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Pretreatment for ovarian endometrioma before in vitro fertilization

Pretreatment for ovarian endometrioma before in vitro fertilization . Prof Dr Sertaç BATIOĞLU. the frequency of pelvic endometriosis is 35–50% in infertile women. Snesky TE 1980.

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Pretreatment for ovarian endometrioma before in vitro fertilization

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  1. Pretreatment for ovarian endometrioma before in vitro fertilization Prof Dr Sertaç BATIOĞLU

  2. the frequency of pelvic endometriosis is 35–50% in infertile women. Snesky TE 1980

  3. Severe disease results in most cases in extensive pelvic adhesions and distortion of pelvic anatomy, which can lead to pain and infertility. • The association between endometriosis and infertility is complex and controversial, especially in mild and moderate forms.

  4. medical Similar PR with COH+IUI • IUI with superovulation pregnancy rates of each cycle; Stage I-II endometriosis; 13 % Stage III-IV endometriosis; 8 % Peterson CM, Fertil Steril 1994

  5. surgery • The use of laparoscopic surgery in the treatment of minimal and mild endometriosis may improve success rates. • Combining ongoing pregnancy and live birth rates there was a statistically significant increase with surgery • OR 1.64, (95% CI 1.05 to 2.57) Jacobson TZ, Laparoscopic surgery for subfertility associated with endometriosis (Cochrane Review) 2004

  6. Pregnancy rate

  7. ongoing pregnacies at 20 Weeks or live birth

  8. IVF + IVF success rates are comparable in women with and without endometriosis (Dmowski 1995; Geber 1995; Olivennes 1995) pregnancy outcome in patients with endometriosis was not different than the outcome for patients with mechanical (tubal) infertility. There were no differences in PRs by stage of endometriosis

  9. In women undergoing IVF-ET with endometriosis ! • Low Ovarian response to medical treatment • decreased oocyte and embryo quality • Lower FR and PR. Wardle et al. 1985; Yovich et al 1985

  10. ! In women undergoing IVF-ET with advanced stageendometriosis • Reduced ovarian response • Less oocyte pick-up • Higher miscarriage rates. (Chillik 1985; O’Shea 1985; Matson 1986; Oehringer 1988; Pellicer 1995)

  11. Advanced stage endometriosis + • lower fertilization rate, but • similar pregnancy rates for every stages. Pal L, J Assist Reprod Genet. 1998 Jan;15(1):27-31.

  12. Treatment option for Endometrioma • USG guided aspiration • Surgical treatment • Laparoscopy • L/S aspiration, • Cystectomy • Aspiration and destruction - Laparotomy

  13. Endometrioma

  14. in patients with endometrioma ! • higher incidence of pregnancy loss • adverse effects on the number of Oocytes on the embryo quality • Yanushpolsky EHJ Assist Reprod Genet. 1998 Apr;15(4):193-7.

  15. + The presence of a small endometrioma does not reduce the success of IVF treatment. endometrioma (+) (n=45) (-) (n=55) GTH/oocyte 760IU 652 IU Mean oocyte 6.5 6.1 Mean. Embryos 3.9* 2.8* Pregnancy %40 %27 Live birth %27 %20 Fertilization %58 %48 Implantation %20 %13 Tinkanen, Acta Obstet Gynecol Scand 79 (2000)

  16. * in patients with endometriomas • reduced ovarian response, • higher doses of gonadotropin treatment • Similar Cumulative pregnancy and live birth rates compared with control Al-Azemi M et al. Hum Reprod 2000,

  17. The presence of ovarian endometriomas is associated with a reduced responsiveness to gonadotropins Edgardo Somigliana Fertil Steril 2006

  18. Removal of endometrioma Enhanced adhesion formation. (Diamond 1987) Reduced folliculer reserve Diminished functional ovarian tissue (Hornstein 1989; Nargund 1995; Hemmings 1998; Loh 1999)

  19. Group A Group B Group C Group A: Ovarian cystectomy Group B: Endometriosis (+); endometrioma (-) Group C: control Canis M, Hum Reprod, 2001

  20. Laser vaporization of ovarian endometriomas: the impact on the response to gonadotrophin stimulation Wyns C, Donnez J.2003 DISCUSSION AND CONCLUSION: The theoretical risk of loss of ovarian cortex when treating endometriotic cysts can be eliminated by the technique ofvaporization of the internal wall of the endometrioma. IVF outcomes are similar in patients treated for endometriosis and those presenting with unexplained or tubal infertility.

  21. Wyns C, Donnez J.Gynecol Obstet Fertil. 2003 Apr;31(4):337-42

  22. fenestration and coagulation leads to a higher recurrence of signs and symptoms a lower cumulative pregnancy rate than laparoscopic cystectomy. Baretta P, Fertil Steril, 1998 Saleh A, Fertil Steril, 1999

  23. A prospective, randomized study comparing laparoscopic ovarian cystectomy versus fenestration and coagulation in patients with endometriomas Saeed Alborzi Fertil Steril 2004; • Conclusion(s): Laparoscopic cystectomy of endometriomas is a better choice than fenestration and coagulation • because the former technique leads to a lower recurrence of signs and symptoms and a lower rate of reoperation and a higher cumulative pregnancy rate than the latter.

