Assisted reproduction in endometriosis Agui Online.ppt

arteendometriosiroma9marzo2009 gianfrancoscarselli m e cocciadepartimentodiginecologia perinatologiaeriproduzioneumanauniversit difirenze endometriosi auditoriumdelministerodellavorodellasaluteedellepolitichesociali endometriosis managementdilemma pain deependometriosis recurrencesandsequelae isnotthesamepatientchoosingamanagement ovariancyst infertility m e coccia2006 endometriosisepidemiology incidencehistologicallyorsurgicallyconfirmeddisease 1 6per1000 yrpre congresseshre20041 3per1000 yrnationalcenterforhealtstatistics2 37 2 49per1000 yrvercellini maastricht2005prevalence6 10 infemalepopulation40 60 womenwithpelvicpain20 30 womensufferingfrominfertilityprevalencehasprobablyincreasedoverthelast100yrsmodernwomenhavemanymoremensesthantheirpredecessorsintroductionoflaparoscopydelayindiagnosisaveraging8 3yrs endometriosisasasocialdisease withthewomanasthefocalpoint investigationbytheitaliansenate barton smith2006 infertilit nelledonneconendometriosi gravidanzespontaneea36mesi collinsja etal 1995 endometriosisassociatedinfertility womenwithminimalormildendometriosiswhoundergolaparoscopyshouldbeofferedsurgicalablationorresectionofendometriosispluslaparoscopicadhesiolysisbecausethisimprovesthechanceofpregnancyitiswidelyacceptedthatminimalandmildendometriosismaybeconsideredequivalenttounexplainedinfertilityandmanagedaccordingly a b minimal mildendometriosis moderate severeendometriosis evidencelevel1b level1a norctsormeta analysesareavailabletoanswerthequestionwhethersurgicalexcisionofmoderatetosevereendometriosisenhancespregnancyrate baseduponthreestudies adamsonetal 1993 guzicketal 1997 osugaetal 2002 thereseemstobeanegativecorrelationbetweenthestageofendometriosisandthespontaneouscumulativepregnancyrateaftersurgicalremovalofendometriosis butstatisticalsignificancewasonlyreachedinonestudy osugaetal 2002 copyrightrestrictionsmayapply vercellini p etal hum reprod 200924 254 269 doi 10 1093 humrep den379 overviewofrctscomparinglaparoscopicablationoflesionswithnosurgeryininfertilewomenwithminimalormildendometriosis surgeryforendometriosis associatedinfertility apragmaticapproachp vercellinihumanreproduction 2009 copyrightrestrictionsmayapply vercellini p etal hum reprod 200924 254 269 doi 10 1093 humrep den379 overviewofrctscomparingvaporization coagulationwithexcisionofovarianendometrioticcysts surgeryforendometriosis associatedinfertility apragmaticapproachpaolovercellinhumanreproduction vol 24 2009 copyrightrestrictionsmayapply vercellini p etal hum reprod 200924 254 269 doi 10 1093 humrep den379 resultsofstudiescomparingivf etwithsecond linesurgeryininfertilewomenwithrecurrentmoderatetosevereendometriosis surgeryforendometriosis associatedinfertility apragmaticapproachpaolovercellinhumanreproduction 2009 conclusionsonlylimitedtheabsolutebenefitincreasesintermsofenhancementofpregnancyratesseemslowerthanthepreviouslysuggested38 adamsonandpasta 1994 beingreasonablybetween10and25 basedontheresultsofobservationalornon randomizedtrialsandappearstobepartlyindependentofspecificlesiontypes thepracticalimpactofsurgeryforstagei iidisease aregreatlyinfluencedbyprevalenceoftheconditioninthepopulationundergoinglaparoscopy theeffectofsurgeryforperitonealdiseaseissmall excisionofrectovaginallesionsisofdoubtfulvalueandassociatedwithseveremorbidity first linesurgeryforlargeovarianendometriomasseemstobetheprocedurewiththemostfavourablebalancebetweenbenefits harmandcosts apracticaladvantageofsurgeryistemporarypainreliefinsymptomaticpatients