Case presentationEndometriosis By: FauziahShari Hospital Ampang
Endometriosis… • Common, chronic disease. • Asymptomatic. • Symptoms: • Pelvic pain. • Infertility. • Adnexal mass.
Summary… • Mrs. RH / 28 yo / Malay / Nulliparous. • Married for 2 years. • Complain of: • Severe dysmenorhea with dyspareunia.
Cont… • History of presenting illness: • She was diagnosed with ovarian cyst in 2007. • Had underwent laparoscopy cystectomy in 2009. • Intra – op revealed stage III endometriosis. • HPE: endometriotic cyst. • Was given 6 cycles of Lucrin post – op. • Subsequently, defaulted follow up.
Cont… • She got married in September 2012. • In December 2012 she presented again with recurrence of the endometriomas and had laparotomy cystectomy done. • Intra – op: Stage IV endometriosis.
Cont… • In February 2013, again she had recurrence of the endometriomas bilaterally. • She was counselled to have transvaginal cyst aspiration and after that to proceed with IVF. • Transvaginal cyst aspiration was done on 01/08/13 without complication. • Currently, undergoing IVF.
Endometriosis… • 25% to 50% of infertile women have endometriosis. • 30% to 50% of women with endometriosis are infertile. • Prevalence: • Undergone tubal sterilisation: 1 – 7%. • Undergone laparoscopy for evaluation of infertility: 9 – 50%. • Among women with pelvic pain: 30 – 80%.
Cont… • Infertile women are 6 – 8 times more likely to have endometriosis than fertile women. • Hypothesis that endometriosis causes infertility remains controversial.
Adenomyosis in endometriosis… Adenomyosis results from the invasion of basal endometrial glands and stroma into the underlying myometrium. The surrounding myometrium results from stromal metaplasia forming peristromal muscular tissue. It is a histological diagnosis.
Cont… Endometriosis has been shown to be significantly associated with adenomyosis in infertile patients. With a prevalence up to 90%, uterine adenomyosis is significantly associated with pelvic endometriosis and constitutes an important factor of sterility in endometriosis.
Mechanism… • The infertility associated with endometriosis has been attributed to several mechanisms: • Distorted pelvic anatomy. • Altered peritoneal function. • Altered hormonal and cell – mediated function. • Endocrine and ovulatory abnormalities. • Impaired implantation. • Oocyte and embryo quality. • Altered uterotubal transport.
Cont… • In current clinical practice, a surgical procedure is required for a definitive diagnosis of endometriosis. • Need to consider the likelihood of the diagnosis as well as potential benefit of treatment. • Medical therapy is effective for relieving pain associated with endometriosis. • However, there is no evidence that medical treatment improves infertility.
Clinical assessment for infertility… • Both partners must be involved. • Includes: • At least 1 semen analysis. • Ovulatory status. • Test of tubal patency. • Women among whom endometriosis is suspected from their history or clinical findings, should be assessed by laparoscopy rather than HSG.
Management… • Medical therapy. • No evidence to support the treatment of infertility. • More harm than good. • Surgical therapy. • Combined medical and surgical therapy. • Not shown to significantly enhance fertility.
Surgery for endometriosis… • Ablation plus adhesiolysis to improve fertility in mild endometriosis is effective compared to diagnostic laparoscopy alone. • The recurrence of endometriomas and symptoms are reduced by excisional surgery, more so than drainage and ablation. • Improved spontaneous pregnancy rates in women who were previously subfertile.
Cont… • Laparoscopic cystectomy for endometriomas > 4cm improve fertility compared to drainage and coagulation. • Possible adverse outcome is loss of viable ovarian cortex. • The decision should be reconsidered if there has been a previous ovarian surgery.
Cont… There is a paucity of evidence regarding the practice of transvaginal aspiration of endometriotic cysts prior to IVF. In suspected recurrent endometriomas, we can’t be certain that this is not a rare occult malignancy. This ought to be discussed with the patient prior to any transvaginal cyst aspiration
Cont… An advantage of transvaginal drainage of endometriomas is easier access to ovaries during oocyte retrieval. The role in improving oocyte quality and pregnancy rates, if any at all, have yet to be proven.
Assisted reproductive technology… • Treatment with SO / IUI improves fertility. • IVF is an option, especially if tubal function is compromised; if there is male factor infertility and / or other treatments have failed.
Decisions among infertile women with endometriosis… • Difficult. • Factors such as age, duration of infertility, ability to undergo IVF – ET, family history and pelvic pain must be taken into consideration.
References… • ASRM; Endometriosis and infertility: a committee opinion. • Green-top Guideline, RCOG. • TOG: Review Management of endometriosis – related subfertility. • Human reproduction: adenomyosis in endometriosis – prevalence and impact on fertility.