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Endometriosis related infertility:Treatment modalities and strategies
Université Paris Descartes, Sorbonne Paris Cité, Faculté de médecine, AP-HP, Cochin Saint Vincent de Paul, Department of Gynecology Obstetrics II and
Reproductive Medicine, Paris, France
Inserm, Unité de recherche U1016 – équipe Pr F. Batteux, Institut Cochin, Paris, France
Inserm, Unité de recherche U1016 – équipe Dr D. Vaiman, Institut Cochin, Paris, France
Dr Pietro Santulli MD, PhD
Journée organisée par le Centre de Formation des Editions ESKA - CFEE : N° 11753436775
Inscription CFEE adressée aux Editions ESKA CONGRÈS - Serge KEBABTCHIEFF - Fanny GASMAN
12, rue du Quatre Septembre – 75002 PARIS - Tél. 01 42 86 55 69 ou 79 – Fax 01 42 60 45 35
E-mail : inscriptions et renseignements: [email protected] - Site : www.eska.fr
16ème Journée sur l’Assistance
Médicale à la Procréation
de l’Hôpital Américain de Paris
Président d’Honneur : Dr Jean-Philippe WOLF
VENDREDI 20 NOVEMBRE 2015
COMITÉ D’ORGANISATION
Dr Edouard AMAR, Dr Charles BRAMI, Dr Pascal BRIOT, Dr Patrice CLEMENT,
Dr Jean-Marc EMMANUELLI, Dr André GAUTHIER, Dr Gérard HELUIN, Dr Florence HERVE,
Dr Carine PESSAH, Dr François ROLET, Dr Eric SEDBON, Dr Alain THEBAULT, Dr Jean THOREL, Dr Charles TIBI
COMITÉ SCIENTIFIQUE
Dr Edouard AMAR, Dr Charles BRAMI, Dr Pascal BRIOT, Dr Patrice CLEMENT, Dr Carine PESSAH,
Dr Eric SEDBON, Dr Alain THEBAULT, Dr Charles TIBI
PROGRAMME
Grand Amphithéâtre
de l’Hôpital Américain de Paris63, boulevard Victor Hugo - 92200 Neuilly-sur-Seine
- Specifications and pathogenesis
- What are the therapeutic options ?
- How to choose between the therapeutic options?
- Proposition for a strategy
Endometriosis related infertility
- Specifications and pathogenesis
- What are the therapeutic options ?
- How to choose between the therapeutic options?
- Proposition for a strategy
Endometriosis related infertility
OMESUP DIE Adenomyosis
Pain Infertility
Asymptomatic
Endometriosis: Heterogeneous disease
de Ziegler, Borghese and Chapron The Lancet 2010
Santulli P et al. JCEM 2014
Uterus:
Alterations of eutopic endometrium:
- PTGS2 overexpression
- CYP-19 and NR5A1 activation
- Resistance to P4 (PR-D)
Pelvic cavity:
Inflammation-related process interferes
with sperm-oocyte intercations:
Reduced chances of IN VIVO fertilization
Ovaries:
Decreased ovarian response to COH:
- More FSH / hMG needeed
- Less oocytes obtained
Endometriosis and infertility: Pathogenesis
- Specifications and pathogenesis
- What are the therapeutic options ?
- How to choose between the therapeutic options?
- Proposition for a strategy
Endometriosis related infertility
- Medical treatment
- Surgery
- Assisted Reproductive Technologies
Endometriosis related infertilityManagement options
- Medical treatment
- Surgery
- Assisted Reproductive Technologies
Endometriosis related infertilityManagement options
All options are contraceptive
Endometriosis related infertilityMedical treatment ?
Hughes E et al. Cochrane Database 2007
- Medical treatment
- Surgery
- Assisted Reproductive Technologies
Endometriosis related infertilityManagement options
Vercellini et al., Human Reprod 2009;24:254-69.
