Endometriosis and infertility

• The hypothesis that endometriosis causes infertility or a decrease in fecundity remains controversial. • Whereas evidence demonstrates an

association between endometriosis and infertility, a causal relationship has not been clearly established.

Endometriosis and infertility: a committee opinion.

The Practice Committee of the American Society for Reproductive Medicine. Sept 2012

A paradox !

•1. Need to do a laparoscopy to make a diagnosis of endometriosis

•2. No need to do laparoscopy routinely for all infertile couples

Routine laparoscopy

• Laparoscopy in infertile woman, simply to confirm or rule out the disease is not warranted.• Endometriosis and infertility: a

committee opinion. The Practice Committee of the American Society for Reproductive Medicine. ASRM, 2012

Routine laparoscopy

• The benefit of laparoscopic treatment of minimal or mild endometriosis is insufficient to recommend laparoscopy solely to increase the likelihood of pregnancy. • Endometriosis and infertility: a

committee opinion . The Practice Committee of the American Society for Reproductive Medicine. ASRM, 2012

No laparoscopy ? Won’t we miss the diagnosis ?

• Yes, we will • So, what ?• We don’t treat a diagnosis, we treat the

infertile couple !• Treating mild endometriosis , either with

medical therapy or operative laparoscopy, does not improve fertility

Routine laparoscopy• Does not change treatment options - or

outcome !• Burning endometriosis lesions, and

cutting adhesions are fun , but “treating” these doesn't improve fertility – and can actually reduce it • Post hoc, ergo propter hoc fallacy -

Patients get pregnant after the laparoscopy and doctor is happy to take the credit

Harm Caused• Misdiagnosis - corpus luteum vs

endometriosis• Burning or excising chocolate cyst reduces

ovarian reserve• Overtreatment – patient “treated” with

Lupron after the surgery• Wastes time – you tell the patient, you have

now been treated, so you can get pregnant on your own

• Don't cut and burn just because you can !

Medical treatment does not improve pregnancy rates

• In infertile women with endometriosis, clinicians should not prescribe hormonal treatment for suppression of ovarian function to improve fertility.

• ESHRE guideline: management of women with endometriosis. Human Reproduction, Volume 29, Issue 3, 1 March 2014, Pages 400–412,

Changing paradigm

• PAST• Removal of lesions is a

priority.• It is a gynecological

lesion• Recurrence means

incomplete primary surgery

• ART had low pregnancy rates

• PRESENT• Preservation of ovarian

function is a priority.• It is an inflammatory

syndrome• Recurrence means

persistent offending factor

• ART is safe and effective

Principles of care• Ovarian reserve should be assessed

before intervention.• Endometriosis surgery should be avoided

in women with diminished ovarian reserve who should be offered ART straightaway.• ART is the best option in women with

recurrent endometriosis

Principles of care• Don’t just treat the lesions !• Need to factor in:• Female age• Duration of infertility• Pelvic pain

Endometrioma diagnosed on ultrasound

Ovarian Endometriomas

Justification for doing laparoscopic ovarian cystectomy

• Confirm the diagnosis histologically • Reduces risk of recurrence over

fulguration • Reduce the risk of infection at IVF • Improves access to follicles• Improves IVF pregnancy rate ( because

endometriosis fluid is “toxic “ to eggs)

IVF and endometriosis

• Embryo implantation is not affected in patients with endometriosis. • The presence of severe

endometriosis or bilateral ovarian endometrioma does not lower implantation rates.

• Although the presence of bilateral endometriomas at the time of IVF affects responsiveness to hyperstimulation, the quality of the oocytes retrieved and the chances of pregnancy are not affected.

• Benaglia L Bermejo ASomigliana E Faulisi SRagni G Fedele L Garcia-Velasco JA In vitro fertilization outcome in women with unoperated bilateral endometriomasFertil Steril 2013 99 6 1714-1719

Ultrasound guided cyst aspiration prior to IVF

• Safe and effective• Temporary solution – good

enough• If she gets pregnant in the IVF

cycle, problem is resolved !

Minimally invasive !

• Ethanol sclerotherapy of ovarian endometrioma: a safe and effective minimal invasive procedure. Preliminary results. Eur J Obstet Gynecol Reprod Biol 2015 Apr;187:25-9. Dr Garcia-Teiedor A

New treatment option

• Sclerotherapy in the management of ovarian endometrioma: systematic review and meta-analysis. Cohen A, Almog B, Tulandi T. Fertile Steril, 2017 Jul;108(1):117-124.• Using ethanol as a sclerosant

Take home messages• Routine diagnostic laparoscopy not indicated

for infertile women

• Medical therapy of endometriosis has no role in improving fertility

• In minimal to mild disease, ovulation induction and IUI is first line therapy.

• IVF is the final common pathway for having a baby

The elephant in the room

• None of us will change what we are doing!• We all have our personal prejudices

Trigger happy doctor

• We like doing things - " Itchy " fingers• Feel good - for yourself, because you did

something• Patient is happy – she feels you have

"diagnosed" the problem and have treated it• Can charge more

Why it’s easy to fool doctors

• Personal experience - Small numbers, no controls, no followup • Patients change doctors. Only the

success stories come back with chocolates !• Reinforces your bias – the easiest person

to fool in the world is yourself

Experts are biased – and often wrong !

• Eminence based medicine - "my experience" - which is plagued with problems• Experts fudge numbers – they lie ! • Sponsored by pharma companies and

medical device manufacturers who want to sell their products

Trust your own eyes !

• Minimal endometriosis is a very common incidental finding • No clinical relevance• Look for it carefully in patients

undergoing lap TL• You will find it in nearly every woman

you put a scope into if you are meticulous

IVF vs Endoscopy

• Do both ! • Gynecologist and Ivf specialist refer

patients to each other ! • Both are happy - only loser is the

patient