MANAGEMENT OF ENDOMETRIOSIS ASSOCIATED INFERTILITY STATE OF THE ART! ISSAM LEBBI MD,PhD Ob-Gyn & Fertility Private Clinic Dream Center,Montplaisir,Tunis Tunisia SGOM session On 13th TJOD , May 12th, 2015

LAPAROSCOPY PERMIT THE DIAGNOSIS ! NORMAL HYSTERO-SALPINGOGRAPHY IN LAPAROSCOPICALLY DIAGNOSED ENDOMETRIOSIS *DONNEZ : 19.2 % *RICE : 45.5 % *WOOD : 42 % *LEBBI : 27 %

LAPAROSCOPY PERMIT THE TREATMENT ! IN LAPAROSCOPY: ENDOMETRIOSIC LESIONS LAPAROSCOPIC TREATMENT IN THE SAME OPERATIVE TIME Why ? *Laparoscopic treatment of stage 1 and 2 improve significantly the spontaneous pregnancy rates: 30.7 % Vs 17.7 % Marcoux J & Maheux R,NEJM.1997 *Surgery improve fertility in stage 3 and 4 Farquhar C, Curr.Opinion Gyn Obs.1998

BUT THE INTEREST OF LAPAROSCOPY IN ENDOMETRIOSIS STILL HIGHLY DISCUSSED *No comparative randomised studies with ART techniques *Operative risks and morbidity of laparoscopy *Wich surgical procedure ?: minimal surgery (coagulation) or radical and extensive surgery (large excision= experience and expertise of the operator) *Benefit /cost of laparoscopy

THE INTEREST OF LAPAROSCOPY IN ENDOMETRIOSIS INFERTILITY +/- ENDOMETRIOSIC CLINICS AND/OR PARACLINICS SYMPTOMS (PROBABLY STAGE 3 & 4 asrm) ! LAPAROSCOPY +/- SURGERY LIMITED TO PERITONEUM OR EXTENSIVE ?? (EL3)

SURGERY OF ENDOMETRIOSIS ALONE OR BEFORE IVF-ET IMPROVE THE RESULTS OF INFERTILITY ! *Retrospective study *29 operated patients AFTER IVF-ET FAILURE *22 pregnancies ( 76 %) -15 without IVF-ET ( 52 % ; 68 % of pregnancies) -7 by IVF/ICSI ( 24 % ; 32 % of pregnancies) Littman E & Nezhat C,Fertil Steril.2005 *107 infertile patients treated by laparoscopy for endometriosis *Follow-up: 1 to 11 years *40 spontaneous pregnancies after surgery : 34,4 % *67 IVF-ET after surgery: Pregnancy rate = 56,1% (significant) *The higher pregnancy rate after surgery is at 6 MONTHS =23,2% Coccia M,Eur J Obstet Gynecol Reprod Biol.2008

SURGERY OF THE ADVANCED STAGES AND DEEP INFILTRATIVE ENDOMETRIOSIS (DIE) DOES EXTENSIVE LAPAROSCOPIC EXCISION OF DIE IMPROVE SPONTANEOUS AND IVF-ET PREGNANCY RATES ? °Yes -Prospective cohort study of 179 women with DIE: *Gr A= 105 IVF without surgery *Gr B= 64 extensive surgery before IVF -The odds ratio of achieving a pregnancy were 2.45 time greater in Gr B than in Gr A: 41% Versus 24%,p=0.001 Bianchi PH, J Minim Invasive Gynecol.2009

SURGERY OF ENDOMETRIOMAS °Q1-EXCISIONAL SURGERY OR ABLATIVE SURGERY (CYSTECTOMY OR DRAINAGE AND ELECTROCOAGULATION OF THE CYST WALL) !? *2 RCTs of laparoscopic surgery of cyst (size>3 cm) *exisional surgery (Cystectomy) provides more favourable oucome with regard to: -The reccurence of endometrioma -The reccurence of pain -The subsequent spontaneous pregnancy rate -BUT,in case of a subsequent ART (IIU OR IVF-ET): « INSUFFISANT EVIDENCE EXISTS TO DETERMINE THE BEST SURGICAL APPROACH »: Hart R,Cochrane Database Sys Rev.2008 *RCTs showed that the excision technique is associated with higher pregnancy rate and a lower rate of reccurence although it may determine severe injury to the ovarian reserve. Somigliana E,Placenta.2011 °Q2-DOES PRESENT ENDOMETRIOMAS REDUCE IVF OUTCOME & DOES LAPAROSCOPIC SURGERY OF ENDOMETRIOMAS BEFORE IVF IMPROVE IVF RESULTS ? 1*Women with endometriomas have a higher cancellation rate, a similar pregnancy, implantation and delivery rate.Endometrioma does not reduce IVF outcome. 2*Lower AFC and higher gonadotropin doses. Surgery of Omas before IVF does not improve IVF outcome. Bongioanni F, Reprod Biol Endocrinol.2011

SURGERY OF ENDOMETRIOSIS ASSOCIATED INFERTILITY « IT IS A PLEA FOR RESEARCH   » Somigliana E,Placenta .2011 *The purported benefit of surgery may be overvalued (uncontrolled studies) *The overal increase in post-operative pregnancy rates is estimated between 10 & 25% *The role of surgery before,after or as an alternative to IVF needs clarification. Vercellini P,Hum Reprod.2009 *Surgery improves the chance of concieving in the 12-18 months afterwards the extension of the disease to the ovaries may reduce the ovarian response to C.O.S in IVF-ET *Surgery of endometriomas can reduce ovarian response to C.O.S in IVF-ET but is not associated with reduced oocyte quality or ART outcome *Pre-ART oral contraception improve ART outcome particularly if endometriomas are present at time of retrieval. De Ziegler D, Minerva Ginecol.2011

THE MEDICAL TREATMENTS !?

A PROPOSAL OF A PRAGMATIC APPROACH Age>35years Poor Ovarian Reserve(AMH) EMMERGENCY ART INFERTILITY +/- ENDOMETRIOSIC CLINICS AND/OR PARACLINICS SYMPTOMS NO LAPAROSCOPY +/- SURGERY LIMITED TO PERITONEUM OR EXTENSIVE ?? (EL3) ALTERED TUBES ABNORMAL SPERM YES NO EXPECTATIVE FOR12-18 MONTHS OP x 6 to 10 weeks GnRh Analogs  2 To 3 Months IVF-ET OVARIAN STIMULATION + IUI  6 à 14 CYCLES (EL3)