ConsiderSx + 6-18 Mo
in vivoCumulative PR
50%
Time (months)6 18
Endometriosis related infertilitysurgery in infertile women
N=222Stages I-IV
≥ 12 months
< 12 months
Pregnancy: 0.79 (95% CI: 0.46–1.35)
Vercellini et al., RBMO 2010
Endometriosis related infertility :Postoperative delayed initiation of attempted
conception
Meuleman C et al., Ann Surg (2013)
Deep endometriosis related infertility :Laparoscopic surgery in women
with moderate to severe endometriosisPatients
operated
Wishing to
conceive
Pregnant
127 94 (74%) 48 (51%)
76 54 (71%) 27 (50%)
44%
58%
1 Y
ear
2 Y
ea
rs
3 Y
ea
rs
73%
Meuleman C et al., Ann Surg (2013)
20% conceived spontaneously
Deep endometriosis related infertility :Laparoscopic surgery in women
with moderate to severe endometriosis
Intestinal DIE: Surgical techniques
Time after surgery (days)
Stepniewska et al., Hum Reprod 2009
Bowel
resection
Residual bowel
endometriosis
Bowel
resection
Residuel bowel
endometriosis
No bowel
endometriosis
Pre
gn
an
cie
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
Conception
No Conception
1 year
Conception
2 years 4 years
Deep endometriosis: Complications 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 findings may 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)
OMAs: Laparoscopic excisionWeb 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%
The Lancet (2010)
Pre op
AMH levels
≥ 3.1ng/ml
Raffi et al., JCEM (2012)
Endometriosis and ovarian reserve
Impact of endometriosis per se on ovarian reserve ?
Impact of endometriosis per se on ovarian reserve ?
Quality Quantity
Endometriosis and ovarian reserveQuality
Sanchez AM et al, Hum Reprod Update (2014)
Leone Roberti Maggiore et al., Human Reprod (2014)
N=244 (183-75% DIE)
Follow up 6 months
1199 cycles of spontaneous ovulation
105 (43.2%) spontaneous pregnancy
Endometriosis and ovarian reserveQuality
Streuli I et al, Hum Reprod (2012)
Endometriosis and ovarian reserveQuantity
AMH
N=726
Streuli I et al, Hum Reprod (2012)
Endometriosis and ovarian reserveQuantity
AMH
N=726
★ ★
Previous OMA surgery
OR= 3.0 (1.40-6.41); p=0.01
Endometriosis and ovarian reserveQuantity
Study group(n = 122)
Control group(n = 106)
0
10
20
30
40
AM
H s
eru
m le
ve
l (n
g/m
l)
0.0015p =
OMA < 5 cm(n = 83 )
OMA ≥ 5(n = 39)
0
2
4
6
8
10
AM
H s
eru
m le
ve
l (n
g/m
l)
0.0003p =
Study group(n = 122)
Control group(n = 106)
0
2
4
6
8A
MH
se
rum
le
ve
l (n
g/m
l)
0.9582p =
sum OMA < 5 cm(n = 72 )
sum OMA ≥ 5(n = 50)
0
2
4
6
8
10
AM
H s
eru
m le
ve
l (n
g/m
l)
0.0316p =
With no DIE(n = 92)
With DIE(n = 30)
0
2
4
6
8
AM
H s
eru
m le
ve
l (n
g/m
l)
0.8588p =
sum OMA ≤ 4 cm(n = 67 )
sum OMA > 4(n = 55)
0
2
4
6
8
10
AM
H s
eru
m le
ve
l (n
g/m
l)
0.1409p =
unilat OMA(n = 91)
bilat OMA(n = 31)
0
2
4
6
8
10
AM
H s
eru
m le
ve
l (n
g/m
l)
0.3153p =
AMH/SIZE OMA SUM CORRELATION
0 5 100
5
10
15A
MH
se
rum
le
ve
l (n
g/m
l)
OMA size (cm)
0.04744R square =
0.0160p =
AMH/SIZE OMA CORRELATION
0 5 100
5
10
15
AM
H s
eru
m le
ve
l (n
g/m
l)
OMA size (cm)
0.05495R square =
0.0094p =
Marcellin - Santulli - Chapron et al, submitted 2015
AMH
Endometriosis and ovarian reserveQuantity
Age
OC use
Infertility
Study group(n = 122)
