Endometriosis 2 Difficulty: Objectives: 1. Management of infertility and endometriosis 2. To choose the most appropriate ART treatment 3. To prevent complications of ART

with 1ry Infertility of 5 years Female factor: Endometriosis diagnosed by laparoscopy Male factor: Semen analysis normal 40y 41y Family History: mother thrombosis at 40 years; brother thrombosis at 31 years Social History: non smoker, no alcohol, no drugs

Obstetrical-Gynaecological History: G0 P0 Menarche 13y Cycles: regular (ovulation confirmed by D21 Progesterone) Moderate dysmenorrhea, No dyspareunia, No chronic pelvic pain No hirsutism No previous infertility treatments BMI=23 Lap and Dye test: Drainage of the endometriomas; both tubes patent

Results FSH 11 mIU/ml LH 8.2 mIU/ml E2 120 pmol/l AMH 3 pmol/l Endometriomas of both ovaries of 3 and 2 cm US: AFC 3+2 Ovarian reserveUS

Which hormonal treatment for suppression of ovarian function is effective to improve fertility and spontaneus conception in patient with endometriosis? A.Danazol B.GnRH analogues C.Oral contraceptive pill D.None of above

Which hormonal treatment for suppression of ovarian function is effective to improve fertility and spontaneus conception in patient with endometriosis? A.Danazol B.GnRH analogues C.Oral contraceptive pill D.None of above

Which treatment do you propose in this case? A.Programmed intercourse B.Egg donation C.IVF D.None of above

Which treatment do you propose in this case? A.Programmed intercourse B.Egg donation C.IVF D.None of above

Decided with the couple to perform IVF Protocol chosen:  Long protocol with GnRH analogues 0.1 mg from day 21  Dose of gonadotropins 375 U/day Treatment

Should surgery be performed prior to treatment with ART to improve reproductive outcomes? A.Yes, surgical therapy is mandatory in endometriosis patients before ART B.Yes, surgical therapy is mandatory only in women with ovarian endometrioma before ART C.Yes, surgical therapy is mandatory only in women with deep endometriosis before ART D.No, there is no evidence that surgery before ART improves pregnancy rate

Should surgery be performed prior to treatment with ART to improve reproductive outcomes? A.Yes, surgical therapy is mandatory in endometriosis patients before ART B.Yes, surgical therapy is mandatory only in women with ovarian endometrioma before ART C.Yes, surgical therapy is mandatory only in women with deep endometriosis before ART D.No, there is no evidence that surgery before ART improves pregnancy rate

A.Yes B.No, first to do PT, PTT, Fibrinogen only C.No, first to perform a thrombophilic screen with coagulation tests D.None of above Can we start directely with the COS in patient with family history of thrombosis?

A.Yes B.No, first to do PT, PTT, Fibrinogen only C.No, first to perform a thrombophilic screen with coagulation tests D.None of above Can we start directely with the COS in patient with family history of thrombosis?

Results of coagulation tests 1. Heterozygous Prothrombin (factor II) mutation 2. Hematologist counseling: start LMWH from COS

Mettere beta

Gonadotropin ovarian stimulation for IVF/ICSI is associated with increased risk of recurrence of endometriosis? A.Yes, you have to inform the patient before to start the treatment B.Yes, only in severe endometriosis C.No, the ESHRE guidilines conclude that Gonadotropin ovarian stimulation for IVF/ICSI is not associated with increased risk D.None of above

Gonadotropin ovarian stimulation for IVF/ICSI is associated with increased risk of recurrence of endometriosis? A.Yes, you have to inform the patient before to start the treatment B.Yes, only in severe endometriosis C.No, the ESHRE guidilines conclude that Gonadotropin ovarian stimulation for IVF/ICSI is not associated with increased risk D.None of above

In agreement with ESHRE guidelines, is the use of antibiotic prophylaxis reasonable at the time of oocyte retrieval? A.Yes, clinicians may use antibiotic prophylaxis, although the risk of ovarian abscess following follicle aspiration is low B.No, antibiotic prophylaxis is contraindicated before ART C.No, you have to utilize anti-inflammatory drugs D.None of above

In agreement with ESHRE guidelines, is the use of antibiotic prophylaxis reasonable at the time of oocyte retrieval? A.Yes, clinicians may use antibiotic prophylaxis, although the risk of ovarian abscess following follicle aspiration is low B.No, antibiotic prophylaxis is contraindicated before ART C.No, you have to utilize anti-inflammatory drugs D.None of above