Chirurgie

 de  l’endométriose

Dr  Marc  EVEN  SILBERSTEIN

Chirurgie  Gynécologique  -­‐ Hôpital  Foch,  Suresnes.
Service  du  Pr  AYOUBI
marc.even@hopital-­‐foch.com

DU  PMA  Paris  Ouest

Hôpital  Foch  – 1  ère  session
7  mars  2019
 Plan

• Principes  de  la  chirurgie  de  l’endométriose  dans  l’infertilité:  

recommandations  HAS  2017

• Description  des  risques    d’impact  de  la  chirurgie  sur  la  réserve  
ovarienne

• Choix  des  approches à  retenir

 Définition  et  épidémiologie

• Présence  d’endomètre  en  dehors  de  la  cavité  utérine

• 10  à  15%  des  femmes  en  âge  de  procréer

Missmer et  al.,  Am  J.Epidemiol,  2004

• 1,5  à  2  millions  de  femmes  en  France

Insee  2016
 Endométriose  :  histoire  naturelle

• Maladie  multifactorielle:  3  facteurs

ØFacteurs  génétiques  

ØFacteurs  environnementaux

ØFacteurs  liés  aux  menstruations:

• -­‐ premières  règles  précoces
• -­‐ volume  menstruel  important
• -­‐ cycles  courts
 Endométriose  :  
« théorie  de  l’implantation »

3  phénotypes
-­‐ SUP:  Peritoneal  superficial   endometriosis
-­‐ OMA:   Ovarian  endometrioma SUP OMA DIE

-­‐ DIE:  Deep  infiltrating  endometriosis

Sampson JA,  AJOG  (1927)
 Endométriose  :
« prise  en  charge  globale »

DOULEUR INFERTILITE
DIE

SUP

OMA

-­‐ DYSMENORRHEE CAVITE  PELVIENNE

-­‐ DYSPAREUNIE UTERUS
-­‐ SFU,  SFD OVAIRES
-­‐-­‐ DOULEUR  CHRONIQUE

de  Ziegler,  Borghese and  Chapron The  Lancet  (2010)

 Endométriose  &  
réserve  ovarienne

-­ Chirurgie

-­‐ Stratégie
Endométriome  ovarien

Ovarian
damage

Risk factor  
for  
OSIS  severity
OMA  et  douleur  pelvienne
 (Brosens et al., 2004
GIS severe 7 (30.4%) 52 (53.1%) 0.051e easily diagnosed, ex
(VAS ≥ 7)c
the DIE extension

OMA  et  douleur  pelvienne

LUS severe 3 (13.0%) 8 (8.2%) 0.436d why surgery is often
(VAS ≥ 7)c
to repetitive operati
DIE, deeply infiltrating endometriosis; DM, dysmenorrhoea; DP, deep dyspareunia; 2005). In this series
NCCPP, non-cyclic chronic pelvic pain; GIS, gastrointestinal symptoms; LUS, lower for endometriosis. T
urinary tract symptoms.
a
Data are presented as mean + standard deviation.
vious surgery is hig
Reproduction, Vol.27, b No.3 pp. 702 – 711, 2012
Student’s
Access publication on January 16, 2012t-test.
doi:10.1093/humrep/der462
(P , 0.001), corresp
c
Data are presented as n (%). cases of DIE, proba
ORIGINAL
d
Fisher’s exact test. ARTICLE Gynaecology
e
Pearson’s x2 test.
the disease at the t
Ovarian endometrioma: severe pelvic painful OMA constitu
pain is associated with deeply Hum  Reprod (2012) DIE lesions. In this
process (Abrao et a
infiltrating endometriosis
According to the TV
Table VI
Charles Determinants
Chapron for severity of painful
1,2,3,*, Pietro Santulli 1,2,3,4, Dominique de Ziegler 1,
of magnetic resonan
Jean-Christophe Noel 5, Vincent Anaf 6, Isabelle Streuli 1,
symptoms results from multiple logistic regression slice computerized
Hervé Foulot 1, Carlos Souza 1,7, and Bruno Borghese 1,2,3
analysis.
1
Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, Assistance Publique – Hôpitaux de Paris (AP- HP), Groupe
2009). Multifocality
Hospitalier Universitaire (GHU) Ouest, Centre Hospitalier Universitaire (CHU) Cochin Saint Vincent de Paul, Department of Gynecology

Downloaded from http://humrep.oxfordjournals.org/ at INSERM on June 11, 2012

2
Obstetrics II and Reproductive Medicine (Professor Chapron), Paris, France Université Paris Descartes, Sorbonne Paris Cité, Institut Cochin,

Independent
Paris, 5
France Department of
3

Variable expressed
Gynecopathology, Academic Hospital as
Erasme,
4
CNRS (UMR 8104), Paris, France Inserm, Unité de Recherche U1016, Paris, France Faculté de Médecine, EA 1833, ERTi, CHU Cochin,
ORUniversité
(95%IC) 6
Libre de Bruxelles, Bruxelles, Belgium Depatment of
multidisciplinary app
7

