Endométriose et infertilité: physiopathologie et stratégies · Deep endometriosis. Hum Reprod (2010) JC Noel (2010) JC Noel (2010) Invasion of the muscularis propria Pathogenesis

Service de Gynécologie Obstétrique 2 et Médecine de la Reproduction

Université Paris Descartes, Groupe Hospitalier Cochin, AP-HP

Département Génétique, Développement, Cancer, Institut Cochin

INSERM, CNRS

Paris, France

Endométriose et infertilité:

physiopathologie et stratégiesPr Bruno BORGHESE, Dr Pietro SANTULLI, Dr Isabelle STREULI,

Pr Dominique de ZIEGLER, Pr Charles CHAPRON

Superficial OSIS

Adhesions

Ovarian endometriomas

Deep endometriosis

Hum Reprod (2010)

JC Noel (2010)

JC Noel (2010)

Invasion of

the muscularis

propria

Pathogenesis

Hormonal

Histological

Symptoms

Lesions

Lymph node with

endometriotic focus

PROGINS

polymorphisms

YES

NO

Pain Infertility

SUP OMA DIE

CC Chemokines

CXC

Chemokines

Reis. Hum Reprod Update 2013,376:730-8

Cholesterol

Androstenedione

STAR

CYP11A1

CYP17

EstroneCYP19A1

NR5A1 Estradiol

PGE2PTGS2

+

+

+

+

VEGF

+

MMP

INSL3

Proliferation

Inflammation

Steroidogenesis

Adhesion-Migration

Angiogenesis

PGTE

adapated form Bulun SE. N Engl J Med 2009

de Ziegler D, Borghese B, Chapron C. Lancet 2010,376:730-

8

Inflammation-related processes impairs sperm-

oocyte interactions

Reduced chances of in vivo fertilization

1


8

2Decreased ovarian response to COH:

More FSH/hMG needed

Less oocytes obtained


8


8

Alteration of eutopic endometrium

Activation of CYP-19

Resistance to P4 (PR-D)

Endometrial receptivity & implantation

3

Kunz. Hum Reprod 2005

Chapron, Millischer in press

Ballester. Hum Reprod 2012

JZ ≤ 12 mm JZ > 12 mm P-value OR (95% CI)

N total DIE lesions > 3 29 (54%) 13 (87%) 0.018 25.6 (1.2 –

27.3)

Surgery improves natural conception

Medical treatment of no value for natural

conception

Surgery of no value for ART

Medical treatment favors ART outcome

Vercellini P et al. Hum Reprod 2009,24:254-69

50%

≥ 12 months

< 12 months

Pregnancy: 0.79 (95% CI: 0.46–1.35)

Vercellini et al., RBMO 2010 Vercellini P et al. RBMO 2010

ConsiderSx + 6-18 Mo

in vivoCumulative PR

50%

Time (months)6 18

N=222Stages I-IV

Vercellini P et al. Hum Reprod 2009,24:254-69

Web Appendix: Effects of surgery on infertility associated with endometriosis. Laparoscopic excision of endometrioma (OMA) N # IUP % IUP

