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Proprietary and confidential — do not distribute
The Newer
Concepts
In
Endometriosis
Management Dr. Sharda Jain
Proprietary and confidential — do not distribute
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
Proprietary and confidential — do not distribute
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 .
Proprietary and confidential — do not distribute
Treatment option for Endometriosis
Surgical Medical
To destroy or
prevent the
recurrence of
lesions
Adhesiolysis
Treatment
option for
Endometriosis
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 .
Wide range of Harmonal Therapy DIENOGEST
DIENOGEST
Endometriosis
Life Long Plan
Proprietary and confidential — do not distribute SPECTRA job code: GLO1167549-2 I July 2023
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.
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)
Proprietary and confidential — do not distribute
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.
Proprietary and confidential — do not distribute
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
Proprietary and confidential — do not distribute SPECTRA job code: GLO1167549-2 I July 2023
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
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
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
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
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
© 2023 Abbott
Proprietary and confidential — do not distribute GLO1167549-2 I July 2023
R BCB B
ROLE OF SURGERY IN FERTILITY ENHANCEMENT
ADVOCATING
LESS AGGRESSIVE APPROACHES
BUT DOES NOT MEAN  DRAIN & COME OUT
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
© 2023 Abbott
Proprietary and confidential — do not distribute GLO1167549-2 I July 2023
MESSAGE OF HOPE & REASSURANCE
FOR THIS CHALLENGING CONDITION
SEGMENTED IVF HELPS
Proprietary and confidential — do not distribute SPECTRA job code: GLO1167549-2 I July 2023
NEW WAY FOR MORE EFFECTIVE , LESS INVASIVE & IMPROVING
QUALITY OF LIFE
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

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The Newer Concepts In Endometriosis Management : Dr Sharda Jain

  • 1. Proprietary and confidential — do not distribute The Newer Concepts In Endometriosis Management Dr. Sharda Jain
  • 2. Proprietary and confidential — do not distribute 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
  • 3. Proprietary and confidential — do not distribute 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 .
  • 4. Proprietary and confidential — do not distribute Treatment option for Endometriosis Surgical Medical To destroy or prevent the recurrence of lesions Adhesiolysis Treatment option for Endometriosis
  • 5. 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 . Wide range of Harmonal Therapy DIENOGEST DIENOGEST Endometriosis Life Long Plan
  • 6. Proprietary and confidential — do not distribute SPECTRA job code: GLO1167549-2 I July 2023 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)
  • 8. Proprietary and confidential — do not distribute 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.
  • 9. Proprietary and confidential — do not distribute 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
  • 10. Proprietary and confidential — do not distribute SPECTRA job code: GLO1167549-2 I July 2023 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
  • 11. 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
  • 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
  • 15. © 2023 Abbott Proprietary and confidential — do not distribute GLO1167549-2 I July 2023 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
  • 17. © 2023 Abbott Proprietary and confidential — do not distribute GLO1167549-2 I July 2023 MESSAGE OF HOPE & REASSURANCE FOR THIS CHALLENGING CONDITION SEGMENTED IVF HELPS
  • 18. Proprietary and confidential — do not distribute SPECTRA job code: GLO1167549-2 I July 2023 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

Editor's Notes

  1. While medical therapy is effective for relieving pain associated with endometriosis, there is no evidence that medical treatment of endometriosis improves fertility; indeed, fertility is essentially eliminated during treatment because all medical treatments for endometriosis inhibit ovulation3 Age, duration of infertility, pelvic pain, and stage of endometriosis should all be considered when formulating a management plan3 References Vercellini P, Buggio L, Berlanda N, Barbara G, Somigliana E, Bosari S. Estrogen-progestins and progestins for the management of endometriosis. Fertil Steril. 2016 Dec;106(7):1552-1571.e2. doi: 10.1016/j.fertnstert.2016.10.022. Epub 2016 Nov 4. PMID: 27817837. Dunselman GA, Vermeulen N, Becker C, Calhaz-Jorge C, D'Hooghe T, De Bie B, Heikinheimo O, Horne AW, Kiesel L, Nap A, Prentice A, Saridogan E, Soriano D, Nelen W; European Society of Human Reproduction and Embryology. ESHRE guideline: management of women with endometriosis. Hum Reprod. 2014 Mar;29(3):400-12. doi: 10.1093/humrep/det457. Epub 2014 Jan 15. PMID: 24435778. Practice Committee of the American Society for Reproductive Medicine. Endometriosis and infertility: a committee opinion. Fertil Steril. 2012 Sep;98(3):591-8. doi: 10.1016/j.fertnstert.2012.05.031. Epub 2012 Jun 15. PMID: 22704630.