........................................................................................ OMAIn conclusion, num

Gynecology, Academic Hospital Erasme, Université Libre de Bruxelles, Bruxelles, Belgium Serviço de Ginecologia e Obstetrı́cia, Hospital de
Clı́nicas de Porto Alegre (HCPA), Coordenação de Aperfeiçoamento de Pessoal de Nı́vel Superior (CAPES), Porto Alegre, Brazil

a
Vincent de Paul, 82, Avenue Denfert Rochereau, 75014 Paris, France. Tel: +33-1-58-41-19-14; Fax: + 33-1-58-41-18-70; E-mail:charles. clearly that OMA s
Dysmenorrhoea Main DIE lesion: intestine
*Correspondence address. Service de Gynécologie Obstétrique II et Médecine de la Reproduction,
5.2 (2.7 – 10.3)
Pavillon Lelong, CHU Cochin Saint

chapron@cch.aphp.fr
Bilateral endometrioma 2.8 (1.4 – 5.6) lesion. In the cont
Submitted on February 15, 2011; resubmitted on September 26, 2011; accepted on October 5, 2011

Deep dyspareunia Main DIE lesion: USLa 2.0 (1.1 – 3.5) however is in favou
kground: The objective of this study was to evaluate the significance of severe preoperative pain for patients presenting with
a
n endometrioma (OMA). Non-cyclic chronic pelvic Main DIE lesion: USL 2.1 (1.1 – 4.3) painful OMA, the e
hods: Three hundred consecutive patients with histologically proven OMA were enrolled at a single university tertiary referral centre
pain Left sided endometrioma 3.5 (1.7 – 7.1)
en January 2004 and May 2010. Complete surgical excision of all recognizable endometriotic lesions was performed for each patient. severe. Severely pa
tensity was assessed with a 10-cm visual analogue scale (VAS). Previous Pain was surgeries
considered for
as severe when 2.2VAS (1.1
was – 4.5)Prospective pre-
DIE
≥7.
ve assessment of type and severity of pain symptoms (VAS) was compared with the peroperative findings (surgical removal and histo- proper non-invasive
analysis) of endometriomas and associated deeply infiltrating endometriosis
endometriosis. Correlations were sought with univariate analysis and a
e regression logistic model.
a
DIE lesions. The ob
lts: After multipleGastrointestinal
logistic regression analysis, uterosacral Main DIE involvement
ligaments lesion: intestine
was related with7.1 (3.3
a high – 15.3)
severity of chronic pelvic
dds ratios (OR) ¼ 2.1; 95% confidence interval (CI): 1.1 – 4.3] and deep dyspareunia (OR ¼ 2.0; 95% CI: 1.1 – 3.5); vaginal involve- nature, location and
symptoms
was related with a higher intensity of lower urinary symptoms (OR ¼ 13.4; 95% CI: 3.2 – 55.8); intestinal involvement was related with
eased severity of dysmenorrhoea (OR ¼ 5.2; 95% CI: 2.7 – 10.3) and gastro-intestinal symptoms (OR ¼ 7.1; 95% CI: 3.3 – 15.3). so that the patient ca
LU symptoms Main DIE lesion: vaginaa 13.4 (3.2 – 55.8)
clusions: In case of OMA, severe pelvic pain is significantly associated with deeply infiltrating lesions. In this situation, the prac-
r should perform an appropriate preoperative imaging work-up Hematuria in order to evaluate the existence10.0 (1.3 – deep
of associated 77.6) nodules and treatment strategy.
the patient in order to plan the surgical intervention strategy.
words: endometrioma / pelvic pain / deeply infiltrating endometriosis / multivariate analysis / nerve fibres
DIE, deeply infiltrating endometriosis; USL, uterosacral ligament(s).
a
According to a previously published surgical classification for DIE by Chapron et al.
oduction (2006).
All
riosis is a disease that P , 60.05.
affects – 10% of women of childbear-
whose cause remains enigmatic to this date (Borghese et al., 2008;
Bulun, 2009; Ngo et al., 2009), is associated with infertility (Matzuk
and Lamb, 2008; de Ziegler et al., 2010) and/or pelvic pain (Faucon-
Acknowle
Giudice and Kao, 2004) and is histologically defined by the nier and Chapron, 2005). Different hypotheses have been proposed
of endometrial-like tissue outside the uterus (Sampson, to explain the relationship that exists between endometriosis and The authors want to
ndometriosis is histologically categorized into three types: pain (Berkley et al., 2005; Evans et al., 2007). For DIE, entrapment
l superficial endometriosis (SUP), ovarian endometrioma ment operating room
 Diagnostic

OME DIE
 Recommandations  HAS  (2017)

• En  cas  d’échec  du  traitement  initial,  de  récidive  ou  d’atteinte  de  
plusieurs  organes  par  l’endométriose,  une  prise  en  charge  
multidisciplinaire est  recommandée  (AE)

• La  voie  d’abord  coelioscopique est  recommandée  pour  le  traitement  

chirurgical  de  l’endométriose  (grade  B)
 Endométriose  superficielle

• La  chirurgie  de  l’endométriose  superficielle   réduit  les  douleurs à  

court  et  moyen  terme  (NP1)