Daniell et al., 1991 32 12 37.5

Marrs et al., 1991 23 7 30.4

Bateman et al., 1994 21 9 42.8

Crosignani et al., 1996 22 6 27.3

Montanino et al., 1996 11 5 45.5

Donnez et al., 1996 814 414 50.8

Sutton et al., 1997 66 30 45.5

Beretta et al., 1998 9 6 66.7

Milingos et al., 1998 32 17 53.1

Busacca et al., 1999 67 39 58.2

Jones and Sutton, 2002 39 15 38.5

Alborzi et al., 2004 32 19 59.4

Fedele et al., 2006 90 29 32.2

Vercellini et al., 2006 237 128 54.0

Total 1495 736 49.2

Deep infiltrating endometriosis (DIE) N # IUP % IUP

Coronado et al., 1990 33 13 39.4

Nehzat et al., 1994 8 1 12.5

Bailey et al., 1994 49 24 48.9

Jerby et al., 1999 7 3 42.8

Chapron et al., 1999 30 15 50.0

Possover et al., 2000 15 8 53.3

Redwine and Wright, 2001 23 7 30.4

Kavallaris et al., 2003 38 18 47.4

Fedele et al., 2004 50 17 34.0

Thomassin et al., 2004 15 4 26.7

Chopin et al., 2005 78 42 53.8

Daraï et al., 2005 22 10 45.5

Fleisch et al., 2005 17 4 23.5

Keckstein et al., 2005 95 47 49.5

Mohr et al., 2005 58 23 39.6

Lyons et al., 2006 3 3 100.0

Vercellini et al., 2006 44 15 34.1

Ferrero et al., 2009 46 22 47.8

Meuleman et al., 2009 33 16 48.5

Stepniewska et al., 2009 30 12 40.0

Total 694 304 43.8

IUP: Intrauterine pregnancy

Adapted and updated from Vercellini et al., 2009, with permission.

References

1. Daniell JF, Kurtz BR, Gurley LD. Laser laparoscopic management of large endometriomas. Fertil Steril 1991; 55: 692-95.

2. Marrs RP. The use of potassium-titanyl-phosphate laser for laparoscopic removal of ovarian endometrioma. Am J Obstet Gynecol

1991; 164: 1622-26.

3. Bateman BG, Kolp LA, Mills S. Endoscopic versus laparotomy management of endometriomas. Fertil Steril 1994; 62: 690-95.

4. Crosignani PG, Vercellini P, Biffignandi F, Costantini W, Cortesi I, Imparato E. Laparoscopy versus laparotomy in conservative

surgical treatment for severe endometriosis. Fertil Steril 1996; 66: 706-11.

5. Montanino G, Porpora MG, Montanino Oliva M, Gulemì L, Boninfante M, Cosmi EV. Laparoscopic treatment of ovarian

endometrioma. One year follow-up. Clin Exp Obstet Gynecol 1996; 23: 70-72.

6. Donnez J, Nisolle M, Gillet N, Smets M, Bassil S, Casanas-Roux F. Large ovarian endometriomas. Hum Reprod 1996; 11: 641-

46.

7. Sutton CJ, Ewen SP, Jacobs SA, Whitelaw NL. Laser laparoscopic surgery in the treatment of ovarian endometriomas. J Am

Assoc Gynecol Laparosc 1997; 4: 319-23.

8. Beretta P, Franchi M, Ghezzi F, Busacca M, Zupi E, Bolis P. Randomized clinical trial of two laparoscopic treatments of

endometriomas: cystectomy versus drainage and coagulation. Fertil Steril 1998; 70: 1176-80.

49.2%


8

Web Appendix: Effects of surgery on infertility associated with endometriosis. Laparoscopic excision of endometrioma (OMA) N # IUP % IUP

