PPT Role of adjuvant therapy in infertility treatment for endometriosis patients ACE BALI 2024 (1).pptx

role of adjuvant therapy

1. Role of Adjuvant therapy in Infertility Treatment for Endometriosis patients BINARWAN HALIM (INDONESIA)

2. Outline : Surgical Treatment Medical Treatment Conclusion

3. Adjuvant therapy SURGICAL MEDICAL

4. Role of Surgical in Infertility Treatment for Endometriosis patients In infertile women with stage I/II endometriosis , operative laparoscopy to excise or ablate endometriosis lesions and adhesiolysis , rather than performing diagnostic laparoscopy only, is advised to increase ongoing pregnancy rates (Jacobson et al. 2010, Nowroozi et al. 1987) . In infertile women with ovarian endometrioma undergoing surgery, excision of the endometrioma capsule is preferred to drainage and electrocoagulation of the endometrioma wall to increase spontaneous pregnancy rates (Hart et al. 2008 ) . Complete surgical removal of minimal to mild disease prior to the start of ART has been shown to improve reproductive outcome ( Opoien et al. Complete surgical removal of minimal and mild endometriosis improves outcome of subsequent IVF/ICSI treatment. 2011) .

5. Pregnancy spontaneous after laparoscopic surgery Cumulative pregnancy rate of 102 patients demonstrated with 95% confidence intervals 27 patients (26.5%) became pregnant during the first 6 months after laparoscopy, and 49 patients (48%) became pregnant during the first 12 months after laparoscopy. The cumulative pregnancy rate increased from the first to the second year by more than 10% (cumulative pregnancy rate of 61.8%, n = 63).

6. Pregnancy with and without ART Rad, M.T et all. Int J Gynaecol Obstet. 2023 The pregnancy rate of endometriosis patients after laparoscopy is higher in patients undergoing ART .

7. Surgery for Superficial/ Peritoneal Endometriosis Overall, 399 women with minimal to mild endometriosis were surgically treated and all visible endometriosis was completely removed prior to IVF while the 262 women included in the control group underwent only a diagnostic laparoscopy. Case demonstrated a significant higher implantation, pregnancy, and live birth rate (OR 1.47; 95% CI 1.01 to 2.13). Furthermore, a shorter time to first pregnancy and a higher cumulative pregnancy rate after surgical removal of endometriosis prior to ART were found.

8. Surgery for Deep Infiltrative Endometriosis A meta-analysis (Casals et al., 2021) of four studies comparing the reproductive outcomes in women with infertility and deep infiltrating endometriosis who received IVF with or without a previous surgery found that live birth rates were 2.2 times (95% CI 1.42–3.46) higher in the operated group versus the non-operated group. The addition of data from the incomplete surgery groups also showed a higher pregnancy rate per patient for surgery before IVF (odds ratio [OR] 1.63; 95% CI, 1.16–2.28).

9. Surgery for Ovarian Endometrioma 4 cm "Table IV. — Laparoscopy after failed IVF. Modified with permission from Littman E, Giudice L, and Lathi R et al. Role of laparoscopic treatment of endometriosis in patients with failed in vitro fertilization cycles. Fertil Steril. 2005;84:1574-8." Comparison of patients with a history of prior failed IVF cycles, who underwent laparoscopic treatment of endometriosis to patients who did not undergo laparoscopic treatment. + Laparoscopy No laparoscopy P value Number of patients (n) 29 35 Average age (y) 34 37 .613 Average FSH 8.0 8.1 NS Average no. of failed IVF cycles 2 2 NS Pregnancy rate 22/29 13/35 <.01 Spontaneous pregnancy rate 13/29 2/35 <.01

10. Surgical pre-treatment is preferred in following conditions: Endometrioma larger than 4 cm with no previous surgery Follicles or ovarian cortex distal to cyst from the vaginal wall and the ultrasound probe Normal ovarian reserve and young patient