• Il  est  recommandé  de  traiter  de  manière  complète les  lésions  

d’endométriose  pelvienne   lorsqu’elles  sont  découvertes  lors  d’une  
coelioscopie (grade  B)

• Le  traitement  des  lésions  par  éxérèse ou  destruction,   associé  à  

l’adhésiolyse,  permet  une  augmentation  du  taux  de  grossesse  
spontanée  (NP1)
Endométriose  superficielle
 Endométriome  ovarien

KIP:  technique  recommandée  pour  la  prise  en  charge  chirurgicale  des    endométriomes  (grade  A)
 Endométriome  ovarien
• Chez  les  femmes  douloureuses,   l’attitude  expectative  ou  la  ponction  
echoguidée ne  sont  pas  recommandées  (grade  C)

• La  sclérothérapie à  l’éthanol    peut  être  proposée  chez  les  patientes  

présentant  des  endométriomes  récidivants  (AE)

• La  technique  destructive  par  coagulation   bipolaire  n’est  pas  

recommandée  (grade  B)

• Manque  d’études  comparant  la  kystectomie à  la  destruction  au  laser  

ou  à  l’énergie  plasma
 Endométriome  ovarien

• Il  est  très  rarement  isolé  (NP3)

• Le  risque  de  récidive augmente  en  cas  de  chirurgie  incomplète  (NP3)

• La  recherche  et  le  traitement  d’autres  localisations  pelviennes   de  

l’endométriose  sont  recommandés  lors  de  la  découverte  ou  de  la  
prise  en  charge  chirurgicale  d’un  endométriome  (grade  C)
 Endométriose  de  vessie

• Le  traitement  chirurgical  de  l’endométriose  vésicale  par  cystectomie  

partielle peut  être  proposée  chez  les  patientes  symptomatiques  
(grade  C)

• La  résection  d’un  nodule  d’endométriose   vésicale  uniquement  par  

voie  transurétrale n’est  pas  recommandée  (grade  C)
-­ Comblement  complet  du  CDS  vésico  utérin,  nodule  3-­4  cm  infiltrant  la  vessie
-­ DIE  latéralisée  à  gauche:  atteinte  thorus,  US  gauche
 -­ nodule  3  cm  infiltrant  la  paroi  vésicale
-­ vessie  adhérent  à  la  face  antérieure  de  l’utérus
-­ nodule  adénomyose focalisée  antérieure
 Endométriose  des  uretères
• Prise  en  charge  par  une  équipe  multidisciplinaire (gynéco  et  uro)  
recommandée  (AE)

• Techniques  conservatrice:  urétérolyse

• Techniques  radicales:  résection  urétérale  avec  anastomose  termino

terminale ou  résection  urétérale  et  réimplantation  vésicale

• Compte  tenu  du  risque  de  sténose  de  l’anastomose  urétéro urétérale  
ou  du  site  de  réimplantation  urétérovésicale et  du  risque  d’atrophie  
rénale  progressive  pauci-­‐symptomatique,  une  surveillance  post  
opératoire  par  imagerie apparait  justifiée  (AE)
 Endométriose  du  colon  et  du  rectum
• La  voie  d’abord  coelisocopique est  aussi  efficace  que  la  laparotomie  
pour  l’amélioration  des  douleurs  à  la  défécation  et  de  la  qualité  de  
vie postopératoires  (NP2)

• La  chirurgie  pour  endométriose   colorectale  peut  être  proposée  chez  

les  patientes  symptomatiques (grade  C)

• Elle  expose  un  risque  de  complications  postopératoires   graves (NP2),  

dont  les  patientes  doivent  être  informées  (grade  B)

• 3  techniques:  shaving,  résection  antérieure  discoide,  résection  

segmentaire
 Endométriose  du  colon  et  du  rectum

• En  cas  de  chirurgie  d’endométriose   du  bas  rectum,  la  réalisation  

d’une  dérivation  digestive  temporaire  (iléostomie  ou  colostomie)  
doit  être  discutée  en  raison  des  complications  liées  à  la  survenue  
d’une  fistule

• Prise  en  charge  multidisciplinaire +++

• En  cas  d’endométriose  colorectale,  la  réalisation  d’une  chirurgie  

incomplète laissant  en  place  la  lésion  digestive  augmente  le  taux  de  
récidive des  douleurs  postopératoires  et  diminue  le  taux  de  
grossesse
 Endométriose  du  colon  et  du  rectum

• La  réalisation  d’une  chirurgie  incomplète  laissant  en  place  la  lésion  

digestive  augmente  le  taux  de  récidives  des  douleurs  postopératoires  
et  diminue  le  taux  de  grossesses   posoperatoires (NP3)

• Lorsque  le  traitement  chirurgical  est  décidé,  il  est  recommandé  de  
faire  une  résection  des  lésions  pelviennes  d’endométriose   aussi  
complète que  possible  (grade  C)
 Endométriose  extra  pelvienne

