Management Of Endometriosis Related Infertility By Dr. Abayomi Ajayi www.abayomiajayi.com.ng

1. MANAGEMENT OF
ENDOMETRIOSIS
RELATED INFERTILITY
By
Dr. Abayomi Ajayi
Physician’s Round Table
12th April 2018

2. DISCLOSURES
Nothing to disclose

3. Chronic debilitating gynae disorder, affects 10% of women in the reproductive age
group 1
3 main types
1.PERITONEAL: 1-2cm, red, blue, black or white
2.ENDOMETRIOMA: chocolate cyst
3.D. I. E: penetrate the bowel, bladder and vaginal wall including nerves

4. 30 to 50% are infertile 2
About half will require treatment
No indices to predict those that will require treatment for infertility
Reduced fecundity 3

5. HOW DOES ENDOMETRIOSIS CAUSE
INFERTILITY
Still unclear but the following are incriminated 4
I.Anatomic distortion
II.Tubal occlusion
III.Oocyte quality / ovarian function
IV.Endometrial receptivity

6. I & II mainly due to Adhesions associated with advanced disease

7. OOCYTE QUALITY

11. TREATMENT OF INFERTILITY RELATED TO
ENDOMETRIOSIS
Most appropriate treatment is still controversial but we have some tools in our
armamentarium
Surgery
ART
Medical therapy though useful in alleviating, if not eliminating symptoms of
endometriosis e.g. danazol, GnRHa and progestogens have not been shown to enhance
pregnancy rates

13. The clinician may need to make a decision either for surgery or ART or both to increase
the chance of pregnancy.
A comprehensive fertility assessment is therefore necessary
a) Age
b) Male factor
c) Tubal patency + Hydrosalpinges
d) Ovarian reserve
e) Uterine cavity assessment

14. Surgery may be considered for early stage disease especially less than 35 years
Hydrosalpinges
Not diagnostic laparascopy: avoid repeated surgery.
Surgery may improve spontaneous pregnancy rates in early stage disease 5
If 6-12 months→ ART

15. IUI + COH if indicated may be beneficial in minimal/mild stages.
50% reduction in pregnancy rates
3-4 cycles (ESHRE GUIDELINES for the diagnosis and treatment of
endometriosis 2008)

16. IVF represents the most efficient and successful means of achieving conception.
Indications
a) Tubal function is compromised
b) Presence of male factor
c) Age factor ≥ 38 years
d) Other treatment failed
e) Advanced disease (stage iii & iv)
Frequently associated with Adhesions, endometriomas and tubal occlusion

19. IMPACT OF ENDOMETRIOSIS ON IVF
OUTCOME
The issue is not yet resolved
Earlier studies showed poorer outcome in patient with
endometriosis

24. a) Increased gonadotropins needed and duration of stimulation
b) Reduced oocytes number and quality
c) Cycle cancellation higher
d) ? ICSI may give better results
e) Reduced fertilization rates
f) Reduced implantation rates
g) Pregnancy outcome poorer in advanced disease particularly
with significant ovarian involvement (endometrioma) or prior
ovarian surgery

25. IMPACT OF IVF ON ENDOMETRIOSIS
PROGRESSION

26. CAN ANYTHING BE DONE TO MINIMIZE THE
DETRIMENTAL EFFECT OF ENDOMETRIOSIS ON
OOCYTE QUALITY?
GnRH agonist was touted to help improve clinical pregnancy rate
? Ovarian/endometrial effect; unexplained

28. Further research is probably needed as there are still no diagnostic markers to
predict the group of patient that will benefit from this protocol

29. Pre-IVF surgery was also tried
The logic was to minimize the effect of peritoneal implants or their secretory products migh
have on oocyte quality, embryo development or implantation.
No obvious improvement in outcome with pre-surgical resection 6
Excision Vs Ablation
Repeated surgical excision should be avoided as large body of evidence suggest a negative
impact on ovarian reserve and response to gonadotropins

32. ENDOMETRIOMAS

34. Rapid growth
Suspicious features on Ultra sound
Painful symptoms attributable to mass
Potential rupture in pregnancy
Inability to access follicles in normal ovarian tissue

37. SUMMARY
When IVF is indicated
1. Counselling:
a) May need to do multiple cycles for egg/embryo pooling + FET as number of
oocytes retrieved might be reduced especially if advanced disease or multiple
previous surgeries
b) Risk of cycle cancellation
2) Increased dosage of gonadotropins
3) Agonist or antagonist can be used
4) Endometrioma do not need to be removed unless indicated

38. 2) Avoid endometriomas at OPU to reduce risk of pelvic infection/abscess
3) Consider prolonged down regulation before FET especially in advanced disease or
previous failed cycle due to implantation failure
Lessey et al: 64% restoration of β 3 integrin expression
7) Frozen embryo transfer

39. FERTILITY PRESERVATION
FP was developed for women undergoing gonadotoxic treatments.
Improvements in methods have made it possible to apply to other conditions that
threaten ovarian reserve
The presence of endometriomas in patients with endometriosis signifies severe disease
and there is a large body of evidence showing that both it’s presence alone and
surgical excision may impact negatively on ovarian reserve 7

43. INDICATIONS FOR FP IN ENDOMETRIOSIS
1. Severe endometriosis with bilateral endometrioma : risk of ovarian tissue damage from
treatment which can lead to premature ovarian failure
2. Recurrent endometriosis
3. ? Age < 35

45. METHODS AVAILABLE
Oocyte cryopreservation
Embryo cryopreservation
Ovarian tissue cryopreservation

47. WHAT NUMBER TO FREEZE

48. WORD OF CAUTION
Oocyte freezing and ovarian tissue cryopreservation rely on autologous folliculogenesis,
disregarding any effect of endometriosis on follicles/oocytes quality at the time of
freezing.
Current literature provides no insight into the survival rate of frozen/thawed oocyte from
women with endometriosis compared to controls

49. CONCLUSION
The purpose of this presentation is to open discussions about the still very poorly
understood disease and to point to the need for further research in the management of
infertility associated with endometriosis.