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Endometriosis Update (Infertility) Dr.Engin Oral Cerrahpaşa Medical Faculty Department of Obstet & Gynecology Div of Reproductive Endocrinology

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1 Endometriosis Update (Infertility) Dr.Engin Oral Cerrahpaşa Medical Faculty Department of Obstet & Gynecology Div of Reproductive Endocrinology



4 Pathophysiology of Pain and Infertility Associated with Endometriosis. Linda C. Giudice, 2010

5 Effects of endometriosis on human reproduction Dominique de Ziegler,, 2010


7 Soru Hangisi endometriozis sıklığını azaltır Müller anomalisi Eksersiz Kızıl saç Alkol/kafein Düşük doğum ağırlığı


9 % 22 CTF n:891


11 2009

12 Endometriosis-associated infertility: a decade’s trend study of women from the Estrie Region of Quebec, Canada KRYSTEL PARIS & AZIZ ARIS, 2010 N: 6845



15 Eijkemans et al., 2008

16 Collins JA, 1995

17 Cumulative conception rates with untreated endometriosis related to disease grading, compared with normal conception rate Kevin D. Jones, 2002 N Minor Moderate Severe

18 Fertility in women with minimal endometriosis compared with normal women was assessed by means of a donor insemination program in unstimulated cycles Roberto Matorras 2010 N: 51 N: 24


20 Success in intrauterine insemination: the role of etiology A total of 1,171 cycles among 532 infertile couples were retrospectively studied and the impact of different prognostic factors on pregnancy rate in five different etiology subgroups was analyzed. Results. The pregnancy rate/cycle was highest (19.2%) among women with anovulatory infertility and lowest (11.9%) in endometriosis based infertility. Katja Ahinko-Hakamaa 2007

21 KOH + IUI İleri evre endometrioziste KOH+IUI ‘ın etkinliğini gösteren RCT mevcut değil KOH+IUI maksimum 3-4 siklusla sınırlanmalı (ESHRE Guidelines, Recommedation grade A,evidence level 1b)

22 To develop a clinical tool that predicts pregnancy rates (PRs) in patients with surgically documented endometriosis who attempt non-IVF conception. 2009



25 Decreased anti-Mullerian hormone and altered ovarian follicular cohort in infertile patients with mild/minimal endometriosis Nadiane Albuquerque Lemos, 2009 E C p:0.004 N:17

26 Anti mullerian hormone serum levels in women with endometriosis: A case–control study 909 patients undergoing in vitro fertilisation/intracytoplasmic sperm injection (IVF/ICSI) treatment or consulting our specific endometriosis unit. Mean AMH serum level was significantly lower in the study than in the control group ( ng/ml vs ng/ml, p 0.001). In women with mild endometriosis (rAFS I-II), the mean AMH level was almost equal to the control group ( ng/ml vs ng/ml; p 0.61). A significant difference in mean AMH serum level was found between women with severe endometriosis (rAFS III- IV) and the control group ( ng/ml vs ng/ml; p ). OMAR SHEBL, 2009

27 Effects of ovarian endometrioma on the number of oocytes retrieved for in vitro fertilization Benny Almog, 2010

28 Soru Endometriozise bağlı infertilitede cerrahi tedavi sonrası spontan gebelik şansı ne kadardır? (tüm evrelerde ve ilk 1 yıl içinde)






34 A comparison of histopathologic findings of ovarian tissue inadvertently excised with endometrioma and other kinds of benign ovarian cyst in patients undergoing laparoscopy versus laparotomy Saeed Alborzi, 2009

35 Excision of endometriotic cyst wall may cause loss of functional ovarian tissue Umut Dilek, 2006 N:46

36 The impact of electrocoagulation on ovarian reserve after laparoscopic excision of ovarian cysts: a prospective clinical study of 191 patients 191 patients with benign ovarian cysts undergoing ovarian cystectomy. When comparing the bipolar group and ultrasonic scalpel group with the suture group, a statistically significant increase of the mean FSH value was found in bilateral-cyst patients at 1-, 3-, 6-, and 12-month follow-up evaluations and in unilateral-cyst patients at the 1-month follow-up evaluation. Statistically significant decreases of basal antral follicle number and mean ovarian diameter were found during the 3-, 6-, 12-month follow-up evaluations as well as statistically significant decreases of peak systolic velocity at all of the follow-up evaluations. Conclusion(s): Electrocoagulation after laparoscopic excision of ovarian cysts is associated with a statistically significant reduction in ovarian reserve, which is partly a consequence of the damage to the ovarian vascular system. Chang-Zhong Li, 2009

