2171–2174.
• Recurrence rates of endometrioma after
surgical excision are quite variable, ranging
from 7%‒30%4,5 depending on the duration
of follow-up, criteria for definition of
recurrence and prognostic profile of
patients
However…
Surgical excision of lesions shown to both improve pain and enhance fertility1

17. 1. Ouchi et al. J Obstet Gynaecol Res 2014;40:230–236; 2. SOGC: Leyland et al. J Obstet Gynaecol Can 2010;37:S1–S3; 3. World
Endometriosis Society: Johnson et al. Hum Reprod 2013;28:1552–1568;
4. ESHRE: Endometriosis Guideline of European Society of Human Reproduction and Embryology. 2022
International guidelines recognise the
importance of post-surgical medical
therapy to minimise recurrence of disease2–4
No post-surgical medical therapy
3 years: 23% recurrence1
5 years: 50% recurrence1
Post-surgical medical therapy for endometriosis can minimize the recurrence of disease

18. ART, assisted reproductive technology; COC, combined oral contraceptive; GnRH, gonadotropin-releasing hormone analogue.
Capezzuoli et al. Reprod Biomed Online. 2021;42:451‒456.
Objective: To identify the role of medical treatment both before and after surgery, with the aim of preventing
endometriosis recurrence and reducing repetitive surgery for recurrence
No hormonal treatment
and after first surgery
N=185 Hormonal treatment after first surgery
n=34
n=75
≥2 years follow-up after surgery
n=76
First
surgery
Hormonal treatment before
(Minimum of 12 months)
Inclusion criteria
● Fertile age (25–45 years)
● Previous surgery for endometriosis
● No desire for pregnancy
● Nulliparity
Exclusion criteria
● Women wishing to become pregnant when the survey was conducted
or those who had previously tried to conceive, both naturally or
through ART
Hormonal treatment:
● Progestins (40%), GnRHa
(30%) or COC (30%)
● Minimum of 12 months before
surgery
● Prolonged for 2 years or more
after surgery
Observational study to determine the effect of long-term hormonal
treatment on the need for repetitive surgery for recurrence of disease

19. ART, assisted reproductive technology; COC, combined oral contraceptive; GnRH, gonadotropin-releasing hormone analogue.
Capezzuoli et al. Reprod Biomed Online. 2021;42:451‒456.
Compared with women who received hormonal
treatment only after surgery, those receiving
hormonal treatment before and after the first
surgery had:
• Lower incidence of endometriosis recurrence
requiring reoperation (P=0.011)
● Lower rate of current dysmenorrhea (P=0.006)
Key message
“Hormonal treatment is useful as an alternative to surgery,
before surgery to plan better, and after surgery to reduce the
risk of recurrence. These data have several implications in
individualized endometriosis surgery.”
Hormonal treatment before and after surgery reduced the need for
repetitive surgery for disease recurrence

20. AMH, anti-Mullerian hormone.
Raffi et al. J Clin Endocrinol Metab 2012;97:3146–3154.
Meta-analysis of weighted mean difference in serum AMH
post-surgery for endometrioma
“The results of this study suggest a negative impact of excision of endometriomas on
ovarian reserve as evidenced by a significant postoperative fall in circulating AMH”
How should the impact of excision of endometriomas on ovarian
reserve be minimized?

21. Surgical Treatment of associated infertility
ESHRE, European Society of Human Reproduction and Embryology; GDG, Guideline Development Group; MRI, magnetic resonance imaging; US, ultrasonography
Becker CM, et al. Hum Reprod Open. 2022 Feb 26;2022(2):hoac009.
Recommendations Strength
Laparoscopy could be offered as a treatment option (in rASRM stage I/II
endometriosis) as it improves the rate of ongoing pregnancy.
Weak
Laparoscopy may be an option in symptomatic patients wishing to conceive in stage
3 & 4 endometriosis. Golden time for ART is 1st 6 months
Weak
ESHRE
2022

22. Few Tips on Medical
Therapies for
Endometriosis with
Pain & Infertility

23. Endometriosis Tt : Pain and Ovulation ESHRE
2022
Pain • Ovulation inhibition is not required and is not
necessary for endometriosis-associated pain
treatment.
• NSAIDS are good enough
• There is also some limited evidence that
NSAIDs might inhibit ovulation if taken
continuously during the cycle (making
conception less likely)

24. Women with endometriosis have a lower
monthly fecundity of about 0.02–0.1 per
month.
Endometriosis is associated with a lower
live birth rate.
Infertile women are 6 to 8 times more likely to
have endometriosis than fertile women.
Endometriosis and Infertility
Bulletti C, et al. J Assist Reprod Genet. 2010;27(8):441–447.

25. Proprietary and confidential — do not distribute
Doctors dilemma in endometriosis pt coming
for ART- pain and infertility
Pain Infertilityb
Combined oral
contraceptives1
GnRH
analogues4
Surgery1,3 Laparoscopic
surgery5,6 c
Ovulation induction7
ART5
Surgery1,3
Analgesics2 a
Progestogens1

26. Endometriosis & A R T
ESHRE, European Society of Human Reproduction and Embryology.
Becker CM, et al. Hum Reprod Open. 2022 Feb 26;2022(2):hoac009.
ESHRE
2022
• for endometriosis-associated infertility,
medical therapies that suppress
ovulation in general are ineffective and
should not be used.TIP 1
• Medical Therapy after surgery in
infertile women with endometriosis
clinicians should not prescribe ovarian
suppression treatment to improve
fertility. TIP 2
Infertility

27. TAKE HOME TIPS :infertility & Endom
ESHRE, European Society of Human Reproduction and Embryology; GDG, Guideline Development Group; MRI, magnetic resonance imaging; US, ultrasonography
Becker CM, et al. Hum Reprod Open. 2022 Feb 26;2022(2):hoac009.
Recommendations Strength
Clinicians should not prescribe ovarian suppression treatment to improve fertility. Strong
Women seeking pregnancy should not be prescribed postoperative hormone suppression
with the sole purpose to enhance future pregnancy rates.
Strong
Women who cannot attempt to conceive immediately after surgery may be offered
hormone therapy (it doesn’t negatively impact fertility and improves the outcome of
surgery for pain).
Weak
Clinicians should not prescribe pentoxifylline, other anti-inflammatory drugs or letrozole
outside ovulation-induction to improve natural pregnancy rates.
Strong
ESHRE
2022

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NEW WAY FOR MORE EFFECTIVE , LESS INVASIVE TT &
IMPROVING QUALITY OF LIFE