Endometriosis: Surgical

Management and Optimal

Ovarian Stimulation
Protocol for ART
 ENDOMETRIOSIS

Jens Martensson
Endometriosis is as the presence of endometrium like tissue outside the uterus
which induces a chronic inflammatory condition.
• Treatment of endometriosis with infertility  surgical excision of the
endometriotic disease along with restoration of normal anatomy or
assisted reproduction techniques or a combination of both

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• The gold standard for definitive diagnosis of endometriosis currently
is laparoscopic visual-ization.

• The surgical goal in endometriosis is to remove all visible disease and

at the same time conserve as much ovarian tissue as possible.
• The laparoscopy need not be timed and performed at a
particular part of the menstrual cycle. To avoid
underdiagnosis, laparoscopy should not be performed during

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or within 3 months of hormonal treatment because of the
resultant temporary suppression of endometriosis with
these hormones.
• Biopsy of a lesion with histopathological con-firmation of
endometriosis is ideal in peritoneal disease
• ovarian endometrio-mas >4 cm, it is mandatory to have a
histopathol-ogy to exclude malignancy 4
 Case of right infundibulopelvic Brownish multiple areas of
ligament with surface endometriosis superficial peritoneal endometriosis
in the pelvis

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Laparoscopic Treatment for Minimal and Mild Endometriosis (AFS
Stage I or II)

The gold standard for surgical management (visu-alization,

excision, ablation, and adhesiolysis)
early endometriosis is laparoscopy with its advan-tage of

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lower morbidity, and visualization of early lesions

Excision or ablation of endometriotic lesions plus adhesiolysis

to improve fertility in minimal-mild endometriosis is effective
compared to diag-nostic laparoscopy alone to improve
ongoing pregnancy rates”
Surgical Treatment in Moderate or Severe
Endometriosis and Endometriomas: AFS Stage
III, IV, and Above
• In patients with moderate or severe endometriosis, the chances of spontaneous conception are
low at a monthly fecundity rate of < 3 %

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• operative laparoscopy can be considered instead of expectant management to increase
spontaneous pregnancy rates (grade B recommendation)
• A good practice point made is that laparoscopic ovarian cystectomy is recommended:
 If an ovarian endometrioma ≥3 cm in diameter is present to confirm the diagnosis
histopathologically
 To reduce the risk of infection
 To improve access to follicles
 To improve ovarian response
 cystectomy did not
predispose to the risk
Effect Of Ovarian Cystectomy of removing normal

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on ovarian reserve ovarian tissue and
compromising ovarian
func-tion
 Role of Hormonal
Treatment in Infertility

According to ESHRE 2014

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guidelines

Ovarian suppression using OCs,GnRH agonists, dan

azol, or progresterone is not recommended to
improve infertility ( Grade A Recomendation)
Role of Hormonal Therapy as an
Adjunct to Surgery
• pre-operative medi-cal treatment may actually be detrimental for
patients with ovarian endometriosis

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• The Guideline Development Group (GDG) recommends not to
prescribe adjunctive hormonal treatment before surgery to improve
spontaneous pregnancy rates, as suitable evidence is lack-ing
• Adjunctive hormonal treatment after surgery is not recommended
to improve spontaneous pregnancy rates (grade A recommendation)
( a ) Endometriomas with adhesions in pouch of Douglas. ( b ) Small
multiple endometria dissected; use sharp dissection during cyst excision
where possible and in the adherent areas. ( c ) Peeling of large
endometriotic cyst wall in progress; cauterize vessels on the side of the
cyst wall rather than on the ovarian surface

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Role of Assisted Reproductive
Techniques
• Assisted reproductive techniques used for
these patients would be IUI or IVF/ICSI.
After surgery it is recommended that one
of these techniques is used depending on
tubal status, ovarian reserve, severity of
disease, and presence of other factors like
male factor infertility.

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Role of IUI
• In mild to moderate endometriosis, IUI with • Best results are within 6 months after
controlled ovarian stimulation using surgical treatment, since pregnancy rates

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gonadotropins increases live birth rates are similar to those achieved in unexplained
instead of expectant management or IUI infertility
alone (5.6 and 5.1 times higher live birth
rates, respectively).

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 Role of IVF/ICSI
( a ) Adherent appendix to
endometrioma. ( b , c ) Retroperitoneal
• The pregnancy rates after IVF/ICSI can be dissection of ureter enables safer
lower in patients with stage III and IV
endometriosis as compared to those with tubal
excision of endometriotic disease in the
factor infertility, Soon after surgical correction area
of advanced endometriosis, IUI or IVF should
be considered for good results.

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• “IVF is appropriate treatment especially if tubal
function is compromised, if there is also male
factor infertility and/or other treatments have
failed”
• “Risk of recurrence is no reason to withhold
IVF therapy after surgery for endometriosis in
stage III or IV, since cumulative endometriosis
recurrence rates are not increased after
ovarian hyperstimulation for IVF”

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Role of IVF/ICSI

• “Treatment with a GnRH agonist for 3–4
months before IVF or ICSI should be
considered in women with endometriosis as
it increases the odds of clinical pregnancy
four fold.” However, the authors of Cochrane
• Laparoscopy is the gold standard for treatment
of endometriosis. Pre- or postsurgery
hormonal therapy is not recommended. Artifi
cial reproductive techniques in the form of IUI
or IVF/ICSI are recommended to improve

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review called for further research pregnancy rates depending on severity of
disease. Preoperative use of GnRH agonists for
3–4 months increases pregnancy rates
• In infertile women with endometrioma larger
than 3 cm, there is no evidence that
cystectomy prior to treatment with ART
improves pregnancy and it is recommended
only to consider cystectomy prior to ART for
improving endometriosis-associated pain or
the accessibility of follicles

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Algorithm for
management of
endometriosis
Thank
You
Jens Martensson
jens@bellowscollege.com