Endométriose: Quand passer la main?

Endométriose:
Quand passer la main?
Dr David HAMID
Strasbourg
Rappels
§  25à50%despa,entessuiviespourinfer,litéontune
endométriose
§  30à50%despa,entesayantuneendométrioseaurontun
problèmed’infer,lité
§  Prévalencedel’endométriose:5à40%desfemmesenâgede
procréer
§  Tauxdefécondabilitémensuelledelapa,enteendométriosique
0,02à0,045%vs0,15à0,2(ASRM)
§  Chancedegrossesseà0,73vs1,57pourstérilitétubaire,1,19pour
lesinfer,litésmasculines,2,64pourlesinfer,litésinexpliquées
(EijkermansetcolHumReprod2008)
2
Mécanismephysiopathologique
§  Théoriedel’implanta,on(Sampson):
§  Régurgita,onparlestrompesdeFallope
§  Implanta,onparphénomèned’adhésionet
proliféra,on
§  Théoriedelamétaplasie(Fuji):
§  localisa,onatypique:prostate,ombilic
§  Théoriedescellulessouchesendométriales
(Sasson)
§  Cellulessouchescirculantessetransformanten
cellulesendométriosiques
reflux du sang et des cellules endométriales dans la cavité péritonéale <1>, défaillance de la défense
immunitaire du péritoine <2>, adhésion des cellules endométriales au péritoine <3>, envahissement du
mésothélium <4>, prolifération <5> et angiogénèse <6> (Louse et al., 2009)
Figure 1 : théorie du reflux et de la transplantation de cellules endométriales
La théorie du reflux est la plus admise aujourd’hui (9), même si elle explique mal les
localisations extra pelviennes atypiques (cérébrale (8) par exemple). Le reflux est observé
Mécanisme
développe par conséquent sous l’influence d’autres facteurs.
physiopathologique
chez 90 % des femmes. (12) Ce chiffre ne correspond pas à la prévalence de la maladie qui se
Concernant les anomalies des systèmes d’épuration, plusieurs études ont démontré que
le liquide péritonéal des femmes endométriosiques diffère de celui des femmes saines.http://www.saintluc.be/services/medicaux/gynecologie/endometriose.php
Endométriomes:physiopathologie
1 : ovaire 2 : trompe 3 : ligament rond 4 : ligament large
a, b : accumulation des débris menstruels
c, d : inversion et invagination du cortex ovarien
Figure 11 : constitution d’un kyste endométriosique
(Roman et al. EMC gynecol 2009)
L’endométriose superficielle voit ses localisations les plus fréquentes au niveau du
cul de sac de Douglas et du ligament large. Les lésions se retrouvent également au niveau du
cul de sac vésical, du dôme utérin, du dôme vésical (et possiblement, comme dit
Mécanismereliantl’endométrioseetl’infer,lité
§  Modifica,onsanatomiques:adhérencesperi-tubairesetperiovariennes,séquellesinflammatoirestubaires
§  Stadeextrême:pelvisgelé
Mécanismereliantl’endométrioseet
l’infer,lité
§  Altéra,ondelafonc,onpéritonéale: concentra,ondes
prostaglandines,protéasesetcytokinesdansleliquide
péritonéal
§  Altéra,ondel’endomètrepouvantaffecterl’implanta,on
embryonnaire: IgG,IgAetlymphocytes
§  Dysovula,oneteffetsdélétèressurl’ovocyte
ENDOMETRIOSE ET INFERTILITE
Quelle place pour la coeliochirurgie face à l’A.M.P ?