  2. While medical therapy is effective for relieving pain associated with endometriosis, there is no evidence that medical treatment of endometriosis improves fertility; indeed, fertility is essentially eliminated during treatment because all medical treatments for endometriosis inhibit ovulation3 Age, duration of infertility, pelvic pain, and stage of endometriosis should all be considered when formulating a management plan3 References Vercellini P, Buggio L, Berlanda N, Barbara G, Somigliana E, Bosari S. Estrogen-progestins and progestins for the management of endometriosis. Fertil Steril. 2016 Dec;106(7):1552-1571.e2. doi: 10.1016/j.fertnstert.2016.10.022. Epub 2016 Nov 4. PMID: 27817837. Dunselman GA, Vermeulen N, Becker C, Calhaz-Jorge C, D'Hooghe T, De Bie B, Heikinheimo O, Horne AW, Kiesel L, Nap A, Prentice A, Saridogan E, Soriano D, Nelen W; European Society of Human Reproduction and Embryology. ESHRE guideline: management of women with endometriosis. Hum Reprod. 2014 Mar;29(3):400-12. doi: 10.1093/humrep/det457. Epub 2014 Jan 15. PMID: 24435778. Practice Committee of the American Society for Reproductive Medicine. Endometriosis and infertility: a committee opinion. Fertil Steril. 2012 Sep;98(3):591-8. doi: 10.1016/j.fertnstert.2012.05.031. Epub 2012 Jun 15. PMID: 22704630.
  3. Fertility Preservation in women of reproductive age (18–40 years) should be the focus of endometriosis therapy. Women with endometriosis are at risk of decreased ovarian reserve and ovarian tissue damage that can lead to infertility, reduced response to ovarian stimulation, and premature ovarian failure.1,2 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. References Carrillo L, Seidman DS, Cittadini E, et al. The role of fertility preservation in patients with endometriosis. J Assist Reprod Genet. 2016;33(3):317–23. Llarena NC, Falcone T, Flyckt RL. Fertility preservation in women with endometriosis. Clin Med Insights Reprod Health. 2019;13:1–8.
  4. References Becker CM, Bokor A, Heikinheimo O, Horne A, Jansen F, Kiesel L, King K, Kvaskoff M, Nap A, Petersen K, Saridogan E, Tomassetti C, van Hanegem N, Vulliemoz N, Vermeulen N; ESHRE Endometriosis Guideline Group. ESHRE guideline: endometriosis. Hum Reprod Open. 2022 Feb 26;2022(2):hoac009. doi: 10.1093/hropen/hoac009. PMID: 35350465; PMCID: PMC8951218.
  5. Endometriosis is closely linked with infertility. In normal couples, fecundity is in the range of 0.15 to 0.20 per month and decreases with age. Women with endometriosis tend to have a lower monthly fecundity of about 0.02–0.1 per month. Also, endometriosis is associated with a lower live birth rate. Infertile women are six to eight times more likely to have endometriosis than fertile women. Reference Bulletti C, Coccia ME, Battistoni S, et al. Endometriosis and infertility. J Assist Reprod Genet. 2010;27(8):441–447.
  6. The pathogenic mechanisms associated with infertility in endometriosis include underlying adhesions, ovarian cyst, change in tubal anatomy,1 abnormal folliculogenesis, elevated oxidative stress, altered immune function, altered hormonal milieu in the follicular and peritoneal environment, and reduced endometrial receptivity.2 References Rafique S, Decherney AH. Medical management of endometriosis. Clin Obstet Gynaecol. 2017;60(3):485. Gupta S, Goldberg JM, Aziz N, Goldberg E, Krajcir N, Agarwal A. Pathogenic mechanisms in endometriosis-associated infertility. Fertil Steril. 2008;90(2):247-257.
  7. Fertility Preservation in women of reproductive age (18–40 years) should be the focus of endometriosis therapy. Women with endometriosis are at risk of decreased ovarian reserve and ovarian tissue damage that can lead to infertility, reduced response to ovarian stimulation, and premature ovarian failure.1,2 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. References Carrillo L, Seidman DS, Cittadini E, et al. The role of fertility preservation in patients with endometriosis. J Assist Reprod Genet. 2016;33(3):317–23. Llarena NC, Falcone T, Flyckt RL. Fertility preservation in women with endometriosis. Clin Med Insights Reprod Health. 2019;13:1–8.
