This document summarizes guidelines on the optimal use of infertility diagnostic tests and treatments from 2000. It discusses the role of laparoscopy in fertility investigation and treatment. Key points include: - Laparoscopy is the gold standard for diagnosing tubal pathology, endometriosis, adhesions and other intra-abdominal causes of infertility. - Diagnostic laparoscopy alters treatment decisions in 25% of patients who would have otherwise been treated with IUI based on an HSG or semen analysis alone. - For mild-moderate endometriosis, laparoscopic surgery may improve pregnancy rates compared to diagnostic laparoscopy only, though further randomized trials are needed. - For

2. Optimal use of infertility diagnostic tests &
treatments
The ESHRE Capri Workshop Group
Guidelines for evaluation of infertility:
Year: 2000
Tests:
• Semen analysis
• Mid-Luteal - P
• Assessment of tubal patency
• LS should be reserved as a further diagnostic procedure
or in combination with endoscopic surgery
• Diagnostic laparoscopy recognized but questioned for
absolute necessity
Human Reprod Vol;15 No:3 pp.723-32,2000

3. Last Ten Years
What has changed in the last 10 years
with the usage of Laparoscopy for diagnostic
and therapeutic purposes?
Can we define to what extend we need
to perform Laparoscopy for fertility
investigation?

4. Infertility - Laparoscopy (L/S)
It is generally accepted that diagnostic-LS is gold
standard in diagnosing:

Tubal pathology,
 Endometriosis,
 Adnexial adhesions,
 Other intra-abdominal causes of infertility
Tanahatoe SJ, et al. Hum. Reprod (18) 1:8-11, 2003
Bosteels J.et al. Hum Reprod.Update, vol.13,No.5pp447-485,2007

5. Advantages and disadvantages of
diagnostic laparoscopy
ADVANTAGES
DISADVANTAGES
•See and treat
•Combine with HS
•Day care surgery
•Cost affectivity ?
•Need for GA
•Complications
•Adhesion formation
•Performance of procedures that
unnecessary or not proven to
benefit the patient

6. Is Laparoscopy outdated?
• When considering the relationship between
Laparoscopy and Infertility with the advantages
mentioned earlier, it is not possible to think that
Laparoscopy is entirely an outdated procedure.
• However nowadays it should be questioned to
what extent Laparascopy is effective for
Infertility investigation in the areas of diagnostic
and therapeutic purposes

7. Is Laparoscopy outdated?
• Understanding the position of Laparoscopy in
infertility investigation should be considered
within the scope of Evidence Based Medicine
datas.
• This assessment can explain the up-to-date
position of Laparoscopy.
• As a result, the effectiveness and the strength of
Laparoscopy will be investigated in different
topics and various parameters based on the
current evidence available for us.

8. Laparoscopy for infertility
•
Diagnostic laparoscopy in otherwise unexplained infertility
− Tubal patency
− Before or after IUI alter treatment decisions ?
− Laparoscopy after failed IVF
• Diagnostic&Therapeutic Fertility promoting laparoscopy in the
infertile couple
–
–
–
–
–
Endometriosis
Myom
Adhesion
PCOS
Hydrosalpinx

9. Tubal
pathology
Tubal patency

10. HSG: Assessing the validity
of the evidence
An ideal (or ‘‘gold standard’’) test for tubal disease
would correctly identify all women with tubal
disease.
Medline search: 2813 articles retrieved, 19
original articles and meta-analysis fit for the
clinical problem (tubal patency)
No RCT and no Prospective cohort studies
investigating the validity of HSG in diagnosis
of tubal patency have been published.
Evers JLH. et al. Seminars in Reprod. Med. 21 (1):9-15 2003
Swart P. Mol.BW et al. Fertil Steril 1995; 64:486-491

11. Interpretation of the findings
According 14 % normal prevalance of disease and
(HSG sensitivity: 0.65 Specificity:0.83)
Predictive value of tubal occlusion if HSG
abnormal is:
38 %
This means:
Tubal occlusion is not confirmed at LS
and Tubes are open in as many as
62 %
if HSG suggests patent tubes,
Tubal occlusion is highly unlikely : 6%

