SURGERY VERSUS IVF FOR ENDOMETROSS Assoc.Prof.Semra KAYATA ESER,

SURGERY VERSUS IVF FOR ENDOMETROSS Assoc.Prof.Semra KAYATA ESER,

SURGERY VERSUS IVF FOR ENDOMETROSS Assoc.Prof.Semra KAYATA ESER, M.D. Zeynep Kamil Women and Children Health Training and Research Hospital Endometriosis and Infertility Fertil population:2-10% of women have endometriosis Subfertile 17-44% population:30-50% of women have endometriosis of women with endometriosis have endometrioma

Fecundity rate: Normal Couples: %15-20 Endometriosis:% 2-10 (ASRM,2004) Endometriosis and Infertility,Pathophysiology Pelvic anatomy distorsion Inflammatory and oxidative damage Impaired endometrial receptivity, implantation

Ovulatory dysfunction Endocrine disorders Decreased oocyte and embryo quality Tubal motility dysfunction H Hamdan et al, 2015 Treatment Modalities

Medical treatment Surgical treatment Expectant management(natural conception) Ovulation induction with IUI Assisted Reproductive Technology Stage 1 - 2 Endometriosis Surgical Treatment Laparoscopic treatment of stage 1-2 endometriosis increases live birth and ongoing pregnancies Study from Canadian (ENDOCAN)

Canadian(ENDOCAN)Multicenter N=172 laparoscopic surgery N=169 diagnostic laparoscopic PR: %29 in LS GR & %17 CONTROL Significant (Marcoux et al., 1997) Study from Italy

Multicenter N=54 laparoscopic surgery N=47 diagnostic laparoscopic LBR: %20 & %22 Not significant (Parazzini et al., 1999) Duffy JM,et al. Cochrane Database Syst Rev 2014 LBR is higher in complete diathermy group ESHRE guideline: management of

women with endometriosis Human Reproduction,Vol.29, No.3 pp.400-412,2014 Stage 1 - 2 Endometriosis ART Treatment Wait 3-6-12 months for natural conception, then 3-4 cycles OI-IUI, then ART Wait 3-4 3-6-12 months for natural conception, then ART

cycles OI-IUI, then ART Direct ART Decide according to age and other prognostic factor Stage 3-4 Endometriosis No RCT, meta-analysis Following

Laparoscopic surgery PR :%50 (%30-67) Vercellini et al., 2009 Stage does not have any impact Endometrioma decreases ART success Pregnancy and ongoing pregnancy rates are higher in group without endometrioma whereas total gonadotropin dose was higher in group with endometrioma 2005 4cm endometrioma

SURGERY Increased spontaneous pregnancy Increased response to COH Easier OPU Decreased pelvic infection risk 2013 > 3 cm endometrioma With

concomittant pelvic pain Increased spontaneous pregnancy Increased response to COH Easier OPU Decreased pelvic infection risk surgery Disadvantages to perform surgery Decreased ovarain reserve

Serum AMH descreases Decreased AFC Raffi et al., 2012; Somigliana et al., 2012 Goodman 2016 Decreased spontanous ovulation following surgery Loh et al., 1999; Candiani et al., 2005; Horikawa et al., 2008 Decreased response to COH Gupta et al.,2006; Somigliana et al., 2011 Effect of surgery on ovarian reserve in women with endometriomas,

endometriosis and controls At baseline, patients with endometriomas had significantly lower antiMu llerian hormone values compared with women without endometriosis. Surgical excision of endometriomas appears to have temporary detrimental effects on ovarian reserve Goodman L, AJOG2016 The post-operative decline in serum anti-Mllerian hormone correlates with the bilaterality and severity of endometriosis The decrease in ovarian reserve should be taken into account in patients indicated for cystectomy for bilateral endometriomas or unilateral endometrioma with high rASRM scores

Yan Tang Fertil Steril 2013 Surgery for recurrent endometriomas is associated with evidence of a higher loss of ovarian tissue and is more harmful to the ovarian reserve evaluated by AFC and ovarian volume, if compared with endometriomas operated for the first time. Indications to surgery for recurrent endometriomas should be reconsidered with caution. Muzzii L, Fertil steril 2015 Effect of endometrioma cystectomy on IVF outcome: a prospective randomized study Ovarian surgery resulted in longer stimulation, higher FSH requirement

and lower oocyte number, but fertilization, pregnancy and implantation rates did not differ between the groups. Demirol et.al.RBM Online 2006 Surgical risks Major ( 1,4%) Vascular

Intestinal Anesthesia-related Minor (7,5%) Surgical site infection Ekstraperitoneal insuflation Chapron et.al,2002

Detrimental effect of surgery on the ovarian reserve !!! No evidence for the beneficial effect of surgery on the fertility outcome !!! Risks of conservative management Oocyte

quality may be affected Opu procedure may become complicated - nfection - Follicular fluid contamination - Visceral injury Endometriomas may affect response to COH Risk of pregnancy complication Malignancy Progression of endometriosis Somigliana et al,2015

Is there any decrease in oocyte quality? Free iron decreases oocyte quality (sanchez et al,2014) Retrospective studies ( 2 major studies) (Ashrafi et al., 2014; Filippiet al., 2014)