Daniell et al., 1991 32 12 37.5

Marrs et al., 1991 23 7 30.4

Bateman et al., 1994 21 9 42.8

Crosignani et al., 1996 22 6 27.3

Montanino et al., 1996 11 5 45.5

Donnez et al., 1996 814 414 50.8

Sutton et al., 1997 66 30 45.5

Beretta et al., 1998 9 6 66.7

Milingos et al., 1998 32 17 53.1

Busacca et al., 1999 67 39 58.2

Jones and Sutton, 2002 39 15 38.5

Alborzi et al., 2004 32 19 59.4

Fedele et al., 2006 90 29 32.2

Vercellini et al., 2006 237 128 54.0

Total 1495 736 49.2

Deep infiltrating endometriosis (DIE) N # IUP % IUP

Coronado et al., 1990 33 13 39.4

Nehzat et al., 1994 8 1 12.5

Bailey et al., 1994 49 24 48.9

Jerby et al., 1999 7 3 42.8

Chapron et al., 1999 30 15 50.0

Possover et al., 2000 15 8 53.3

Redwine and Wright, 2001 23 7 30.4

Kavallaris et al., 2003 38 18 47.4

Fedele et al., 2004 50 17 34.0

Thomassin et al., 2004 15 4 26.7

Chopin et al., 2005 78 42 53.8

Daraï et al., 2005 22 10 45.5

Fleisch et al., 2005 17 4 23.5

Keckstein et al., 2005 95 47 49.5

Mohr et al., 2005 58 23 39.6

Lyons et al., 2006 3 3 100.0

Vercellini et al., 2006 44 15 34.1

Ferrero et al., 2009 46 22 47.8

Meuleman et al., 2009 33 16 48.5

Stepniewska et al., 2009 30 12 40.0

Total 694 304 43.8

IUP: Intrauterine pregnancy

Adapted and updated from Vercellini et al., 2009, with permission.

References

1. Daniell JF, Kurtz BR, Gurley LD. Laser laparoscopic management of large endometriomas. Fertil Steril 1991; 55: 692-95.

2. Marrs RP. The use of potassium-titanyl-phosphate laser for laparoscopic removal of ovarian endometrioma. Am J Obstet Gynecol

1991; 164: 1622-26.

3. Bateman BG, Kolp LA, Mills S. Endoscopic versus laparotomy management of endometriomas. Fertil Steril 1994; 62: 690-95.

4. Crosignani PG, Vercellini P, Biffignandi F, Costantini W, Cortesi I, Imparato E. Laparoscopy versus laparotomy in conservative

surgical treatment for severe endometriosis. Fertil Steril 1996; 66: 706-11.

5. Montanino G, Porpora MG, Montanino Oliva M, Gulemì L, Boninfante M, Cosmi EV. Laparoscopic treatment of ovarian

endometrioma. One year follow-up. Clin Exp Obstet Gynecol 1996; 23: 70-72.

6. Donnez J, Nisolle M, Gillet N, Smets M, Bassil S, Casanas-Roux F. Large ovarian endometriomas. Hum Reprod 1996; 11: 641-

46.

7. Sutton CJ, Ewen SP, Jacobs SA, Whitelaw NL. Laser laparoscopic surgery in the treatment of ovarian endometriomas. J Am

Assoc Gynecol Laparosc 1997; 4: 319-23.

8. Beretta P, Franchi M, Ghezzi F, Busacca M, Zupi E, Bolis P. Randomized clinical trial of two laparoscopic treatments of

endometriomas: cystectomy versus drainage and coagulation. Fertil Steril 1998; 70: 1176-80.

43.8%


8

Patients

operated

Wishing to

conceive

Pregnant

127 94 (74%) 48 (51%)

76 54 (71%) 27 (50%)

44%

58%

1 Y

ea

r

2 Y

ea

rs

3 Y

ea

rs

73%

Meuleman C et al. Ann Surg 2013

41% conceived spontaneously

Bowel resection p

Yes No

Recurrence 2/76 (3 %) 6/127 (5%) <0.05

Meuleman C et al. Ann Surg 2013

Time after surgery (days)

Bowel resection Residual bowel

endometriosis

Bowel

resection

Residuel bowel

endometriosis

No bowel

endometriosisP

regnancie

s (

%)

Bowel resection Residual bowel

endometriosisNo bowel

endometriosis

IVF treatment

No bowel

endometriosis

Spontaneous conception

P=0.03

P=0.005

12/30 7/23 24/34

5/13 1/13 4/6

No Conception

1 year

Conception

2 years 4 years

Stepniewska et al. Hum Reprod

2009

of conservative surgery for rectovaginal endometriosis in which the

reproductive outcome in operated patients was compared with that

observed in women undergoing expectant management (Vercellini

et al., 2006b). Amongthe 44 women who had resection of rectovaginal

endometriosis at laparotomy, 15 (34.1%) became pregnant, as com-

pared with 22 of the 61 (36.1%) women who choose expectant man-

agement. The 12-month cumulative probability of conception was

20.5%in the former group and 34.7%in the latter (P¼ 0.12). Corre-

sponding figures at 24-month survival analysis were, respectively, 44.9

and 46.8%(P¼ 0.38). However, a statistically significant longer time to

recurrence of moderate or severe pain recurrence wasobserved in the

surgery group compared with the expectant management group for all

of the symptoms considered. The benefit of surgery was particularly

evident with regard to deep dispareunia and dyschezia.

