4. Prevalence of Endometriosis
176 million women with endometriosis
during the prime years of their lives…
1 in 10 women suffer from endometriosis
Rogers et al, Reprod Sci 2009;16:335-346
World Bank, Population Projection Tables by Country and Group, 2010
Most of whom have not been diagnosed &
Adamson et al. J of Endometriosis 2010;2:3-6
5. Prevalence of endometriosis in India
“5% girls below 18 who complained of dysmenorrhea
are affected by endometriosis”
Endometriosis Society, India
at least 26 million Indian women between the ages of
18 and 35 were afflicted by endometriosis
Dr P Das Mahapatra
Endometriosis Society of India
7. Getting to know the woman
Nnoaham et al, J of Endometriosis
Not a life-style disease
8. Endometriosis is a challenging disease and
requires decision making at every stage by
the clinician & the patient
9. Endometriosis at ALL stages has a
negative impact on infertility
More severe is
the disease ,
lesser is the
10. Important Facts
• 25-50% of infertile
• 30-50% of women with
• Infertile women are 6-8
times more likely to
than fertile women
Endometriosis and Infertility
11. Guidelines to manage infertility in
patients of endometriosis
ESHRE Guidelines Jan 2014
Human Reproduction vol.0 pg 1-13 2014
14. “There is much , that is
still not understood
and the condition
continues to arise
Robert W. Shaw
““ He who knows endometriosisHe who knows endometriosis
knows Gynaecology ”knows Gynaecology ”
Sir William Osler
15. There is a BIG Tussle
between Laproscopists and IVF specialists about
management of infertility in patients of
16. Aim is to help Gynaecologists
make their own decision
18. Stage I (Minimal) Stage II (Mild)
Stage III (Moderate) Stage IV (Severe)
Classification of Endometriosis
19. Hormonal therapy and infertility
Suppression of ovarian function by means of
hormonal contraceptives , progestagens
GnRH analogues or danazol to improve
fertility in patients with minimal or mild
endometriosis is NOT effective and hence
should not be offered for this indication
Evidence does not comment on more severe disease
(Hughes et al., 2007). A
21. Infertile women with Stage I/II endometriosis
that clinicians should
and adhesiolysis )
rather than performing
only to increase
(Nowroozi , 1987; Jacobson , 2010).
22. Women with Stage III/IV Endometriosis
So far no RCT,s comparing the reproductive
outcome after surgery and after expectant
management is available but
2 cohort studies have shown
better pregnancy rate after surgery so
Clinicians can consider operative laparoscopy,
instead of expectant management,
to increase spontaneous pregnancy rate
(Nezhat et al., 1989; Vercellini et al.,2006). B
24. Effectiveness of Surgical techniques
Guidelines recommend that in infertile
patients with chocolate cyst clinicians
should perform excision of the
endometrioma capsule, instead of
drainage and electrocoagulation to
increase spontaneous pregnancy rates .
(Hart et al., 2008) A
25. why excision and not ablation ?
Cyst wall excision provids greater improvement
– Spontaneous pregnancy rates
– Dysmenorrhea and deep-dyspareunia
–Recurrence and repeat surgery
– Allows histo-pathological examination
Coagulation/ laser vaporization without excision is
associated with increase risk of cyst recurrence.
ASRM Practice Guidelines 2013
Possibility of occult malignancy to be kept in mind
27. Other techniques
• Clinicians may consider CO2 laser vaporization of
endometriosis, instead of monopolar
electrocoagulation, as laser vaporization is
associated with higher cumulative spontaneous
pregnancy rates .
• Unfortunately cost has been a big factor to prevent
widespread availability of co2 laser
(Chang et al., 1997).
28. Counselling ….. Two concerns
Ovarian Reserve Recurrence
Decision to proceed with surgery should
be considered very carefully ,especially if the
women has had previous ovarian surgery
In minimal or mild
does not enhance
fertility and hence
should not be offered
Offered in minimal
or mild and
moderate to severe
Medical treatment is not effective
Rather delays fertility restoration
31. • In infertile women with endometriosis, clinicians
should not prescribe adjunctive hormonal
treatment before or after surgery to improve
spontaneous pregnancy rates (Furness et al., 2004).
But clinicians should not withhold hormonal
treatment for pain in symptomatic women in the
waiting period before undergoing surgery or
medically assisted reproduction .
40. Issues to be considered
Endometriosis has decreased per cycle
conception rates in comparison with male
factor and unexplained infertility .
Recurrence rates of endometriosis does
not increase after COH for IVF - ICSI
Ultra long protocol and ICSI is Rx of
choice for endometriosis
41. If patient is for IVF ......
Is medical therapy effective as an
adjunct to ART for
42. Answer is ….
Clinicians can prescribe GnRH agonists for a
period of 3–6 months prior to ART to
improve clinical pregnancy rates in infertile
women with endometriosis.