11. Role of Medical in Infertility Treatment for Endometriosis patients Medical management, which includes various hormonal treatments, deals with ovulation suppression and, therefore, does not have much role for infertility treatment. Cochrane review by Hughes et al. concluded that there is no role for suppressing ovulation in women with endometriosis who plan to conceive . ( E.Hughes , 2007) Neither preoperative nor postoperative hormonal therapy increases the chances of spontaneous conception . ( Vatsa R & Sethi , A. Middle East Fertility Society Journal. 2021)

12. Pregnancy outcome ovulation suppression vs placebo From the 12 trials, there were 88 pregnancies in 420 women administered an ovarian suppression agent ( danazol , MPA, gestrinone , oral contraceptive(OC ), or GNRHa ) compared with 84 pregnancies in 413 women receiving no treatment or placebo. The common OR for pregnancy across trials was 0.97 (95% CI 0.68 to 1.37, P = 0.85) for all women randomised There was no evidence of clinical heterogeneity between studies with an I2 statistic of 25% and 24%, respectively, for both the total population and subgroup analysis

13. Presurgical medical therapy compared with placebo or no medical therapy

14. Postsurgical medical therapy compared with placebo or medical therapy

15. Presurgical medical therapy compared with postsurgical medical therapy

16. Role of Medical therapy in Infertility Treatment for Endometriosis patients as pre treatment prior to IVF The Cochrane review that odds of clinical pregnancy in endometriosis patients increased by fourfold when GnRH agonists were given for 3–6 months before IVF or ICSI . (Cochrane Database Syst Rev 2019) Dienogest (DNG) has anti-inflammatory and anti- angiogenic activity and so may theoretically improve IVF outcomes in women with endometriosis. (Barra, F et all. 2020) 6 to 8 weeks of OC treatment before ART may be as effective as suppressing ovarian function with a GnRH agonist for 3 to 6 months for optimizing ART outcome in endometriosis. (Ziegler de D.et all. 2010 )

17. Pretreatment with injectable GnRH agonist depot with letrozole for 2 months The clinical pregnancy rate was significantly higher in the letrozole-treated group ( 50% versus 22%, P = 0.003), as was the live birth rate ( 40% versus 17%, P = 0.008). The combination of depo-leuprolide acetate monthly for 60 days combined with daily letrozole has better clinical outcomes at IVF in women with endometriomas than depo-leuprolide acetate treatment alone.

18. Pretreatment with dienogest for 3 months

19. Pretreatment with Oral contraceptive pills Clinical Pregnancy Rate was higher in the group receiving Pretreatment with Oral contraceptive pills Group 1 (with OC) Group 2 (no OC) Endometriosis Endometriosis Controls II-I III-IV OMA Controls II-I III-IV OMA >37 y 42.0 55.0 39.6 40.9 39.7 29.7 23.8 12.0 >38 y 16.7 28.6 33.3 50.0 18.5 8.0 10.0 16.7 Total 35.0 48.1 37.9 41.4 32.5 23.6 21.2 12.9 sclerotherapy

20. Previous surgery/surgeries for endometriosis First time endometriomas less than 4 cm Compromised ovarian reserve Advanced age (AMA and POR) Medical pre-treatment is preferred in the following conditions: Dienogest for 3 months prior to COS Oral contraceptive pills for 6 to 8 weeks prior to COS Two monthly doses of injectable GnRH agonist depot with letrozole for 2 months as pre-treatment Medical pre-treatment:

21. Sclerotherapy for treatment Endometriosis

22. Ovarian endometrioma aspiration

23. Role of Adjuvant therapy in Infertility Treatment for Endometriosis patients : higher implantation, pregnancy, and live birth rate . Surgical pre-treatment is preferred in following conditions : Endo > 4cm, Follicles or ovarian cortex distal to OMA, and normal ovarian reserve & young patient Medical pre-treatment is preferred in the following conditions : Previous surgery, Endo < 4cm, compromised ovarian reserve and Advanced age (AMA and POR) Conclusion

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