The above data suggest that excision of rectovaginal plaques does

not improve the likelihood of pregnancy nor reduces the

time-to-conception in women with endometriosis-associated inferti-

lity. These findingsmay be explained by a process of ‘pseudoretroper-

itonealization’ of implants leading to a reduction of the biochemical

impact of deep lesions on fertilization processes. In fact, adhesion

between the anterior rectal wall and the posterior vaginal fornix or

uterine isthmus results in exclusion of the deepest portion of the

pouch of Douglas, where infiltrating endometriosis originates and

develops (Vercellini et al., 1996, 2000; Vercellini, 1997). Excision of

deep endometriotic implants is unlikely to influence the probability

of conception to a major extent if their burial limits the inflammatory

consequences on the pelvic environment. Consequently, the

........................................................................................

T able I Major int ra- and post -operat ive complicat ions

of radical surgery for rectovaginal endomet r iosis

Complicat ion Observed incidence

(%)

Neurogenic bladder dysfunction 4–10

Rectovaginal fistula formation 2–10

Blood transfusion 2–6

Inadvertent rectal perforation 1–3

Anastomotic leakage 1–2

Pelvic abscess 1–2

Temporary diverting loop ileostomy/

colostomy

0.5–1.5

Intraoperative ureteral lesion 0.5–1

Post-operative ureteral fistula formation 0.5–1

Post-anastomotic rectal stenosis 0.5–1

Post-anastomotic ureteral stenosis 0.5–1

From Vercellini et al. (2009, in press). Literature data, 2000–2008: Possover et al.

(2000), Anaf et al. (2001), Chapron et al. (2001), Redwine and Wright (2001), Wright

and Shafic (2001), Duepree et al. (2002), Fedele et al. (2004a), Ford et al. (2004),

Thomassin et al. (2004), Volpi et al. (2004), Campagnacci et al. (2005), Chopin et al.

(2005), Darai et al. (2005), Fleisch et al. (2005), Keckstein and Weisinger (2005), Mohr

et al. (2005), Vignali et al. (2005), Angioni et al. (2006), Dubernard et al. (2006), Landi

et al. (2006), Langebrekke et al. (2006), Lyons et al. (2006), Ribeiro et al. (2006),

Vercellini et al. (2006b), Brouwer and Woods (2007), Kristensen and Kjer (2007),

Mereu et al. (2007), Secchiaroli et al. (2007) and Zanetti-Dallenbach et al. (2008).

Figur e 5 Pregnancy rates observed after excisional surgery of rectovaginal endometriosis at laparotomy or laparoscopy.Diamonds represent per-

centage point estimates and horizontal lines 95% CIs. Modified from Vercellini et al. (2006b), with permission.

Surgery for endometriosis and infertility 259

Vercellini et al., Hum Reprod (2009)


Medical treatment of no value for natural conception



Hughes E et al., Cochrane Database 2007

Vercellini, Obstet Gynecol Clin North Am 2003, 30:163-80.

Conception rate: 22.9% 18.1%

All options are contraceptive



conception



Garcia-Velasco J et al. Fertil Steril 2004,81:1194-7No impact on IVF

outcome

Impact on

pregnancy rate

Somigliana E et al. Hum Reprod 2008;23:1526-30.

