Dr Jodie Semmler presented about the treatment options available for sufferers of Endometriosis. She outlined what they entail and how fertility treatment is individualised to provide the best possible outcomes. Dr Semmler is one of Adelaide's leading gynaecological surgeons. She has had extensive experience in laparoscopic keyhole surgery treating fertility issues including the excision of endometriosis. Dr Semmler is also a sitting member of the Australian IVF Directors group. For more information on Dr Semmler, please follow this link http://www.fertilitysa.com.au/dr-jodie-semmler-specialist.html

1. Endometriosis and Infertility
Treatment Options
Presented by
Dr Jodie Semmler

2. 1. Healthy diet and exercise
2. Natural remedies
3. Medical management
4. Surgical management
5. Fertility treatment options – IUI, IVF
6. Importance of individualising fertility treatments
7. Future possible treatments
Summary of Treatment Options

3. Normal Pelvis

4. Severe endometriosis (stage 4)

5. Minimal and Mild endometriosis (stage 1 and 2)

6. Endometriosis in Pouch of Douglas

7. Endometriosis over bladder

8. Endometriosis on surface of uterus

9. • Maintaining healthy weight is of paramount
importance
• Higher weight (BMI) leads to higher oestrogen
levels which encourages growth of endometriosis
• Lack of ovulation will exacerbate – eg PCOS
• Exercise has been shown to reduce symptoms,
pain and recurrence rates
Healthy diet and exercise

10. • Healthy diet and plenty of aerobic exercise
• Co-Enzyme Q10 – may reduce fatigue
• Vit B6, vit E, Copper, magnesium, acupunture - may
reduce menstrual pain
• Chinese herbs – safety NOT proven, specific
ingredients often unclear (quality), no proof for benefit
• Progesterone cream – may act as a mild contraceptive
(as may herbs that claim to regulate hormones)
Natural Remedies

11. • Hormonal therapies all effective in pain reduction but
do NOT improve fertility
• Examples include – OCP, progesterone tablets,
Mirena device, GnRH agonists (zoladex, synarel)
• Most work by preventing ovulation and stopping
periods
• Useful for reducing pain and preventing recurrence
of endometriosis when NOT trying to conceive
Medical Management

12. • Ablation (burning the lesions)
- Includes laser, diathermy, microwave
- Technically easier but bigger nodules often under-
treated, higher chance of recurrence
• Resection/Excision (cutting out)
- scissors, diathermy, laser, harmonic scalpel
- Technically more challenging, reduces chance of
recurrence, need to be careful to spare as much ovarian
tissue as possible
Surgical treatment for endometriosis

13. Surgical Excision using Harmonic Scalpel

14. • Laparoscopic treatment of minimal to moderate
endometriosis (stage 1,2 and 3) has been proven to
increase chance of natural conception by 25-40% over
the following 2 years
• Laparoscopic treatment before IVF
- Unfortunately studies have NOT been able to prove
that surgical excision of endometriosis leads to any
improvement in IVF success rates
Does surgery improve fertility

15. • Indications for surgical excision of endometriosis
- Pain
- A desire to maximise chance of natural conception
- Large endometriosis cysts (endometriomata) in ovaries
- Recurrent unsuccessful IVF cycles
However, repeated excisional surgeries have NOT been
shown to improve pregnancy rates and may further
reduce egg supply so careful consideration required
When should we operate?

16. • IUI – Intrauterine insemination
• IVF – Invitro Fertilisation
• IVF with donor eggs
Fertility Treatment Options

17. • Involves inseminating partners sperm through the cervix
into the uterus
• Need to have normal fallopian tubes and pelvic anatomy
• Pregnancy rates reduce in women with endometriosis
probably because endometriosis and adhesions interfere
with function of fallopian tubes, sperm and eggs
• May still be reasonable option if mild endometriosis +
anovulation, mild sperm issues, sexual difficulties
IUI – Intrauterine insemination

18. • IVF often the best option for conception in women with
endometriosis
• Chance of success with IVF is slightly reduced in
women with endometriosis conpared to other causes of
infertility (eg male factor, blocked tubed)
• Success rates with IVF are directly related to severity of
endometriosis (more severe = lower success rates)
IVF – Invitro Fertilisation

19. • Women with endometriosis may do better when we suppress
hormone production (which switches off the endometriosis)
prior to starting the stimulation injections
- This is called a long down-regulation cycle
• Studies showed no clear difference between standard long
down-regulation cycle (2 weeks of suppression) and short cycle
(antagonist) IVF
• Studies HAVE shown improved pregnancy rates when
hormones are switched off for 3-6 months before IVF cycle
(Ultra long down-regulation cycle)
.
Tailoring IVF treatments for endometriosis

20. • May need to be considered if recurrent IVF failure,
low egg supply, poor quality eggs, advanced female
age etc
• When eggs from a healthy donor are used live birth
rates rates in recipients with endometriosis = live birth
rates in control recipients
This shows endometriosis does NOT affect the
ability to carry a pregnancy
IVF with donor eggs (oocytes)

21. • Couples with endometriosis as a fertility factor
will often have other contributing factors/issues
• Pain and other symptoms need to be considered
• The couples preference, including time frames,
desire to avoid surgery or IVF are paramount
• Individualisation of treatments to suit each
couple will lead to best outcomes
Importance of individualizing fertility treatment

22. Consulting Clinic
345 Carrington Street
Adelaide SA 5000
Phone 8100 2900
e info@fertilitysa.com.au
w www.fertilitysa.com.au