HOW TO MANAGE ENDOMETRIOSIS Surgical limitations

HOW TO MANAGE
ENDOMETRIOSIS
Squifflet J, Donnez J
Université Catholique de Louvain
Cliniques Universitaires Saint
Saint-Luc,Brussels,, Belgium
Luc,Brussels
2006
Parachute use to prevent death and
major trauma
Smith, GCS BMJ,2003
No RCT
Common sense vs EBM
Surgical limitations
• Equipment
• Surgeon’s experience / skill
• Pain / fertility status / complications
• Past history (surgical) / patient’s age
1
Surgeon’s experience
• Adhesiolysis / peritoneal lesions
+
• Cystectomy
• Bladder endometriosis
+++
• Ureterolysis
• Rectovaginal nodules / frozen pelvis
Influence of pathology
• Adhesions
• Endometriomas
• Peritoneal lesions
• Rectovaginal nodules
Endometriosis and IVF
• When should we propose IVF ?
• Depends on :
–
–
–
–
–
patient
patient’ss age
duration of infertility
recurrence of pain
recurrence of endometriosis
radical cure for endometriosis impossible
• IVF availability / cost
2
Preoperative evaluation
> 50 % of women with rectovaginal nodules have a
past surgical history of at least one pelvic surgical
procedure (sterility, pain,…)
•
•
•
•
•
•
Vaginal examination
Vaginal echography
MRI
TRUS
BBE
IVP
Three debates!
Endometriosis
CONTROVERSY
P it
Peritoneal
l
S
Surgery
E
Expectant
t t
Ovarian
Excision
Ablation
Aggressive
surgery
Debulking
surgery
Rectovaginal
nodule
Endometriosis - IVF
• Endometriosis vs tubal pathology
• Severe vs mild
or : 0.56
or : 0.60
Barnhart et al, Fertil. Steril, 2002
3
Endometriosis was confirmed in only 54 % of cases
Mild and minimal endometriosisendometriosisassociated infertility
Laparoscopic destruction
versus expectant management
Marcoux et al, 1997
Italian study, 1999
Pregnancy rates
30.7 versus 17.7
No differences
But bias exists
Marcoux study
Patients are aware of the
randomization
Italian study
• Small series
• Seven centers (mean: 14 patients)
• Histological confirmation not requested
• Percentage of active lesions unknown
4
Three debates!
Endometriosis
CONTROVERSY
Peritoneal
Surgery
Expectant
Ovarian
Excision
Ablation
Aggressive
surgery
Debulking
surgery
Rectovaginal
nodule
Endometriomas
Cystectomy - laser vaporization
•
•
•
•
No plane of cleavage
Cortex removal
Dilaceration
Bleeding (extensive coagulation)
Ovarian cortex
follicle
cyst
Bladder
cyst
Bladder
5
Ovarian endometrioma
Endometrioma capsule
capsule
Chocolate
fluid
Endometrioma
Endometrial
epithelium and
stroma
Residual ovarian
cortex
Ovocytes
Fibrosis
Cochrane review
The Cochrane
Library, Issue 3,
2005,, by
y Hart et al.
Gold standard unproven
« Ovarian endometriomas require surgery in infertile women
prior to IVF »
• Reduced response after cystectomy
–
–
–
–
Pagidas, 1996
Lol,, 1999
Al--Azemi, 2000
Al
Tinkanen, 2000
• Similar response and outcome
– Donnez, 2001
– Canis, 2001
– Marconi, 2002
Control group
cystectomy vs tubal infertility
6
Cystectomy prior to IVF , if not done properly,
may compromise ovarian response
Careful surgery in symptomatic women, either
laser vaporization or cystectomy, does not
compromise IVF outcome
Is surgical treatment before IVF
useful or benefical ?
Garcia Velasco, Fertil. Steril., 2004
• RTC : removal of endometriomas prior to IVF
(retrospective)
– CPR =
– Implantation rate =
Does IVF affect cystic
endometriosis?
endometriosis
?