thismayrenderfeasiblespontaneousattemptsatconceptioninwomenwhorefuseorprefertopostponeivf completeanddetailedinformationonrisksandbenefitsoftreatmentalternativesmustbeofferedtopatients inordertoallowunbiasedchoicesbetweendifferentpossibleoptions paolovercellinihumanreproduction 2009 objectiveisthebaby whynotivf surgicalmanagementbytheablationofendometrioticlesionsandtheremovalofendometriomasisanestablishedapproachbutmanywomenwithendometriosisofallseveritieschoosetohaveivftreatment ovarianendometrioma laparoscopicovariansurgeryrecommendedifovarianendometrioma 3cmconfirmthediagnosishistologicallyreducetheriskofinfectionimproveaccesstofolliclespossiblyimproveovarianresponsedecisionshouldbereconsideredifshehashadpreviousovariansurgery gpp a laparoscopiccystectomyforovarianendometriomas 4cm mayofferbetterresultsvsdrainageandcoagulation painrelief prcoagulationorlaservaporizationofendometriomaswithoutexcisionofthepseudocapsule sign riskofcystrecurrencefenestrationfollowedbygnrhawherenocystwallpresentmayprovebeneficial beforeart 2008 2006 doesendometriosisaffectchancesofsuccessusingart us cdc2006 canada2006metanalysis2002doesthepresenceofendometriosisaffectthesuccessrateofart effectofsurgicallytreatedendometriosisontheoutcomeofartourdata endometriosis artobjective doesendometriosisaffectthechancesofsuccessusingart i whatarethecausesofinfertilityamongcoupleswhouseart artsuccessrayes2008usdepartmentofhealtandhumanservicescdccentersfordiseasecontrolandprevention 2005 doesthecauseofinfertilityaffectthechancesofsuccessusingart nationalaveragesuccessrateslightly 28 successratesvariedsomewhatdependingondiagnosis usdepartmentofhealtandhumanservicescdccentersfordiseasecontrolandprevention 2008 hadabove averagesuccessratestubalfactor ovulatorydysfunction endometriosis malefactor unexplainedinfertility lowsuccessrates survellaincessummaries art usa2001 april30 2004 effectofendometriosisonivfkurtbarnhart 2002 unadjustedmeta analysisofoddsofpregnancyinendometriosispatientsvs tubalfactorcontrols i iistagesvstubalfactor significativedifferencesinallcomparisonsprnostatisticalsignificance or 0 79 ci 0 60 1 03 iii ivstagesvstubalfactor pr largereduction or 0 46 ci 0 28 0 74 fr higherin withsevereendometriosis or 1 54 ci 1 39 1 70 kurtbarnhart fertilityandsterility june2002 meta analysiskurtbarnhart fertilityandsterility june2002 ourconsiderationsnoneofthestudiesrctandveryoldstudymuchmoreimprovementofembryo labduringlast5yearsthestudiesdidnotreportwhichpatientsweretreatedprevioustreatedendometriosis endometriosispresentatthetimeofivf notdeterminatedpresenceorabsenceofhydrosalpinxwerewomenwithtubalinfertilitysubmittedtodiagnosticlaparoscopybeforeivftoassessthepresenceofminimal mildendometriosis availablestudieshaverarelydistinguishedbetween previouslysurgeryendometriomas endometriomasnotpreviousovariansurgery bothendometriomas previousovariansurgery withendometriosisnocystatthetimeoftheivf etcycle notpossibletodiscernwhetherobservedeffectsareconsequenttothepresenceoftheendometriomaand ortosurgicaltreatment althoughthereareindicationstosupportsurgery mediateddamagethepossibilitythatinjurymay atleastinpart alsoprecedesurgerycannotbeexcluded consequently somigliana2006 literaturereviewofthelast5yrs endometriosisandivfoutcome p 0 05 doesthepresenceofendometriomaaffectthesuccessrateofart ii theimpactofovarianendometriomasontheoutcomeofartiscontroversialongoingdebateonhowtomanageendometriomas especiallyforthoselargerthan3cmin