ENDOMETRIOSIS & INFERTILITY. Professor T C Li Sheffield

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1 ENDOMETRIOSIS & INFERTILITY Professor T C Li Sheffield

2 PRESENTATIONS Pain dysmenorrhoea dyspareunia chronic pain low back iliac fossa Infertility Ovarian cyst/mass

3 PAIN PAIN IS THE PASSION OF THE SOUL

4 MANAGEMENT OF PAIN Medical temporary Surgery laparoscopic surgery laparotomy LUNA pelvic clearance (oophorectomy)

5 MEDICAL TREATMENT Danol 200 mg/day Progestogen eg provera 10 mg tds GnRH OC pill Others e.g. gestrione

6 ESHRE GUIDELINE FOR THE DIAGNOSIS & TREATMENT OF ENDOMETRIOSIS (Kennedy et al 2005, Human Reprod 20:2698) Hormonal treatment for endometriosis-associated pain The various hormonal drugs are equally effective but their side-effects and cost profiles differ.

7 ESHRE GUIDELINE FOR THE DIAGNOSIS & TREATMENT OF ENDOMETRIOSIS (Kennedy et al 2005, Human Reprod 20:2698) Hormonal Treatment There are no data to justify hormonal treatment prior to surgery to improve the success of surgery.

8 E ESHRE GUIDELINE FOR THE DIAGNOSIS & TREATMENT OF ENDOMETRIOSIS (Kennedy et al 2005, Human Reprod 20:2698) Hormonal Treatment Several RCTs suggested that adjuvant medical treatment after laparoscopic surgery produced further significant reduction of pain.

9 INFERTILITY

10 MANAGEMENT OF INFERTILITY ASSOCIATED WITH ENDOMETRIOSIS Medical / hormonal no benefit Surgical diathermy adhesiolysis ovarian cystectomy Assisted conception IUI IVF

11 LAPAROSCOPIC SURGERY IN INFERTILE WOMEN WITH MINIMAL OR MILD ENDOMETRIOSIS Canadian multicentre trial. Marcoux et al, NEJM, 1997, 337: women, randomised to 2 groups Follow up 36 weeks, CCR Treatment: 31% No treatment: 18%

12 Cumulative probability of pregnancy 50 Cumulative probability of a pregnancy of > 20 weeks (%) Laparoscopic surgery Diagnostic laparoscopy Weeks after randomisation Marcoux et al. N Engl J Med 1997; 337: 217? 2.

13 RCOG EVIDENCE-BASED GUIDELINES Surgical ablation of minimal and mild endometriosis improves fertility in subfertile women Medical treatment of minimal and mild endometriosis does not enhance fertility in subfertile women

14 RCOG EVIDENCE-BASED GUIDELINES Ovarian stimulation with intrauterine insemination is more effective than no treatment or IUI alone in subfertile women with minimal or mild endometriosis

15 SURGICAL TECHNIQUES PERITONEAL DEPOSITS

16 TREATMENT OPTIONS Laser Diathermy Excision

17 REMOVAL OF PERITONEAL ENDOMETRIOSIS Ablation or Excision?

18 EXCISION : ADVANTAGES Histological diagnosis possible? More complete removal

19 ABLATION : ADVANTAGES Easier to perform Excellent haemostasis and therefore adhesions less likely to form

20 A randomized trial of excision versus ablation for mild endometriosis (Wright et al 2005 Fertil Steril 83:1830) 12 patients each arm No difference in results

21 ABLATION OF ENDOMETRIOSIS Diathermy or Laser?

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23 L ICENCE TO A DD S URGICAL E XPENSES & R EMUNERATION

24 TREATMENT OPTIONS SUPERFICIAL DEPOSITS laser electrical energy - diathermy DEEP LOCALISED DEPOSITS excision

25 MODERATE / SEVERE ENDOMETRIOSIS

26 NICE Guidelines 2004 Women with moderate or severe endometriosis should be offered surgical treatment because it improves the chance of pregnancy