EndométrioseetFIV
Effets de l’endométriose sur les résultats de la F.I.V.E.T
Méta-analyse évaluant les résultats de la F.I.V dans l’endométriose
22 publications
Comparaison : endométriose vs infertilité tubaire
Barnhart. IVF in endometriosis-associated infertility.Fertil Steril 2002
Taux de Grossesses cliniques selon L’indication en FIV
EndométrioseetFIV
FIVNAT 2006
StadeAFS-R
§ Baséesurlésionsanatomiques
§ 
§ 
§ 
§ 
Stade1:1à5
stade2:6à15
Stade3:16à40
Stade4:>40
§ Stade1et2:22%grossesseà1an
(Parazzini1999)
§ Stade4:3%grossesseà1an
(Adamson1997)
§ CorrélaEonexcellenteentrestadeet
hypoferElité,pasdecorrélaEonavec
ladouleur
Figure 3. Staging: American Society for Reproductive Medicine
Revised Classification of Endometriosis
STAGE I (MINIMAL)
PERITONEUM
Superficial Endo — 1–3cm
L. OVARY
Superficial Endo — <1cm
Filmy Adhesions — <1/3
TOTAL POINTS
STAGE II (MILD)
-2
-1
-1
4
STAGE III (MODERATE)
PERITONEUM
Superficial Endo — >3cm
L. TUBE
Dense Adhesions — <1/3
L. OVARY
Deep Endo
— <1cm
Dense Adhesions — <1/3
R. TUBE
Filmy Adhesions — <1/3
R. OVARY
Filmy Adhesions — <1/3
TOTAL POINTS
PERITONEUM
Deep Endo
— >3cm
L. OVARY
Superficial Endo — <1cm
Filmy Adhesions — <1/3
R. OVARY
Superficial Endo — <1cm
TOTAL POINTS
STAGE III (MODERATE)
-6
-1
-1
-1
9
STAGE IV (SEVERE)
-3
-16*
-4
-4
PERITONEUM
Superficial Endo — >3cm
L. OVARY
Deep Endo
— 1–3cm
Dense Adhesions — <1/3
L. TUBE
Dense Adhesions — <1/3
TOTAL POINTS
-1
-1
29
*Point assignment changed to 16
**Point assignment doubled
PERITONEUM
Deep Endo
— >3cm
CULDESAC
Partial Obliteration
L. OVARY
Deep Endo
— 1–3cm
TOTAL POINTS
-6
-4
-16
26
STAGE IV (SEVERE)
-3
-32**
-8**
-8**
51
PERITONEUM
Deep Endo
— >3cm
CULDESAC
Complete Obliteration
R. OVARY
Deep Endo
— 1–3cm
Dense Adhesions — >1/3cm
L. TUBE
Dense Adhesions — >2/3cm
L. OVARY
Deep Endo
— 1–3cm
Dense Adhesions — >2/3cm
TOTAL POINTS
-6
-40
-16
-4
-16
-16
-16
114
Images 2012 © Jespersen & Associates, LLC.
-function score and the Endometriosis Fertility Index. Note: The Tab
«Forcesenprésence»
RPC
COLLÈGE
NATIONAL DES
GYNÉCOLOGUES ET
OBSTÉTRICIENS
FRANÇAIS
2006
PRISE EN CHARGE
DE L’ENDOMÉTRIOSE
RECOMMANDATIONS POUR LA PRATIQUE CLINIQUE
(Texte court)
CNGOF ,RPC 2006/2010: Infertilité
RPC2006
Arguments en faveur d’une endométriose
NON: 3 à 4 IIU avec
stimulation ovarienne
OUI: COELIOSCOPIE
DIAGNOSTIQUE
Lésions extensives
avec risques de
complications
chirurgicales
LESIONS TRAITABLES PAR
COELIOSCOPIE
Facteurs péjoratifs:
âge, OATS,
adhérences,
atteinte tubaire
Agonistes de la LHRH
Pas de facteurs
péjoratifs
Essai de G spontanée
6 à 12 mois
Récidive
FECONDATION IN
VITRO
Echec
Pas de récidive: 3 à 4
IIU avec stim ov
Placedelachirurgiechezlapa,ente
endométriosiqueinfer,le
Quandgarderlamain?
AMPetendométriosedestadeI/II
EndometriosisandFerElity:acommiteeopinion.FerElandSteril2012
EndométriosedeStadeI/II
• 
• 
• 
• 
• 
MarcouxetcolNEngJMed1997
ParazzinietcolHumReprod1994
AdamsonetcolSeminReprodEndoc1997
Chirurgie>absten,on
Increased fertility after treatment
in infertile women with endometriosis?
Chirurgie>traitementmédical
JACOBSON ET AL, COCHRANE DATABASE SYST REV, 2002
Chirurgie versus abstention
Marcoux et al (341 cas)
OR = 1,95 (1,18 – 3,22)
OR = 0,85 (0,32 – 2,28)
Parazzini et al (96 cas)
OR = 1,64 (1,05 – 2,57)
Synergiechirurgie/AMP
Reproductive BioMedicine Online (2010) 21, 179– 185
www.sciencedirect.com
www.rbmonline.com
ARTICLE
Endometriosis-associated infertility: surgery and
IVF, a comprehensive therapeutic approach
Pedro N Barri *, Buenaventura Coroleu, Rosa Tur, Pedro N Barri-Soldevila,
Ignacio Rodrı́guez
of Reproductive Medicine, Department of Obstetrics, Gynecology and Reproduction, Institut Universitari Dexeus,
• Service
825pa,entesde20à40ansde2001à2008
Gran Via Carles III 71–75, 08028 Barcelona, Spain
•  Duréemoyenned’infer,litéde3,2ans
* Corresponding author. E-mail address: [email protected] (PN Barri).