• Difficult to evaluate
• Growth and rupture in pregnancy
• May have a toxic effect on oocytes and
embryos
• Risk of abscess
7
ABSCESSED ENDOMETRIOMA
during IVF procedure
Abscess following IVF
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Younis, JS. J. Assist. Reprod. Genet.,
Genet., 1997
Yuko Matsunagan, Amer. Perinatal.,
Perinatal., 2003
Jan den Boon, Hum. Reprod., 1999
Ludwig, Obst. Gyn., 1999
Zikopoulos, Acta Scandinavica, 2004
Wei, Tapei, 1998
Yung--Chien Tsai, J. Assist. Reprod. Genet., 2005
Yung
Ashraf Moini. J. Assist. Reprod. Genet., 2005
Kimberley Sharpe, Fertil. Steril., 2006
Bennet SJ, J. Assist. Reprod. Genet., 1993
Vargas M, Clin. Exp. Obst. Gynecol., 2003
Sauer, Am. J. Obstet. Gynecol., 1992
Friedler S, Fertil. Steril., 1996
Marlowe SD, Clin. Imaging, 1995
Padilla SL, Hum. Reprod., 1993
Ochninger S, Fertil. Steril., 1989
8
Sterility
ENDOMETRIOMA
ENDOMETRIOTIC CYST
- Clinical examination + sperm
- Transvaginal echography
Laparoscopy
> 3 cm
< 3 cm
- Drainage
g
- Biopsy
- Cystectomy
- Laser vaporization
3 months GnRH
GnRH--a
3 months GnRH
GnRH--a
if peritoneal lesion
associated
- Laser vaporization
- Cystectomy
Spontaneous 99-12 months
IVF
Sterility
Recurrence of endometriosis
Laparoscopy
one step
GnRH agonist 3 months
IVF
Three debates!
Endometriosis
CONTROVERSY
Peritoneal
Surgery
Expectant
Ovarian
Excision
Ablation
Aggressive
surgery
Debulking
surgery
Rectovaginal
nodule
9
Type I
Type II
Type III
10%
65%
25%
Rectovaginal
septum
DiaboloDiabololike
Fornix
E
BL
R
V
Bl
From Squifflet and Donnez (Obstet. Gynecol. Invest., 2002)
Prevalence according to the size of
the nodule
Size of the Nodule Ureteral Prevalence
nodule
n:
lesions
> 3 cm
96
9
93%
9.3
2-3 cm
97
1
1%
< 2 cm
61
0
0%
TOTAL
254
10
3.9 %
Donnez et al,Fertil.Steril., 2002
Fornix: lateral extension
10
Fornix: lateral extension
Sigmoid endometriosis
11
Sigmoid endometriosis
Surgical therapy
•
•
•
•
By laparoscopy
Diagnosis, staging, histology
Cyst rupture
rupture, abscesses
Ureteral stenosis, sigmoid occlusion
Complications: POF, adhesions, fistulas,…
12
Reviews in Gynecological and Perinatal Practice 2006; 6: 153153-60
Recommandations
• Centres d’excellence et traitement chirurgical de l’infertilité doivent
toujours être envisagés
• Chez des patientes asymptomatiques devant bénéficier d’une FIV,
une chirurgie systématique pour augmenter le taux de succès n
n’est
est
pas justifiée
• La Chirurgie est indiquée chez des patientes symptomatiques avec
un kyste endométriotique de > 5 cm
• La Chirurgie de récidive pour endométriose chez des patientes
asymptomatiques n’est pas encouragée même en présence
d ’endométriomes
• Eviter de drainer les endométriomes durant les ponctions pour FIV
Endometriosis - IVF
• Endometriosis may affect IVF cycles
(oocytes)
• IVF after
ft 9-12
9 12 months’
th ’ spontaneous
t
cycles (after complete surgical treatment)
• Pre-treatment with 3 months’ GnRH-a
seems to be beneficial before IVF
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