5. Important Facts
• 25-50% of infertile
women have
endometriosis
• Infertile women are
6-8 times more likely
to have E
• South india : 73%
INCIDENCE 10%
11. The stages of Endometriosis
Stage – 1 • Mild / moderate endometriosis
• Isolated implants
• No significant adhesions
• Superficial implant <5mm
Stage – 2 • Moderate endometriosis
• Multiple implants both superficial and deep >5mm ,peritubal +
para – ovarian adhesions
• <4 cm endometrioma
Stage 3 • Severe endometriosis
• Multiple superficial & deep implant
• Large ovarian endometrioma > 4 cm
• Flimsy + dense adhesions
Stage 4 • Advanced
• Recto-vaginal Infiltrates
• Frozen Pelvis
12. Recommendations for the diagnosis of Endometriosis
Category Recommendation Grade Quality of
Evidence
CPP Consider endometriosis in the
presence of : dysmenorrhea non
cyclical pelvic pain , deep dyspareunia
, infertility & fatigue in the presence
of any of the above
- -
CPP In women of reproductive age with
non – gynacological cyclical symptoms
( dyschezia , dysuria, hematuria, ractal
bleeding , shoulder pain)
- -
CPP Perform a thorough clinical examination
including per abdominal/ per vaginal , per
rectal & rectovaginal examination in women
with suspected endometriosis
- -
13. Recommendations for the diagnosis of Endometriosis
Category Recommendation Grade Quality of
Evidence
CCR Suggest diagnosis of deep endometriosis in
patients with deep pelvic pain and findings of
nodules & / or induration of the rectovaginal
wall
c -
CCR Suspect endometrioma if examination
shows adnexal mass
c -
CCR Absence of clinical evidence during
examination & USD does not rule out
the disease.
c -
16. Recommendations for the diagnosis of Endometriosis
Category Recommendation Grade Quality of
Evidence
EBR
Laparoscopy remains the
gold standard for
diagnosis of
endometriosis –but
discouraged just for
diagnosis
A II
19. Stage I (Minimal) Stage II (Mild)
Stage III (Moderate) Stage IV (Severe)
Classification of Endometriosis R
A
F
S
S
C
O
R
E
R
E
V
I
S
E
D
A
F
S
S
C
O
R
E
20. Recommendations for the diagnosis of Endometriosis
Category Recommendation Grade Quality of
Evidence
CCR CA - 125 is poorly sensitive for
diagnosis . however , it has a role in
treatment follow – up
A -
CPP One should assess ureter , bladder and bowel
involvement by additional imaging
techniques
- -
22. Question 1
Are hormonal therapies effective
for infertility associated with
endometriosis ??
23. Hormonal therapy and infertility
Suppression of ovarian function by means of
hormonal contraceptives , progestagens
GnRH analogues or danazol to improve
fertility in patients with minimal or mild
endometriosis is NOT effective and hence
should not be offered
Evidence does not comment on more severe disease
(Hughes et al., 2007). ,recommendation 21,22
A
25. Infertile women with Stage I/II endometriosis
Evidence recommends that clinicians
should not perform operative
laparoscopy readily .
Diagnostic laparoscopy To diagnose
ENDOM….OUT
.
27. Recommendations for the management of infertility in
women with endometriosis
Category Recommendation Grad
e
Quality of
Evidence
EBR IN INFERTILITY WOMEN WITH
ENDOMETRIOMA < THAN 3 CM THERE
IS NO EVIDENCE THAT CYSTECTOMY
PRIOR TO TREATMENT WITH ART TO
IMPROVE PR
A II
28. Recommendations for the management of infertility in
women with endometriosis
Category Recommendation Grade Quality of
Evidence
CPP ENDOMETRIOMA LARGER THAN 3 CM
CLINICIANS SHOULD CONSIDER
CYSTECTOMY PRIOR TO ART ONLY
TO IMPROVE ENDOMETRIOSIS –
ASSOCIATED PAIN OR THE
ACCESSIBILITY OF FOLLICLES
- -
29. Recommendations for the management of infertility in
women with endometriosis
Category Recommendation Grade Quality of
Evidence
EBR
IN STAGE III/IV OPERATIVE
LAPAROSCOPY INSTEAD OF
EXPECTANT MANAGEMENT
INCREASES CHANCES OF
SPONTANEOUS PREGNACY
A III
30. Women with Stage III/IV Endometriosis
So far no RCT,s comparing the reproductive
outcome after surgery and after expectant
management is available but
4 cohort studies have shown
better pregnancy rate after surgery so
Clinicians can consider operative
laparoscopy, instead of expectant
management ,& senf for IVF to increase
spontaneous pregnancy B
32. Effectiveness of Surgical techniques
Guidelines recommend that in infertile
patients with chocolate cyst clinicians
should perform excision of the
endometriric cyst, instead of drainage
and electrocoagulation to increase
spontaneous pregnancy rates .
