Download to read offline
Uploaded bySujoy Dasgupta
AGAINST the Motion- “Surgery is the ONLY treatment of Endometriosis with Infertility”
Dr. Sujoy Dasgupta argues against the notion that surgery is the only treatment for endometriosis causing infertility, emphasizing that surgery should be performed by well-trained specialists in a multidisciplinary team. Evidence suggests that while surgery can improve chances of spontaneous conception in certain cases, it may also negatively impact ovarian reserve and does not guarantee success in assisted reproductive technologies (ART). Therefore, individual patient circumstances, including age, symptoms, and reproductive plans, should guide treatment decisions rather than solely relying on surgical intervention.
More Related Content
Similar to AGAINST the Motion- “Surgery is the ONLY treatment of Endometriosis with Infertility”
More from Sujoy Dasgupta
AGAINST the Motion- “Surgery is the ONLY treatment of Endometriosis with Infertility”
- 1. AGAINST the Motion- “Surgeryis the ONLY treatment of Endometriosis with Infertility” Dr Sujoy Dasgupta MBBS (Gold Medalist, Hons) MS (OBGY- Gold Medalist) DNB (New Delhi) MRCOG (London) Advanced ART Course for Clinicians (NUHS, Singapore) Diploma, Sexual and Reproductive Medicine (University of South Wales, UK) Consultant: Reproductive Medicine, Genome Fertility Centre, Kolkata Winner: Prof Geoffrey Chamberlain Award, RCOG World Congress, London, 2019
- 2. AGAINST? Endometriosis surgery shouldbe performed ONLY be persons • Having adequate training • Having expertise in dealing with such complex procedure • In the multidisciplinary team (MDT) setup *ESHRE, 2022; NICE, 2017; RCOG, 2017; ETIC, 2018
- 3. Difference between “what wecan” and “what we should”.
- 4. Surgery is oneof the treatments of Endometriosis with Infertility Peritoneal Endometriosis- • Both ablation and excision improve the chance of spontaneous conception in ASRM stage I/II endometriosis (CO2 laser vaporization > monopolar electrocoagulation) Ovarian Endometrioma- • ≥3 cm- cystectomy preferred to drainage and coagulation/ CO2 laser vaporization • controversial if cumulative pregnancy rate is more after surgery but time to achieve the first pregnancy in infertile patients was significantly shorter Deep Endometriosis- • radical excision of endometriosis combined with bowel segmental resection and anastomosis was associated with a higher postoperative spontaneous pregnancy rate *ESHRE, 2022
- 5. “Surgery is theONLY treatment of Endometriosis with Infertility”
- 6. Case 1 • MrsFR, 32 years, has been trying for pregnancy for last 2 years. AMH, AFC, HSG all normal. • Husband is having severe oligospermia. Donor sperm is no acceptable. Opts for IVF-ICSI. • 6 cm right ovarian endometrioma, minimum dysmenorrhoea.
- 7. Endometrioma and IVFOutcome 1. Lower serum AMH 2. Inadequate ovarian response to gonadotrophin 3. Lower number of oocytes retrieved (mean difference –0.23; 95% CI 0.37–0.1) 4. Higher cancellation rate (OR 2.83; 95% CI 1.32– 6.06) *Maneschi et al., 1993; Sanchez et al., 2014; Coccia et al., 2014; Somigliana et al., 2014; Hamdan et al., 2015; Goodman et al., 2016; Ferrero et al., 2017
- 8.
- 10. Surgery prior toIVF • Lowers serum AMH levels further • Progressive decline in ovarian reserve • Higher gonadotrophin consumption • Lower number of oocyte retrieved *Raffi et al., 2012; Somigliana et al., 2012; Sugita et al., 2013; Hamdan et al., 2015; Polyzos and Sunkara, 2015; Brink Laursen et al., 2017; Tao et al., 2017; Nickkho-Amiry et al., 2018
- 11. IVF in Endometrioma (ESHRE,2022) 11
- 12. IVF in Endometrioma (ESHRE,2022) 12
- 13. Complications during andafter OPU • Technical difficulties during oocyte retrieval is low, • No data to suggest that surgery will prevent adhesion reformation and facilitate oocyte retrieval effectively. • Risks of infection from an endometrioma (0–1.9%) • Progression of pelvic endometriosis and ovarian endometriomas- ? *Koch et al., 2012; RCOG, 2017, ESHRE, 2022
- 14. Risk of missingmalignancy • Extremely low in endometrioma • The lifetime probability of Ca ovary 1-2% in the presence of an endometrioma. • In the context of IVF treatment, delaying surgery for a few months or years, until the treatment has been completed or following delivery, would usually be a reasonable course of action unless there are other immediate concerns. *RCOG, 2017
- 15. RCOG Scientific ImpactPaper (2017) Directly ART • Asymptomatic women, • women of advanced reproductive age, • those with reduced ovarian reserve, • B/L endometriomas, • a history of prior ovarian surgery Surgery before IVF • highly symptomatic women, • with an intact ovarian reserve, • unilateral and large cysts, • cysts with suspicious radiological and clinical features. 15
- 16. Endometriosis as acause of IVF Failure • Undetected endometriosis- reason for RIF • Altered endometrial receptivity- aromatase, B-3 integrin expression • Need to do 40 laparoscopy to achieve a pregnancy *Lessey et al., 1996; ASRM, 2012
- 17. Case 2 • MrsAB, 33, P0+0, had been trying to conceive for one year. She is having severe dysmenorrhoea not responding to NSAID. There was 4 cm endometrioma in right ovary. • HSG, AMH (2.1 ng/ml), husband’s semen- all are normal. • She underwent laparoscopy- ovarian cystectomy and adhesiolysis. Tubal patency was confirmed.