12. Comparison of HSG / LS as a predicting fertility
outcome
 HSG: Two-sided occluded
LS: Normal (42% of patients)
FRR*: Slightly impaired (FRR:0.70)
 HSG: Two-sided abnormal
LS: One or two –sided abnormal (23% of patients)
FRR: Fertility prospects is strongly impaired
FRR (0.38 and 0.19 respectively)
Mol BWL Hum Reprod (14) 5:1237-1242, 1999

13. Recommendations - RCOG
• Women who are not known to have comorbidities as:
Pelvic inflamatory disease
Previous ectopic pregnancy
Endometriosis
should be offered HSG …. strength of evidence: B
• Women thought to have co-morbidities should be
offered L/S so that tubal and other pelvic pathology can
be assessed at the same time ……… B
• Tubal pathology detected at L/S has stronger effect on
future fertility than HSG.
Clinical Guideline for the NHS by NICE February 2004 p:48 RCOG press

14. Conclusion
-Tubal Pathology-
The prognostic significance of LS and HSG for fertility outcome
• It is suggested that performing a diagnostic
LS after a two-sited occluded HSG is very
useful since it enables a division between
two groups with significantly different
fertility prospect.
• LS can be delayed after normal HSG for at
least 10 months because of the very low
probability of only 5% that bilateral tubal
occlusion may be found.

15. Does diagnostic laparoscopy before or
after IUI alter
treatment decisions ?
-assessement&management-

16. Does diagnostic laparoscopy alters
treatment decisions ?
Design: Retrospective
Patient(s): Who had undergone diagnostic L/S after a normal
HSG and before IUI (n:495)
Intervention(s): Diagnostic LS in infertility work up before IUI
Results: Altered treatment desicion was 124 (25%) after LS
21 (4% ) had severe abnormalities that resulted in a change
to IVF 8 (1.6%) and laparotomy 13(2.6%)
103 (21%) abnormalities, endometriosis stage I/II adhesions
were directly treated by LS
Conclusion(s): This study shows that:
Diagnostic-L/S alters treatment decision in 25% of patients
who would have been treated with IUI if this test had not
been performed.
Tanahatoe SJ. Et. al. Fertil Steril 2003;79:361-6

17. Does diagnostic laparoscopy alters
treatment decicions ?
Discussion:
 Delaying L/S might probably lead to inappropriate treatment of IUI which
is expensive and stressful to patients.
 Omiting L/S would probably lead to lower pregnancy rates, longer times
to achieve pregnancy and more patients receiving IVF which is expensive.
 IVF cycle is around 3.5 times higher than for stimulated cycles of IUI and
5 times higher than a spontaneous IUI cycle
 Given the low sensitivity of HSG, IVF may be chosen as an option for some
cases, leading to high rates of over treatmen
 Diagnostic L/S may be of considerable value, provided the change of
treatment decision effective. it is impossible to determine a possible
beneficial effect of LS –surgery on the cycle pregnancy rate or on the
Crude-PR. At least 1000 patients should have been included to show
difference of 10% in the cumulative ongoing-Pregnancy. Of course, this
finding(s) justify further prospective studies to ascertain the role (if any).
CONCLUSİON

18. •ENDOMETRİOSİS

19. •ENDOMETRİOSİS
• Stage I-II
• Mild-Moderate Endometriosis and
Infertility

20. Two randomised studies (Marcoux
1997; Gruppo Italiano 1999)
Two randomised studies directly addressed the
question of whether laparoscopic surgery
improved outcomes in patients with otherwise
unexplained infertility.

21. Meta-analysis also demonstrated an advantage of laparoscopic surgery when compared to
diagnostic laparoscopy only in terms of clinical pregnancy rates with an OR of 1.66 (95%Cl
1.09to 2.51) (437 participants, two trials, analysis) favouring laparoscopic surgery
BUT,There are very few trials in this area and further trials are crucial.

22. Mild-Moderate Endometriosis and
Infertility
• The experimental event rate is 26% versus a
control event rate of 18%.
• The absolute benefit increase of 8% translates
into a number needed to treat (NNT) of 12
laparoscopies should be performed to obtain one
additional pregnancy compared with treatment
abstention)
• This estimate should be doubled or tripled
considering that preoperative identification of
subjects with stage I–II disease is unfeasible, and
that only one-third to one-half of the women
undergoing laparoscopy for unexplained
infertility actually have the condition.

23. International Guidelines

24. CONCLUSİON
FURTHER TRİALS
Further trials should carefully address the
methods of randomisation and blinding
The interpretation of the outcomes of any
trial of this nature depends on these factors
and they are crucial.

