Endometriosis and Infertility: Surgery or ART? · Endometriosis and Infertility: Surgery or ART?...
Transcript of Endometriosis and Infertility: Surgery or ART? · Endometriosis and Infertility: Surgery or ART?...
Université Paris‐Descartes, Hôpital Cochin, Paris, France
Charlers ChapronBruno Borghese
Hervé Foulot
Antoine Bouret
Paul Mazurk
Guillaume Pierre
Marie Christine Lafay
Fouzia Decupere
François X. Aubriot
Dominique de ZieglerVanessa Gayet
Pietro Santulli
Paul Pirtea
Blandine Boquet
Aurélie Vincent
Bander Kuttbi
François Aubriot
Ann Marszalek
Endometriosis and Infertility: Surgery or ART?
DisclosureOn the advisory board of IBSA pharmaceuticalsSeventure Inc.
Holds equity interests in:Ultrast Inc.
Medical treatment of endometriosis
Surgical treatment of endometriosis
Surgery and ovarian reserve
Endometriosis and ART
Endometriosis and endometrial receptivity
Practical management
Endometriosis and Infertility: Surgery or ART?
Medical treatment of endometriosis
Surgical treatment of endometriosis
Surgery and ovarian reserve
Endometriosis and ART
Practical management
Endometriosis and endometrial receptivity
Endometriosis and Infertility: Surgery or ART?
de Ziegler D, Borghese B, Chapron C. The Lancet 2010;376:730‐8..
Endometriosis and Infertility: Surgery or ART?
Medical treatment of endometriosis
All treatments are contraceptive
1. Pelvic pain2. Recurrence after surgery
Equally Effective
Inneffective
1. Fertility after surgery2. Enhancing fertility
Endometriosis and Infertility: Surgery or ART?
Medical treatment of endometriosis
Surgical treatment of endometriosis
Surgery and ovarian reserve
Endometriosis and ART
Practical management
Endometriosis and endometrial receptivity
Endometriosis and Infertility: Surgery or ART?
Endometriosis and Infertility: Surgery or ART?
At all stages of OSIS, Sx provides 50% chances on conceiving naturally in 12‐18 months.
Endometriosis and Infertility: Surgery or ART?
Ressection of endometriomas
Endometriosis and Infertility: Surgery or ART?
Ressection of recto‐vaginal endometriosis
Endometriosis and Infertility: Surgery or ART?
Sx w/ & w/o post‐op medical treatment
Endometriosis and Infertility: Surgery or ART?
Colorectal surgery does not hamper the benefit of endometriosis surgery
Endometriosis and Infertility: Surgery or ART?
Medical treatment of endometriosis
Surgical treatment of endometriosis
Surgery and ovarian reserve
Endometriosis and ART
Practical management
Endometriosis and endometrial receptivity
Endometriosis and Infertility: Surgery or ART?
Retrospective measurement of AMH in 927 women with and without OSIS. No difference seen.
n = 514(E) + 413(C)
Streuli I et al. Hum Reprod. 2012;27:3294‐303
Endometriosis and Infertility: Surgery or ART?
Retrospective measurement of AMH in 927 women with and without OSIS. No difference seen.
n = 514(E) + 413(C)
Streuli I et al. Hum Reprod. 2012;27:3294‐303
Endometriosis and Infertility: Surgery or ART?
Endometriosis and Infertility: Surgery or ART?
AFCEffect of Sx
AFCEffect of Non‐exis Sx
AFCEffect of OMAVs other side
AFCOperated OMAVs other side
Endometriosis and Infertility: Surgery or ART?
Endometriosis and Infertility: Surgery or ART?
0
10
20
30
n=68 n=1360
n=68 n=1360
PR/ sarting cycle
Endometriosis and Infertility: Surgery or ART?
Endometriosis and Infertility: Surgery or ART?
Endometriosis and Infertility: Surgery or ART?
Kalalau BeachKauai, Hi
GnRH‐a
COS #1 COS #2
OR #1
GnRH‐a
OR #2
P4 P4
ET
E2
Endometriosis and Infertility: Surgery or ART?
GnRH‐a
COS #1 COS #2
OR #1
GnRH‐a
OR #2
P4 P4
ET
E20
2
4
6
p = NS
Endometriosis and Infertility: Surgery or ART?
GnRH‐a
COS #1 COS #2
OR #1
GnRH‐a
OR #2
P4 P4
ET
E2
0
0.5
1
1.5
p = NS
Endometriosis and Infertility: Surgery or ART?
Medical treatment of endometriosis
Surgical treatment of endometriosis
Surgery and ovarian reserve
Endometriosis and ART
Practical management
DiagnosisAdenomyosisEndometriomasManagement Endometriosis and endometria
Endometriosis and Infertility: Surgery or ART?
Endometriosis and Infertility: Surgery or ART?