Fertilisation , high quality embryo rates are similar (Ashrafi et al., 2014; Filippiet al., 2014 Decreased number of mature oocytes (Ashrafi et al., 2014) How does it affect OPU technique? Distorsion of pelvic anatomy Difficulty may be experinced while avoiding entry to endometrioma itself

risk of visceral injury Malignancy potential? The The risk risk of of missing missing an an occult occult malignancy malignancy at at the the time time of

of IVF IVF 2 Endometrioid big studies 8/950 Clear cell histotypes

Age %0.8 Mostoufizadeh and Scully (1980) 9/1000 The risk of long-term ovarian cancer development from unoperated endometriomas. Family history

USG feature Size(8-10?) %0.9 Recurrent endometrioma Stern et al. (2001) Risk is very low (NNT > 300) Van Leeuwen et al., 2011; Rizzuto et al., 2013; Stewart et al.,2013, Kobayashi et al., 2007 Infection of the endometriomas, follicular fluid contamination with the

endometrioma content, higher risk of pregnancy complications risks do not justify surgery because these events are uncommon . Somigliana E, Human Reprod Update, 2015 No significant difference in terms of ovarian responsiveness to hyperstimulation Somigliana et al., 2015 Women with intact endometrioma when compared with women without endometrioma; - Similar LBR, CPR and MR

- Lower mean number of oocytes retrieved in women with intact endometrioma - Higher cycle cancellation rate Women with intact endometrioma when compared with women with surgical treatment prior to IVF/ICSI - Similar LBR, CPR and MR - Lower AFC, MNOR treatment - Higher total gonadotrophin stimulation dose

in women with surgical Surgery vs ART Should we perform surgery ? No evidence for favorable IVF outcome when surgery is performed before ART

Risks of conservative management do not overweight surgical risks Multiparametric score for the indication to surgery in case of endometrioma (MISE score) Score 0 1 2 Size (cm) <3

3-5 >5(if>10, score is 3) Growth rate 1.0 cm/6 mo >1.0 cm/6 mo / Pain Absent/mild /

Moderate/severe* nfertility** Absent / Present* Ultrasound features Typical

/ Atypical(if blood flow, score is 3) History positive for cancer *** Absent Familiar Personal Recurrent

endometrio ma No Yes / Age 40 >40 /

Score <2: Follow up Score >3: Surgery f score of 3 is obtained with 2a :medical treatment 2b:IVF Muzii L. et al., 2017 In summary, ndications for surgery in patients with endometriosis-related subfertility without significant pain: Stage

1-2 endometriosis (If surgery is performed for other indications) Improving Doubts exist about their exact nature of endometrioma Treating Patient access for oocyte retrieval hydrosalpinges to improve IVF outcomes declines ART due to personal, cultural, or religious reasons

Patient choice for surgery or unable to access interventions such as ART Sukhbir S et al.,2017 In summary, The management of ovarian endometriomas for women with pain Ovarian reserve may be lower in women with ovarian endometrioma compared with those women without

Surgical excision of an endometrioma is ideal for pain but may lead to reduced ovarian reserve Bilateral, compared to unilateral, ovarian cystectomy for endometriomas may result in a greater negative effect on ovarian reserve Recurrent endometrioma excision may further reduce ovarian reserve compared with primary surgery does not improve fertility consider individualizing the care of women with endometrioma Sukhbir S et al.,2017

Thank you ZK ESHRE guideline: management of women with endometriosis Human Reproduction,Vol.29,No.3 pp.400-412,2014 Human Reproduction,Vol.29,No.3 pp.400-412,2014 g ntakt endometrioma versus non-endometrioma

Elde Elde edilen edilen oosit oosit says says dk dk Bazal Bazal FSH FSH yksek yksek Total Total FSH FSH dozu

dozu benzer benzer AFC AFC benzer benzer Hamdan et al, Hum Reprod, 2015 ntakt endometrioma versus non-endometrioma Canl doum oranlar benzer Klinik gebelik oranlar benzer

Abort Abort oranlar oranlar benzer benzer Siklus Siklus iptal iptal oranlar oranlar 2.8 kat fazla 2.8 kat fazla Hamdan et al, Hum Reprod, 2015

Tedavi edilmi endometrioma versus intakt Elde Elde edilen edilen oosit oosit says says dk dk Bazal FSH benzer Total FSH dozu yksek AFC dahha dk Hamdan et al, Hum Reprod, 2015

Tedavi edilmi endometrioma versus intakt endometrioma Canl Canl doum doum oranlar oranlar benzer benzer Klinik Klinik gebelik gebelik oranlar oranlar benzer

benzer Abort Abort oranlar oranlar benzer benzer Siklus Siklus iptal iptal oranlar oranlar benzer benzer Hamdan et al, Hum Reprod, 2015 Endometrioma (intact) vs peritoneal endometriosis

Elde edilen oosit says benzer Bazal FSH benzer AFC anlaml dk Hamdan et al, Hum Reprod, 2015 Endometrioma(intact) vs peritoneal endometriosis Canl Canl doum doum oranlar

oranlar benzer benzer Klinik Klinik gebelik gebelik oranalr oranalr benzer benzer Abort Abort oranlar oranlar benzer benzer Siklus Siklus iptal

iptal oranlar oranlar benzer benzer Hamdan et al, Hum Reprod, 2015 Conclusion

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