Endometriosis associated infertility: ESHRE2022

Endometriosis associated infertility: ESHRE2022

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  3/15/2022 ABOUBAKR ELNASHAR You canget this lecture and 500 lecture from: 1.My scientific page on Face book: Aboubakr Elnashar Lectures. https://www.facebook.com/groups/2277448840913 51/ 2.Slide share web site [email protected] 4.My clinic: Elthawra St. Mansura TREATMENT OF ENDOMETRIOSIS-ASSOCIATED INFERTILITY ESHRE guidelines 2022 Prof. ABOUBAKR ELNASHAR Benha university Hospital, Egypt ABOUBAKRELNASHAR ABOUBAKRELNASHAR CONTENTS I. DIAGNOSIS OF ENDOMETRIOSIS II. TREATMENT OF ENDOMETRIOSIS-ASSOCIATED PAIN III. TREATMENT OF ENDOMETRIOSIS-ASSOCIATED INFERTILITY IV. IMPACT OF ENDOMETRIOSIS ON PREGNANCY AND PREGNANCY OUTCOME V. ENDOMETRIOSIS RECURRENCE VI. ENDOMETRIOSIS AND ADOLESCENCE VII. ENDOMETRIOSIS AND MENOPAUSE VIII.EXTRAPELVIC ENDOMETRIOSIS IX. ASYMPTOMATIC ENDOMETRIOSIS X. PRIMARY PREVENTION OF ENDOMETRIOSIS XI. ENDOMETRIOSIS AND CANCER ABOUBAKRELNASHAR  Recommendations either ‘‘strong’’ or ‘‘weak” according to the GRADE approach, ABOUBAKRELNASHAR DIAGNOSIS OF ENDOMETRIOSIS  Symptoms  Cyclical & non-cyclical:  Dysmenorrhea,  Deep dyspareunia ,  Infertility  Dysuria  Dyschezia  Painful rectal bleeding or haematuria,  shoulder tip pain,  catamenial pneumothorax, cyclical cough/haemoptysis/ chest pain, cyclical scar swelling and pain, fatigue. GPP ABOUBAKRELNASHAR 3/15/2022  Diary/questionnaire/app  No evidence that a symptom reduces the time to diagnosis or leads to earlier diagnosis  Potential benefit in  completing the traditional history  pain  Other symptoms. GDG STATEMENT  Clinical examination, including vaginal examination  should be considered to identify  deep nodules or  endometriomas in patients with suspected endometriosis  Diagnostic accuracy is low.⊕Strong recommendation ABOUBAKRELNASHAR  Investigation  Biomarkers: not to be used.⊕⊕⊕ Strong recommendation 1. Imaging (US or MRI):  Should be considered even if the clinical examination is normal.⊕⊕ Strong recommendation  Negative finding does not exclude endometriosis, particularly superficial peritoneal disease ⊕⊕Strong recommendation ABOUBAKRELNASHAR  Justification:  For endometrioma & DIE: TVS & MRI have a similar or slightly better specificity & sensitivity than laparoscopy  For superficial disease: imaging modalities have inferior diagnostic value compared to laparoscopy (Wykes, et al., 2004).  Dedicated TVS in experienced hands (also MRI)  can replace laparoscopy  the gold standard for the diagnosis of endometrioma & DIE in the pelvis ABOUBAKRELNASHAR 2. Laparoscopy is considered for the diagnosis &TT in 1. Patients with negative imaging results 2. Empirical TT was unsuccessful or inappropriate GPP  Endometriotic lesions is confirmed by histology although negative histology does not entirely rule out the disease GPP  Justification:  The benefits of laparoscopy need to be weighed up against its risks (Bafort, et al., 2020, Byrne, et al., 2018b, Chapron, et al., 1998).  Expensive, invasive& associated with morbidity mortality.  Direct, photographic& histological proof of lesions: an important psychological factor for women ABOUBAKRELNASHAR  2-step approach  Can be considered  endometriosis is suspected  imaging results are negative  not trying to conceive  TVS followed by empirical TT  oral contraceptive pill or progestogens(Kuznetsov, et al., 2017).  If symptoms improve: endometriosis is presumed the main underlying condition, although other clinical causes can coexist. ABOUBAKRELNASHAR  Women suspected of endometriosis  Diagnostic laparoscopy and  Imaging combined with empirical TT  Can be considered  No evidence of superiority of either approach:  Pros & cons should be discussed with the patient. GDG STATEMENT ABOUBAKRELNASHAR
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  3/15/2022 TREATMENT OF ENDOMETRIOSIS-ASSOCIATED INFERTILITY LINES OF TREATMENT I. IUI & OS II. SURGERY III. IVF IV. FERTILITY PRESERVATION  Medical  Non medical ABOUBAKRELNASHAR  Medical treatment  Ovarian suppression Should not be prescribed to improve fertility ⊕⊕Strong recommendation  Justification:  Based on the results of the Cochrane review, suppression of ovarian function (by means of danazol, GnRH agonists, progestogens, OCP) to improve fertility is not effective and should not be offered for this indication alone  Pentoxifylline, other anti-inflammatory drugs or letrozole outside ovulation-induction: should not prescribed to improve natural pregnancy rates ⊕Strong recommendation ABOUBAKRELNASHAR  Justification  As endometriosis is associated with inflammation. Pentoxifylline has anti‐inflammatory properties.  