Is removal of endometriomas necessary before IVF/ICSI treatment?

Tam metin

(1)

Is removal of endometriomas necessary before IVF/ICSI

treatment?

F. Kübra BOYNUKALIN, M.D., M.s.C

Bahçeci Health Group

(2)

Endometrioma

• 

Prevalence

-0.5-5 % general population -25-40 % infertile women

Ozkan et al. 2008

- 10-25% IVF patients

-17-44% of those have endometriomas.

Redwine 1999

(3)

http:/www.sart.org

Endometriosis

(4)

Dysmenorrhea 60–80%

Chronic pelvic pain 40–50%

Deep dyspareunia 40–50%

Infertility 30–50%

Irregular flow or premenstrual spotting

10–20%

Other 2-4%

Common symptoms of endometriosis and rate of occurance

JAARG 2010

(5)

Agenda

•  The effect of unoperated ovarian endometrioma on ovarian reserve

•  The effect of unoperated ovarian endometrioma on IVF/ICSI outcome

•  IVF/ICSI outcome after endometrioma surgery

(6)

The effect of ovarian endometrioma on ovarian reserve

(7)

Endometriomas and Ovarian Reserve

•  Mechanical streching

Meneschi et al.,1993

•  Biochemical negative influence

Khamsi et al.,2001

•  Adhesions which typically surround affected ovaries

Kaplan et al.,1989

(8)

Ovarian Reserve Tests

•  D3 FSH

•  D3 E

2

•  Inhibin

•  CC chagellenge test

•  AMH

•  AFC

•  Previous IVF performance

(9)

Uncu et al Hum. Rep. 2013

(10)
(11)
(12)

The effect of unoperated ovarian endometrioma on IVF/ICSI outcome

•  Number of follicles growth during COH

•  Number of oocytes retrieved

•  Oocyte and embriyo quality

  Ongoing pregnancy rates

  Live birth rates

(13)

Somigliana et.al. 2006

(14)

Beneglia et.al Hum. Rep. 2011

(15)

Almog et.al. Fertil.Steril. 2011

(16)

Filippi et.al Fertil.Steril 2014

(17)

Benaglia et.al Fertil.Steril.2013

(18)

Benaglia et.al Fertil.Steril.2013

(19)

Morphokinetic Parameters

Endometrioma Control p

No of emriyos 264 175  

tPB2 6.51±9.07 3.71±1.98 p<0.01

tPNa 12.50±7.87 11.13±3.74 p<0.01

tPNf 25.90±6.31 25.30±7.87 NS

t2 28.64±5.24 28.25±5.40 NS

t3 38.02±6.87 37.67±6.33 NS

t4 41.44±7.35 40.19±6.29 NS

t5 50.51±9.86 49.76±10.41 NS

t6 55.28±10.14 53.77±9.91 NS

t7 58.11±10.14 58.33±10.28 NS

t8 62.67±11.80 61.45±11.09 NS

t9 71.57±13.37 69.62±11.58 NS

Bahçeci Unpublished Data

(20)

Ballester et.al.Fertil.Steril.2013

(21)

Opoein Fert & Steril 2012

(22)
(23)
(24)
(25)

•  Avoidance of pelvic abscess / rupture

•  Avoidance of occult malignancy (0.8%)

•  Retrieval difficulties

•  Contamination with endometrioma content

•  Endometriosis progression

Advantages Of Surgery

(26)

Disadvantages of Surgery

•  Major (1.4%) and minor (7.5%) L/S complications

•  Increased cost

•  Increased time to conception

•  Surgery mediated ovarian damage

(27)

Surgery mediated damage

•  Presence of healthy ovarian tissue adjacent to removed the cyst wall

Muzzi et al.,2002; Hachisuga and Kawarabayashi,2002

•  Excission of healthy ovarian cortex with follicles

Brosens et al.,2004

•  Surgery related local inflamation and

electrocoagulation during haemostasis

La Torre et al.,1998;Marconi et al.,2002;Fedele et al.,2004

(28)

The effect of endometrioma surgery on IVF/ICSI outcome

•  Ovarian reserve

•  Number of follicles growth during COH

•  Number of oocytes retrieved

•  Oocyte and embriyo quality

  Ongoing pregnancy rates

  Live birth rates

(29)

Impact of sugical treatment of

endometriosis on AMH

(30)

Impact of surgical treatment of

endometriosis on AMH

(31)

Vignali Gynecol and Obstet Research 2016

(32)
(33)
(34)
(35)
(36)
(37)

Tsoumpou Fertil Steril 2009

(38)

Tsoumpou Fertil Steril 2009

(39)

Cochrane Database 2010

(40)

Cochrane Database 2010

(41)

Cochrane Database 2010

(42)

Cochrane Database 2010

(43)

Harada JAARG 2015

(44)
(45)

Drawbacks that may affect outcome

•  Different patient types undergoing IVF

–  Endometrioma with no previous surgery

–  Surgically resected endometrioma and disease free at the time of ART

–  Surgical resected endometrioma with recurrence at the time of ART

•  Diameter of the endometrioma

•  Bilaterality

•  Surgical technique

•  Length of follow-up (surgery – IVF)

(46)

International Guidelines

ESHRE 2005 ASRM 2006 RCOG 2006

Stage I-II Limited benefit:

Recomended

Small benefit:

Recomended

Demostrated benefit:

Recomended Stage III-IV Possible but unproven

benefit: Recomended

Possible benefit:

Recomended

Possible benefit:

Recommendation uncertain

Recurrent endometriosis

No recomendations Second line surgery not recomended

No recomendation

(47)

ESHRE Guidline 2014

(48)

Garcia Velasca Human Repr 2009

Characteristics Favours Surgery Favours expectant management

Previous surgery None ≥1

Ovarian reserve Intact Damaged

Pain Symptoms Present Absent

Bilaterality Monolateral disease Bilateral disease Sonographic feature of

malignancy

Present Absent

Growth Rapid growth Stable

(49)

Thank you for your attention

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