Control group(n = 106)
0
10
20
30
40
AM
H s
eru
m le
ve
l (n
g/m
l)
0.0015p =
OMA < 5 cm(n = 83 )
OMA ≥ 5(n = 39)
0
2
4
6
8
10
AM
H s
eru
m le
ve
l (n
g/m
l)
0.0003p =
Study group(n = 122)
Control group(n = 106)
0
2
4
6
8
AM
H s
eru
m le
ve
l (n
g/m
l)
0.9582p =
sum OMA < 5 cm(n = 72 )
sum OMA ≥ 5(n = 50)
0
2
4
6
8
10
AM
H s
eru
m le
ve
l (n
g/m
l)
0.0316p =
With no DIE(n = 92)
With DIE(n = 30)
0
2
4
6
8
AM
H s
eru
m le
ve
l (n
g/m
l)
0.8588p =
sum OMA ≤ 4 cm(n = 67 )
sum OMA > 4(n = 55)
0
2
4
6
8
10
AM
H s
eru
m le
ve
l (n
g/m
l)
0.1409p =
unilat OMA(n = 91)
bilat OMA(n = 31)
0
2
4
6
8
10
AM
H s
eru
m le
ve
l (n
g/m
l)
0.3153p =
AMH/SIZE OMA SUM CORRELATION
0 5 100
5
10
15
AM
H s
eru
m le
ve
l (n
g/m
l)
OMA size (cm)
0.04744R square =
0.0160p =
AMH/SIZE OMA CORRELATION
0 5 100
5
10
15
AM
H s
eru
m le
ve
l (n
g/m
l)
OMA size (cm)
0.05495R square =
0.0094p =
Study group(n = 122)
Control group(n = 106)
0
10
20
30
40
AM
H s
eru
m le
ve
l (n
g/m
l)
0.0015p =
OMA < 5 cm(n = 83 )
OMA ≥ 5(n = 39)
0
2
4
6
8
10
AM
H s
eru
m le
ve
l (n
g/m
l)
0.0003p =
Study group(n = 122)
Control group(n = 106)
0
2
4
6
8
AM
H s
eru
m le
ve
l (n
g/m
l)
0.9582p =
sum OMA < 5 cm(n = 72 )
sum OMA ≥ 5(n = 50)
0
2
4
6
8
10
AM
H s
eru
m le
ve
l (n
g/m
l)
0.0316p =
With no DIE(n = 92)
With DIE(n = 30)
0
2
4
6
8
AM
H s
eru
m le
ve
l (n
g/m
l)
0.8588p =
sum OMA ≤ 4 cm(n = 67 )
sum OMA > 4(n = 55)
0
2
4
6
8
10
AM
H s
eru
m le
ve
l (n
g/m
l)
0.1409p =
unilat OMA(n = 91)
bilat OMA(n = 31)
0
2
4
6
8
10
AM
H s
eru
m le
ve
l (n
g/m
l)
0.3153p =
AMH/SIZE OMA SUM CORRELATION
0 5 100
5
10
15
AM
H s
eru
m le
ve
l (n
g/m
l)
OMA size (cm)
0.04744R square =
0.0160p =
AMH/SIZE OMA CORRELATION
0 5 100
5
10
15
AM
H s
eru
m le
ve
l (n
g/m
l)OMA size (cm)
0.05495R square =
0.0094p =
AMH
Endometriosis and ovarian reserveQuantity
Marcellin - Santulli - Chapron et al, submitted 2015
Endometriosis and ovarian reserveThe impact of OMA on IVF outcomes
Coccia et al. Reprod biomed online 2014
N=64
Endometriosis and ovarian reserveThe impact of OMA on IVF outcomes
Hamdan et al. Human Reprod Update 2015
IVF and diminished ovarian reserve: Post OMA cystectomy versus idiopathic
Roustan et al., Hum Reprod (2015)
Diminished ovarian reserve
AMH < 2ng/ml
Retrospective study
OMA Cystectomy Idiopathic
- Medical treatment
- Surgery
- Assisted Reproductive Technologies
Endometriosis related infertilityManagement options
Endometriosis: IVF outcome: Life birth rate
Hamdan et al., Obstet Gynecol (2015)
Appendix 1: A. Overall live birth rate in women with endometriosis compared to control. B. Overall clinical pregnancy rate in women with endometriosis compared to control. C. Overall mean number of oocytes retrieved from women with endometriosis compared to control. D. Overall miscarriage rates in women with endometriosis compared to control. A)
B)
Hamdan M, Omar SZ, Denselman G, and Cheong Y. Influence of Endometriosis on Assisted Reproductive Technology Outcomes: A Systematic Review and Meta-analysis. Obstet Gynecol 2015;125. The authors provided this information as a supplement to their article. © Copyright 2015 American College of Obstetricians and Gynecologists. Page 1 of 2