Down regulation for 3-6 months with a GnRH
agonist (depot preparation) increases the odds of
clinical pregnancy by more than 4 fold.
(sallam et al.,2006 ) B
43. Should surgery be performed prior to
treatment with ART to improve
44. Does Surgery improves success ??
In women with Stage I / II endometriosis
undergoing laparoscopy prior to ART,
clinicians may consider the complete
surgical removal of endometriosis to
improve live birth rate, although the benefit
is not well established .
(Opoien et;al 2011) C
45. Laparascopy should
NOT be performed
prior to ART in all
women with the
only aim to
order to improve
the result of the ART
46. Remember ….
• Benefit of laparoscopy in minimal or mild
endometriosis is insufficient to recommend
laparoscopy solely to increase pregnancy
• Laparoscopy in infertile woman,
simply to confirm or rule out the disease is
ASRM COMMITTEE REPORT 2012
47. Surgical Rx
17 – 44 % of patients with endometriosis
develops ENDOMETRIOMA which affects
Female age, duration of infertility, stage of
disease, pelvic pain should be considered
while formulating a treatment plan.
48. Women with stage 3- 4 endometriosis
Women with chocolate cyst
larger than 3 cm there is NO evidence that
cystectomy prior to treatment with
ART improves pregnancy rates . ( A )
Consider cystectomy prior to ART
ONLY to improve
• endometriosis-associated pain or
• difficulty in oocyte retrival (GPP)
50. TO DRAIN OR NOT TO DRAIN
• Satistically reproductive outcome with or
without cyst aspiration is NOT different.
• If more than 4 cm , aspiration may be better
than surgery , (especially in recurrent cases)
Bigger & Recurrent cysts are
drained before stimulation
51. Deep infiltrating endometriosis
The effectiveness of surgical excision is NOT
well established with regard to reproductive
However, these women often suffer from
pain, requesting surgical treatment.
52. What to do in Recurrent
Hum reprod 2009
IVF – ICSI is a better option
53. experiences & strategy
• On laparoscopy , even
small deposits seen are
fulgurated & thus
managed aggressively .
• Generally , laparoscopy
is reserved for chocolate
cyst of more than 4 cm in
• Small chocolate cysts with
short period of infertility ,
COH & IUI is tried for 3- 4
cycles before taking up for
• For chocolate cysts
cystectomy is done , but
sometimes there may be
technical difficulties then
removal of the cyst lining
as much as possible is
done , along with
fulguration of the rest.
54. Tips from……
• Do a complete surgery.
• Do not cauterize excessively.
• Adhesions preventing barriers have
• Medical management: improves pain, not fertility
• Surgical management improves both pain and infertility
Success depends upon the residual
disease left behind
55. To conclude …….
• Medical Rx has no role in
• In minimal to mild disease,
ovulation induction and IUI is
first line therapy.
• Laparoscopic Sx with removal of
all endometriotic implants and
IVF –ICSI with long long protocol
is the treatment of choice for
moderate to severe disease.
58. He/ She who knows Endometriosis
Thank youThank you
11 Gagan Vihar, Near Karkari
Morh Flyover, Delhi - 51
Notes de l'éditeur
Global surveys reveal that one in 10 women during their reproductive years have endometriosis.
Do you realize that, this means there are 1,761,680,000 women worldwide between the ages of 15 and 49 are dealing with endometriosis!!!!
During the prime of their life, whether they are living, loving , forming relationships having children, building careers, they suffer from endometriosis and most of them have not been diagnosed or treated. The disease continue to progress and worsen to stages where even her fertility can be hampered….
Prevelance data shows a slightly higher incidence of endometriosis in Asian women as compared to African or caucasian ethinicity.
Survey on Indian women show that about 26 million women in the reproductive age group suffer from endometriosis. About 5% of the young girls who are less than 18 years of age and complain of painful menstruation actually suffer from endometriosis which if not diagnosed at that age can worsen with time.
A Global study conducted by World Endometriosis Research Foundation recruiting more than 1400 women found that 18% women are in age group of 10 and 19 when they first visit a doctor for pelvic pain. Infact 2/3 of the women were less than 30 years old when they first saw help for their symptoms again emphasizing that endometriosis affects women during their prime time of their life
The studies show that 50% of the women suffering from endometriosis had a profound impact on their relationships. They had dysmenorrhea, dysparenuria and a chronic pelvic pain which contributed to a negative effect on both the physical and mental components of quality of life. It affected their work and lifestyles.
Realistically speaking, this is not a life style disease. Changing a habit cannot get you rid of the disease or help you prevent the disease. You just have to manage with it.
Big Question 2
Dictim is to send the patient for ART earlier than late
Depot preparations increases fertility 6 fold
Hum reprod 2009
Success depends upon the residual disease left behind