Dr Pedro N Barri was born in Barcelona in 1949. He graduated from the Faculty of Medicine in Barcelona in 1971
and completed his doctorate in 1993 with a thesis entitled ‘‘Respuesta Anómala a la Estimulación de la
Maduración Folicular en Fecundación In Vitro’’ with qualification Cum Laude. He is Director of the Department
arian reserve and response to stimulation
P < 0.03) than the 93 patients suffering from unilateral
affection.
Synergiechirurgie/AMP
e ovarian reserve of the whole population of 825 patients
fore undergoing any treatment was compared with that
served in a simultaneous control group, made up of 334
tients who were going to have IVF for male factor infertiland adjusted for age. Patients with endometriosis had
sal follicle-stimulating hormone concentrations on cycle
Table 1
<35 years
!35 years
Total
Among the 144 patients who went on to IVF after not
becoming pregnant post surgery, 32 presented recurrence
Endometriosis-associated infertility: pregnancy rates after surgery and/or IVF.
Group 1a (surgery)
(n = 483)
Age
Can IVF be attempted in a patient previously
operated on for endometriosis who has a
recurrence?
Group 1b (surgery and IVF)
(n = 144)a
Group 2 (IVF first option)
(n = 173)b
Pregnancyc
Time (Months)
Pregnancyc
Pregnancyc
229/372 (61.6)
33/111 (29.7)
262/483 (54.2)
12.5 ± 12 (1–66)
6.6 ± 7.2 (1–14)
11.8 ± 12.1 (1–66)
34/99 (34.3)
22/85 (25.9)
56/184 (30.4)
51/143 (35.7)
17/68 (25.0)
68/211 (32.2)
Values are number/total (%) or mean ± SD (range).
a
184 IVF cycles.
b
211 IVF cycles.
c
P < 0.05.
BarrietcolReprodBiomedOnline2010
Synergiechirurgie/AMP
Figure 1
Table 2
Age influence on pregnancy rate after surgery for endometriosis.
Endometriosis-associated infertility: pregnancy rate according to different treatment strategies.
Pregnancies after surgery (n)
Pregnancies after IVF (n)
Total pregnancies
Final clinical pregnancy
rate (%)
Group
Group
Group
Group
Group 1a
(surgery)
(n = 483)
Group 1b
(surgery and IVF)
(n = 483)
Group 2
(IVF first option)
(n = 173)
Group 3
(no treatment)
(n = 169)
262
–
262
54.2
262
56
318
65.8
–
68
68
32.2
–
–
20 (spontaneous)
11.8
I-a versus Group I-b: P < 0.0001.
I (a–b) versus Group II: P < 0.0001.
I (a–b) versus Group III: P < 0.0001.
II versus Group III: P < 0.0001.
Table 3
IVF outcomes in patients with endometriosis or male factor infertility after IVF
BarrietcolReprodBiomedOnline2010
treatment.
Endometriosis
(n = 317)
Male factor infertility
(n = 334)
P-value
Barrietcol
182
Figure 1
Age influence on pregnancy rate after surgery for endometriosis.
PN Barri et al.
Barrietcol
•  Absencederandomisa,onmais
Chirurgie
FIV
•  MieuxvautFIVa>37ans
Chirurgie+FIV
Tauxdegrossesse
>35ans
29,7%
25%
25,9%
Tauxdegrossesse
<35ans
61,6%
35,7%
34,3%
BarrietcolReprodBiomedOnline2010
ZiegleretcolLancet2010
FIV>37ans
Spécificitédel’endométriome
Opéreroupasopérerencas
d’infer,lité?