27 RCOG EVIDENCE-BASED GUIDELINES There is no evidence that medical treatment of moderate and severe endometriosis either alone or as an adjunct to surgery improves fertility Surgical treatment of moderate and severe endometriosis may improve fertility but controlled studies and comparisons with assisted reproduction techniques are required

28 OVARIAN ENDOMETRIOMA

29 ENDOMETRIOMA Ovarian endometrioma do not respond to medical therapy

30 NICE Guidelines 2004 Women with ovarian endometrioma should be offered laparoscopic cystectomy because this improves the chance of pregnancy

31 METHODS OF TREATING OVARIAN ENDOMETRIOMA Simple drainage (puncture) cystectomy / excision cystotomy & ablation of cyst wall oophorectomy

32 ENDOMETRIOMA ULTRASOUND GUIDED DRAINAGE Risk of infection Ineffective / high recurrence Zanetta et al, 1995 Vercellini et al, 1992 May cause severe pelvic adhesions Muzii et al, 1995 S Garrey et al, 1999

33 SURGICAL MANAGEMENT OF OVARIAN ENDOMETRIOMA Cystectomy or Cystotomy and ablation of cyst wall?

34 Prospective randomized study 1 FAYEZ & VOGEL 1991 OBSTET GYNEC 78:660 Prospective randomized study assignment to one of 4 methods of treatment according to which week of the month no desire for pregnancy outcome measure : second-look laparoscopy at 8 week - adhesion, recurrence of disease all had postop danazol 600 mg/d for 8 weeks until second-look

35 Prospective randomized study 1 FAYEZ & VOGEL 1991 OBSTET GYNEC 78:660 Adhesion at second-look excision 26/26 100% stripping 9/24 37% laser ablation of lining 9/30 30% drainage 12/44 27%

36 Prospective randomized study 1 FAYEZ & VOGEL 1991 OBSTET GYNEC 78:660 Recurrence of endometrioma excision 0/34 0% stripping 7/32 22% laser ablation of lining 8/37 22% drainage 12/56 27%

37 OVARIAN ENDOMETRIOMA: PROSPECTIVE STUDY - 1 Excision of endometrioma had a significantly higher rate of adhesions (100%) compared with the other three techniques; but there was no recurrence of endometrioma in the excision group compared with 21-22% recurrence in the other three groups. Fayez and Vogel, 1991 Obstet Gynae 78:660

38 Prospective randomized study 2 Berette et al 1998, Fertil Steril 70: patients in each group: cystectomy, cystotomy 24 months follow-up dysmenorrhoea cystectomy 16% cystotomy 53% dyspareunia cystectomy 20% cystotomy 75% non-menstrual pelvic pain cystectomy 10% cystotomy 53%

39 Prospective randomized study 2 Berette et al 1998, Fertil Steril 70:1176 median op time cystectomy 60 min cystotomy 55 min estimated blood loss cystectomy 50 ml cystotomy 20 ml length of stay cystectomy 1 day cystotomy 1 day

40 Prospective randomized study 2 Berette et al 1998, Fertil Steril 70:1176 Interval between operation and recurrence of significant pain cystectomy median 19 months ( ) cystotomy median 9.5 months (3-20)

41 Prospective randomized study 2 Berette et al 1998, Fertil Steril 70: month cumulative conception rate cystectomy 66.7% cystotomy 23.5%

42 OVARIAN ENDOMETRIOMA: PROSPECTIVE STUDY - 2 Cystectomy produced significantly better pain relief (80-90%) and a higher pregnancy rate (67%) than drainage and coagulation of the cyst wall (25-47%, 24%) at 24 months. Beretta et al, 1998 Fertil Steril 70:1176

43 Prospective randomised study 3 Alborzi et al 2004, Fertil Steril 82:1633 Cystectomy n=52, ablation n=48 Recurrence of pain after two years : cystectomy 15.8%, ablation 56.7% Re-operation : cystectomy 5.8%, ablation 22.9% CCR at one year : cystectomy 59.4%, ablation 23.3%

