3.
Ovarian
Endometrioma
• Ovarian
endometrioma
>
3cm
should
be
operated
if
pain
or
subfer6lity
• First
surgery
is
the
window
of
opportunity
• Skilled
surgeon
• No
role
of
pre-‐op
adjuvants
4.
Endometrioma
&
Subfer6lity
• In
ovarian
endometrioma
(>4cm),
• Excision
of
capsule
improves
pregnancy
rates
(compared
to
drainage
&
coagula6on)
• But
may
cause
reduced
ovarian
func6on
• Conserva6ve
surgery
improves
fer6lity
if
no
other
iden6fiable
infer6lity
factor,
but
viable
cortex
lost
• Secondary
surgery
no
benefit,
ART
beRer
• If
previous
ovarian
surgery,
careful
considera6on
5.
What
surgery?
• Simple
aspira6on
of
cyst
• Endometrioma
excision
(cystectomy)
:
1.
Risk
of
excessive
surgery
2.
destroy
normal
ovarian
cortex
6.
What
surgery?
• Endometrioma
Abla6on
• Aspira6on
• Irriga6on
• Laser
Vaporiza6on
• Electrocautery
•
Risk
Of
Incomplete
Surgery
(Early
Recurrence)
Look
for
extra-‐pelvic
&
deep
infiltra5ng
endometriosis
7.
Ovarian
Endometrioma
• Aspira6on
Not
Recommended
• Abla6on/Drainage
&
Coagula6on
(Aspira6on/
Irriga6on/Diathermy)
:
Risk
Of
Incomplete
Surgery
(Early
Recurrence)
• Excison/Cystectomy
Preferable
(Less
Recurrence)
8.
Ovarian
Damage
in
Surgery
• Reduced
Ovarian
Response
On
S6mula6on
– Somigliana
Et
Al.
Hum
Reprod
2008
– Ragni
Et
Al.
Am
J
Obstet
Gynecol
2005
• Reduced
Ovarian
Volume
&
Antral
Follicle
Count
• No
Effect
On
Ivf
Pr
Or
Ovarian
Response
To
COH
– Tsompou
Et
Al.
Fer5l
Steril
2009
(Systema6c
Review)
• 13%
Risk
Of
Severe
Ovarian
Damage
– Benaglia
Et
Al.
Hum
Reprod
2010
• More
Damage
In
Ovarian
Cystectomy
– Var
Et
Al.
Fer5l
Steril
2011
9.
Combined
Excision/Abla6on
• Aspira6on
• Irriga6on
• Cyst
Enuclea6on
Till
Reach
Hilum
• Cut
Cyst
Wall
With
Scissors
• Vaporize
At
Hilum
With
Laser/Electrocautery
– Donnez
Et
Al.
Fer5l
Steril
10.
Excision
Vs
Abla6on
of
Endometrioma
• Less
Pain
With
Cystectomy
• Less
Recurrence
Risk
(6-‐8%
Vs
12-‐23%)
• Less
Recurrence
Of
1. Dysmenorrhoea
2. Dyspareunia
3. Non-‐menstrual
Pelvic
Pain
• More
Reduc6on
Of
Ovarian
Reserve
11.
Surgical
Treatment
:
Success
• Surgery
Despite
Its
Proven
Efficacy
Is
Challenged
By
High
Recurrence
Rate
– 40–45%
Recurrence
Rate
Within
5yrs
Post-‐
opera6vely
– In
Case
Of
Endometriomas,
Symptoms
(Pain
Or
Infer6lity)
Recur
In
76%
Of
Pa6ents
• Even
Ager
Cura6ve
Surgery,
Rates
Of
Recurrence
Are
As
Great
As
5–10%.2
12.
WHAT
AFTER
SURGERY
(ESHRE)
• Danazol
Or
A
Gnrh
Agonist
For
6
Months
1. Reduces
Endometriosis
Associated
Pain
2. Delays
Recurrence
At
12
And
24
Months
Compared
With
Placebo
&
Expectant
Management
• Post-‐op
Treatment
With
A
Coc
Is
Not
Effec6ve
– Telimaa
Et
Al.,
1987;
Parazzini
Et
Al.,
1994;
Hornstein
Et
Al.,
1997;
Bianchi
Et
Al.,
1999;
Morgante
Et
Al.,
1999;
Vercellini
Et
Al.,
1999b;
Muzii
Et
Al.,
2000;
Busacca
Et
Al.,
2001
13.
