1. 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

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

3. 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

4. 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

5. 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)

6. 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

7. 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= Bianchi PH, J Minim Invasive Gynecol.2009

8. 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

9. 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 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

10. THE MEDICAL TREATMENTS !?

11. 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)