(Hart et al., 2008) ,Guidelines 21
A
33. why excision ?
Cystectomy
provides greater improvement pain
–Spontaneous pregnancy rates
–Decreases Recurrence and repeat surgery
ASRM Practice Guidelines 2013
Possibility of occult malignancy to be kept in mind
34. MOST IMPORTANT !!!!
surgery must be complete &
performed by a best qualified gynae
surgeon with experience in dealing
with endometriosis.
35. Counselling ….. Two concerns
Ovarian Reserve Recurrence
Decision to proceed with surgery should
be considered very carefully ,especially if the
women has had previous ovarian surgery
36. AMH
AMH should be done pre –operatively & 3
months post Operatively to determine
the effect of surgery on the Ovarian
reserve
39. • In infertile women with endometriosis, clinicians
should not prescribe adjunctive hormonal
treatment before or after surgery to improve
spontaneous pregnancy rates (Furness et al., 2004).
A
But clinicians should not withhold hormonal
treatment for pain in symptomatic women in the
waiting period before undergoing surgery or
medically assisted reproduction .
GPP
40. Endometriosis:Take Home Tips
Medical
In minimal or mild
endometriosis it
does not enhance
fertility and hence
should not be offered
Surgical
is not offered in
minimal or mild
But helps in
moderate to
severe
endometriosis
Medical treatment is not effective
Rather delays fertility restoration
41. Is ART needed in
women with
Endometriosis
???
Question 5
BIG YES
43. Objective is the baby
Dictum is to send the patient for ART
earlier than late
44. IUI in endometriosis stage 1,2
Live Birth Rate is 5.6 times higher in
couples with minimal to mild endometriosis
after COS with oral ovulogens or
gonadotrophins and IUI as compared to
couples after expectant management .
45. Recommendations for ART
IVF is the treatment of choice if
Tubal function is compromised
There is male factor infertility
Other treatments have failed
Stage 3 -4 endometriosis
46. Recommendations for A..R.T. in women with
endometriosis
Category Recommendation Grade Quality of
Evidence
CPP ART should be recommended on
presence of tubal dysfunction or in
presence of male factor or if other
management options fail
B
-
CPP Recurrence rate of endometriosis is
not increased with controlled ovarian
stimulation
-B -
52. Women with stage 3- 4 endometriosis
Women with chocolate cyst
< than 3 cm there is NO evidence that
cystectomy prior to treatment with
ART improves pregnancy rates . ( A )
Consider cystectomy prior to ART
ONLY to improve
• endometriosis-associated pain or
• difficulty in oocyte retrival (GPP)
53. Take home Messages
• Consider female age ,duration of infertility and
stage of endometriosis for formulating the
management plan
• Benefits of laparoscopy for diagnosis in minimal &
mild endometriosis in not reported however , if
surgery performed , ablation or excision should be
done
• Consider expectant management or super ovulation
& intrauterine insemination as first – line therapy
in younger women (<35years) with stage i/ii
endometriosis – associated infertility
54. Take home Messages
• Consider more aggressive treatment , such as Super
ovulation+ IVF for women more than 37 years of
age or older
• Remember Conservative surgical therapy with
laparoscopy or possible laparotomy followed by
ART is beneficial in women with stage III/IV
endometriosis – associated infertility
55. Tips ……
• Surgery should be given
backseat
• Do not cauterize excessively.