• Pariétale,  diaphragmatique,  thoracique

• En  cas  de  découverte   d’endométriose  thoracique,  une  consultation  

avec  un  gynécologue  est  conseillée  (grade  C)

• En  raison  d’un  effet  favorable  sur  les  douleurs  (NP3),  le  traitement  
chirurgical  peut  être  proposé  chez  les  patientes  symptomatiques  
porteuses   d’une  endométriose  pariétale,  thoracique  ou  
diaphragmatique  
 Endométriose  des  racines  nerveuses  et  
du  nerf  sciatique

• Il  peut  y  avoir  une  infiltration  des  racines  sacrées  ou  du  tronc  du  nerf  
sciatique.  Cela  entraine  des  symptomes nerveux  somatiques  
(territoire  du  nerf  sciatique  ou  pudendal)  ou  végétatif (vésicaux,  
colorectaux  ou  vaginaux)  à  caractère  cyclique  (NP3)

• Au  cours  de  la  chirurgie  pelvienne  pour  endométriose,  il  est  

recommandé  de  préserver   les  nerfs  végétatifs  à  chaque  fois  que  cela  
est  possible  (grade  C)
Place  de  l’hysterectomie conservatrice  ou  
avec  annexectomie  bilatérale

• Chez  les  femmes  sans  souhait  de  grossesse,   l’hysterectomie avec  

résection  des  lésions  d’endométriose,   avec  ou  sans  annexectomie  
bilatérale,  peut  être  proposée  dans  le  but  de  réduire  le  risque  de    
récidive  (AE)

• En  tenant  compte  des  effets   défavorables  multiples  de  la  ménopause  

précoce  sur  l’espérance  de  vie  et  la  qualité  de  vie  (NP2),  la  
conservation  ovarienne  doit  être  discutée  avec  la  patiente  en  cas  
d’hysterectomie pour  endométriose   profonde  (AE)
 OMA  et  grossesse
Web Appendix: Effects of surgery on infertility associated with endometriosis.

Laparoscopic excision of endometrioma (OMA) N # IUP % IUP

Daniell et al., 1991 32 12 37.5
Marrs et al., 1991 23 7 30.4
Bateman et al., 1994 21 9 42.8
Crosignani et al., 1996 22 6 27.3
Montanino et al., 1996 11 5 45.5
Donnez et al., 1996 814 414 50.8
Sutton et al., 1997 66 30 45.5
Beretta et al., 1998 9 6 66.7
Milingos et al., 1998 32 17 53.1
Busacca et al., 1999 67 39 58.2
Jones and Sutton, 2002 39 15 38.5
49.2%
w Alborzi et al., 2004 32 19 59.4
Fedele et al., 2006 90 29 32.2
Vercellini et al., 2006 237 128 54.0

Total 1495 736 49.2

Endometriosis and infertility: pathophysiology and

management
Deep infiltrating endometriosis (DIE) N # IUP The  Lancet  %(2010)
IUP
Dominique de Ziegler, Bruno Borghese, Charles Chapron
Coronado et al., 1990 33 13 39.4
0–38 Endometriosis
Nehzat et al., 1994and infertility are associated
8 clinically. Medical and
1 surgical treatments 12.5
for endometriosis have
 !0.61 ng/ml; 95% CI 0.03 to !1.25; I2 " 78%). The timing of postoperative serum AMH measurement
varied in different studies, although the majority of studies
Studies with analysis of changes in AMH stratified (five studies, 142 excisions) performed the measurement
by baseline AMH (>3.1 ng/ml)
Impact  de  la  chirurgieat the 3-month follow-up (25, 27–29, 36), and only two
Five studies (24, 25, 29, 35, 36), including 111 cystec- studies (28, 36) performed multiple measurements (56 ex-
NAL ARTICLE
tomies, were identified. Pooled analysis showed a statis- cisions). In these two studies, we used the latest sample (9
tically significant postoperative fall in serum AMH with and 3 months of follow-up) because this is likely to rep-
rine Care
low heterogeneity between studies (WMD !1.52 ng/ml; resent the most sustained postoperative change of serum
95% CI !1.04 to !2.00; I2 " 0%) (Fig. 3). AMH. This is clinically more important than the imme-
The Impact of Excision of Ovarian Endometrioma on which may be only temporary.
diate effect of surgery,
Studies with endometriomas 5 cm greater than A subgroup analysis for studies assessing AMH at 6–9
Ovarian Reserve: A Systematic
and baseline serum AMH 3.1 ng/ml or greater
Review and
months after surgery was also carried out. This analysis
Meta-Analysis
Two studies were identified (25, 35), involving 57 cys- was important to investigate the possibility of recovery of
tectomies. Pooled analysis showed a statistically signifi- ovarian reserve with time as suggested by a previous study
N=237
Francesca Raffi, Mostafa Metwally, and Saad Amer
La  chirurgie  altère  la  réserve  ovarienne
University of Nottingham (F.R., S.A.), Royal Derby Hospital, Derby, DE22 3NE, United Kingdom; and
Ninewells Assisted Conception Unit (M.M.), Dundee DD1 9SY, United Kingdom

Pre op
AMH  levels
Context: Endometriomas are mainly treated surgically. However, there has been concern over the ≥  3.1ng/ml
potential damaging effect of this surgery on ovarian reserve.