Endometriosis and IVFThe Phenotype n=359
Santulli P, Maignien C, Chapron C. Submitted 2015
DIE Oma Sup P value
Patients 212 98 49
No. of cycles 425 200 95
No. of ET 282/425 (66.4) 141/200 (70.5) 77/95 (81.1) 0.018
Clinical pregnancy rate per cycle 98/425 (23.1) 55/200 (27.5) 29/95 (30.5) 0.22
Clinical pregnancy rate per ET 98/282 (34.8) 55/141 (39) 29/77 (37.7) 0.67
Implantation rate 111/513 (21.6) 62/265 (23.4) 35/140 (25.0) 0.66
Abortion rate 30/98 (30.6) 22/55 (40.0) 16/29 (55.2) 0.049
Effects of GnRH-a IVF outcome
the administration of GnRH-a or OC prior to IVF/ICSI in women w/ endometriosis increases the odd of pregnancy > 4 fold.
Ovarian suppression before COH
controls Osis IV OMA present
w/ OC pretreatment
425 57 28 **
P<0.01
83 52 31
*
P<0.05
No pretreatment
* **
pre-ART OC x6-8 wks Center 1 & 2
PR
%
Effects of OC IVF outcome
Sellam et al Cochrane (2006)
de Ziegler et al., Fertil Steril (2010)
Endometriosis related infertilitySurgery vs ART
ARTSurgery
Fertility
Limits
Advantages
DIE surgery complications
Ovarian reserve damage
Post retrieval Infection
Pain ?
Pain treatment OMA surgery not necessary
- Specifications and pathogenesis
- What are the therapeutic options ?
- How to choose between the therapeutic options?
- Proposition for a strategy
Endometriosis related infertility
- Endometrioma: to remove or not ?
- Clinical symptoms
- Adenomyosis
- Iterative Surgery
- Large endometrioma
How to choose between the therapeutic
options?
Endometrioma and IVF: To remove or not to remove
That is the question
Pain progressionPost retrieval
infection
Fertility preservation in women with
endometriosisPain progression
Santulli-Bourdon-Chapron et al., Fertil Steril in press 2015
N=102
N=104
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 (2015) 513 2 (0.38%)
TOTAL 835 4 (0.48%)
Fertility preservation in women with
endometriosisPelvic infection after oocyte retrieval
Endometrioma and IVF: To remove or not to remove
That is the question
Somigliana, et al., Human Reprod Update (2015)
No systematic surgery before IVF
Endometriosis: n = 870 patients
Pelvic pain Infertility
Asymptomatic
202 23.2%
SUP 21 10.4%
OMA 36 17.8%
DIE 145 71.8%* Oma + 76 52.4%
* Oma - 69 47.6%
453 52.1%
SUP 52 11.5%
OMA 105 23.2%
DIE 296 65.3%
110 12.6%
SUP 25 22.7%
OMA 59 53.6%
DIE 26 23.6%
Chapron and Santulli, (2014)
105 120%
SUP 49 46.7%
OMA 29 27.6%
DIE 27 25.7%* Oma + 9 33.3%
* Oma - 18 66.7%p < 0.001
≠
Determinants for pain ≥ 7 in endometriotic women with infertility
results from muliple logistic regression analysis
OR (95%IC) P value
DIE intestine 3.9 (1.3-11.2) 0.012
Previous endometriosis surgery 2.7 (1.3-5.4) 0.006
Santulli-Lamau-Chapron, Submitted (2015)
Endometriosis related infertility:Pelvic pain
Endometriosis: Preoperative work-up Questionning and Imaging
QuestionningPelvic
examination
Biochemical
markers
MRI Uro-MRI
Trans-vaginal
USTrans-rectal US
Kidney scintigraphy
Endometriosis and infertility: PhenotypeAdenomyosis
OMESUP DIE Adenomyosis
Vercelllini et al RBMO 2014
Adenomyosis and infertilityIntestinal DIE
Endometriosis: Surgical management
Disease Surgery
Progression
Recurrence
Unnecessary
Inappropriate
?
