Achieving therapeutic balance in treatment of infertility associated with deep endometriosis!

 

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Endometriosis is a benign gynecologic disease diagnosed in 10%-15% of the general population and as many as one third of women with endometriosis are infertile.

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Asymptomatic endometriosis does not need to be treated. For patients with recurrent or constant symptoms, medical or surgical treatments can be offered.

The management of endometriosis in infertile women is somewhat controversial.

Controversy exists surrounding the issue of surgical treatment of deep, infiltrating endometriosis in infertile women.

This opinion paper by Somigliana E and Garcia-Velasco JA from  Fertil Steril. 2015; 104:764-770 addresses this latter issue.

High-quality scientific evidence to support the treatment of deep endometriosis in the context of infertility is scant because in 50%-70% of affected women, superficial endometriosis can be found in addition to deep endometriosis.

Superficial endometriosis, compared with deeply buried, infiltrating lesions, is more likely to release inflammatory cytokines that can affect reproduction. Furthermore, a sizeable proportion of cases are complicated by the presence of adenomyosis, which interferes with successful implantation. Therefore, it is difficult to draw a definite conclusion about the management of women with deep endometriosis only.

According to a systemic review and meta-analysis by Hamdan M et al- Compared with women without endometriosis, women with endometriosis undertaking in vitro fertilization and intracytoplasmic sperm injection have a similar live birth rate per woman and a similar miscarriage rate per woman and lower clinical pregnancy rate per woman and a lower mean number of oocyte retrieved per cycle.

Women with more severe disease (American Society for Reproductive Medicine III-IV) have a lower live birth rate, clinical pregnancy rate, and mean number of oocytes retrieved when compared with women with no endometriosis.

They concluded that women with and without endometriosis have comparable ART outcomes in terms of live births, whereas those with severe endometriosis have inferior outcomes. There is insufficient evidence to recommend surgery routinely before undergoing ART.

Infact, Extensive surgery for intraperitoneal and deep endometriosis in infertile women does not modify global fertility outcome but is associated with a higher complication rate.

In vitro fertilization (IVF) can be offered as an option to treat infertility in women with deep endometriosis. Conflicting results have been published about the added benefit of pre-IVF surgical excision of deep endometriosis

The opinion statement concludes that the current evidence is confounded by the lack of pure studies on deep endometriosis that are free of the negative impact of superficial endometriosis and adenomyosis.

Women who are asymptomatic or whose symptoms can be managed by medical therapy should probably go straight to IVF without any surgery beforehand.

Women whose symptoms are refractory to medical therapy or those who need immediate surgery for ureteral or bowel stenosis should undergo operative treatment before IVF, however. Surgery can also be considered for asymptomatic patients with multiple failed assisted reproduction cycles.

References

1.      Revised American Fertility Society classification of endometriosis: 1985. Fertil Steril. 1985;43:351-352. Abstract

2.      Vercellini P, Viganò P, Somigliana E, Fedele L. Endometriosis: pathogenesis and treatment. Nat Rev Endocrinol. 2014;10:261-275. Abstract

3.      Dunselman GA, Vermeulen N, Becker C, et al; European Society of Human Reproduction and Embryology. ESHRE guideline: management of women with endometriosis. Hum Reprod. 2014;29:400-412. Abstract

4.      http://www.fertstert.org/article/S0015-0282%2815%2901757-4/abstract

5.      http://www.fertstert.org/article/S0015-0282%2815%2901876-2/abstract

6.      Marcoux S, Maheux R, Bérubé S. Laparoscopic surgery in infertile women with minimal or mild endometriosis. Canadian Collaborative Group on Endometriosis. N Engl J Med. 1997;337:217-222. Abstract

7.      Vercellini P, Pietropaolo G, De Giorgi O, Daguati R, Pasin R, Crosignani PG. Reproductive performance in infertile women with rectovaginal endometriosis: is surgery worthwhile? Am J Obstet Gynecol. 2006;195:1303-1310. Abstract

8.      Douay-Hauser N, Yazbeck C, Walker F, Luton D, Madelenat P, Koskas M. Infertile women with deep and intraperitoneal endometriosis: comparison of fertility outcome according to the extent of surgery. J Minim Invasive Gynecol. 2011;18:622-628. Abstract

9.      http://whisperedwordsforevercaptured.blogspot.com/2015/03/what-is-endometriosis_1.html