Objective: The aim of this meta-analysis was to investigate the impact of surgery for endometri-
omas on ovarian reserve as determined by serum anti-Müllerian hormone (AMH).

Data Sources: MEDLINE, PubMed, and Embase were searched electronically.

FIG. 3. Meta-analysis. Weighted mean difference in serum AMH after surgery for endometrioma: pooled results for studies with analysis of
changes in AMH stratified by baseline AMH (!3.1 ng/ml).
Study Selection: All prospective cohort studies that analyzed changes of serum AMH concentra- Raffi et  al.,  JCEM,  2012
tions after surgical treatment of endometriomas were eligible. Twenty-one studies were identi-
 Impact  de  la  chirurgie :  IOP
Bilateral endometrioma excision  :  Postoperative ovarian failure
N=126 IOP

424 Busacca et al
Rate  of  
Table III
ian failure
Characteristics of patients with postsurgical ovar- postoperative ovarian failure:
Patient Patient Patient 2.4%  (95%  CI  0.5%  -­ 6.8%)
Characteristics 1 2 3
Clinical characteristics
Age (y) 31 33 39
Menstrual cycle characteristics
Regularity Regular Regular Regular
Length (d) 28-31 28-31 28-31
Previous pregnancies No No Yes
Symptoms at the time
of surgery
Dysmenorrhea Yes Yes Yes
Dyspareunia No Yes No
Infertility No No Yes
Surgical characteristics
Stage (ASRM Classification*) IV IV IV
Ovarian endometriomas
Right ovary
Number 1 2 3
Diameter (mm) 50 55 20
Left ovary
Number 1 1 3
Diameter (mm) 30 20 20 Figure Cumulative pregnancy rate according to the duration
Deep peritoneal endometriosis No No No of infertility. Sixty-five women have tried to become pregnant
Superficial peritoneal Yes No Yes and have a child after surgery, 43 of them had at least 1 preg-
endometriosis nancy (66.2%).
Douglas obliteration No Partial No
Adnexal adhesions score* 16 4 8 Busacca et  al., AJOG,  2006
autoimmune reaction from severe local inflammation caus-
4,5,17
 Chirurgie  pour  OMA  unilatéral:
680
risque  d’IOP Benaglia et al.

680 Benaglia et al.

Table II Baseline clinical characteristics of the 93
selected patients.
Table II Baseline clinical characteristics of the 93
Characteristics
selected patients. Mean + SD or number (%)
........................................................................................
At the time of surgery
Characteristics
Age (years) N  =  93 Mean + SD or number (%)
........................................................................................
31.4 + 3.4
Absence  of  follicular growth:
At the time of surgery
Diameter of the excised cyst (cm)
Age (years)
4.2 + 1.8
31.4 + 3.4
Operated ovary =    12  cases  (13%)
At the time of IVF
Diameter of the excised cyst (cm)
Age (years)
4.2 + 1.8
34.4 + 3.4 Controlateral ovary:  0  cases  (0%)
At the time of IVF
Time since ovarian surgery (years)
Age (years)
Duration of infertility (years)
3.0 + 2.4
34.4 + 3.4
3.7 + 2.2
(p  <  0.001)
Time since ovarian surgery (years) 3.0 + 2.4
Previous IVF cycles* 9 (10%)
Duration of infertility (years) 3.7 + 2.2
BMI (kg/m2) 21.9 + 3.4

Severe ovarian damage:

Previous IVF cycles* 9 (10%)
Day 3 serum 2 FSH (IU/ml) 8.6 + 3.7
BMI (kg/m ) 21.9 + 3.4
Day IVF
3 serum
cycles FSH (IU/ml)
cycles before and8.6 3.7
+ surgery.
13%  (95%   CI  7%  -­ 21%)
*Previous included after

*Previous IVF cycles included cycles before and after surgery.