Ultrasound Obstet Gynecol. 2015;46:730‐6
Endometriosis and Infertility: Surgery or ART?
Ultrasound Obstet Gynecol. 2015;46:730‐6
Fertil Steril 2016;105:1421‐31.
Fertil Steril 2016;105:1421‐31.
FS 2015;103:1252‐60.
Endometriosis and Infertility: Surgery or ART?
Fertil Steril 2016
Medical treatment of endometriosis
Surgical treatment of endometriosis
Surgery and ovarian reserve
Endometriosis and ART
Practical management
DiagnosisAdenomyosisEndometriomasManagement Endometriosis and endometria
Endometriosis and Infertility: Surgery or ART?
Endometriosis and Infertility: Surgery or ART?
Endometriosis and Infertility: Surgery or ART?
ART and Adenomyosis
ART, Adenomyosis & miscarriages
ART, Adenomyosis & long or short protocol
ART, Adenomyosis: MRI vs. US
Endometriosis and Infertility: Surgery or ART?
Endometriosis and Infertility: Surgery or ART?
Fecundity: likelyhood of spont preg
DiagnosisAdenomyosisEndometriomasManagement
Medical treatment of endometriosis
Surgical treatment of endometriosis
Surgery and ovarian reserve
Endometriosis and ART
Practical management
Endometriosis and endometria
Endometriosis and Infertility: Surgery or ART?
Endometriosis and Infertility: Surgery or ART?
Endometriosis and Infertility: Surgery or ART?
400,059 cycles reported during 2008–2010, 347,185 cycles after excluding donor, gestational carrier, and banking cycles.
39,356 initiated cycles with endometriosis, (11%)o Of these, 14,053 cycles (4%) isolated endometriosis (Endometriosis Only), o 25,303 cycles (7%) in endometriosis and additional diagnosis (Endometriosis Plus).
Endometriosis and Infertility: Surgery or ART?
Conclusion Endometriosis, when associated with other alterations in the reproductive tract (either
as a result of progression or by chance) has the lowest chance. In contrast, for the minority of women who have endometriosis in isolation, the live
birth rate is similar or slightly higher compared with other diagnostic groups.
Medical treatment of endometriosis
Surgical treatment of endometriosis
Surgery and ovarian reserve
Endometriosis and ART
Practical management
Endometriosis and endometria
DiagnosisAdenomyosisEndometriomasManagement
Endometriosis and Infertility: Surgery or ART?
Impact of ARTRisk of complication
Fertil Steril 2016;105;978‐87.
Endometriosis and Infertility: Surgery or ART?
Fertil Steril 2016;105;978‐87.
Fertil Steril 2016;105;978‐87.
Endometriosis and Infertility: Surgery or ART?
Fertil Steril 2016;105;978‐87.
Different from reports of endometriosis flare during COH‐IUI COH‐IUI: Ovulation ART: No ovulation
Endometriosis and Infertility: Surgery or ART?
Endometriosis and Infertility: Surgery or ART?
HRU 2015;10:1‐14.
Endometriosis and Infertility: Surgery or ART?
HRU 2015;10:1‐14.
Ovarian responsiveness to COS
Technical difficulties during oocyte retrieval
Infection of endometrioma
Follicular fluid contamination w/ endometrioma content
Progression of endometriosis
Pregnancy complications
Endometriomas and cancer
Risk of conservative management of women with endometriomas
Endometriosis and Infertility: Surgery or ART?
Oocyte competence
HRU 2015;10:1‐14.
Ovarian responsiveness to COS
Oocyte competence
Technical difficulties during oocyte retrieval
Infection of endometrioma
Follicular fluid contamination w/ endometrioma content
Progression of endometriosis
Pregnancy complications
Endometriomas and cancer
Risk of conservative management of women with endometriomas
Reinblatt et al., 2011 Benaglia et al., 2013Reported that albeit lesser oocytes were retrieved in women w/ endometriomas, fert and good‐embryo rates were similar.
Endometriosis and Infertility: Surgery or ART?
HRU 2015;10:1‐14.
Ovarian responsiveness to COS
Oocyte competence
Technical difficulties during oocyte retrieval
Infection of endometrioma
Follicular fluid contamination w/ endometrioma content
Progression of endometriosis
Pregnancy complications
Endometriomas and cancer
Risk of conservative management of women with endometriomas
Endometriosis and Infertility: Surgery or ART?
Risk of conservative management of women with endometriomas
22ds – 25wks
intervalAspirated
Padilla, 1993; Yaron et al., 1994; Younis et al., 1997; Den Boon et al., 1999; Matsunaga et al., 2003; Moini et al.,2005; Sharpe et al., 2006; Romero et al., 2013.