DNG
Vs
Gnrh
a
Post
Op
• Post
Laparoscopy
For
Endometriosis
Women
•
Randomised
To
Dienogest
2mg/D
For
6months
•
Or
• Monthly
Goserelin
X
6
Months
• Those
Who
Refused
Post
Op
Adjuvant
Observed
• Recurrence
Rates
&
Symptom
Relief
Similar
In
Both
Treatment
Groups,
BeRer
Than
No
Treatment
• Less
S/E
In
Dienogest
Group
• Takesu
Et
Al.
J
Obstet
Gynecol
Res
2016
14.
Secondary
Preven6on
• Post
Op
Adjuvant
Hormonal
Therapy
• For
Contracep6on
• Secondary
Preven6on
• Long
Term
Post-‐op
Hormonal
Treament
(>6months)
• Secondary
Preven6on
15.
Secondary
Preven6on
• Secondary
Preven6on
:
1. COCP
2. LNG
IUS
3. DNG
• LNG
IUS,
Inserted
At
Laparoscopy,
May
Reduce
The
Risk
Of
Recurrent
Moderate-‐severe
Dysmenorrhoea,
But
Does
Not
Reduce
Endometrioma
Recurrence
– Chen
Et
Al.Am
J
Obstet
Gynecol
2017
16.
Adjuvant
Treatment
• Pre-‐op
Hormone
Therapy
Improves
Rafs
Scores
• Post-‐op
Hormonal
Treatment
Has
No
Beneficial
Effect
On
Pregnancy
Rates
Ager
Surgery
(A)
• Treatment
With
A
Gnrh
A
For
3–6
M
Before
Ivf
In
Women
With
Endometriosis
Increases
The
Rate
Of
Clinical
Pregnancy
(A)
17.
ART
&
Endometrioma
• Operate?
• Does
not
impair
IVF
success
rate
• Prevents
rupture
• Facilitate
oocyte
retrieval
• Avoid
contamina6on
of
follicular
fluid
with
contents
• Detect
occult
malignancy
• Prevent
progression
• Do
not
operate?
• LOC
prior
to
IVF
does
not
improve
PR
• Risk
of
surgery
• Pote6al
reduc6on
of
ovarian
reserve
• Aspira6on
prior
to
IVF
:
no
increase
in
PR
18.
Should
Endometriomas
Be
Treated
Before
ART?
Table
3.
Clinical
variables
to
be
considered
when
deciding
whether
to
perform
surgery
or
not
in
women
with
endometriomas
selected
for
IVF
Characteris6cs Favours
surgery Favours
expectant
management
Previous
interven6ons
for
endometriosis
None ≥1
Ovarian
reservea Intact Damaged
Pain
symptoms Present Absent
Bilaterality Monolateral
disease Bilateral
disease
Sonographic
feature
of
malignancyb
Present Absent
Growth Rapid
growth Stable
a
ovarian
reserve
is
es6mated
based
on
serum
markers
or
previous
hypers6mula6on
cycles;
b
sonographic
feature
of
malignancy
refers
to
solid
components,
locality,
echogenicity.,
regularity
of
shape,
wall,
septa,
loca6on
and
presence
of
presence
of
peritoneal
fluid.
Value
of
laparoscopic
excision
of
ovarian
endometriomas
in
women
selected
for
IVF–ICSI
cycles
is
debated.
Edgardo Somigliana, Paolo Vercellini et al. Human Reproduction Update, 2006.
19.
Carry
Home
Messages
• Endometrioma
:
• Cystectomy
Treatment
Of
Choice
• No
Role
Of
Pre-‐op
Adjuvants
• Cystectomy
Preferable,
Usually
If
Pain,
Primary
Surgery
And
Normal
Ovarian
Reserve
• Post-‐op
Adjuvant
Treatment
For
Secondary
Preven6on