SR show no benefit of pentoxifylline, postoperative aromatase inhibitor (letrozole), or postoperative GnRH agonist (triptorelin) to improve pregnancy rates in women with endometriosis. ABOUBAKRELNASHAR  Non-medical management strategies for infertility  Nutrition, Chinese medicine,  Electrotherapy, acupuncture  Physiotherapy, exercise, and psychological interventions  No clear evidence of benefit to increase the chance of pregnancy.  No recommendation can be made to support any to increase fertility.  The potential benefits and harms are unclear GDG STATEMENT ABOUBAKRELNASHAR I. IUI with ovarian stimulation:  rASRM stage I/II, instead of expectant management or IUI alone, as it increases PR ⊕Weak recommendation  could be considered in rASRM stage III/IV with tubal patency Although the value is uncertain ⊕Weak recommendation ABOUBAKRELNASHAR II. SURGERY  Should be guided by  Presence or absence of pain symptoms  Patient age and preferences  History of previous surgery  Presence of other infertility factors  Ovarian reserve  Estimated Endometriosis Fertility Index (EFI) GPP  Women should be counselled of their chances of becoming pregnant after surgery. ABOUBAKRELNASHAR 3/15/2022 ABOUBAKRELNASHAR  Operative laparoscopy  For rASRM stage I/II could be offered {improves the rate of ongoing pregnancy} ⊕⊕Weak recommendation  For endometrioma-associated infertility May be considered {may increase their chance of natural pregnancy}, although no data from comparative studies exist ⊕ Weak recommendation  For deep endometriosis: No convincing evidence exists that it improves fertility  May represent TT option in symptomatic patients wishing to conceive ⊕Weak recommendation ABOUBAKRELNASHAR  Postoperative hormone suppression  Should not be prescribed with the sole purpose to enhance future pregnancy rates ⊕⊕Strong recommendation  may be offered for women who cannot attempt to or decide not to conceive immediately after surgery {does not negatively impact their fertility and improves the immediate outcome of surgery for pain} ⊕⊕ Weak recommendation ABOUBAKRELNASHAR III. ART  Can be performed especially if 1. Tubal function is compromised 2. Male factor infertility 3. Low EFI and/or 4. Other treatments have failed ⊕⊕ Weak recommendation  To identify patients that may benefit from ART after surgery  EFI should be used as it is validated, reproducible and cost-effective.  Other fertility investigations such as their partner’s sperm analysis GDG STATEMENT ABOUBAKRELNASHAR  Surgery prior ART  rASRM stage I/II endometriosis: Not recommended as the potential benefits are unclear ⊕⊕Strong recommendation  Endometrioma  Not recommended {no benefit& surgery is likely to have a negative impact on ovarian reserve}. ⊕⊕Strong recommendation  can be considered to improve endometriosis-associated pain or accessibility of follicles GPP  Deep endometriosis: should be guided mainly by pain symptoms& patient preference as its effectiveness on reproductive outcome is uncertain due to lack of RCT ⊕Strong recommendation ABOUBAKRELNASHAR  Protocol  Both GnRHan & agonist can be offered based on patients’& physicians’ preferences as no difference in PR or LBR ⊕ Weak recommendation  The extended GnRHa is not recommended, as the benefit is uncertain ⊕Strong recommendation  Insufficient evidence to recommend prolonged administration of COC/progestogens as a pre-TT to ART to increase LPR ⊕ Weak recommendation  The data are very limited and do not allow to draw any conclusion.  This does not preclude use of OCP for planning purposes. ABOUBAKRELNASHAR
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  3/15/2022  Oocyte retrieval In women with endometrioma, clinicians may use antibiotic prophylaxis  Although the risk of ovarian abscess formation following follicle aspiration is low GPP  Recurrence rates are not increased compared to those women not undergoing ART ⊕⊕⊕ Weak recommendation ABOUBAKRELNASHAR IV. Fertility Preservation (FP): oocyte cryopreservation  In case of extensive ovarian endometriosis, clinicians should discuss the pros & cons of FP  The true benefit of FP is unknown ⊕ Strong recommendation  FP may increase future chances of pregnancy of some women  FP is expensive& ±some clinical risks.  Still many questions remain unanswered  Cost effectiveness  Criteria to select those women.  Strong recommendation for counselling& information provision. ABOUBAKRELNASHAR ABOUBAKRELNASHAR ABOUBAKR ELNASHAR You can get this lecture and 500 lecture from: 1.My scientific page on Face book: Aboubakr Elnashar Lectures. https://www.facebook.com/groups/2277448840913 51/ 2.Slide share web site [email protected] 4.My clinic: Elthawra St. Mansura