Sibiude, Santulli, Chapron, Obstet Gynecol 2014n = 790 patients
Repetitive surgery:24-month cumulative pregnancy rate
Endometriosis-related infertilityEndometriosis
First line S.
First line S.
Repetitive S.Repetitive S.
40%
22%19%
34%
Vercellini et al., Fertil Steril 2009
OMA: Ovarian reserve and repetitive cystectomy
Ferrero et al., Fertil Steril (2015)
Fertility preservation in endometriosis
Validity of fertility preservation
Somigliana, et al., Human Reprod (2015)
Large EndometriOMAs :Surgery before ART ?
Pre-ART intervention: GnRH-a + OMA aspiration vs. GnRH-a
Contemporary Clinical Trials (2012)
- Specifications and pathogenesis
- What are the therapeutic options ?
- How to choose between the therapeutic options?
- Proposition for a strategy
Endometriosis related infertility
Take home
messages
- Multidisciplinary management
Endometriosis
and
Patients
Pelvic pain
Infertility
- Global approach
Surgery
Medical Ttt
AR
T
OMAs DIE
Adenomyosis
Strategy
Semen analysis
Fallopian tubes
SurgeryProvide 6-18 mo
for spontaneous preg.
IVF / ICSI
2
3
Ovarian reserveTime available for in vivo
1
if not pregnant
pre ART
IVF for severe male factor
IVF fortubal factor
Emergency I V F
2
3
1
in principleNO surgery
(3 months)
• Pelvic pain• Hydrosalpinx• Large oma???
InfertilityWork up
de Ziegler,
Borghese,
and Chapron
The Lancet, 2010
Ovarian reserve
Adenomyosis
Infertility:
management
Infertility Pelvic pain
A
Referral center
Classical center
B
« Emergency ART »
Fertility preservation ?
Previous surgery
Endometrioma x2
OC
?
Surgery ? ART
without
surgeryPhenotypeSurgery ?
Phenotype
Take home
messages
Best indication for surgery
in cases of endometriosis
related infertility is
pelvic pain
- DIE surgery should be complete
- Risks of DIE surgery
- Endometrioma alters the ovarian responsiveness per se
- Endometrioma surgery alters the ovarian reserve
- OMA surgery unnecessary before ART
- Fertility preservation should be considered as part of preoperative
counselling in young women with severe endometriosis
- Oocyte vitrification
Take home messages
One goal - One surgery
in « the endometriosis life »
Gynecology
Surgical unit:
C Chapron, B Borghese, P Santulli,
H Foulot, MC Lafay-Pillet, A Bourret, G
Pierre,
M Even, MC Lamau, L Marcellin, P
Marzouk
Medical unit:
A Gompel, G Plu-Bureau, L Maitrot
Reproductive endocrinology unit:
D de Ziegler, P Santulli, V Gayet, P Pirtea,
FX Aubriot
Intestinal surgery
B Dousset, S Gaujoux, M Leconte
Radiology
AE Millischer, L Maitrot
Laboratory: Genetic
D Vaiman, F Mondon, S Barbaux
Laboratory: Imunulogy
F Batteux, S Chouzenoux, C Nicco,
C Chéreau, B Weill
Laboratory: Reproducive biology
JP Wolf, V Lange, K Pocate,
JM Kuntzman, C Chalas
Statistical unit
F Goffinet, PY Ancel
D de Ziegler, Professor and Head, Reproductive Endocrinology and Infertility unit,
A Gompel, Professor and Head, Medical Gynecological unit,
C Chapron, Professor and Chair, Gynecology Obstetrics II and Reproductive Medicine