25. ENDOMETRİOSİS
stage III-IV

26. Surgery for ovarian disease
(ASRM stage III-IV)
• (ESHRE) guidelines for the diagnosis and
treatment of endometriosis (Kennedy et al.,
2005), it has been pointed out that
• ‘No RCT or meta-analysis are available to
answer the question whether surgical
excision of moderate–severe endometriosis
enhances pregnancy rates’.

27. International Guidelines

28. CONCLUSİON
FURTHER TRİALS
Further trials should carefully address the
methods of randomisation and blinding
The interpretation of the outcomes of any
trial of this nature depends on these factors
and they are crucial.

29. ENDOMETRİOSİS
Endometriotic cystsENDOMETRİOMA

30. Pregnancy rates observed after laparoscopic excision of endometriomas.
Very different outcomes have been reported in uncontrolled studies evaluating the impact of
laparoscopic treatment of ovarian endometriotic cysts on post-operative reproductive
performance.
Pregnancy rates vary from 30% (Marrs, 1991) to 67% (Beretta et al., 1998), with an overall weighted
mean of about 50%. This is most likely an overestimate due to multiple confounding factors,
including selection bias (inclusion of women who did not try to conceive preoperatively and that are
not necessarily infertile) Few authors indicate how many patients achieved a pregnancy postoperatively by means of IVF. In these cases it is questionable to attribute success exclusively to
laparoscopy.
Vercellini P et al. Hum. Reprod. 2009;24:254-269

31. Endometrioma: Excision vs Ablation
Spontaneous conception
Overview of RCTs comparing vaporization/coagulation with excision of ovarian endometriotic
cysts.
NNT= 2.7
2006
Vercellini P et al. Hum. Reprod. 2009;24:254-269
© The Author 2008. Published by Oxford University Press on behalf of the European Society of
Human Reproduction and Embryology. All rights reserved. For Permissions, please email:
journals.permissions@ oxf ordj our nals .org
Accordingly, the potential absolute benefit increase over background pregnancy rate
12 months after surgery in women with patent tubes could be hypothetically estimated to not greater than 25%.
Based on this estimate, the NNT would be 4. Vercellini et al. Hum Reprood Advance Access October 23,2008

32. International Guidelines

33. Conclusion
Ablation of endometriotic lesions plus adhesiolysis to improve fertility in minimal-mild endometriosis is
effective compared to diagnostic LS alone……A
Women with moderate or severe endometriosis should be offered surgical treatment because it improves
the chance of pregnancy……………………………….B
A Directly based on level 1 evidence
B Directly based on level 2 evidence or extrapolated recommendation from
level 1 evidence
Conservative surgery may be indicated in women with infertility and endometriotic ovarian cysts (stage
III/IV) also because of the need for histological examination to rule out early ovarian cancer.
RCTs are badly needed to clarify whether and how much, surgery for endometriomas improves the
reproductive prognosis of infertile women.

34. ENDOMETRIOSIS
Recurrent Endometriosis

35. • After repeat conservative surgery for
infertility, the pregnancy rate is almost half
the rate obtained after primary surgery.
• More data are needed to define the best
therapeutic option in women with recurrent
endometriosis, in terms of pain relief,
pregnancy rate and patient compliance.

36. International Guidelines
After repeat conservative surgery for infertility, the pregnancy rate is almost half
the rate obtained after primary surgery.

37. Conclusion
More data are needed to define the best
therapeutic option in women with
recurrent endometriosis,
in terms of pain relief, pregnancy rate and
patient compliance.

38. MYOMECTOMY
Intramural (IM):
Subserosal (SS):

39. Effect of intramural, subserosal, and submucosal fibroids on
the outcome of assisted reproductive technology treatment
Eldar-Geva Tet al. Fertil Steril. 1998 Oct;70(4):687-91

40. Effect of myomectomy on fertility:
-intramural fibroids-
.
Pritts EA, Parker WH, Olive DL Fibroids and infertility: An updated systematic review of the evidence. Fertil Steril. 2009 Apr;91(4):121523.