37 Analysis of risk factors for the removal of normal ovarian tissue during laparoscopic cystectomy for ovarian endometriosis A total of 121 patients who had histologically confirmed ovarian endometriosis and 56 control patients who had other histologically confirmed benign cysts were included Normal ovarian tissue adjacent to the cyst wall was detected in 71 patients (58.7%) with endometriosis, whereas normal ovarian tissue was removed from only three patients (5.4%) with other benign cysts. A significant factor that was independently associated with the removal of normal ovarian tissue with ovarian endometriosis was pre-operative medical treatment Sachiko Matsuzaki1,2009

38 IVF-ICSI outcome in women operated on for bilateral endometriomas. 68 cases (bilat. cystectomy)- 136 controls the number of follicles (P = 0.006), oocytes retrieved (P = 0.024) and embryos obtained (P = 0.024) were significantly lower. The clinical pregnancy rate per started cycle in cases and controls was 7% and 19% (P = 0.037) CONCLUSIONS: IVF outcome is significantly impaired in women operated on for bilateral ovarian endometriomas. Edgardo Somigliana1, 2008


40 P¨ aivi H¨arkki, 2010



43 P. Vercellini, 2009 Results of studies comparing IVF-ET with second-line surgery in infertile women with recurrent moderate to severe endometriosis

44 Tekrarlayan Endometriozis ve İnfertilite; Cerrahi Primer cerrahi sonrası (% 41) Primer cerrahi sonrası spontan gebelik 236/577 (% 41) Sekonder cerrahi sonrası(% 23) Sekonder cerrahi sonrası spontan gebelik 28/124 (% 23)

45 Tekrarlayan Endometriozis ve İnfertilite; Cerrahi Laparotomi (%27) Laparotomi ile yapılan cerrahi sonrası spontan gebelik % 12 – 47 (%27) Laparoskopi(%25) Laparoskopi ile yapılan cerrahi sonrası spontan gebelik % (%25)


47 30 June 2007 Laparoscopic ovarian cystectomy is recommended if an ovarian endometrioma ≥4 cm in diameter is present to confirm the diagnosis histologically; reduce the risk of infection; improve access to follicles and possibly improve ovarian response. The woman should be counselled regarding the risks of reduced ovarian function after surgery and the loss of the ovary. The decision should be reconsidered if she has had previous ovarian surgery. GPP Endometrioma and IVF

48 Endometriosis-associated infertility: surgery and IVF, a comprehensive therapeutic approach Pedro N Barri, patients

49 Does Controlled Ovarian Hyperstimulation in Women with a History of Endometriosis Influence Recurrence Rate? retrospective cohort study of 592 patients submitted to laparoscopy for endometriosis, 177 with infertility-related endometriosis who underwent a periodic ultrasound follow-up after laparoscopy were selected. Women who started ART after laparoscopy (n90) were compared with the control group, who did not undergo ART (n87). Recurrence of endometriosis was defined as the presence of endometriotic lesions observed through TV-US. During a long-term TV-US follow-up (1–15 years), 40 (22.6%) recurrences were observed. Patients submitted to ART showed a cumulative recurrence rate similar to that of the control group (28.6% and 37.9% respectively, p0.471). Maria Elisabetta Coccia, 2010

50 Soru SART sonuclarına göre endometriozisli olgularda canlı doğum oranları nedir ? ( )

51 SART-2005

52 SART-2006

53 SART-2007

54 Algorithm for management of infertility associated with endometriosis Dominique de Ziegler,, 2010

55 ŞG 37 y, 3yıldır pr infertilite Sol overde 6 cm end’oma+ male faktör(3mil/ml+%10+%37) FSH:10 Op vs ART anlatıldı. Hasta önce ART’yi tercih etti. Nisan’08 Hybrid px; 300IU FSH+ 2 amp HMG step down, 11 gün stimülasyon, 7 oosit 5 MII 5x 2pn, 2. gün 5 ET ( grade 1) Sonuç(+) tekil gebelik, 38 GH SCA, 2850 gr, E


57 EÇ 29y, 5 yıldır pr infertilite Dismenore+, dyspareni+, kr pelvik ağrı+ Kasım’05de L/S, Evre IV end’zis; Adezyolizis ve sağ overden5 cm end’oma ekstirpasyonu. Şubat’06 Antg px 3 MII 3x2pn, 2. gün 3 ET sonuç(-) Mayıs’06 Antg px 5 MII, 2. gün 2 ET Sonuç(-) Temmuz’06 da her iki overde loküller halinde 3-4 cm boyutunda multipl end’oma odakları izleniyor. Geri kalan over rezervi grade 2


59 2 ay depo GnRH analog tx - Eylül’06 da mikrodoz px, 15 oosit, 15 MII,7x 2pn 3.gün 4 ET sonuç negatif -Ocak ‘07 de Antg px ( 2 ay GnRH analog tx yi takiben) 12 oosit, 12 MII 9x2pn 3. Gün 4ET sonuç(+) 33. Haftada dikor-diamn ikiz gebelik, Pl.previa, 2095gr kız/ 1885 gr kız bebek SCA ile doğurdu.

