Ls,infertility 2007

Optimal use of infertility diagnostic tests & treatmentsThe 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

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?

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, 2003Bosteels J.et al. Hum Reprod.Update, vol.13,No.5pp447-485,2007

ADVANTAGES

•See and treat•Combine with HS•Day care surgery

DISADVANTAGES

•Cost affectivity ?•Need for GA•Complications•Adhesion formation•Performance of procedures that unnecessary or not proven to benefit the patient

Advantages and disadvantages of diagnostic laparoscopy

Is Laparoscopy outdated?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and Infertility with the advantages mentioned earlier, it is not possible to think that Laparoscopy is entirely an outdated procedure.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

Is Laparoscopy outdated?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.

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

Tubal pathology

Tubal patency

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

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%

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

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.

Clinical Guideline for the NHS by NICE February 2004 p:48 RCOG press

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.

Does diagnostic laparoscopy before or after IUI alter

treatment decisions ?

-assessement&management-

Does diagnostic laparoscopy alters treatment decisions ?

Design: RetrospectivePatient(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 IUIResults: 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

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

At this point further , RCT are needed to define the role of endoscopic surgery for assessement &management in IUI.

•ENDOMETRİOSİS

•ENDOMETRİOSİS• Stage I-II

• Mild-Moderate Endometriosis and Infertility

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.

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 surgeryBUT,There are very few trials in this area and further trials are crucial.

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.

International Guidelines

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.

ENDOMETRİOSİSstage III-IV

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’.


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.

ENDOMETRİOSİS

Endometriotic cysts- ENDOMETRİOMA

Pregnancy rates observed after laparoscopic excision of endometriomas.

Vercellini P et al. Hum. Reprod. 2009;24:254-269

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 post-operatively by means of IVF. In these cases it is questionable to attribute success exclusively to laparoscopy.

2006

Endometrioma: Excision vs AblationSpontaneous conception

NNT= 2.7

Overview of RCTs comparing vaporization/coagulation with excision of ovarian endometriotic cysts.

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@oxfordj 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


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.

ENDOMETRIOSIS

Recurrent Endometriosis

• 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.


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

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.

MYOMECTOMY

Intramural (IM):

Subserosal (SS):

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

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):1215-

23.

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.

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

Implications for practice

It is not identified any randomized controlled trial evidence tosuggest that myomectomy improves fertility efficacy as indicatedby clinical pregnancy rate or live birth rate, although there aremany 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 pre-operative haemoglobin concentration when compared to laparotomy.

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.

ADHESIONS

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

AdhesionsCase-controlled studies usually claim that adhesiolysisincreases the pregnancy rate in a certain period of time.

However, randomized controlled trials have shownthat 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.

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 thatsurgical 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 Published Online: 1APR 2009

Implications for practiceDoes adhesiolysis increase the success rate in ARTcycles? Does adhesiolysis have any beneficial effect onectopic 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

?

Conclusion-IIAdhesions/ 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

Endoscopic Surgery and Tubal Infertility

Hydrosalpinx

What is the place of endoscopic surgery before IVF cyclesHydrosalpinx

• 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

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 theIVF program

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.

Polycystic ovary syndrome - LOD

Polycystic ovary syndromeLOD

There was no evidence of a difference in the live birth rate and miscarriage rate in women with clomiphene-resistant PCOS undergoing LOD compared to gonadotrophin treatment.

The reduction in multiple pregnancy rates in women undergoing LOD makes this optionattractive.

However, there are ongoing concerns about long-term effects of LOD on ovarian function.

Polycystic ovary syndromeLOD

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 procedurewith the patient.chance of pregnancy following ART cycles.However,few clinical situations fit these criteria.

Current evidence advocates laparoscopy and salpingectomy for visiblehydrosalpinx before starting ART cycles.In addition,laparoscopy may be used to replace transposed ovaries.

Finally, it could be considered performing LOD for PCOSpatients who repeatedly suffer from severe OHSS.

Conclusions

LOD cannot be recommended as a first line treatment for women with PCOS undergoing IVF-ET.

It could be considered performing LOD for PCOSpatients who repeatedly suffer from severe OHSS.

The role of Laparoscopic Treatment of Endometriosis

in patients who have Failed In Vitro Fertilization

+ Laparoscopy No laparoscopy p-value

Number of patients (n) 29 35

Average Age 34.75 35 NS

Average no. of failed IVF cycles

2.25 2.4 NS

Pregnancy rate 22/29 13/35 <.01

Spontaneous pregnancy rate

13/29 2/35 <.01

Fertility and Sterility Volume 84, Issue 6 , December 2005, Pages 1587-1588

Laparoscopy in Patients with Failed IVF

13

2

7 7

20

11

22

0

5

10

15

20

25

Study group Control group

Spontaneous

OI/IUI

IVF

No conception

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

Conception rates

Stage n total n conceived Conception %

I 4 4 100

II 6 5 83

III 6 5 83

IV 13 8 62


Conception rates by endometriosis stage

LS after failed IVF


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, 2003Bosteels J.et al. Hum Reprod.Update, vol.13,No.5pp447-485,2007

Findings at diagnostic laparoscopy in women with otherwise unexplained

infertilityFinding Treatment related Alters to improvement of management fertilityEndometriosis Unknown Yes/NoAdhesions Unknown Yes/NoTubal occlusion Yes/No Yes

ConclusionsDiagnostic 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 establishedThe 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.

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

ConclusionManagement

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

ConclusionMild- MinimalEndometriosis

• Ablation of endometriotic lesions plus adhesiolysis to improve fertility in minimal-mild 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 .2698-2704,2005RCOG Guideline.No.24,2006

ConclusionMild- 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

Conclusion-Management-

moderate-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

Conclusion-Management-

moderate-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

Conclusion-Management-Endometrioma

• 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

Conclusions

The benefit of therapeutic laparoscopy for endometriosis is not established

Surgery recommedation&Minimal/mild Endometriosis:

ESHRE-2005: Limited benefitASRM-2006: Small benefitRCOG-2006:Demonstrated benefit

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

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

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

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

– 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


Health & Medicine

Ls,infertility 2007