41. There are several excellent reasons for avoiding myomectomy
in the infertile woman with IM myomas.

Abdominal or laparoscopic myomectomy can be associated with
significant morbidity,
including infection,
damage to internal organs,
risk of blood or blood product transfusions.
Also of concern for the infertile woman is the
high rate of postoperative adhesion formation, especially with myomectomies
performed through posterior uterine incisions

Add to these the risks of uterine rupture during pregnancy and
increased likelihood of cesarean section, and there are many reasons to be
wary of myomectomy when the indications are unclear.

Pritts EA, Parker WH, Olive DL Fibroids and infertility: An updated systematic review of the evidence. Fertil Steril. 2009 Apr;91(4):1215-23.

43. The only randomised controlled study that met with the Cochrane
inclusion criteria was probably underpowered to look at fertility outcomes.

44. Implications for practice
It is not identified any randomized controlled trial evidence to
suggest that myomectomy improves fertility efficacy as indicated
by clinical pregnancy rate or live birth rate, although there are
many retrospective observational studies that suggest this.
There was no evidence identified to suggest there is a difference in the
clinical pregnancy rate or live birth rate between the different
surgical modalities available to remove fibroids.
There were some non fertility benefits of removal via laparoscopy including
shorter hospital stay, less febrile illness and asmaller drop in preoperative haemoglobin concentration when compared to laparotomy.

45. Conclusions
Infertility increasing effect of Laparoscopic
Myomectomy when compared with the
Laparotomic Myomectomy is not proven.
There were some non fertility benefits of
removal via laparoscopy including shorter
hospital stay, less febrile illness and asmaller
drop in pre-operative haemoglobin
concentration when compared to
laparotomy.

46. ADHESIONS

47. Recommendations - RCOG
• Women who are not known to have
co-morbidities as:
• Pelvic inflamatory disease
• Previous ectopic pregnancy
• Endometriosis
should be offered HSG strength of evidence:
B
• Women thought to have co-morbidities
should be offered L/S so that tubal and other
pelvic pathology can be assessed at the same time
B
• Tubal pathology detected at L/S has stronger effect
on future fertility than HSG.
RCOG - Clinical Guideline February 2004 p:48

48. Adhesions
Case-controlled studies usually claim that adhesiolysis
increases the pregnancy rate in a certain period of time.
However, randomized controlled trials have shown
that laparoscopic adhesiolysis following pelvic
reproductivesurgery does not have a significant impact
on the odds ratio of pregnancy, live birth, ectopic
pregnancy and miscarriage.
Thus adhesiolysis does not seem to be a primary option
in the treatment of an infertile couple.
Tulandi T, Collins JA, Burrows E, et al. Am .J .Obstet Gynecol 1990; 162:354–357.

49. Implications for practice
There is insufficient evidence to support the routine practice of postoperative
hydrotubation or second-look laparoscopy with adhesiolysis following female pelvic
reproductive surgery.
Although no previous studies have shown the beneficial effects of adhesiolysis prior to
IVF, laparoscopic adhesiolysis may have a role in assuring initial access to the ovaries
during oocyte recovery and in improving subsequent attempts.
To summarize, there is no evidence to show that
surgical treatment of adhesions by laparoscopic interventionprior to ART is beneficial.
Unfortunately there are no randomized controlled trials examining the outcomes of ART cycles in
women who have had previous adhesiolysis compared with those who have not.
Periovarian adhesions may constrict the ovarian blood
Postoperative procedures for improving fertility following pelvic reproductive surgery Editorial Group: Cochrane Menstrual Disorders and Subfertility Group
1APR 2009
Published Online:

50. Implications for practice
Does adhesiolysis increase the success rate in ART
cycles?
Does adhesiolysis have any beneficial effect on
ectopic pregnancy in ART cycles?
?
Unfortunately there are no randomized controlled trials examining the outcomes of ART cycles in
women who have had previous adhesiolysis compared with those who have not.
•Unfortunately there is no truly randomised studies examining second-look LS with adhesiolysis
following pelvic reconstructive surgery.
Periovarian adhesions may constrict the ovarian blood
There is insufficient evidence to support the routine practice of post operative sec-look LS with
adhesiolysis or hydrotubation for improving fertility
Duffy JMN et al The Cochrane Library 2009,Issue 2

