The Newer Concepts In Endometriosis Management ENDOMETRIOSIS IS ENIGMA DIAGNOSTIC DELEMMA 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

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The Newer
Concepts
In
Endometriosis
Management Dr. Sharda Jain

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ENDOMETRIOSIS IS ENIGMA
• DIAGNOSTIC DELEMMA
• 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

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Diagnostic Tips Signicant Shift to more
Traditional Approaches .
• Endometriosis is a chronic condition ,delay in diagnosis ,
• Non-Invasive Diagnostic Methods
• Does not require Laparoscopy for diagnosis.
• Good Gynaecologist should plan –
SURGERY once in life time.
Caution against Repeated Surgeries .

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

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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 .
Wide range of Harmonal Therapy DIENOGEST
DIENOGEST
Endometriosis
Life Long Plan

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

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

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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.

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Possible Pathogenic Mechanisms in
Endometriosis-Associated Infertility
Underlying
adhesions1
Ovarian cysts1
Change in
tubal anatomy1
Abnormal
folliculogenesis
2
Elevated
oxidative stress2
Altered immune
function2
Alteration of
follicular and
peritoneal
hormones2
Reduced
endometrial
receptivity2
1. Rafique S, et al. Clin Obstet Gynaecol. 2017;60(3):485. 2. Gupta S, et al. Fertil Steril. 2008;90(2):247–57.
Underlying
adhesions1
Elevated
oxidative stress2

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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

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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

12. 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

13. Infertility - Main guidance
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. Infertility - Main guidance
ESHRE, European Society of Human Reproduction and Embryology.
Becker CM, et al. Hum Reprod Open. 2022 Feb 26;2022(2):hoac009.
WHAT IS NEW?
•The extended administration of GnRH
agonist prior to ART treatment to improve live
birth rate in infertile women with endometriosis
(ultralong protocol) is NO longer
recommended due to unclear benefits.
ESHRE
2022

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R BCB B
ROLE OF SURGERY IN FERTILITY ENHANCEMENT
ADVOCATING
LESS AGGRESSIVE APPROACHES
BUT DOES NOT MEAN  DRAIN & COME OUT

16. 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
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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MESSAGE OF HOPE & REASSURANCE
FOR THIS CHALLENGING CONDITION
SEGMENTED IVF HELPS

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

19. 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 increase the chance of natural pregnancy, although no data from
comparative studies exist.
Weak
Laparoscopy may be an option in symptomatic patients wishing to conceive. Weak
ESHRE
2022