2. ENDOMETRIOSIS Dr. Zahra AsgariDr. Zahra Asgari Associate ProfessorAssociate Professor

3. The presence of viable, estrogen-sensitive, endometrial-like glands and stroma associated with aninflammatory response outside the uterus is globally referred to as endometriosis. Three subtypes of endometriosis endometriomas (ovarian cysts) superficial endometriotic implants (focus of disease primarily on the peritoneum) deeply infiltrating endometriosis (rectovaginal nodules).

4. disease affects 6–10% of reproductive aged Women The average age is approximately 28 years 21–47% of women presenting with subfertility 87% of those with chronic pelvic pain First degree relatives of individuals are 7 to 10-times more likely to have the disease

5. average time between onset of symptoms and a definitive diagnosis is 7–8 years

6. SymptomPercentage of Women With Endometriosis Presenting With Symptom Confounding Disorders Dysmenorrhea 79Adenomyosis, primarydysmenorrhea Pelvic pain69Irritable bowel syndrome,neuropathic pain,adhesions Dyspareunia45Psychosocial issues, vaginal atrophy Bowel symptom36 Hemorrhoids; constipation,inflammatory bowel disease Bowel pain29Anal fissures Infertility26Unexplained subfertility Ovarian mass or tumor 20Hydrosalpinx, benign ovarian cyst Dysuria10Cystitis

7. Mechanism of Subfertility Adhesion Reduced AMH Sperm damage Altered oocyte cytoskeleton Defect in endometrial biomarkers anatomic distortion from pelvic adhesions production of substances which are "hostile" to normal ovarian function, fertilization, and implantation

8. Mechanism of Pain Cytokines Hyperalgesic state

9. According to the Practice Committee of the American Society for Reproductive Medicine, “endometriosis should be viewed as a chronic disease that requires a life-long management plan with the goal of maximizing the use of medical treatment and avoiding repeated surgical procedures”

10. Clinical manifestations of endometriosis fall into three general categories: pelvic pain, infertility, and pelvic mass

11. There is no high quality evidence treatment decisions are individualized, taking into account the severity of symptoms, the extent and location of disease, whether there is a desire for pregnancy, the age of the patient, medication side effects, surgical complication rates, and cost

12. After the initial diagnostic procedure, expectant management is considered primarily for two groups of patients: women with no or minimal symptoms and perimenopausal women.

13. Initial approach Analgesics Estrogen-progestin oral contraceptives Thus, it is unclear whether a cyclic, continuous, or tricycle regimen is most effective [8]. If pain does not respond well to cyclic therapy, switching to continuous OC administration may be effective [22]. A monophasic pill is adequate822 Treatment of pelvic pain

14. Failure of initial medical therapy are not achieving adequate pain relief after a three- to six-month trial with analgesics or OCs

15. GnRH agonists: 6 months Progestrons: 6 to 12 months bone mineral density and lipid levels may be monitored, as appropriate, in patients on long-term therapy. Progesterone antagonists — Progesterone antagonists and selective progesterone receptor modulators. Aromatase inhibitors

16. Danazol is a 19-nortestosterone derivative with progestin-like effects. Mechanisms : 1) inhibition of pituitary gonadotropin secretion 2) direct inhibition of endometriotic implant growth 3) direct inhibition of ovarian enzymes responsible for estrogen production. Danazol is given orally in divided doses ranging from 400 to 800 mg daily, generally for six months

17. TREATMENT OF INFERTILITY Medical or Surgical?

18. Surgery’s aim is to remove macroscopic endometriosis implants and restore normal pelvic anatomy. it is important to weigh up benefits versus harm of surgical procedure Laparoscopy is preferred to laparotomy because of advantages of minimal tissue damage, of magnification, of faster recovery, and shorter hospital stay

19. Several studies demonstrated that, in infertile women with endometriosis stage I/II, clinicians should perform operative laparoscopy (excision or ablation of endometriosis lesions) including adhesiolysis, rather than performing diagnostic laparoscopy only, since there is a positive effect in regards to live birth and ongoing pregnancy According to ESHRE guidelines, clinicians may consider CO 2 laser vaporization of endometriosis

20. In infertile women with AFS/ASRM Stage I/II endometriosis, clinicians may perform IUI with controlled ovarian stimulation,

21. In infertile women with AFS/ASRM Stage III/IV endometriosis, clinicians can consider operative laparoscopy, instead of expectant management, to increase spontaneous pregnancy rates. Consider COH/ IUI or IVF

22. TREATMENT OF PELVIC MASS In women with ovarian endometrioma of >3 cm in size, surgeons should perform excision of endometrioma capsule instead of ablative surgery that is drainage and electro-coagulation of the endometrioma wall.

23. In infertile women with endometrioma larger than 3 cm there is no evidence that cystectomy prior to treatment with ART improves pregnancy rates In women with endometrioma larger than 3 cm, the Eshre recommends clinicians only to consider cystectomy prior to ART to improve endometriosis-associated pain or the accessibility of follicles.

24. The Eshre recommends that clinicians counsel women with endometrioma regarding the risks of reduced ovarian function after surgery and the possible loss of the ovary. The decision to proceed with surgery should be considered carefully if the woman has had previous ovarian surgery.

25. TREATMENT OF SYMPTOMS RELATED TO DEEP ENDOMETRIOSIS infiltrative forms of the disease that involve the uterosacral ligaments, rectovaginal septum, bowel, ureters, or bladder Asymptomatic disease is managed expectantly Medical therapy is appropriate for women with bothersome symptoms, except those with obstructive uropathy or symptomatic bowel stenosis Surgical therapy is effective for relieving pelvic pain, dyspareunia, painful defecation, and lower urinary tract symptoms recurrence rates of 30 and 43 percent at four and eight years follow-up Surgical resection does not enhance future pregnancy rates