Endométriomesetinfer,lité
•  Tsoumpouetcol:FerElSteril2009
«Surgicalmanagementofendometriomashasno
significanteffectsonIVFpregnancyrateandovarian
responssEmulaEoncomparedwithnotreatment»
•  Garci-Velascoetcol:HumanReprod2009
«Responsivenesstogonadotrophinsa]erovarian
cystectomyisreduced.Surgeryshouldbeenvisaged
onlyinpresenceoflargeortotreatpainsymptoms,
orwhenmalignancycanbesuspected»
Absten,onchirurgicale
OUI, MAIS…
20 ± 10
VOLUME MOYEN DES ENDOMETRIOMES: 20 ±mm
10
OUI, MAIS…
20 ± 10
VOLUME MOYEN DES ENDOMETRIOMES: 20 ±mm
10
EndométriomesetAMP
TheimpactofendometriomaonIVF/ICSIoutcomes:a
systema,creviewandmeta-analysis
Hamdametcol.Humanreprodupdate2015
•  Meta-analysede33études(30/33rétrospec,ves).
•  Pa,entesavecendométriomesvssans
endométriomes
Résultats
Hamdametcol
•  Différencedetauxdenaissancesvivantesnon
significa,ve
•  Différencedetauxdegrossessesnon
significa,ve
•  5études(900pa,entes)concluaientàun
nombreplusimportantsdefollicules
recrutéesaprèschirurgieet5(900)l’inverse
•  Femmesopéréesounonavaientlemême
tauxdenaissancesvivantes
Facteursprédic,fs?
Aucunmarqueursuffisammentfiableenpré-opératoire
Chirurgiedesrécidives
d’endométriomes
Rôledelatechniqueopératoire?
–  Trauma,smethermique
–  Vasculaire
–  Exérèsedu,ssussain
•  Placedestechniquesnon-chirurgicalesavant
AMP
•  Yazbecketcol.Reprodbiomed2009
•  Onpasselamain…
EndométriosedestadeIII/IV
Endométrioseviscéraleprofondeet
infer,lité
Quandpasserlamain..Quandla
reprendre?
Endométrioseviscérale
Endométriose
urétérale
Endométriose
diges,ve
Situa,onclinique
•  Qualitédeviedétériorée
•  Chirurgieextensivepseudo-carcinologique
•  Morbiditésévère
–  Vessieneurologique4à10%
–  Fistulerecto-vaginale2à10%
•  «Equipesentrainées»
•  Neoeaméliora,ondelaqualitédevieaprèschirurgie
•  Quid/fer,lité?
Résultats/Fer,lité
Hindawi Publishing Corporation
BioMed Research International
Volume 2015, Article ID 438790, 7 pages
http://dx.doi.org/10.1155/2015/438790
Research Article
The Surgical Treatment of Severe Endometriosis
Positively Affects the Chance of Natural or Assisted
Pregnancy Postoperatively
Erin M. Nesbitt-Hawes,1,2 Neil Campbell,1,2 Peta E. Maley,1 Haryun Won,1,2
Dona Hooshmand,2 Amanda Henry,1,2 William Ledger,1,2 and Jason A. Abbott1,2
1
University of New South Wales, Sydney, Australia
Royal Hospital for Women, Locked Bag 2000, Barker Street, Randwick, NSW 2031, Australia
2
Correspondence should be addressed to Jason A. Abbott; [email protected]
Received 27 September 2014; Accepted 12 January 2015
BioMed Research International
Pa,entes
(1997-2002)
3
Table 1: Demographic data.
Age (median and range)
BMI (median and IQR)
Previous laparoscopic surgery
Smoking
Yes
Indication for surgery
Pain
Fertility
Both
Not stated
Prior pregnancy
Trying to conceive pre-op
Trial ART pre-op
Duration of surgery mins (median and IQR)
r-ASRM stage
III
IV
Length of stay hours (median and IQR)
All participants
(𝑛 = 253)
Trying to conceive post-op
(𝑛 = 142)
Pregnancy post-op
(𝑛 = 109)
37 (17–55)
24 (21–28)
149 (59%)
37 (26–50)
24 (21–28)
83 (59%)
36 (26–48)
24 (21–28)
58 (53%)
111 (44%)
60 (42%)
46 (42%)
164 (65%)
27 (11%)
58 (23%)
4 (1%)
79 (31%)
114 (45%)
20 (8%)
120 (90–145)
58 (41%)
27 (19%)
55 (39%)
2 (1%)
38 (27%)
95 (67%)
17 (12%)
120 (90–150)
48 (44%)
24 (22%)
35 (32%)
2 (2%)
30 (28%)
67 (62%)
10 (9%)
120 (90–140)
98 (39%)
155 (61%)
44 (29–52)
51 (36%)
91 (64%)
45 (29–51)
42 (39%)
67 (61%)
42 (28–50)
SD: standard deviation; IQR: interquartile range; ART: assisted reproductive technology; r-ASRM: revised American Society of Reproductive Medicine.
had s
0.0
0
20
40
60
80
Time to conception (months)
Erinetcol2015BioMedRes
ART
Natural conception
100
4. D
(%)
Pregnancy (%)
Surgi
has b
Figure 2: Postoperative pregnancy (women attempting to con4
BioMed
Research
International
and q
ceive).
