This blog post is based on points taken from a TOG article which was published in January 2024. This article delves into the pathology, diagnostic approaches, and management strategies for endometriosis-associated subfertility.
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Introduction
- Prevalence of endometriosis in UK ~10% in reproductive age
- With subfertility 25-50%
- Clinical presentation pelvic pain, subfertility & bowel dysfunction or incidental (during fertility investigations)
- Challenging to manage in context of subfertility as mainstays of management are often long-term hormonal treatments
Pathology of endometriosis-associated infertility
- Endometriosis defined as endometrial tissue, ectopic glands & stroma outside uterus, mostly within pelvis
Anatomical distortion
- Up to 30% women with endometriosis have tubal pathology. Tubal damage may impair egg capture & transport
- Degree of endometriosis corresponds to decline in conception rates. Lower fertility rates even with mild disease
Endometrioma
- Found in 17-44% 1/3 have bilateral cysts
- Detrimental to ovarian function. Can be a significant cause of dyspareunia
- Recurrence — 30% in 2-5 yrs after surgery 80% in treated ovary, 8% in both & 11% in contralateral ovary
- Endometrioma presence is the marker of more severe disease
- 50% with deep endometriosis (DE) have endometrioma
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Ref: TOG
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Investigating endometriosis-related subfertility
- Must have a holistic diagnostic workup for subfertility
- Baseline Ultrasound (USS), Ovarian reserve assessment (AMH & AFC), Ovulatory disorders, Tubal patency & Semen analysis
- ESHRE guideline
- Laparoscopy no longer the gold standard for diagnosis of endometriosis
- Laparoscopy to be only done if negative imaging ± failed or inappropriate empirical t/m
- Imaging to be done — MRI & USS as first-line for deep endometriosis. Choose an imaging depends on clinical skills & equipment availability
Staging and scoring endometriosis
revised American Society of Reproductive Medicine (rARSM)
- Originally designed to classify disease extent & relationship with pregnancy rate
- Most common & easy to use. Does not correlate with pain or subfertility
ENZIAN scoring system
- Descriptive surgical scoring system Applied to peri-operative imaging assessment
- Proven clue in per-operative prediction of laparoscopic operating time
- There is no or very little correlation with patient symptoms & infertility
Endometriosis fertility index (EFI)
- Specific for women where fertility is priority
- 10-point scoring with 5 categories of risk
- Developed to predict pregnancy rates in women with surgically assessed endometriosis attempting non-IVF conception
- High inter-user reproducibility & good at predicting non-IVF pregnancy rates post-surgery & also pregnancy after ART
- EFI can help in shared decision-making about whether to perform surgery
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| Ref: TOG |
Management of endometriosis-related subfertility
- Challenging to balance adequate management of symptoms & desire for fertility
- MDT approach — gynaecologist, colorectal surgeon, urologist, specialist nurses & fertility specialist
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| Ref: TOG |
Assisted conception in the context of endometriosis
- Assisted conception offered as first-line t/m as best chance to achieve parenthood
Effect of endometriosis on ART
- minimal/mild no impact on clinical pregnancy or live birth rates
- moderate/severe significantly lowers number of eggs collected & reduces live birth rate by ~1/4
- Reduced number of retrieved oocytes but no effect on clinical pregnancy & live birth rates
Surgical treatment of endometriosis prior to ART
- Surgical t/m of endometrioma prior to ART — does not improve live birth rate
- Cystectomy
- associated with poorer response to stimulation & greater risk of cycle cancellation as compared to no surgery
- reduces the risk of recurrence
- Sclerotherapy vs Cystectomy — more oocytes collected & improved live birth rates with sclerotherapy
- Routine removal of endometrioma prior to ART not recommended but considered if pain or to allow access to follicles at egg collection and in DE
Risks of ART in women with endometriosis
- IVF does not increase endometriosis-related pain, nor does IVF increase the risk of recurrence
- Ovarian stimulation has minimal impact of endometrioma size
- Risk of pelvic infection with an endometrioma undergoing egg collection <1% Use antibiotics (good practice)
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