51. Conclusion-II
Adhesions/ Adhesiolysis
• Direct LS Observation is the most reliable method in
diagnosis of adhesions.
• However, in the infertility assessment LS is not a routine
clinical practice to be the primary choice for the diagnosis
of adhesions.
• In this topic alternative diagnostic methods for
tuboperitoneal infertility&adhesions ,should based on
Medical history, Chlamydia screening, HSG
• There is insufficient evidence to support the routine
practice of post operative sec-look LS with adhesiolysis
for improving fertility
• Ablation of endometriotic lesions plus adhesiolysis to
improve fertility in minimal-mild endometriosis is
effective compared to diagnostic LS alone……A

52. Endoscopic Surgery and
Tubal Infertility
Hydrosalpinx

53. What is the place of endoscopic surgery
Hydrosalpinx
•
•
•
before IVF cycles
The presence of hydrosalpinx is associated with early pregnancy loss and
poor implantation and pregnancy rates, probably due to alteration in
endometrial receptivity……….Evidence level 2b
A systematic review of three RCTs showed that tubal surgery such as
laparoscopic salpingectomy significantly increased live birth rate (OR 2.13;
95% CI 1.24 to 3.65) and pregnancy rate (OR 1.75; 95% CI 1.07 to 2.86) in
women with hydrosalpinges before IVF when compared with no treatment.
………..Evidence level 1a
Women with hydrosalpinges should be offered salpingectomy, preferably by
laparoscopy, before in vitro fertilisation treatment because this improves the
chance of a live birth ………..A
Bosteels J. Et al. Human reprod Update, Vol.13,No.5 pp477-85,2007 , Johnson NP et al Cochrane database issue:3,2000 , Strandel A
Human Reprod Update 2000;6:387-95

54. Authors’ conclusions
Laparoscopic salpingectomy should be considered for all women with
hydrosalpinges prior to IVF treatment.
Currently unilateralsalpingectomy for a unilateral hydrosalpinx
(bilateral salpingectomy for bilateral hydrosalpinges) should be
recommended, although this requires further evaluation.
Further randomised trials are required to assess other surgical
treatments for hydrosalpinx, such as salpingostomy, tubal occlusion
or needle drainage of a hydrosalpinx at oocyte retrieval.
The role of surgery for tubal disease in the absence of a hydrosalpinx
is unclear and merits further evaluation.
Removing blocked or diseased fallopian tubes before in vitro
fertilisation (IVF) can increase pregnancy rates for women on the
IVF program

55. Authors’ conclusions
Before commencing an ART cycle
•If the patient has bilateral visible
hydrosalpinges on hysterosalpingography or
ultrasonography, a previous ectopicpregnancy,
and endometrial fluid collection during
previous COH, a laparoscopy should be
performed in order to consider salpingectomy.

56. Polycystic ovary syndrome - LOD

57. Polycystic ovary syndrome
LOD
There was no evidence of a difference in the live birth
rate and miscarriage rate in women with clomipheneresistant PCOS undergoing LOD compared to
gonadotrophin treatment.
The reduction in multiple pregnancy rates in women
undergoing LOD makes this option
attractive.
However, there are ongoing concerns about long-term
effects of LOD on ovarian function.

58. Polycystic ovary syndrome
LOD
LOD cannot be recommended as a first line treatment for women with
PCOS undergoing IVF-ET.
This treatment should be reserved for women who have previously
had at least one treatment cycle abandoned for risk of OHSS,
and then after a thorough discussion of the procedure
with the patient.chance of pregnancy following ART cycles.
However,few clinical situations fit these criteria.
Current evidence advocates laparoscopy and salpingectomy for visible
hydrosalpinx before starting ART cycles.
In addition,laparoscopy may be used to replace transposed ovaries.
Finally, it could be considered performing LOD for PCOS
patients who repeatedly suffer from severe OHSS.

59. Conclusions
LOD cannot be recommended as a first line
treatment for women with PCOS undergoing IVFET.
It could be considered performing LOD for PCOS
patients who repeatedly suffer from severe OHSS.