Overall, 14 cases described despite using prophylactic antibiotics in at least 11 cases. Endometrioma infectionfollowing oocyte retrieval can occur. Prophylactic ABmay reduce this risk but cannot abolish it. Cyst aspiration/puncture is a definite risk factor.
Endometriosis and Infertility: Surgery or ART?
HRU 2015;10:1‐14.
Ovarian responsiveness to COS
Oocyte competence
Technical difficulties during oocyte retrieval
Infection of endometrioma
Follicular fluid contamination w/ endometrioma content
Progression of endometriosis
Pregnancy complications
Endometriomas and cancer
Risk of conservative management of women with endometriomas
Endometriosis and Infertility: Surgery or ART?
HRU 2015;10:1‐14.
Ovarian responsiveness to COS
Oocyte competence
Technical difficulties during oocyte retrieval
Infection of endometrioma
Follicular fluid contamination w/ endometrioma content
Progression of endometriosis
Pregnancy complications
Endometriomas and cancer
Risk of conservative management of women with endometriomas
Missing an occult malignancy at IVF
Cancer development after IVF
Mostoufizadeh and Scully (1980): Ca in 8/950 operated endometriomas (0.8%, 95% CI: 0.4–1.6%)
Stern et al. (2001): 9/1000 (0.9%; 95% CI: 0.4–1.6%).
Overestimation, as are pathological findingsMost should have been picked up by imaging.
Complex issue concerning the rarity of ovarian cancer (lifetime risk of ~1%) and possible links of COS/ART and/infertility w/ ov cancer.
Endometriosis and Infertility: Surgery or ART?
HRU 2015;10:1‐14.
Risk of conservative management of women with endometriomas
Endometriosis and Infertility: Surgery or ART?
Fertil Steril 2016 in press
Endometriosis and Infertility: Surgery or ART?
Accident prevention:Proper management of risk: build your defenses
Risk in ARTPresents w/pain/shivering/WBCTT w/ IV AB
Endometriosis and Infertility: Surgery or ART?
Accident prevention:Proper management of risk: build your defenses
Risk in ARTPresents w/pain/shivering/WBCTT w/ IV AB
Failed to improve (10/11)48h, Laparoscopy, drainageimproved and curedovary saved 10/10
Endometriosis and Infertility: Surgery or ART?
Oocyte quantityOocyte quality
Medical treatment of endometriosis
Surgical treatment of endometriosis
Surgery and ovarian rese
Endometriosis and ART
Practical management
Endometriosis and endometrial receptivity
Endometriosis and Infertility: Surgery or ART?
donor‐egg ART
reg. ART
37
Endometriosis and Infertility: Surgery or ART?
37
donor‐egg ART
reg. ART
37
Endometriosis and Infertility: Surgery or ART?
de Ziegler et al. Fertil Steril 2010;94:2796‐9.
poor responderspreserved outcome
Endometriosis and Infertility: Surgery or ART?
Medical treatment of endometriosis
Surgical treatment of endometriosis
Surgery and ovarian reserve
Endometriosis and ART
Practical management
Endometriosis and endometrial receptivity
Endometriosis and Infertility: Surgery or ART?
Medical treatment of endometriosis
Surgical treatment of endometriosis
Surgery and ovarian reserve
Endometriosis and ART
Practical management
Treatment before ART
Endometriosis and Infertility: Surgery or ART?
Endometriosis and Infertility: Surgery or ART?
Fallopian tubes
SurgeryProvide 6-18 mo
for spontaneous preg.
3
Ovarian reserveTime available for in vivo
1
InfertilityWork up
No COH‐IUI
Semen analysis2
Ovulation may flare disease
Fallopian tubes3
Ovarian reserveTime available for in vivo
1
if not pregnant
SurgeryProvide 6-18 mo
for spontaneous preg.
IVF for severe male factor
IVF fortubal factor
Emergency I V F
2
3
1
InfertilityWork up
IVF / ICSI(3 months)
in principleNO surgery
Semen analysis2
Fallopian tubes
SurgeryProvide 6-18 mo
for spontaneous preg.
3
Ovarian reserveTime available for in vivo
1
if not pregnant
IVF for severe male factor
IVF fortubal factor
Emergency I V F
2
3
1
InfertilityWork up
IVF / ICSI(3 months)
in principleNO surgery
Semen analysis2
• Pelvic pain• Hydrosalpinx• Large endometrioma
Université Paris‐Descartes, Hôpital Cochin, Paris, France
Charlers ChapronBruno Borghese
Hervé Foulot
Antoine Bouret
Paul Mazurk
Guillaume Pierre
Marie Christine Lafay
Fouzia Decupere
François X. Aubriot
Dominique de ZieglerVanessa Gayet
Pietro Santulli
Paul Pirtea
Blandine Boquet
Aurélie Vincent
Bander Kuttbi
François Aubriot
Ann Marszalek
Endometriosis and Infertility: Surgery or ART?