  8. The medical management of endometriosis is targeted towards controlling pain and suppression of the hormonally active endometriotic tissue1 Hormonal therapies that rely on suppression of the endometriotic tissue include combined oral contraceptives, progesterone-only contraceptives, gonadotropin-releasing hormone (GnRH) agonists, aromatase inhibitors, and danazol.1 However, they are limited by their side effects and negative impact on fertility1 Management of infertility in women with endometriosis is a complex issue and needs to take into account age, duration of infertility, severity of symptoms, and stage of the disease1 References Rafique S, Decherney AH. Medical Management of Endometriosis. Clin Obstet Gynecol. 2017 Sep;60(3):485-496. doi: 10.1097/GRF.0000000000000292. PMID: 28590310; PMCID: PMC5794019. Dunselman GA, Vermeulen N, Becker C, Calhaz-Jorge C, D'Hooghe T, De Bie B, Heikinheimo O, Horne AW, Kiesel L, Nap A, Prentice A, Saridogan E, Soriano D, Nelen W; European Society of Human Reproduction and Embryology. ESHRE guideline: management of women with endometriosis. Hum Reprod. 2014 Mar;29(3):400-12. doi: 10.1093/humrep/det457. Epub 2014 Jan 15. PMID: 24435778 Leonardi M, Gibbons T, Armour M, Wang R, Glanville E, Hodgson R, Cave AE, Ong J, Tong YYF, Jacobson TZ, Mol BW, Johnson NP, Condous G. When to Do Surgery and When Not to Do Surgery for Endometriosis: A Systematic Review and Meta-analysis. J Minim Invasive Gynecol. 2020 Feb;27(2):390-407.e3. doi: 10.1016/j.jmig.2019.10.014. Epub 2019 Oct 31. PMID: 31676397. Rzewuska AM, et al. Gonadotropin-Releasing Hormone Antagonists—A New Hope in Endometriosis Treatment? Journal of Clinical Medicine. 2023; 12(3) Chapron C, Marcellin L, Borghese B, Santulli P. Rethinking mechanisms, diagnosis and management of endometriosis. Nat Rev Endocrinol. 2019 Nov;15(11):666-682. doi: 10.1038/s41574-019-0245-z. Epub 2019 Sep 5. PMID: 31488888. Zondervan KT, Becker CM, Missmer SA. Endometriosis. N Engl J Med. 2020 Mar 26;382(13):1244-1256. doi: 10.1056/NEJMra1810764. PMID: 32212520. Deaton JL, Gibson M, Blackmer KM, Nakajima ST, Badger GJ, Brumsted JR. A randomized, controlled trial of clomiphene citrate and intrauterine insemination in couples with unexplained infertility or surgically corrected endometriosis. Fertil Steril 1990;54(6):1083–1088. doi: https://doi.org/10.1016/S0015-0282(16)54009-6 Carrillo L, Seidman DS, Cittadini E, Meirow D. The role of fertility preservation in patients with endometriosis. J Assist Reprod Genet. 2016 Mar;33(3):317-323. doi: 10.1007/s10815-016-0646-z. Epub 2016 Jan 14. PMID: 26768141; PMCID: PMC4785156.
  9. References Becker CM, Bokor A, Heikinheimo O, Horne A, Jansen F, Kiesel L, King K, Kvaskoff M, Nap A, Petersen K, Saridogan E, Tomassetti C, van Hanegem N, Vulliemoz N, Vermeulen N; ESHRE Endometriosis Guideline Group. ESHRE guideline: endometriosis. Hum Reprod Open. 2022 Feb 26;2022(2):hoac009. doi: 10.1093/hropen/hoac009. PMID: 35350465; PMCID: PMC8951218.
  10. References Becker CM, Bokor A, Heikinheimo O, Horne A, Jansen F, Kiesel L, King K, Kvaskoff M, Nap A, Petersen K, Saridogan E, Tomassetti C, van Hanegem N, Vulliemoz N, Vermeulen N; ESHRE Endometriosis Guideline Group. ESHRE guideline: endometriosis. Hum Reprod Open. 2022 Feb 26;2022(2):hoac009. doi: 10.1093/hropen/hoac009. PMID: 35350465; PMCID: PMC8951218.
  11. References Becker CM, Bokor A, Heikinheimo O, Horne A, Jansen F, Kiesel L, King K, Kvaskoff M, Nap A, Petersen K, Saridogan E, Tomassetti C, van Hanegem N, Vulliemoz N, Vermeulen N; ESHRE Endometriosis Guideline Group. ESHRE guideline: endometriosis. Hum Reprod Open. 2022 Feb 26;2022(2):hoac009. doi: 10.1093/hropen/hoac009. PMID: 35350465; PMCID: PMC8951218.
  12. References Becker CM, Bokor A, Heikinheimo O, Horne A, Jansen F, Kiesel L, King K, Kvaskoff M, Nap A, Petersen K, Saridogan E, Tomassetti C, van Hanegem N, Vulliemoz N, Vermeulen N; ESHRE Endometriosis Guideline Group. ESHRE guideline: endometriosis. Hum Reprod Open. 2022 Feb 26;2022(2):hoac009. doi: 10.1093/hropen/hoac009. PMID: 35350465; PMCID: PMC8951218.
  13. References Becker CM, Bokor A, Heikinheimo O, Horne A, Jansen F, Kiesel L, King K, Kvaskoff M, Nap A, Petersen K, Saridogan E, Tomassetti C, van Hanegem N, Vulliemoz N, Vermeulen N; ESHRE Endometriosis Guideline Group. ESHRE guideline: endometriosis. Hum Reprod Open. 2022 Feb 26;2022(2):hoac009. doi: 10.1093/hropen/hoac009. PMID: 35350465; PMCID: PMC8951218.