Table III IVF cycle outcome. Operated ovary Non operated ovary
Table III IVF cycle outcome.
Characteristics Mean + SD (n 5 93) or
number (%)
Characteristics Mean + SD (n 5 93) or
........................................................................................
Duration of stimulation (days) number (%)
11.1 + 2.0
........................................................................................
Total rFSH
Duration of (IU)
stimulation (days) 3196
11.1 2.01372
++
Number of (IU)
Total rFSH oocytes retrieved 5.9 +
3196 3.3
+ 1372
Number
Number ofof oocytes
embryosretrieved
transferred 2.2
5.9 ++ 0.7
3.3
Number
Number of (%) of transfers
embryos not
transferred 12+
2.2 (13%)
0.7
performed
Number (%) of transfers not 12 (13%)
Number
performed of clinical pregnancies and PR 15 (19%)
per transfer
Number of clinical pregnancies and PR 15 (19%)
Number of implanted embryos and
per transfer 20 (12%) Figure 1 Sonographic findings in a 34-year-old woman who under-
implantation rate
Number of implanted embryos and 20 (12%) went 1excision of a findings
4 cm right ovarian endometrioma, three years
Figure Sonographic in a 34-year-old woman who under-
implantation rate prior
went to IVF.
excision of a 4 cm right ovarian endometrioma, three years
rFSH, recombinant FSH; PR, pregnancy rate.
rFSH, recombinant FSH; PR, pregnancy rate.
prior to IVF.
A representative sonographic section of the operated and contralateral non-
operated gonad
A representative on the day
sonographic of hCG
section of the administration is shown in non-
operated and contralateral the upper
and lower
operated gonadpanel, respectively,
on the day of hCG andadministration
the total number of follicles
is shown in the with
uppera mean
Absence of follicular growth was observed in 12 operated ovaries.
and diameter mm in the two
!11respectively,
lower panel, ovaries
and the totalwas 0 andof10,
number respectively.
follicles with a mean
This event never
Absence occurred
of follicular growthin was
the contralateral
observed in 12gonad (Fisher’s
operated exact
ovaries. diameter !11 mm in the two ovaries was 0 and 10, respectively.
This event
test, never occurred
P , 0.001). The frequencyin the (95%
contralateral gonad (Fisher’s exact
CI) of non-responsive ovaries
test, P , 0.001).
following surgeryThe wasfrequency
13% (7 – (95%
21%).CI) of non-responsive
A representative ovaries
case is illus- issue. Of relevance here is that this result is in line with a recent
following
trated in surgery
trated Absence
cycle.
was of
Fig. 1. Six
in Fig. 1.ofSix
13%
of these
follicular
(7 – 21%).
these
12 women
growth
A representative
12 women underwent case
in the underwent
is illus-IVF
a second
a second
operated ovaries wasIVFcon-
issue.
paper
Of relevance
paper reporting here
reporting
ovarian failurea in2.4% Benaglia et  al., Hum  Reprod (2010)
is that
a 2.4%
women
(95%
(95%who
this CI:
result
CI: were
0.5is– 6.8)
0.5 – 6.8)
in line withofa post-surgical
rate
rate of
operated
recent
forpost-surgical
bilateral ovarian
cycle. Absence
firmed in all ofofthem.
follicular growth
Clinical in the operated
characteristics andovaries was con- in
cycle outcome ovarian failure in women
endometriomas who
(Busacca et were operated
al., 2006). for bilateral
Indeed, ovarian
if the risk of severe
firmed 12
these in all of them.
cases were Clinical
compared characteristics
with those andincycle
the outcome
remainingin 81 endometriomas (Busacca independent
damage is considered et al., 2006). for
Indeed, if the
the two risk ofthe
ovaries, severe
expected
 Coelioscopie OME

Oma cyst wall:

no follicule
Ovarian cysts Recognizable ovarian tissue  
adjacent  to  OC  wall

N n %

OMAs 26 14 54

Serous 7 0 0
Oma cyst wall:
Scanty primordial follicule Dermoid 6 1 17

Mucinous 3 0 0

Total 42 15 36

`Oma cyst wall:

Two primordial follicule
Destruction  parenchyme  ovarien

Muzii et  al.,  Fertil Steril (2002)

TABLE 3 Impact  d ’une  chirurgie  
i térative  sur  la  
réserve  ovarienne
Comparison of ovarian reserve before and after second surgery in case subjects.
Before second After second
Variable surgery (n [ 18) surgery (n [ 18) P value
AMH (ng/mL), mean " SD 2.7 " 1.9 1.2 " 1.2 <.001
Basal FSH (mIU/m)L, mean " SD 8.7 " 3.9 14.9 " 6.6 <.001
Total AFC (n), median (range)Chirurgie  itérative:  altération  
8 (4–15) 6.5R (4–13)O .34
AFC in the healthy ovary (n), median (range) 5.5 (3–9) 5.5 (4–12) .65
AFC in the affected ovary (n), median (range) 2 (1–6) 1 (0–4) .005
Volume of the affected ovary (cm3), mean " SEM 95.0 " 22.2 4.7 " 0.2 <.001
Volume of the healthy ovary (cm3), mean " SEM 6.9 " 0.3 6.4 " 0.2 .23
Note: Abbreviations as in Table 1.
Ferrero. Ovarian reserve and recurrent surgery. Fertil Steril 2015. Ferrero  et  al.,    Fertil Steril,  2015
 Chirurgies   itératives   et   endométriose