Benaglia et al., Hum Reprod (2010)

Absence of follicular growth:Operated ovary = 12 cases (12%)

Contralateral ovary = 0 cases (0%)

(p < 0.001)

Severe ovarian damage:13% (95% CI 7% - 21%)

N = 93

Operated ovary Non operated ovary

Streuli I et al. Hum Reprod 2012,27:3294-303

** **

Pre op

AMH levels

≥ 3.1ng/ml

Raffi et al., JCEM (2012)

Tang et al., Fertil Steril (2013)

Variable Inexperienced

surgeon

Experienced

surgeon

p

Antral follicule count 7.53.8 9.66.6 0.015

Implantation rate (%) 13.9 18.5 NS

Clinical pregnancy rate per cycle (%) 26.3 41.1 NS

Live-born rate per cycle (%) 9.3 32.9 < 0.001

Yu et al., EJOGRB (2010)

Muzii et al., Fertil Steril (2011)

Endometriosis and IVF Fears

Pain progression Post retrieval infection

Obstetrical Risks Cancer risk

OMAs and ART Pelvic infection after oocyte retrieval

ART in global population Oocyte

retrieval

Post procedure

infection

Bennett SJ et al. J Assist Reprod Genet (1993) 2 670 18 (0.67%)

Dicker D et al. Fertil Steril (1993) 3 656 9 (0.24%)

Moini A et al. J Assist Reprod Genet (2005) 5 958 10 (0,16%)

TOTAL 12 284 37 (0.30%)

ART in endometriotic women Oocyte

retrieval

Post procedure

infection

Tsai YC et al. J Assist Reprod Genet (2005) 108 2 (1.9%)

Benaglia L et al. Fertil Steril (2008) 214 0 (0.0%)

de Ziegler et al. In press (2013) 513 2 (0.38%)

TOTAL 835 4 (0.48%)

22ds – 25wks

intervalAspirated

14 cases described

despite using

prophylactic antibiotics

in at least 11 cases.

Endometrioma infection

following oocyte

retrieval can occur.

Prophylactic AB

may reduce this risk but

cannot abolish it.

Cyst

aspiration/puncture is a

definite risk factor.

Somigliana HRU 2015

OMAs and ART Pelvic infection after oocyte retrieval

Risk of conservative management of women with endometriomas

OMAs and ART Follicular fluid contamination


Controversial and paradoxical findings: Numerous toxic substances (free iron)

Animal study: Brief exposure to OMA fluid did not affect mouse emb develop but reduced the blast hatching rate.

Benaglia et al. 2014: In 19 cases of contamination vs 38 matched controls w/ OMABut w/o contamination: Fert rate and top quality emb rates were higher but pregnancy rates were significantly lower.

Somigliana HRU 2015

OMAs and ART Risk of cancer


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.

Importance of preoperative work-up

QuestionningPelvic

examination

Biochemical

markers

MRI Uro-MRI

Trans-vaginal

US

Trans-rectal

US

Kidney scintigraphy

Endo and ART Painful symptoms

progression

4 cases of severe digestive complications under ovarian stimulation


progression

Benaglia et al., Hum Reprod (2011)


progression

• Pain during ART :

endometriosis Women

• Endometriosis complaints before

and after ART treatment

• Moderate to severe surgically

proven endometriosis

• IUI (n=25) / IVF (n=25) / IVF

ultra long (n=25)

Van der Houwen Gynecol Endocrinol 2014

Prospective cohort study : 1058 Oocyte retrievals

Ludwig et al, 2006, Human Reproduction

Pain assessment after oocytes retrieval

Fertility and Sterility 2012

The Prepregnancy Uterine Milieu as a Risk Factor of Placental Bed Disorders

ENDOMETRIOSIS

Altered eutopic

endometrium

Vascular & ureteral complications

Maignien 2013

Autor, year Origin of

bleeding site

Number

of cases

Gestational

age at diagnosis

(Noack and Hohlweg-Majert,

1984)

