IVF - ICSI ÖNCESİ ENDOMETRIOMALAR

ÇIKARTILMALI MI?

Prof. Dr. Bülent Baysal

İ.Ü. İstanbul Tıp Fakültesi

ENDOMETRİOZİS

17.yy...............peritoneal ülser 1860..............Von Rokitansky (mikroskopik tanı)

Prevalans: kadınların %5 inde, infertilite problemi olan kadınların %30-50 sinde

Impact of ovarian endometrioma on oocytes and pregnancy outcome in in vitro fertilization.Suzuki T, et al. Fertil Steril 2005

Group A: 80 cycles with ovarian endometriomas; group B: 248 cycles with endometriosis - without

endometrioma group C: 283 cycles - tubal factor .

Fewer oocytes were retrieved from groups A and B than from group C (P<.005).

pregnancy rates (group A: 25.3%, group B: 22.3%, group C: 23.9%).

CONCLUSIONS: Endometriosis affects oocyte number but not embryo quality or pregnancy outcome

KİSTEKTOMİNİN OVER REZERVİNE ETKİSİ ??

IVF-ICSI outcome in women operated on for bilateral endometriomas.Somigliana E,et al. Hum Reprod. 2008

68 cases (bilat. cystectomy)- 136 controls

the number of follicles (P = 0.006), oocytes retrieved (P = 0.024) and embryos obtained (P = 0.024) were

significantly lower.

The clinical pregnancy rate per started cycle in cases and controls was 7% and 19% (P = 0.037)

CONCLUSIONS: IVF outcome is significantly impaired in women operated on for bilateral ovarian endometriomas.

Studies evaluating response to ovarian stimulation in patients previously operated for endometriomas (EM)

AuthorSurgical technique olgu oosit embryo gebelik

EM Ctr EM Ctr EM Ctr EM (%) Ctr (%)

Al-Azemi et al. (2000)*

Not reported 40 80 6.9 ± 0.7 7.1 ± 0.5 NA NA 15 15

Canis et al. (2001)

Cyst enucleation

41 59 9.4 ± 6.2 10.9 ± 6.5

4.7 ± 3.6

5.8 ± 4.9

36 30

Donnez et al. (2001)

Laser vaporization

85 289

10.6 ± 4.2

8.6 ± 6.3 4.4 ± 3.2

4.0 ± 3.6

37 35

Marconi et al. (2002)

Cyst enucleation

39 36 7.5 ± 3.9 8.7 ± 5.1 3.8 ± 0.8

3.6 ± 1.2

38 33

Geber et al. (2002)

37 46 12.0 ± 5.9

NA NA 53 56

Pabucco et al. (2004)

Cyst enucleation

44 46 7.2 ± 1.5 NA NA 25 30

End.çıkarılmış 147 siklüs - %25.4 gebelikÇıkarılmamış 63 siklüs - %22.7 gebelik (p=0.776)(Fertil Steril 2004)

Effect of endometrioma cystectomy on IVF outcome: a prospective randomized study.Demirol A, Reprod Biomed Online. 2006

prospectively randomized group I (49 patients) - ovarian surgery before ICSI group II (50 patients) -ICSI cycle directly Group 1- lower oocyte number There was no difference in terms of fertilization

(86% in group I and 88% in group II), implantation (16.5% in group I and 18.5% in group II)

pregnancy rates (34% in group I and 38% group II).

Outcome of in vitro fertilization/intracytoplasmic sperm injection after laparoscopic cystectomy for endometriomas.Yaralı et al. Fertil Steril 2006

unilateral (n = 34) bilateral (n = 23) laparoscopic cystectomy control group (n= 99 ) tubal factor infertility

The mean number of oocytes, metaphase II oocytes, and two-pronucleated oocytes were significantly lower in the bilateral cystectomy group

fertilization rate, the mean number of embryos transferred, the mean number of grade 1 embryos transferred, the clinical PR/ET, implantation rate, were comparable among the three groups.

Laparoscopic resection or sonography-guided vaginal aspiration of endometriomas prior to ICSI-ET does not worsen treatment outcomesTavmergen E , et al. Clin Exp Obstet Gynecol. 2007;

resection group (Group I) 36 cycles ; aspiration (Group II) - 26 cycles control group (Group III) - 53 cycles - tubal factor

Gonadotropin consumption was higher, peak estradiol level lower, the number of oocytes less in the laparascopic resection group (Group I) with respect to the control group.

laparascopic endometrioma resection, transvaginal ultrasound-guided endometrioma cyst aspiration

do not worsen the treatment outcome.

Impact of ovarian endometrioma on assisted reproduction outcomes.Gupta S. Reprod Biomed Online. 2006

Metaanalysis

The odds for clinical pregnancy were not affected significantly in patients with ovarian endometrioma compared with controls, with an overall odds ratio of 1.07 from three studies [95% CI: (0.63-1.81), P = 0.79].

The effect of surgical treatment for endometrioma on in vitro fertilization outcomes: a systematic review and meta-analysis.Tsoumpou I, .UK Fertil Steril 2008

A systematic review and meta-analysis three electronic databases - 1985 - 2007 20 eligible studies. Meta-analysis - five studies that compared surgery vs.

no treatment of endometrioma. There was no significant difference in clinical pregnancy

rate between the treated and the untreated groups. no significant difference -to controlled ovarian

hyperstimulation with gonadotrophins

Should endometriomas be treated before IVF-ICSI cycles?Somigliana E, et al. Human Reprod Update 2006

The idea that surgery increases IVF pregnancy rates is not supported by the available evidence.

However, the chance of conception is not the only issue that has to be considered.

Somigliana, E. et al. Hum Reprod Update 2006 12:57-64; doi:10.1093/humupd/dmi035

Pros and cons of surgical treatment of endometriomas before IVF-ICSI cycles

Copyright restrictions may apply.

Vercellini, P. et al. Hum. Reprod. 2008 0:den379v1-15; doi:10.1093/humrep/den379

Pregnancy rates observed after laparoscopic excision of endometriomas

Management of endometriomas in women requiring IVF: to touch or not to touch.Garcia-Velasco JA. Human Reprod 2008

proceeding directly to IVF to reduce time to pregnancy, to avoid potential surgical complications and to limit patient costs.

Surgery should be envisaged only in presence of

*large cysts,

*pain symptoms which are refractory to medical treatments,

*malignancy cannot reliably be ruled out

International guidelines on surgical treatment of endometriosis-associated infertility in asymptomatic women.

ESHRE 2005 ASRM 2006 RCOG 2006

Minimal-mild endometriosis (stage I–II disease)

Limited benefit: surgery recommended Small benefit: surgery recommended Demonstrated benefit: surgery recommended

Moderate–severe endometriosis (stage III-IV disease)

Possible but unproven benefit: surgery recommended

Possible benefit: surgery recommended

Possible benefit: recommendation uncertain

Post-operative adjuvant treatment

No benefit: not recommended No benefit: not recommended No benefit: not recommended

Surgery before IVF 4 cm Doubtful benefit: no recommendation

4 cm

Recurrent endometriosis No recommendation Second-line surgery not recommended

No recommendation

1- IVF öncesi cerrahi zorunlu değil 2-Semptom varsa opere edilebilir

3-Hastanın kaderini belirlemede ilk operasyon çok önemli

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