beforeartthepresenceofanovarianendometrioticcystmightimpairoocytequalityintheipsilateralovaryresponsetocohfertilization implantationrates removalofendometriomasbeforeivfdoesnotimprovefertilityoutcomes artcycleoutcomesinwomentreatedbylaparoscopiccystectomyforanendometrioma 3cmwithanovarianendometrioticcystofsimilarsizewhohadnotpreviouslyundergoneconservativeovariansurgery garcia velasco2004 laparoscopiccystectomydoesnotcompromisenumberorqualityofoocytesobtainedwithcohdoesnotofferanyadditionalbenefitintermoffertilityoutcomegarcia velasco2004thepresenceofovarianendometriomasisassociatedwithareducedresponsivenesstogonadotropinssomigliana2006 effectofsurgicallytreatedendometriosisontheoutcomeofart iii endometriosisstagesiii iv womenwithsevereendometriosiswhohadhadprevioussurgicaltreatmentsignificantlyhigherwithdrawalratethantubalinfertilitydiscontinuedbecauseofpoorovarianresponse 29 7 withendometriosis1 1 withtubalinfertilityavoidsurgeryininfertilepatients aboulgharetal 2003 vaporizationoftheinternalcystwallofendometriomasdidnotimpairovarianfunctionno inovarianresponsetostimulationbetweenand withtubalinfertilitydonnezetal 2001 surgicaltreatmentpriortoin vitrofertilization surreyes2003 retrospectivestudystudygroup withendometriosis excluded withpersistentorrecurrentendometriomas 3cmatthetimeofivf dividedinto2groupsbasedontheintervalbetweenthemostrecentsurgicalinterventionandoocyteaspiration moreorlessthan6months nosignificant ovarianstimulation numberofoocytesretrieved ongoingpr possiblythepregnancy enhancingeffectofsurgeryonspontaneousconceptionisovercomebytheinherentlygreaterimpactofivf embryotransferonimplantationandpregnancygarcia velascoja2004 retrospectivecase controlstudyremovalofendometriomaspriortoivfdoesnotimprovefertilityoutcomesthestudywasrecentlycriticizedbylittmane 2005sincediagnosisofendometriomasinthecontrolgroupwasonlybasedonuscompleteresectionoftheendometrioticcystwasimpossibleinsomecasetheauthorsdidnotmentionifperitonealendometriosis knowntobecopresentwithovarianendometriomas wassurgicallyexcisedatthesametime thesimpletruthisthatwedonotknowandthatrandomizedtrialsaredesperatelyneededtosolvethisissue dehondt 2006 surgicalablationorresectionperformedinthe6monthspriortoivf etdidnothaveabeneficialeffectoncycleoutcomeintheabsenceoflargeendometriomas internationalguidelinesonsurgicaltreatmentofendometriosis associatedinfertilityinasymptomaticwomen surgeryforendometriosis associatedinfertility apragmaticapproachpaolovercellini humanreproduction 2009 ourdataendometriosisandivfoutcome iv retrospectivecohortstudyivfcycles1999 2004 40yrs144 withendometriosis48previousovariancystectomyforendometriomas22previousovariancystectomyforendometriomasandthepresenceofendometriomaduringtv usexamination11presenceofendometriomaduringtv usexaminationwithoutpreviouscystectomy63 whohadendometriosisbutnotendometriomas70 tubalfactor toevaluateeffectofendometriosisorsurgeryforendometriosisvstubalfactoron ivf etcycles aim materialsandmethods cocciaetalpelvicpainmilan2006 clinicalpregnancyrate gestationalsaconus primaryoutcome peakserumestradiollevelstotalnumberofmatureoocytesfertilizationratenumberofembryosthatwereobtainedandtransferredimplantationrateoverallpregnancyrate secondaryoutcomes p 0 05 p 0 052 r45gtf results pregnancyrate ss intheclinicalprbetweentubalfactorand previouslysubmittedtocystectomywithoutrecurrences 28 6 vs10 4 p 0 05 thedirectiontowardsahigherclinicalpramong withtubalfactorandnopastorcurrentdiagnosisofendometriomas wong2004 withhystoryofendometriomashigherprwereobservedamongthosewhowereneversubmittedtoovariansurgery 