Pelvic 1 3rd trimester

(Inoue et al., 1992) Anterior uterus 1 29

(Mizumoto et al., 1996)

Uterine vessels 28

(Leung et al.,

1998) Right uterine artery 1 33

(Ismail and

Shervington, 1999)

Vascular area of the Douglas

2 33 / PP

(Aziz et al., 2004) Left uterine artery 1 20 Wu (Wu et al.,

2007)

Superficial posterior venous of uterus

1 32

(Katorza et al.,

2007)

Anterior uterin wall, Right Adnexe

Posterior wall of the uterus

3 25 /26 / 29

(Passos et al.,

2008)

Large ligament, right uterine venous

2 32 / 31

(Roche et al.,

2008) Right uterine artery 1 33

(Chiodo et al.,

2008)

Right uterine artery and

right ureter 1 31

(Gonzalez Rosales

et al., 2008) Right uterine artery 1 22

(Tourette et al.,

2011)

Posterior face of the

uterus

(Lajtman et al.,

2011) - 1 -

(Maignien et al.,

2014) Left ovary 1 15

(Berlac et al.,

2014)

Anterior varicous of

uterus 1 28

Marcellin et al. Seud 2015

Ovarian responsiveness to COS

Oocyte competence

Technical difficulties during oocyte retrieval

Infection of endometrioma

Follicular fluid contamination w/ endometrioma content


Infertility and ART in women with

endometriosisPregnancy complications

Somigliana HRU 2015;10:1-14.

AuthorStudy

design

Cohort

size

Study

period

(years)

SIR, OR, RR or SMR (95% CI)

Small for

Gestational age

Hypertensive

pathology

Preterm birth

(< 37)

Kortelahti,

2003Case-control 137 1.09 (0.46 – 2.57) - 0.34 (0.88 – 1.88)

Fernando,

2009Case-control 95 13 1.95 (1.06 – 3.60) - 1.98 (1.09 – 3.62)

Stephansson

,

2012

Cohort 13,090 14 1.17 (1.05 – 1.30) 1.17 (1.06 – 1.29) 1.39 (1.30 – 1.49)

Benaglia,

2012Case-control 61 4 0.56 (0.12 – 2.56) 0.56 (0.12 – 2.56) 0.47 (0.14 – 1.54)

Carassou-

Maillan

2014

Case-control 227 5 - 0.69 (0.30 - 1.55) 1.68 (1.11 - 2.53)

Lin,

2015Case-control 249 18 1.75 (0.41–7.49) 0.78 (0.31–2.00) 2.42 (1.05–5.57)

Endometriosis and Obstetrical Outcomes

Inflammation

Interface Materno-fœtale pathologique

AuthorStudy

design

Cohort

size

Study

period

(years)

SIR, OR, RR or SMR (95% CI)

Cesarean sectionPlacenta

preaviaAntepartal bleeding

Kortelahti,

2003Case-control 137 1.03 (0.62 - 1.72) 1.52 (0.42 - 5.52) -

Stephansson,

2012Cohort 13,090 14 1.76 (1.69 – 1.84) - 1.95 (1.75 – 2.18)

Benaglia,

2012Case-control 61 4

1.25 (0.63 – 2.50) - -

Carassou-

Maillan

2014

Case-control 227 5 1.16 (0.84 - 1.60) 5.47 (2.24 - 13.38) 2.54 (1.23-5.24)

Lin,

2015Case-control 249 18 1.93 (1.31–2.84) 4.51 (1.23–16.50) -

Endometriosis and Obstetrical Outcomes



conception



Canada

2004

Australia

2009

France

2001-2005

USA

2009

IVF ICSI IVF + ICSI IVF + ICSI IVF + ICSI

Primary

diagnosis

Pregnancies

(% per

retrieval)

Pregnancies

(% per

retrieval)

Pregnancies

(% per initiated

cycle)

Pregnancies

(% per initiated

cycle)

Live births

(% per

aspiration)