44 OVARIAN ENDOMETRIOMA: PROSPECTIVE STUDY - 3 Cystectomy produced significantly better pain relief (84% vs 43%), a higher pregnancy rate at one year (59% vs 23%) & a lower re-op rate (6% vs 23%) than drainage and coagulation of the cyst wall. Alborzi et al, 2004 Fertil Steril 82:1633

45 COCHRANE REVIEW Hart et al 2005, Human Reprod 20:3000 Two studies included : Beretta et al 1998 & Alborzi 2004 Fayez & Vogel 1991 not included because of inadequate randomization

46 COCHRANE REVIEW Hart et al 2005, Human Reprod 20:3000 OR, Cystectomy vs ablation Endometrioma recurrence Further surgery Recurrence of dysmenorrhoea Recurrence of dyspareunia Recurrence of pelvic pain Spontaneous pregnancy

47 ENDOMETRIOMA DETECTED BEFORE IVF To remove or not to remove?

48 PROS May improve spontaneous conception rate Reduce risk of inadvertent rupture during follicle retrival predisposes to infection & abscess Endometrioma may be symptomatic Eliminate theoretical, small risk of malignancy

49 CONS Delay treatment Increase cost of treatment Introduce potential complications of surgery May compromise ovarian response

50 REMOVAL OF ENDOMETRIOMA EFFECT ON IVF Reduced follicle & oocyte numbers compared with the contralateral normal ovary (Nargund et al,1995; Somigliana et al 2003) No beneficial or adverse impact on ovarian response (Canis et al, 2001) or IVF outcome (Donnez et al 2001; Garcia-Velasco et al, 2004)

51 QUESTION Does the size of the endometrioma affect the treatment options?

52 RECTAL-VAGINAL ENDOMETRIOSIS

53 Recto-vaginal endometriosis Deeply infiltrating endometriosis involving the recto-vaginal septum incidence : 3% of all endometriosis (Leiman et al 1986) pathology : often resembles adenomyoma, with abundant muscular tissue invaded by glandular epithelium

54 Symptoms of R-V endometriosis Severe, deep dyspareunia dysmenorrhoea pain often radiates to the rectum or sacral region cyclical rectal bleed cyclical pain during defaecation

55 Signs of R-V endometriosis Combined recto-vaginal examination performed simultaneously - tender nodule or thickening of the R-V septum

56 Diagnosis of R-V endometriosis MRI - most useful trans-rectal ultrasonography sigmoidoscopy & biopsy to exclude rectal cancer laparoscopy - reduction of cul-de-sac space, but this may be easily missed

57 Treatment of R-V endometriosis Medical treatment - value uncertain but worth trying especially in young women who wish to preserve fertility surgical treatment - principle is to completely resect the leison Pre-op bowel preparation essential pre-op counselling of the nature of surgery & possible complications

58 Surgical treatment of R-V endometriosis Principle is excision of the nodule Segmental resection or discetomy? Or anterior resection? laparoscopy or laparotomy? Who should do the operation?

59 Jessop series of R-V endometriosis 17 cases of surgical treatment all laparotomy all joint operation with colorectal surgeon complication : one case of compartment syndrome 6 cases of anterior resection sustained improvement of pain - 88%

60 TIPS IN MANAGEMENT Listen to your patient carefully Trust your fingers Make sure there is a good indication to operate Prepare your patient Don t avoid laparotomy at all cost Ask : who should do the operation

61 The two unforgivable sins of surgery. The first great error in surgery is to operate unnecessarily; the second, to undertake an operation for which the surgeon is not sufficiently skilled technically Max Thorek,

62 SUMMARY 1 The treatment of endometriosis in women with infertility is primarily surgical, medical treatment has no role. Ideally, endometriosis should be treated at the same time it is diagnosed (see and treat) There is no evidence that excision is better than ablation in the management of superficial peritoneal leisons. Cystectomy is better than cystotomy and ablation of the cyst wall in the management of endometrioma.

63 SUMMARY 2 Most cases of endometriosis are suitable for laparoscopic surgery, whereas laparotomy has a role in some, severe cases Recto-vaginal endometriosis and cases with significant bowel involvement should be managed by a specialised team including a colorectal surgeon