1. Endometriosis and
Dr. Sharda Jain / Dr. Jyoti Agarwal
…Caring Hearts, Healing hands
INFERTILITY
an update

2. Katrina Kaif
Queen Visctoria
Hillary Clinton
Marilyn Monroe
Endometrios is a full of mystery

3. •Diagnostic Dilemma
•Debilitating Disease
•Progressive Disease
•Disease with “No Cure”
A Gynaecologist’s Dilemma

4. Prevalence of Endometriosis
176 million women with endometriosis
during the prime years of their lives…
1 in 10 women suffer from endometriosis
Rogers et al, Reprod Sci 2009;16:335-346
World Bank, Population Projection Tables by Country and Group, 2010
Most of whom have not been diagnosed &
treated!!!
Adamson et al. J of Endometriosis 2010;2:3-6

5. Prevalence of endometriosis in India
“5% girls below 18 who complained of dysmenorrhea
are affected by endometriosis”
Kolkata Survey
Endometriosis Society, India
at least 26 million Indian women between the ages of
18 and 35 were afflicted by endometriosis
2007 survey
Dr P Das Mahapatra
Endometriosis Society of India

6. Endometriosis begins at early age
Nnoaham et al, Global Study of women`s Health

7. Getting to know the woman
with endometriosis
Nnoaham et al, J of Endometriosis
2009;1:36-45
Not a life-style disease
No prevention

8. Endometriosis is a challenging disease and
requires decision making at every stage by
the clinician & the patient

9. Endometriosis at ALL stages has a
negative impact on infertility
More severe is
the disease ,
lesser is the
fecundity

10. Important Facts
• 25-50% of infertile
women have
endometriosis
• 30-50% of women with
endometriosis are
infertile
• Infertile women are 6-8
times more likely to
have endometriosis
than fertile women
Endometriosis and Infertility

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

12. Why do we need
these guidelines
???

13. Even today endometriosis remains
an enigma full of mystery

14. “There is much , that is
still not understood
and the condition
continues to arise
interest and
controversies”.
Robert W. Shaw
““ He who knows endometriosisHe who knows endometriosis
knows Gynaecology ”knows Gynaecology ”
Sir William Osler

15. There is a BIG Tussle
between Laproscopists and IVF specialists about
management of infertility in patients of
endometriosis

16. Aim is to help Gynaecologists
make their own decision

17. Query 1
Are hormonal therapies effective
for infertility associated with
endometriosis ??

18. Stage I (Minimal) Stage II (Mild)
Stage III (Moderate) Stage IV (Severe)
Classification of Endometriosis
R
E
V
I
S
E
D
A
F
S
S
C
O
R
E
R
E
V
I
S
E
D
A
F
S
S
C
O
R
E

19. Hormonal therapy and infertility
Suppression of ovarian function by means of
hormonal contraceptives , progestagens
GnRH analogues or danazol to improve
fertility in patients with minimal or mild
endometriosis is NOT effective and hence
should not be offered for this indication
alone .
Evidence does not comment on more severe disease
(Hughes et al., 2007). A

20. Big Question 2
Is Surgery effective for infertility
associated with
endometriosis ??

21. Infertile women with Stage I/II endometriosis
Evidence recommends
that clinicians should
perform operative
laparoscopy (excision
and adhesiolysis )
rather than performing
diagnostic laparoscopy
only to increase
pregnancy rates
(Nowroozi , 1987; Jacobson , 2010).

22. Women with Stage III/IV Endometriosis
So far no RCT,s comparing the reproductive
outcome after surgery and after expectant
management is available but
2 cohort studies have shown
better pregnancy rate after surgery so
Clinicians can consider operative laparoscopy,
instead of expectant management,
to increase spontaneous pregnancy rate
(Nezhat et al., 1989; Vercellini et al.,2006). B

23. Effectiveness of Surgical
techniques
Big Question

24. Effectiveness of Surgical techniques
Guidelines recommend that in infertile
patients with chocolate cyst clinicians
should perform excision of the
endometrioma capsule, instead of
drainage and electrocoagulation to
increase spontaneous pregnancy rates .
(Hart et al., 2008) A

25. why excision and not ablation ?
Cyst wall excision provids greater improvement
– Spontaneous pregnancy rates
– Dysmenorrhea and deep-dyspareunia
–Recurrence and repeat surgery
– Allows histo-pathological examination
Coagulation/ laser vaporization without excision is
associated with increase risk of cyst recurrence.
ASRM Practice Guidelines 2013
Possibility of occult malignancy to be kept in mind

26. MOST IMPORTANT !!!!
surgery must be complete &
performed by a qualified gynae
surgeon with experience in dealing
with endometriosis.

27. Other techniques
• Clinicians may consider CO2 laser vaporization of
endometriosis, instead of monopolar
electrocoagulation, as laser vaporization is
associated with higher cumulative spontaneous
pregnancy rates .
• Unfortunately cost has been a big factor to prevent
widespread availability of co2 laser
(Chang et al., 1997).