Male factor 31.0% 37.7% 24.9% 20.1% 37.6%

Tubal factor 33.5% 29.4% 23.5% 21.0% 32.2%

Idiopathic 36.4% 34.7% 23.7% 21.6% 33.7%

Endometriosis 37.8% 41.4% 25.7% 23.7% 35.3%

Ovulatory

disorder

35.6% 36.3% 23.2% 22.6% 40.4%

Other 37.6% 27.9% 18.5%% 27.7%

Gunby J et al. Fertil Steril (2008)

Yueping A et al. Assisted Reproductive technology in Australia and New Zeland (2009)

FIVNAT (2001-2005)

USA, 2009 aspirations: National Center for Chronic Disease Prevention and Health Promotion Division of Reproductive Health

Harb et al. BJOG

2013

Results: Effects of GnRH-a IVF outcome

The 3 trials retained for study indicate that the administration of GnRH-a for 3-6 months prior to IVF/ICSI in women w/

endometriosis increases the odd of pregnancy > 4 fold.

2006

0

10

20

30

40

50

controls OSIS IV OMA present

with OC pretreatment

425 57 28**

P <0.01

83 52 31

*

P <0.05

OC pretreatment (6-8 wk) in ovarian

endometriosis

No pretreatment

* **

Effects of pre-ART treatment with OC

pre-ART OC x6-8 wks

Center I & 2

De Ziegler et al. Fertil Steril 2010,94:2796-9

with OC pretreatment pre-ART OC x6-8 wks

De Ziegler et al. Fertil Steril 2010,94:2796-9

OC pretreatment (6-8 wk) in ovarian

endometriosis

Unoperated bilateral OMAs ART outcome

Benaglia et al., Fertil Steril, (2013)

Characteristics Case n = 39 Control n = 78 p

Operated bil Omas

n = 68

No prior ovarian

surgery n = 136pCharacteristics

Somigliana et al., Hum Reprod (2008)

Operated bilateral OMAs ART outcome

Relationship between « oocyte quantity and quality »

Oocytes

Cumul PR Life birth rate

Amp FSH

OMA

OMA

Tubal infertility

Tubal infertility

NS NS

Al-Azemi et al., Hum Reprod (2000)

http://humrep.oupjournals.org/content/vol15/issue1/images/large/h012501.jpeg

37

reg. ART

donor-egg ART

37

Streuli I et al. Hum Reprod 2012,27:3294-303

** **

Endometriosis Age

Quantity

Quality

FSH < 8 mIU/ml 8-12 mIU/ml > 12 mIU/ml

AFC > 8 total 5-7 total < 5 total

AMH > 1ng/ml 0.5-1 ng/ml < 0.5 ng/ml

de Ziegler and Chapron, IFFS Newsletter (2013)

Ovarian reserve testing in ART patients

AMH, AFC and FSH/E2 predict

magnitude of ovarian response

in ART but not fecundity

Ovarian reserve predicts the number of oocytes

responding to COS, not their quality

Ovarian reserve reflects the efficacy of ART as infertility

treatment

Endo has an impact on

quantity but not quality

(≠ age)

Multidisciplinary management

Endometriosis

and

Patients

Pelvic pain

Infertility

Global approach

Surgery

Medical Ttt

ART

SUP OMAs DIE

Adenomyosis

Global approach of endometriosis

Avoid that the choosing of surgery or ART

reflects the primary activity

of the doctor first consulted

Ovarian reserve

Adenomyosis

Infertility Pelvic pain

A

Referral center

VAS < 7:

Moderate DIE

VAS ≥ 7:

Severe DIE

Classical center

B

« Emergency ART »

ART

Without surgery

Fertility preservation ?

Previous surgery

Endometrioma

OC

Documents

Endométriose et infertilité: physiopathologie et stratégies · Deep endometriosis. Hum Reprod (2010) JC Noel (2010) JC Noel (2010) Invasion of the muscularis propria Pathogenesis