• Adhesions preventing barriers
have a role.
• Medical management: improves pain, not fertility
Success depends upon the residual
disease left behind
57. CASE 1 - Large Endometriotic Cyst
32 year old female married for 4 years; keen to
conceive in the last 2 years; came with complaint of
severe dysmenorrhea for 3 months.
• Investigations-
Semen Analysis: within normal limits.
USG suggestive of 6 x 4.5 x 3.6 cms left ovarian
endometriotic cyst.
• Management: given Dienogest outside .No decrease
in size
58. CASE 1 - Large Endometriotic Cyst
.
• Management:
Laparoscopic left ovarian cystectomy done along
with chromopertubation with methylene blue to
check for tubal patency.
Ovulation induction with low dose gonadotropins
done in the next cycle followed by IUI.
Patient conceived in second IUI cycle
59. CASE 2 - Surgery Post GnRH agonist depot given
twice
• Patient Details-
30 years old patient,3 years infertility, referred by a
Gynaecologist after giving GnRH agonist 3.75 mg
depot twice as her dysmenorrhoea was+++
She was referred for surgery+ chromotubation
60. CASE 2 - Surgery Post GnRH agonist
depot given twice
MANAGEMENT
Upper abdomen normal
• stage 2 ,Post depot surgical planes were well
defined and even though there was little
obliteration of Pouch of Douglas.
61. CASE 2 - Surgery Post GnRH agonist
depot given twice
At Laparoscopy endometriotic spots were
fulgurated. No cysts in ovaries
Both the tubes were patent and anatomy was
restored.
She conceived with ovulation induction with
letrozole along with low dose gonadotropins
followed by IUI.
62. CASE 3 - Frozen Pelvis with Deep Infiltrating Endometriosis
• Patient details
29 year old patient present primary infertility
3years; came with complaint of severe
dyspareunia associated with dysmenorrhea
and dyschezia since 4 months.
• Investigations-
USG and MRI pelvis suggestive of B/L
ENDOMETRIOMA + frozen pelvis with dense
adhesions and rectovaginal involvement.
63. CASE 3 - Frozen Pelvis with Deep Infiltrating Endometriosis
Management:
Extensive Adhesiolysis with Enterolysis done along with bilateral ovarian
cystectomy. Blocked tubes on both sides.
Patient taken for IVF in view of poor ovarian reserve (AMH
1.5) and blocked tubes with ultra long protocol. INJ
LEUPRIDE DEPOT 3.75
ANTAG PROTOCOL in treatment cycle.
Recombinant FSH used for ovarian stimulation.
7 M2 oocytes retrieved and 3 blastocysts were formed.
All the embryos were frozen due to poor endometrial lining
Patient conceived in first frozen embryo cycle with blastocyst transfer.
64. CASE 4 - Recurrent endometrioma
Patient details: 23 years unmarried with bilateral very
large endometriomas.
Laparoscopic surgery was done B/L Cystectomy done
She came to us after marriage again with H/O bilateral
endometrioma 5 cms each
FOR which Laparoscopic surgery was done again outside
No comment on tubal patency. Told verbally ok
65. CASE 4 - Recurrent endometrioma
Investigations: Semen Analysis suggestive of 1 to 5 million count hence IUI
not possible. Suggested LIFE STYLE ADVICE
Management:
Tab dydrogesterone 10 mg from day 5 to day 25 was given for 6 months .
At follow up we had advised her to take tab Letrozole 2.5 mg from day 3
– day 7 + antioxidants vit C ,E BD ( H & w )
She conceived naturally with letrozole and few years later again
conceived spontaneously without even ovulation induction.
NO DEPOT WAS GIVEN. NO IVF DONE
67. Do not remove small ovarian
endometriomas
(specially a diameter<4 cm)
-Impairs ovarian function,
-AMH decrease may happen
68. Do not recommend repeated
follow-up serum CA-125 (or other
currently available biomarkers)
measurements in women
successfully using medical treatments for
uncomplicated endometriosis in the
absence of suspicious ovarian cysts
