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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| picture courtesy: whisperedwordsforevercaptured.blogspot.com |
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
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