18 2 comparedwith submittedtocystectomy 10 4 and submittedtocystectomyandwithrecurrences 9 characteristicsivf icsicyclesinptoperatedbilateralendometriomasandcontrols somiglianahum reprod2008 results tubalfactorthemostresponsivenesstoovarianstimulationwhilewomenwithhystoryofcystectomyandrecurrencesrequiredhigherdosageofgonadotropinsovarianreserve in neversubmittedtosurgerywithendometriomaduringivf comparabletoendometriosiswithnohystoryofendometriomaandtubalfactor estradiollevels numfollicles numoocytesretrieved surgeryforovarianendometriomareducesovarianreserve loh1999 canis2001 marconi2002 wong2004 varioustechniques natureofendometriomas differentsurgeons muziietal 2002strippingprocedure pathologicalanalysisofendometrioticcystwallovariantissueinadvertentlyexcisedin54 ofcasesinnocasethistissueshowanormalfollicularpatternastheonepresentinhealthyovaries riskofreducedovarianreserve removalofathinlayerofovariantissue ifany maynotrepresentanovertreatment muziietal 2005stripofovariantissue 0 1 0 3mmthickinthewholespecimenthickernearthehilus 0 8mm mostofspecimens devoidoffollicles orscantyprimordialfolliclesapproachingthehilus 70 ofspecimens functionalstagesoffolliculardevelopment strippingprocedureisatissue preservingproceduregreatcautionwhilestrippingandhemostasisnearthehilus infertile submittedtoendometriomacystectomy ourstudy stagei iiendometriosisortubalfactorinfertilityneverundergoneovariansurgery vs cocciaetal 2006 worldpelvicpainmilan youngerpatients 35years meanfollicularresponseofpostcystectomyovaries significantlyolderpatients 35years eventhenormalovariesshowedpoorresponsenossdbetweentheovarianresponsesofpostcystectomyandcontrols meanfollicularresponseofcontrolsandmeannumberoffollicleof 15mmwerereducedsignificantlywhencomparedtocontrolovariesinwomen 35yrs 4 1 3 5vs8 7 4 4 1 9 1 8versus5 1 2 7 whilepost surgeryovariesshowedasimilarreducedresponseinbothagegroups cocciaetal 2006 laqualit dell ovocita alteratanelledonneconendometriosidistadioiii iv simon etal 1994 aimofthestudytoassesswhetherivf etcansignificantlyincreasetheoverallpregnancyrateininfertilepatientswithendometriosiswhofailedtoconceivespontaneouslyafterlaparoscopicsurgerystudyonacohortofwomenwithendometriosiswhowereinfertileatthetimeoflaparoscopy 47additionalinfertilityfactors 154infertility related endometriosisatleast1year sduration 440laparoscopyendometriosis 107womenwithendometriosis related infertility retrospectivestudymarch1995anddecember2003endometriosisstagedaccordingtother asrm characteristicsofinfertilewomen endometriosis infertility surgeryandartanintegratedapproachforasuccessfulmanagement coccia 2008 pregnancyratesafterlaparoscopyandivf et cumulativefecundityratesanalysedaccordingtothestageofendometriosisandaccordingtothepatients ageareshownrespectivelythecumulativepregnancyrateforstagesiandii 57 7 wassignificantlyhigherthanthecumulativepregnancyrateforstagesiiiandiv 31 p 0 05 cumulativepregnancyratesin107infertile undergoinglaparoscopicconservativesurgeryforendometriosis thecumulativeprobabilityofspontaneousconceptionaftersurgerywas42 5 theprobabilityofconceptioninthefirst6monthswas25 and inthefollowing6months 10 onlyeightpregnancieswereachievedmorethan13monthsafterlaparoscopy thefecundityrateduringthefirst6monthsafterlaparoscopywassignificantlyhighercomparedtothefollowingintervals p 0 05 cumulativepregnancyratesin107infertilewomenundergoinglaparoscopyconservativesurgeryforendometriosis fecundityrateduringfirstinterval months0 6 afterlaparoscopy 25 wassignificantly