Coef = 0.62, 95% CI 0.47-0.77, p<0.0001

Number   of  DIE  lesions

Determinants  for  existence  of  D IE  results  

with  multiple   logistic  regression  analysis.  
AOR (95%  CI) p

Previous  surgery  ( yes  vs no) 2.7 (1.7-­‐4.3) <0.001

Plus  les  femmes  sont  opérées  plus  il  y  a  des  lésions  sévères

Sibiude,  Santulli,  Chapron,   Obstet Gynecol,    2014

TABLE 2 Impact  d’une  récidive  d’OME  
sur  la  réserve  ovarienne
Comparison of ovarian reserve before second surgeryof  inocase
Comparaison   subjectsreserve
varian and at similarbefore
follow-up insecond  
control subjects.
surgery
Homolateral No  OMA  
Variable Récidive  d’OME  :  pas  d’altération   Case (n [ 18)
de  la  réserve  
OMA  recurrence ovarienne
recurrence Control (n [ 18) P value
AMH (ng/mL), mean " SD 2.7 " 1.9 3.1 " 1.9 .59
Basal FSH (mIU/mL), mean " SD 8.7 " 3.9 8.4 " 3.7 .85
Total AFC (n), median (range) 8 (4–15) 9 (5–15) .37
AFC in the healthy ovary (n), median (range) 5.5 (3–9) 6 (2–12) .54
AFC in the affected ovary (n), median (range) 2 (1–6) 3 (1–5) .24
Volume of the affected ovary in case subjects and of the previously 95.0 " 22.2 6.8 " 0.4 <.001
operated ovary in control subjects (cm3), mean " SEM
Volume of the healthy ovary (cm3), mean " SEM 6.9 " 0.3 6.6 " 0.3 .44
Note: Abbreviations as in Table 1.
Ferrero  et  al.,  Fertil Steril,  2015
 Endométriose  &  infertilité
Place  de  la  chirurgie
N=222
Cumulative  PR
Stages  I  -­ IV

50%

30  %

Time  (months)
6 18

Vercellini et  al.,  Human Reprod,  2009

 er group in women
were 96seeking
(23%),conception
43 (10%), who underwent
146 (35%), and 126
,31%), primary (n ¼ 411,
respectively. solid line) and
Laparoscopy wasrepetitive
performed (n ¼in89,
71
-89%) dotted
cases atline) conservative
second-line surgery
surgery andforinendometriosis
369 (90%) at
.rst-line(log-rank
surgery.test,
2
1 ¼ 8.16(interquartile
Thec median , P¼.006). Lower range)panel:
time
pent in24-month
eery was
pregnancycumulative
women who underwent
21 (10–35)
pregnancy
seeking after
primary
and 15 (6–36) Chirurgie  itérative
repetitiverates
and in
(n ¼ 290,
months,
infertilesur-
primary
solid line)
respectively.
- Afterand the
repetitive (n ¼ 67, dotted line) conservative
second operation 20(log-rank
of 89 (22%)
nchieved surgery for endometriosis test, cof
2 patients
1 ¼ 4.11 ,
spontaneous
P¼.043). conception compared with 165 of
r11 (40%) women who underwent first-line surgery
eFisher’s exact test, P¼.002; Relative risk [RR], 0.56;
-5% CI, 0.37 to 0.84). Survival Endométriose Endométriose
analysis confirmed
Infertilité   -­ a signif- Infertilité   +
6cantly reduced chance of pregnancy after second-line com-
eared with first-line surgery (log-rank test, c2 ¼ 8.16,
1
s¼.004, Fig. 1, upper panel). The 12- and 24-month cumu-
9ative pregnancy rates were 14% and 26% after repetitive
-urgery compared with, respectively, 32% and 38% after
6 first-line procedure. Of the women operated on twice in
40%
1ur department, 24%First  line  S.
(15 of 62) achieved conception, and 34%
t9% (5 of 27) of patients who underwent primary surgery
First  line  S.
en another hospital succeeded in conceiving (Fisher’s exact
22%
-est, P¼.78). Cox regression models confirmed a statisti- 19%
Repetitive  S. Repetitive  S.
ally significant reduced probability of conception after
second-line compared with first-line surgery (P¼.006),
hef adjusted IRR being 0.51 (95% CI, 0.32 to 0.82).
y The analyses were repeated in the subgroup of patients
; Vercellini. Correspondence. Fertil Steril 2009.
eporting infertility at the time of surgery (67 and 290 re-
-
pectively in the second- and first-line surgery group). Thir-
-een (19%) conceived after repetitive surgery compared
, Vercellini
cally significant reduced et  al.,  of
probability Fertil Steril (2009)  
conception after
with 98 (34%) after primary surgery (Fisher’s exact test,
 Place  de  la  chirurgie:
quid  de  la  littérature?

• Meleman,  2013

• Vercellini,  2012

• Bendifallah,  2017

Nombreux  biais  dans  la  littérature……

rine with moderate endometriosis. No statistically significant difference
69) was observed between the number of patients with dysmenorrhea,
deep dyspareunia, and CPP in the study and control groups pre- and
was postoperatively (P > 0.05).
tive
and
Deep DISCUSSION
endometriosis related infertility :
To our knowledge, Laparoscopic
this is the firstsurgery in  wcohort
prospective omenstudy
with moderate
in which the full clinical to  severerate,
outcome (complication endometriosis
reintervention,
Patients Wishing  to   Pregnant
nant operated conceive
ese
127 94  ( 74%) 48  ( 51%)
The
76 54  ( 71%) 27  ( 50%)
own 73%
rate 58%
1). 44%
7%
east 50,7  %
% (n 75/148
The

3  Years
the 2  Years
1  Year

ups,
94,

d
FIGURE 1. Time to first pregnancy after (first) intervention
aser for moderate to severe endometriosis in function of bowel
on- resection. Meuleman C  et  al., Ann  Surg (2013)
study (71%; n = 54/76) and in the control (74%; n = 94/127) groups,
as was their pregnancy rate (50%; n = 27/54 and 51%; n = 48/94,
respectively) (Fig 1).