  24. Comparing laparoscopic ovarian cystectomy and bipolar cauterization in women with bilateral endometriomas. (unpublished data) the decrease in both baseline follicle numbers and ovarian volume was more extensive with cystectomy than cauterization

  25. Ultrasound guided aspiration of endometrioma--a new therapeutic modality to improve reproductive outcome • UGA of endometrioma can be an effective and safe alternative therapeutic procedure in infertile patients with endometrioma to improve their reproductive outcome. Mittal S, Int J Gynecol Obstet, 1999

  26. Ovarian endometriomas do not adversely affect pregnancy success following treatment with in vitro fertilization 108 women with endometriosis Endometrioma (-) N=84; 147 cycles Endometrioma (+) N=24; 29 cycles OPU + aspiration IVF IVF peak E2 # mature follicles # oocytes #available embryos # PR Isaacs JD, J Assist Reprod Genet. 1997

  27. Reproductive performance after ultrasound-guided transvaginal ethanol sclerotherapy for ovarian endometriotic cysts.Koike T, Minakami H, Motoyama M, Ogawa S, Fujiwara H, Sato I. Eur J Obstet Gynecol Reprod Biol. 2002 Oct 10;105(1):39. • No complications associated with TV-EST were observed. • There were no differences in the numbers of pregnancies (47% (21/45) versus 39% (25/65)), term deliveries (76% (16/21) versus 76% (19/25)), abortions (19% (4/21) versus 24% (6/25)), retrieved oocytes, or quality of embryos between the Study and Comparison groups, respectively. • The serum levels of LH and FSH did not increase after TV-EST. • The serum levels of CA125 and CA19-9 did not significantly decrease after TV-EST. • Ovarian cysts recurred in six (13.3%) of the 45 women 5.2+/-3.9 months after TV-EST. • CONCLUSION: Although only a small number of women were studied, our observational study suggested that TV-EST appeared not to adversely affect reproductive performance in subfertile women with ovarian endometriotic cysts.

  28. Pretreatment for ovarian endometrial cyst before in vitro fertilization.Suganuma N, Wakahara Y, Ishida D, Asano M, Kitagawa T, Katsumata Y, Moriwaki T, Furuhashi M. Gynecol Obstet Invest. 2002;54 Suppl 1:36-40; discussion 41-2 • The results showed that pretreatment for endometrioma reduces the number of retrieved oocytes. Although oocyte quality as a rate of mature oocytes was not affected by the presence of an ovarian endometrial cyst, the fertilization rate was improved by cyst aspiration. • We propose that surgical pretreatment is not necessary for ovarian endometrial cyst before IVF-ET, but cyst aspiration may be beneficial after several failed attempts of IVF

  29. Aspiration of ovarian endometriomas before intracytoplasmic sperm injection Recai Pabuccu FERTILITY AND STERILITY 2004 Conclusion(s): In the current study, all patients with endometriomas had significantly lower numbers of MII oocytes compared with those in patients with tubal factor infertility. We propose that aspiration of endometriomas before COH neither reduces the amount of gonadotropins nor increases the number of follicles 17 mm, the number of MII oocytes retrieved, the implantation rates, or the clinical pregnancy rates. Resection of small endometriomas (1–6 cm) may not present any additional benefits to the IVF-ICSI cycle outcomes.

  30. Removal of endometriomas before in vitro fertilization does not improve fertility outcomes: a matched, case–control studyJuan A. Garcia-Velasco Fertility and Sterility 2004 Conclusion(s): Laparoscopic cystectomy for endometriomas before commencing an IVF cycle does not improve fertility outcomes. Proceeding directly to controlled ovarian hyperstimulation in women with asymptomatic ovarian endometriomas might reduce the time to pregnancy, the costs of treatment, and the hypothetical complications of laparoscopic surgery. Conversely, conservative surgical treatment of ovarian endometriomas in symptomatic women does not impair IVF or intracytoplasmic sperm injection success rates..

  31. Women with advanced-stage endometriosis and previous surgery respond less well to gonadotropin stimulation, but have similar IVF implantation and delivery rates compared with women with tubal factor infertility. Ioannis M. Matalliotakis, Fertil Steril 2007 • Conclusion(s): Women with advanced-stage endometriosis who have undergone previous surgery respond less well to gonadotropins than women with tubal-factor infertility. • However, implantation, pregnancy, and delivery rates are similar, suggesting that embryo quality and uterine receptivity remains unaffected despite diminished ovarian reserve in women with endometriosis.

  32. Current status of management of endometriomas Mohamed AboulgharReviews in Gynaecological Practice, 2004, • It is well documented that there is no successful medical treatment for ovarian endometriomas. Transvaginal aspiration is associated with a very high recurrence rate. The use of sclerosing agents as tetracycline and ethanol may reduce the recurrence rate, however, aspiration may possibly result in infection or adhesions. • Surgical treatment of endometriomas is the appropriate approach in the management of associated pain. Laparoscopic surgery proved to be superior to laparotomy in the treatment of endometriomas as it showed less postoperative pain, less blood loss and shorter hospital stay. It is believed that coagulation and ablation of the superficial endometrium lining of the cyst wall is an effective line of treatment as it causes the minimal possible damage to the ovarian tissue. Ovarian cystectomy is considered to be more effective treatment and is associated with lower incidence of recurrence rate. However, there is no available randomized studies to compare both modalities concerning infertility treatment. Assisted reproduction in the form of ovarian stimulation and intrauterine insemination could be tried if the tubes are patent, and IVF is considered as the first line of treatment in extensive adhesions or after failure of surgical treatment.

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