60. The role of Laparoscopic
Treatment of
Endometriosis
in patients who have Failed
In Vitro Fertilization

61. Laparoscopy in Patients with
Failed IVF
+ Laparoscopy
No laparoscopy
29
35
34.75
35
NS
2.25
2.4
NS
Pregnancy rate
22/29
13/35
<.01
Spontaneous pregnancy
rate
13/29
2/35
<.01
Number of patients (n)
Average Age
Average no. of failed IVF
cycles
Fertility and Sterility Volume 84, Issue 6 , December 2005, Pages 1587-1588
p-value

62. Conception rates
25
22
20
15
13
11
10
7
7
Spontaneous
OI/IUI
IVF
No conception
5
2
0
Study group
2
0
Control group
Eva Litman, MD,Amin Milki, MD,Linda Giudice, MD,Lynn Westphal, MD,Ruth Lathi,MD,Bulent Berker,
MD,Camran Nezhat, MD.Fertility and Sterility Volume 84, Issue 6 , December 2005, Pages 1587-1588

63. Conception rates by endometriosis stage
Stage
n total
n conceived
Conception %
I
4
4
100
II
6
5
83
III
6
5
83
IV
13
8
62
Eva Litman, MD,Amin Milki, MD,Linda Giudice, MD,Lynn Westphal, MD,Ruth Lathi,MD,Bulent Berker,
MD,Camran Nezhat, MD.Fertility and Sterility Volume 84, Issue 6 , December 2005, Pages 1587-1588

64. LS after failed IVF
Eva Litman, MD,Amin Milki, MD,Linda Giudice, MD,Lynn Westphal, MD,Ruth Lathi,MD,Bulent Berker, MD,Camran Nezhat, MD.Fertility and
Sterility Volume 84, Issue 6 , December 2005, Pages 1587-1588

65. Infertility - Laparoscopy (L/S)
It is generally accepted that diagnostic-LS is gold
standard in diagnosing:




Tubal pathology
Other intra-abdominal causes of infertility:
Endometriosis,
Adnexial adhesions
Tanahatoe SJ, et al. Hum. Reprod (18) 1:8-11, 2003
Bosteels J.et al. Hum Reprod.Update, vol.13,No.5pp447-485,2007

66. Findings at diagnostic laparoscopy in
women with otherwise unexplained
infertility
Finding
Endometriosis
Adhesions
Tubal occlusion
Treatment related
to improvement of
fertility
Unknown
Unknown
Yes/No
Alters
management
Yes/No
Yes/No
Yes

67. Conclusions
Diagnostic laparoscopy is not an integral part of infertility evaluation
The place of diagnostic laparoscopy prior to and after failed IUI/IVF is not clear
The benefit of therapeutic laparoscopy for endometriosis is not established
The benefit of therapeutic laparoscopy for IM myomas is not established
The removal of the SM myomas enhance the rates of conception and live births.
SS fibroids do not affect fertility or spontaneous abortion.
Myomas that distort the uterine cavity adversely affect fertility both spontaneous and during
IVF treatment.
Therapeutic laparoscopy is indicated for removal of hydrosalpinges
The benefit of therapeutic laparoscopy for adhesion is not well established.
ART & LS are not mutually exclusive, but coexisting & complimentary tretment.

71. Removal of endometriomas before in vitro
fertilization does not improve fertility
outcomes: a matched, case-control study
Juan A. Garcia-Velasco, M.D., Neal G. Mahutte, M.D.,
José Corona, M.D., Victor Zúñiga, M.D., Juan Gilés,
M.D., Aydin Arici, M.D., and Antonio Pellicer, M.D.
Fertility and Sterility, vol. 81, no. 5, May 2004

72. Conclusion
Management
Mild- MinimalEndometriosis
Whether or not minimal and mild Endometriosis
should be treated in case of infertility still remains
aseemingly never –ending discussion
There still is a need for further RCT in order to solve
this issue but it may be hard to convince ethical
committees and even harder to recruit pat,ente ,in
view of the current level of evidence.
ESHRE Guideline.Hum Reprod. Vol.20,No.10 pp .2698-2704,2005
Bosteels J. Et al. Human reprod Update, Vol.13,No.5 pp477-85,2007

73. Conclusion
Mild- MinimalEndometriosis
• Ablation of endometriotic lesions plus
adhesiolysis to improve fertility in minimalmild endometriosis is effective compared
with diagnostic LS-alone….A
……..Evidence Level 1a
Clinical guidelinefor the NHS by NICE,RCOG Press,2004
ESHRE Guideline.Hum Reprod. Vol.20,No.10 pp .2698-2704,2005
RCOG Guideline.No.24,2006

