IVF - ICSI ÖNCESİ

ENDOMETRIOMALAR
ÇIKARTILMALI MI?
Prof. Dr. Bülent Baysal
İ.Ü. İstanbul Tıp Fakültesi
 ENDOMETRİOZİS
 17.yy...............peritoneal ülser
 1860..............Von Rokitansky (mikroskopik tanı)
Prevalans: kadınların %5 inde, infertilite
problemi olan kadınların %30-50 sinde
Impact of ovarian endometrioma on oocytes and
pregnancy outcome in in vitro fertilization.
Suzuki T, et al. Fertil Steril 2005

 Group A: 80 cycles with ovarian endometriomas;

 group B: 248 cycles with endometriosis - without
endometrioma
 group C: 283 cycles - tubal factor .

 Fewer oocytes were retrieved from groups A and B than

from group C (P<.005).
 pregnancy rates (group A: 25.3%, group B: 22.3%,
group C: 23.9%).

 CONCLUSIONS: Endometriosis affects oocyte number but

not embryo quality or pregnancy outcome
KİSTEKTOMİNİN OVER REZERVİNE
ETKİSİ ??
IVF-ICSI outcome in women operated on for
bilateral endometriomas.
Somigliana E,et al. Hum Reprod. 2008
 68 cases (bilat. cystectomy)- 136 controls

 the number of follicles (P = 0.006), oocytes retrieved

(P = 0.024) and embryos obtained (P = 0.024) were
significantly lower.

 The clinical pregnancy rate per started cycle in cases

and controls was 7% and 19% (P = 0.037)

 CONCLUSIONS: IVF outcome is significantly impaired in

women operated on for bilateral ovarian endometriomas.
Studies evaluating response to ovarian stimulation in patients previously operated for
endometriomas (EM)

Surgical technique
Author olgu oosit embryo gebelik
EM Ctr EM Ctr EM Ctr EM (%) Ctr (%)

Al-Azemi et Not reported 40 80 6.9 ± 0.7 7.1 ± 0.5 NA NA 15 15

al. (2000)*

Canis et al. Cyst 41 59 9.4 ± 6.2 10.9 ± 6.5 4.7 ± 3.6 5.8 ± 4.9 36 30
(2001) enucleation

Donnez et al. Laser 85 289 10.6 ± 4.2 8.6 ± 6.3 4.4 ± 3.2 4.0 ± 3.6 37 35
(2001) vaporization

Marconi et Cyst 39 36 7.5 ± 3.9 8.7 ± 5.1 3.8 ± 0.8 3.6 ± 1.2 38 33
al. (2002) enucleation

Geber et al. 37 46 12.0 ± 5.9 NA NA 53 56

(2002)

Pabucco et Cyst 44 46 7.2 ± 1.5 NA NA 25 30

al. (2004) enucleation
End.çıkarılmış 147 siklüs - %25.4 gebelik
Çıkarılmamış 63 siklüs - %22.7 gebelik
(p=0.776)
(Fertil Steril 2004)
Effect of endometrioma cystectomy on IVF
outcome: a prospective randomized study.
Demirol A, Reprod Biomed Online. 2006

 prospectively randomized
 group I (49 patients) - ovarian surgery before ICSI
 group II (50 patients) -ICSI cycle directly
 Group 1- lower oocyte number
 There was no difference in terms of fertilization
(86% in group I and 88% in group II), implantation
(16.5% in group I and 18.5% in group II)
 pregnancy rates (34% in group I and 38% group II).
Outcome of in vitro fertilization/intracytoplasmic
sperm injection after laparoscopic cystectomy for
endometriomas.
Yaralı et al. Fertil Steril 2006

 unilateral (n = 34)
 bilateral (n = 23) laparoscopic cystectomy
 control group (n= 99 ) tubal factor infertility

 The mean number of oocytes, metaphase II oocytes, and

two-pronucleated oocytes were significantly lower in the
bilateral cystectomy group

 fertilization rate, the mean number of embryos

transferred, the mean number of grade 1 embryos
transferred, the clinical PR/ET, implantation rate, were
comparable among the three groups.
Laparoscopic resection or sonography-guided
vaginal aspiration of endometriomas prior to ICSI-
ET does not worsen treatment outcomes
Tavmergen E , et al. Clin Exp Obstet Gynecol. 2007;

 resection group (Group I) 36 cycles ;

 aspiration (Group II) - 26 cycles
 control group (Group III) - 53 cycles - tubal factor
 Gonadotropin consumption was higher, peak estradiol
level lower, the number of oocytes less in the
laparascopic resection group (Group I) with respect to
the control group.
 laparascopic endometrioma resection, transvaginal
ultrasound-guided endometrioma cyst aspiration
do not worsen the treatment outcome.
Impact of ovarian endometrioma on assisted
reproduction outcomes.
Gupta S. Reprod Biomed Online. 2006

 Metaanalysis

 The odds for clinical pregnancy were not affected

significantly in patients with ovarian endometrioma
compared with controls, with an overall odds ratio of 1.07
from three studies [95% CI: (0.63-1.81), P = 0.79].
The effect of surgical treatment for endometrioma
on in vitro fertilization outcomes: a systematic
review and meta-analysis.
Tsoumpou I, .UK Fertil Steril 2008

 A systematic review and meta-analysis

 three electronic databases - 1985 - 2007
 20 eligible studies.
 Meta-analysis - five studies that compared surgery vs.
no treatment of endometrioma.
 There was no significant difference in clinical pregnancy
rate between the treated and the untreated groups.
 no significant difference -to controlled ovarian
hyperstimulation with gonadotrophins
Should endometriomas be treated before
IVF-ICSI cycles?
Somigliana E, et al. Human Reprod Update 2006

 The idea that surgery increases IVF pregnancy rates is

not supported by the available evidence.
 However, the chance of conception is not the only issue
that has to be considered.
Pros and cons of surgical treatment of endometriomas before
IVF-ICSI cycles

Somigliana, E. et al. Hum Reprod Update 2006 12:57-64; doi:10.1093/humupd/dmi035

 Pregnancy rates observed after laparoscopic excision of endometriomas

Vercellini, P. et al. Hum. Reprod. 2008 0:den379v1-15; doi:10.1093/humrep/den379

Copyright restrictions may apply.

 Management of endometriomas in women
requiring IVF: to touch or not to touch.
Garcia-Velasco JA. Human Reprod 2008

 proceeding directly to IVF to reduce time to pregnancy,

to avoid potential surgical complications and to limit
patient costs.

 Surgery should be envisaged only in presence of

*large cysts,
*pain symptoms which are refractory to medical
treatments,
*malignancy cannot reliably be ruled out
 International guidelines on surgical treatment of
endometriosis-associated infertility in asymptomatic women.

ESHRE 2005 ASRM 2006 RCOG 2006

Minimal-mild endometriosis Limited benefit: surgery recommended Small benefit: surgery recommended Demonstrated benefit: surgery
(stage I–II disease) recommended

Moderate–severe Possible but unproven benefit: surgery Possible benefit: surgery recommended Possible benefit: recommendation
endometriosis (stage III-IV recommended uncertain
disease)

Post-operative adjuvant No benefit: not recommended No benefit: not recommended No benefit: not recommended
treatment

Surgery before IVF 4 cm Doubtful benefit: no recommendation 4 cm

Recurrent endometriosis No recommendation Second-line surgery not recommended No recommendation

Sonuç
1- IVF öncesi cerrahi zorunlu değil

2-Semptom varsa opere edilebilir

3-Hastanın kaderini belirlemede ilk

operasyon çok önemli