28. Counselling ….. Two concerns
Ovarian Reserve Recurrence
Decision to proceed with surgery should
be considered very carefully ,especially if the
women has had previous ovarian surgery

29. Is hormonal therapy
effective as an
adjunct to surgical
therapy for
treatment of
infertility?
Question 3

30. Endometriosis:
Medical
In minimal or mild
endometriosis it
does not enhance
fertility and hence
should not be offered
Surgical
Offered in minimal
or mild and
moderate to severe
endometriosis
Medical treatment is not effective
Rather delays fertility restoration

31. • In infertile women with endometriosis, clinicians
should not prescribe adjunctive hormonal
treatment before or after surgery to improve
spontaneous pregnancy rates (Furness et al., 2004).
A
But clinicians should not withhold hormonal
treatment for pain in symptomatic women in the
waiting period before undergoing surgery or
medically assisted reproduction .
GPP

32. Is ART needed in
women with
Endometriosis
???

33. ART …. Not complementary but needed

34. Objective is the baby
Dictum is to send the patient for ART
earlier than late

35. IUI in endometriosis
Live Birth Rate is 5.6 times higher in
couples with minimal to mild endometriosis
after COS with gonadotrophins and IUI as
compared to couples after expectant
management .

36. Recommendation ......for IUI
In women with stage I/II endometriosis,
Clinicians may perform IUI with
controlled ovarian stimulation
• instead of expectant management &
• instead of IUI alone .
C

37. Definitely refer for ART a little earlier
 IUI improves fertility with
superovulation .
 Role of unstimulated IUI is
uncertain
 IVF is appropriate where IUI fails

38. Recommendations for ART
IVF is the treatment of choice if
 Tubal function is compromised
 There is male factor infertility
 Other treatments have failed
 Stage 3 -4 endometriosis

39. What’s different ???
IVF in Endometriosis

40. Issues to be considered
Remember …..
Endometriosis has decreased per cycle
conception rates in comparison with male
factor and unexplained infertility .
Recurrence rates of endometriosis does
not increase after COH for IVF - ICSI
Ultra long protocol and ICSI is Rx of
choice for endometriosis

41. If patient is for IVF ......
Is medical therapy effective as an
adjunct to ART for
endometriosis-associated
infertility ???

42. Answer is ….
Clinicians can prescribe GnRH agonists for a
period of 3–6 months prior to ART to
improve clinical pregnancy rates in infertile
women with endometriosis.
Down regulation for 3-6 months with a GnRH
agonist (depot preparation) increases the odds of
clinical pregnancy by more than 4 fold.
(sallam et al.,2006 ) B

43. Should surgery be performed prior to
treatment with ART to improve
reproductive outcome?

44. Does Surgery improves success ??
In women with Stage I / II endometriosis
undergoing laparoscopy prior to ART,
clinicians may consider the complete
surgical removal of endometriosis to
improve live birth rate, although the benefit
is not well established .
(Opoien et;al 2011) C

45. Laparascopy should
NOT be performed
prior to ART in all
women with the
only aim to
diagnose and
subsequently treat
endometriosis in
order to improve
the result of the ART
treatment .

46. Remember ….
• Benefit of laparoscopy in minimal or mild
endometriosis is insufficient to recommend
laparoscopy solely to increase pregnancy
rates.
• Laparoscopy in infertile woman,
simply to confirm or rule out the disease is
not warranted.
ASRM COMMITTEE REPORT 2012

47. Surgical Rx
17 – 44 % of patients with endometriosis
develops ENDOMETRIOMA which affects
ART outcome
Female age, duration of infertility, stage of
disease, pelvic pain should be considered
while formulating a treatment plan.

48. Women with stage 3- 4 endometriosis
Women with chocolate cyst
larger than 3 cm there is NO evidence that
cystectomy prior to treatment with
ART improves pregnancy rates . ( A )
Consider cystectomy prior to ART
ONLY to improve
• endometriosis-associated pain or
• difficulty in oocyte retrival (GPP)

49. Role of ultrasound guided
cyst aspiration
TVS aspiration offers a nonsurgical approach

50. TO DRAIN OR NOT TO DRAIN
• Satistically reproductive outcome with or
without cyst aspiration is NOT different.
• If more than 4 cm , aspiration may be better
than surgery , (especially in recurrent cases)
Bigger & Recurrent cysts are
drained before stimulation

51. Deep infiltrating endometriosis
The effectiveness of surgical excision is NOT
well established with regard to reproductive
outcome.
However, these women often suffer from
pain, requesting surgical treatment.
C

52. What to do in Recurrent
endometriosis ??
Hum reprod 2009
IVF – ICSI is a better option

53. experiences & strategy
• On laparoscopy , even
small deposits seen are
fulgurated & thus
managed aggressively .
• Generally , laparoscopy
is reserved for chocolate
cyst of more than 4 cm in
size.
• Small chocolate cysts with
short period of infertility ,
COH & IUI is tried for 3- 4
cycles before taking up for
laparoscopy .
• For chocolate cysts
cystectomy is done , but
sometimes there may be
technical difficulties then
removal of the cyst lining
as much as possible is
done , along with
fulguration of the rest.

54. Tips from……
• Do a complete surgery.
• Do not cauterize excessively.
• Adhesions preventing barriers have
a role.
• Medical management: improves pain, not fertility
• Surgical management improves both pain and infertility
Success depends upon the residual
disease left behind

55. To conclude …….
• Medical Rx has no role in
improving fertility
• In minimal to mild disease,
ovulation induction and IUI is
first line therapy.
• Laparoscopic Sx with removal of
all endometriotic implants and
IVF –ICSI with long long protocol
is the treatment of choice for
moderate to severe disease.

56. So friends…..
Take a step in the right
direction ….

57. ASRM 2012
ENDOMETRIENDOMETRI OSIS & INFERTILITYOSIS & INFERTILITY

58. He/ She who knows Endometriosis
knows Gynaecology
Thank youThank you

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