60 Endometriosis-GnRHa Pain After operation for the prevention Before IVF Empirical




64 GnRH agonist v/s no agonist before IVF (Clinical pregnancy rate per woman) Sallam et al, Cochrane Database Syst Rev 25;(1):CD004635, 2006


66 Use of oral contraceptives in women with endometriosis before assisted reproduction treatment improves outcomes In women with endometriosis, including those with endometriomas, 6 to 8 weeks of continuous use of oral contraception (OC) before assisted reproduction treatment (ART) maintains ART outcomes comparable with the outcomes of age-matched controls without endometriosis. In contrast, ART outcomes are markedly compromised in endometriosis patients who are not pretreated with OC. Ovarian responsiveness to stimulation was not altered by 6 to 8 weeks’ use of pre-ART OC, including in poor responders with endometriomas Dominique de Ziegler, 2010

67 Cryopreservation of oocytes in a young woman with severe and symptomatic endometriosis: a new indication for fertility preservation. 2009

68 Soru Derin endometriozisli olgularda infertilite oranı ne kadardır ? (%)

69 Deep Endometriosis: Symptoms Pandis GK, 2010

70 Deep endometriosis: Excisional surgery Pregnancy rates Vercellini et al., Hum Reprod (2009)


72 Fertility and clinical outcome after bowel resection in infertile women with endometriosis 62 infertile women who underwent laparoscopic excision of endometriosis with segmental bowel resection performed for severe intestinal symptoms. Among women younger than 30 years trying to conceive spontaneously, the cumulative pregnancy rate was 58% and the cumulative pregnancy rate was 45% in those aged 30–34 years. Anna Stepniewska, 2010

73 Results of first in vitro fertilization cycle in women with colorectal endometriosis compared with those with tubal or male factor infertility Emmanuelle Mathieu d’Argent, 2010

74 Deep endometrisois: Complications Vercellini et al., Hum Reprod (2009)

75 Endometrioma ve oosit toplanması Hacim artması Enfeksiyon, abse Akut abdomen Toksik etki Malignite

76 Endometrioma and oocyte retrieval–induced pelvic abscess: a clinical concern or an exceptional complication The authors evaluated the risk of developing a pelvic abscess in a series of 214 in vitro fertilization cycles that were performed in women with endometriomas. This complication was never recorded, indicating that its risk is very low (0.0; 95% confidence interval, 0.0–1.7%). Literature – nine cases were described. Prophylactic antibiotics have been administered in at least eight cases. The endometrioma was punctured at the time of oocyte retrieval in at least six cases. Laura Benaglia, 2008

77 Preterm birth, ovarian endometriomata, and assisted reproduction technologies Shavi Fernando, 2009

78 Sorular ve cevaplar Evre I-II Endometriozis infertilite nedeni mi – Evet Endometrioziste KOH+IUI etkin mi – I-II de etkin III-IV de yeri yok Endometriozis over rezervini azaltıyor mu – Evet Derin endometriozis infertilite nedeni mi – Evet Endometriozis düşük riskini arttırıyor mu – Hayır

79 Sorular ve cevaplar Endometriozis IVF sonuclarina etkili mi – Etkili değil (ileri evre ?) Endometrioma varlığı fertiliteyi etkiliyor mu – değiştirmiyor Ivf oncesi endometrioma cerrahisi ivf sonuçları etkiliyor mu – Değiştirmiyor (azalmış over rezervi ) IVF endometriozis rekürrensini arttırıyor mu – Hayır Başarısız IVF sonrası cerrahi faydalı mı – Hayır (Bazı olgularda)

80 Sorular ve cevaplar IVF oncesi depo GnRHa faydalı mı – Etkili gibi ama daha çok çalışmaya gerek var Endometrioma varlığında ovum toplanmasında risk var mı – yok Tekrarlayan endometriomanın yönetim (Cerrahi vs. ivf) – İvf Hangi protokol – Fark yok Ne zaman IVF – Olguya göre değişir

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