74. Conclusion
Mild- MinimalEndometriosis
• When LS is performed,the surgeon should consider safetly
ablating or excising visible lesions of endometriosis
• In women with stage I/II endometriosis-associated
infertility, expectant management or superovulation/IUI
after LS can be considered for younger patients.
• Women ≥ 35 should be treated with superovulation/IUI or
IVF-ET.
• In women with stage III/IV endometriosis-associated
infertility, conservative therapy with LS and possible LT
are indicated.
ASRM Fertil Steril 2004;81(5):1441-6

75. Conclusion
-Managementmoderate-severe Endometriosis
• No RCT or meta-analyses are avaible to
answer the question.Based upon three
studies there seems to be a negative
correlation between the stage of
Endometriosis and the spt –CPR after
surgical removal of Endom. But statistical
significance was only reached in one study
Adamson GD et al.Fertil Steril.1993;59:35-44 ,Guzick DS et al.Fertil Steril.1997;67:822-9
Osuga Y et al. Gynecol Obstet Invest.2002;53(Suppl 1):33-9 ,RCOG Guideline.No.24,2006

76. Conclusion
-Managementmoderate-severe Endometriosis
• Does surgery for moderate- severe disease
improve pregnancy rates ?
• The role of surgery in improving pregnancy rates
for moderate-severe disease is uncertain……..B
………Evidence Level 3
• Postoperative medical treatment does not
improve pregnancy rates in women with
moderate to severe endometriosis and is not
recommended….A
Clinical guidelinefor the NHS by NICE,RCOG Press,2004 ,ESHRE Guideline.Hum Reprod . Vol.20,No.10 pp .
2698-2704,2005 ,RCOG Guideline.No.24,2006

77. Conclusion
-ManagementEndometrioma
• LS-cystectomy for ovarian endometriomas> 4 cm
diameter improves fertility compared to drainage and
coagulation ……A ……..Evidence Level 1b
• Coagulation or Laser vaporization of Endometriomas
without excision of the pseudo- capsula is associated
with a significantly increased risk of cyst recurrence……A
……..Evidence Level 1b
• Subsequent spontaneus pregnancy rates in women who
were previously sub fertile are also improved with this
treatment……A ……..Evidence Level 1a
Hart RJ. et al,Cochrane database 2005, issue 3 ,RCOG Guideline.No.24,2006

78. Conclusions
The benefit of therapeutic laparoscopy for
endometriosis is not established
Surgery recommedation&Minimal/mild
Endometriosis:
ESHRE-2005: Limited benefit
ASRM-2006: Small benefit
RCOG-2006:Demonstrated benefit

79. Conclusions
• A number needed to treat (NNT) of 12 laparoscopies should be
performed to obtain one additional pregnancy compared with
treatment abstention)
• This estimate should be doubled or tripled considering that
preoperative identification of subjects with stage I–II disease is
unfeasible
• Endometriosis prevalance .30-50%
• NNT:12X2-12X3 =24-36 (30)
• Diagnostic laparoscopy is not an integral part of infertility
evaluation
• Women with minimal or mild endometriosis who undergo
laparoscopy should be offered surgical ablation or resection of
endometriosis plus laparoscopic adhesiolysis because this
improves the chance of pregnancy………………………. A

80. Infertility treatment: the viability of
the Laparoscopic view
• ART & LS are not mutually exclusive, but
coexisting & complimentary tretment.
• For disease conditions contrubuting to
infertility in addition to other concomitant
or potantial morbidity ,LS represent a
more comprehensive approach.
Fertil Steril 2008 ;89:461-4 by ASRM

81. Recommendation:
• If minimal or mild endometriosis is
diagnosed by L/S, surgical treatment is
recommended but if pregnancy does not
occur, patients should be treated in the
same way as couples with unexplained
infertility.
Sutter DP Best practice and research Clin. Obstet Gynecol 2006:1-18

82. • no RCT or meta-analysis are available to
answer the question whether surgical
excision of moderate–severe endometriosis
enhances pregnancy rates’.

83. – 22 out of 29 patient (76%) achieved
pregnancy
– 15 of the 29 patients conceived without
further IVF therapy
– >60% of patients with Stage IV
endometriosis, conceived, spontaneously or
with additional IVF
Eva Litman, MD,Amin Milki, MD,Linda Giudice, MD,Lynn Westphal, MD,Ruth Lathi,MD,Bulent
Berker, MD,Camran Nezhat, MD.Fertility and Sterility Volume 84, Issue 6 , December 2005,
Pages 1587-1588