Effect of Surgery on Pain, General Satisfaction, and

Quality of Life FIGURE 1. Time to first pregnancy after (first) intervention
Deep endometriosis related infertility :
The median follow-up period after multidisciplinary CO2 laser for moderate to severe endometriosis in function of bowel
surgery was 20 months (<1–45 months). For the EHP30 Question- resection.
Laparoscopic surgery in  women
TABLE 6. Mode ofwith moderate
Conception to  severe
(For the First Pregnancy) After endometriosis
Surgery for Endometriosis
Patients With at
Least 1 Functional Study Group Control Group
Mode of Conception (First Pregnancy) Total (n = 75) Tuba (n = 66) (n = 48) (n = 27)
Spontaneous 31 (41%) 30 (45%) 18 (38%) 13 (48%)
Stimulation + HIUI 7 (9%) 7 (11%) 6 (13%) 1 (4%)
IVF 24 (32%) 20 (30%) 14 (29%) 10 (37%)
IVF with donor sperm 1 (1%) 0 (0%) 1 (2%) 0 (0%)
Intracytoplasmatic sperm injection 7 (9%) 6 (9%) 6 (13%) 1 (4%)
Cryo 3 (4%) 2 (3%) 1 (2%) 2 (7%)
Oocytes reception 2 (3%) 1 (2%) 2 (4%) 0 (0%)

41%     conceived  spontaneously

8 | www.annalsofsurgery.com C 2013 Lippincott Williams & Wilkins
⃝

Bowel  resection p
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Yes No
Recurrence 2/76  (3  %) 6/127  (5%) <0.05

Only 21%  (31/148)  conceived spontanously

Meuleman C  et  al., Ann  Surg (2013)
DIE  related infertility:  Bias in  pregnancy
rates

Vercellini,  2012
DIE  related infertility:   Bias in  pregnancy rates

Spontaneous 25-­30%

Spontaneous +  ART
 Stratégie  en  FIV

• Il  n’est  pas  recommandé  de  réaliser   un  traitement  chirurgical  de  

l’endométriose  superficielle dans  le  seul  but  d’augmenter  les  chances  
de  grossesse   en  FIV  (grade  C)

• Le  traitement  chirurgical   des  endométriomes  dans  le  seul  but  

d’améliorer   les  résultats  de  la  FIV  n’est  pas  recommandé  (grade  B)

• Il  n’est  pas  recommandé  de  réaliser   une  aspiration   transvaginale

systématique  sous  contrôle  échographique  des  endométriomes   avant  
FIV  afin  d’augmenter  les  taux  de  grossesse   (grade  C)
 Stratégie  en  FIV

• Il  n’est  pas  recommandé  de  réaliser  un  traitement  chirurgical  

préalable  de  l’endométriose  profonde  dans  le  seul  but  d’améliorer  les  
résultats  en  FIV  (grade  C)

• En  cas  d’échec  d’une  ou  plusieurs  tentatives  de  FIV  dans  un  contexte  
d’endométriose  profonde,  une  concertation  médico-­‐chirurgicale   est  
recommandée  pour  discuter  d’une  chirurgie  de  l’endométriose  (AE)
 Take Home  Messages
-­‐ La  chirurgie des  endométriomes altère la  réserve
ovarienne

-­‐ Chirurgie  si  DOULEUR ou  désir  de  grossesse

« once  in  life »

-­‐ Pas de    chirurgie  si  :  asymptomatique,  OME,  avant  ART,  

adénomyose

-­‐ Chirurgie des  OMA  non  nécessaire avant FIV

 Avant….

Diagnosic Chirurgie Traitement  

Chirurgie itératives FIV
endométriose première médical
Immédiate

La  FIV  arrive  au  terme  du  parcours

Chapron,  2017
 En  2019:

Désir  de  grossesse

Diagnostic Chirurgie Traitement

UNIQUE médical
Traitement FIV
médical

Chapron,  2017
 En 2019

-­ Diminuer  le  nombre  de  

chirurgies  inutiles

-­ Pas  de  place  pour  la  

coelioscopie exploratrice

-­ Pas  de  chirurgie  pour  

augmenter  les  résultats  de  
Photo  FIV
la  FIV
 Take home  messages

• Traitement  individualisé

• PEC  multidisciplinaire

• Challenge:  Planifier  le  meilleur  moment  pour  la  chirurgie

• Médicament,  Chirurgie,  FIV

• Chirurgie si  douleur

• Préservation   de  la  fertilité   chez  les  patientes  jeunes  +++  (DU  PMA)
• Merci  pour  votre  attention