- 18. Case 2 (Contd.) •Mrs AB, now 37 presented 4 years after the initial laparoscopy. Tried many cycles of OI and IUI. She wants to try IVF. • Now there is 6 cm endometrioma in right ovary. • Dysmenrrhoea is well controlled with NSAID. • AMH 0.8 ng/ml
- 19. IVF can NOTbe the only treatment Medical Overuse • a combination of overtesting/overdiagnosis with overtreatment that results in an unfavorable balance between 1. incremental benefits 2. risk of harms 3. cost of healthcare interventions *Moynihan et al., 2012; Colla, 2014; Morgan et al., 2016
- 20. 1. 3-10% chancesof damaging the surrounding organs- bladder, bowel, ureter, nerves 2. Risk of oophorectomy. 3. Complete excision of endometriotic tissue not possible. 4. May not reverse the inflammatory and biomolecular changes shown to influence fertilisation and implantation. *Vercellini et al., 2009; Lebovic, 2016
- 21. Case 3 • MrsPC, 32, trying for pregnancy for 1 year. • All investigations (Semen, AMH, HSG) normal. • 2 cm endometrioma in left ovary. • No pain.
- 22. Conservative management forspontaneous conception Encourage to try natural conception before seeking fertility treatment- 1. Young women, 2. regular menstrual cycles and 3. an incidental finding of an ovarian endometrioma 4. without suspicion of malignancy •43% spontaneous pregnancy rate during the 6-month follow up period •Similar ovulation rates in the affected ovary to the healthy ovary *Benaglia et al., 2009; Leone Roberti Maggiore et al., 2015; RCOG, 2017 22
- 23. Unexplained infertility and Endometriosis •20-40% cases of unexplained infertility may be because of undiagnosed endometriosis *Hurt, 2003; Fadhlaoui et al., 2014
- 24. Recent Studies onEndometriosis and Unexplained Infertility • RCTs- Parazzini, 1999; Gad and Badroui, 2012 • Meta-Analysis Jacobson et al., 2010 Duffy et al., 2014 OR for ongoing pregnancy (95% CI) 1.64 (1.05– 2.57) 1.94 (1.20–3.16) The number of infertile women that should undergo destruction of superficial peritoneal endometriosis 12 8 The prevalence of grade I/ II endometriosis among women with unexplained infertility ≤50% NNT 24 16
- 25. Recent Studies onEndometriosis and Unexplained Infertility • RCTs- Parazzini, 1999; Gad and Badroui, 2012 • Meta-Analysis • Success rate of IVF - ∼25% (NNT- 4) *European IVF-Monitoring Consortium (EIM) for ESHRE, 2016 Jacobson et al., 2010 Duffy et al., 2014 OR for ongoing pregnancy (95% CI) 1.64 (1.05– 2.57) 1.94 (1.20–3.16) The number of infertile women that should undergo destruction of superficial peritoneal endometriosis 12 8 The prevalence of grade I/ II endometriosis among women with unexplained infertility ≤50% NNT 24 16
- 26. Staging of Endometriosis •Does not correlate well with the symptoms of pain or fertility. • Offer endometriosis treatment according to the woman's symptoms, preferences and priorities, rather than the stage of the endometriosis. *NICE, 2017
- 27. • Routine laparoscopyshould NOT be done in women with infertility without pelvic pain (Quality of evidence- High) • Consider surgery for superficial endometriosis ONLY in women 1. Having moderate-severe pain 2. Seeking natural conception, declining ART
- 28. Deep endometriosis -asymptomatic • Uncommon to be asymptomatic • Uncomplicated- If no symptoms of ureter/ bowel stenosis- No need of surgery • 9 out of 10 will not progress • Improper resection will worsen bowel/ bladder symptoms *Dunselman et al., 2014; Berlanda et al., 2016; ETIC, 2018
- 29. Deep endometriosis- whento operate Only when- 1. Occlusive disease (ureter/ bowel) 2. Wishing natural conception, declining IVF *Dunselman et al., 2014; Berlanda et al., 2016; ETIC, 2018
- 30. Patient's age Pain symptoms Extentof disease Patient's reproductive plans Treatment risks Side effects Cost considerations Every endometriosis is different
- 31. Conclusion • ‘Endometriosis shouldnot be treated just because it’s there’ (Thomas, 1993). • Surgery is one of the treatment modalities in improving pain. • Surgery can improve the chance of natural conception (but NOT the success of ART) in some cases. • The potential benefits must be balanced against the risks and alternatives. • Surgery is NOT the ONLY treatment
- 32.