[7, 18
place
or gonadotrophin
releasing hormone analogues), or those
100
1.0
repor
who had been trying for a pregnancy preoperatively. Thereexcisi
9
were no90differences in pregnancy
rates
for women who hadmode
16
8
5
endometriomas
resected 64/111 (58%); women having a bowelof wo
0.8
80
0
resection 5/9 (55%); or those with2 incomplete resection ofGiven
1
disease7016/35 (46%)
compared with those who did not.
for ad
2
13
2 13 recorded
There
were
complications.
These
included
availa
0.6
19
60
two major
intraoperative complications, one of blood losswom
disea
>2000 mL
50 requiring a blood transfusion and
4 one unintenM
tional
trauma
to
the
bladder
repaired
laparoscopically.
There
0.4
40 minor intraoperative complications of uninten-disea
were four
tional entry
into
the vagina, with one of these requiringfollow
18
30
a second suturing due 23
to postoperative
dehiscence. There19, 27
0.2
37
were one
of urinarymode
20 case of pulmonary oedema, two cases
7
retention, one urinary tract infection, and two patients whopregn
no m
10
0.0
had swelling
or bleeding at a laparoscopic port site.
fertili
0
their
0
20
40
60
80
100
<30
≥40
30–34
35–39
no di
Time to conception (months)
surge
4.
Discussion
ART
No pregnancy
ART
be giv
Natural conception
Unexpected conception
Natural conception
Surgical excision of moderate-to-severe stage endometriosisto ha
3: Pregnancy
distribution
age bands
(women
has been
demonstrated
to across
improve
women’s
painattemptsymptomsis 12
Figure 2: Postoperative pregnancy (women attempting to con- Figure
ing
to
conceive
𝑛
=
142
and
women
with
unexpected
conceptiontrialskeepi
and
quality
of
life
in
randomised
placebo
controlled
ceive).
𝑛 = 5).
[7, 18, 26]. For fertility outcomes, the largest randomisedmore
placebo controlled trial assessed only stage I-II disease and19]. C
10073%dechanced’êtreenceintespontanémentdansles12mois
reported an improvement in live birth rate following surgicalmust
was
no significant
difference
(Figure
3). There were
no ofprogr
excision
[14]. No RCTs
exist for
the reproductive
outcomes
Cumulative pregnancy rate after ICSI-IVF
in patients with colorectal endometriosis: Results of a multicentre study
Adénomyose
Age
Réserve ovarienne
From january 2005 to june 2011. 75 patients with
colorectal endometriosis and proved infertility for deep
infiltrating endometriosis.
The CPR per patient after three ICSI-IVF cycles was 68.6%
Marcos Ballester and al.
Human Reproduction, Vol 27, N°4 pp. 1043-1049,
2012
SérieHUS
•  CenEnyetcol.Theimpactoflaparoscopicsurgical
managementofdeependometriosison
pregnancyrate.J MininminvasiveGynecolsept
2015
•  22moisdesuivimoyenpostopératoireavectaux
degrossessede54.78%(n=63)
•  Tauxdenaissancevivantede42.6%(n=49).
•  60%detauxdegrossesseglobale:
–  38,7%spontanémentet21,4%parAMP
•  CONCLUSIONS:Résec,onmaximaleaméliorele
tauxdegrossessespontanéeetavecAMP
Conclusion
•  EndométriosestadeI/II:chirurgiepremièreau
coursdelacoelioscopieexploratrice
•  Endométriomeovarien:
–  <35ans?:chirurgiepuisAMP(6-12moisaprès?)
–  >35ans?:AMP(sclérothérapie?)
–  Récidive:pasdechirurgie
•  Endométrioseprofonde:
–  Chirurgiepremièresuivied’AMP?
–  AMPetpuischirurgiesiéchec(plussimpleà
accepter?)