ART

in
ENDOMETRIOSIS
PCO
HYDEROSALPINX

BY
MAHMOUD ABD ELLATIF
UNDER SUPERVISION OF
PROF. MOHAMED HISHAM
 Assisted Reproductive Technologies
Assisted Reproductive Technologies Individualization

 The way to approach any patients for an ART treatment should be
fully personalized
 Individualization of ART treatment protocols potentiate the results and
decrease the risks

 Endometriosis , PCOS, Hydrosalpinx has special concerns during

ART wok up following specific treatment protocols
 Steps Of ART Treatment Cycle
1- Initial consultation & assessment: Consent, Success rates, Complications, Storage of genetic
material

2- Pretreatment adjuvant strategies: Hormonal, Surgical, Other (Antioxidant, Metformin,

Vasodilators)

3- Pituitary down regulation: GnRH agonist (Long, Short), GnRH antagonists (Fixed, Flexible)
4- Controlled ovarian hyper stimulation: FSH (Standard, Individualized depend on ovarian
reserve)

5- Final follicular maturation trigger: HCG, GnRH agonist , dual trigger, Kisspeptin
6- Oocyte and sperm retrieval: Ovum pick-up (Transvaginal, Transabdominal), Sperm retrieval
7- Embryology process (IVF/ICSI)
8- Monitoring of embryos: Morphological evaluation, Blastocyst grading, pre-implantation genetic
screening
 ART IN PATIENT WITH HYDROSALPINX

BACKGROUND:
 Hydrosalpinx: Collection of watery fluid in the fallopian tube

 Causes:
 PID: Chlamydial (the most common ), Gonococcal infection
 Others: Ovulation induction, Tubal ligation

 Clinical Presentation:
 Asymptomatic
 Pelvic pain
 Infertility
 Diagnosis:
TVS:
• Elongated or folded, tubular, C-shaped, or S-shaped fluid-filled structure
• Distinct from the uterus and ovary.

HSG:
• Retort-like shape of the distended tubes
• Absence of free spillage

 Laparoscopy:
• Distended tubes
• Associated adhesions affecting the pelvic organs
IMPACT OF HYDROSALPINX ON FERTILITY
 Incidence:
• Tubal factors account for 25-35% of female infertility

• Hydrosalpinx is found in 10-30% of couples with infertility

Mechanisms: hydrosalpinx fluid

• Embryo toxic effects : embryotoxic components , growth inhibiting factors
• Mechanical effects: wash-out of embryos through leakage of fluid
• Endometrial alterations: hostile to embryo implantation and implantation
IVF & HYDROSALPINX
IVF now is the major treatment for infertile women with
hydrosalpinx

IVF patients with untreated hydrosalpinx have lower conception

rates than controls

IVF in patients with hydrosalpinx has poor outcome compared with

other types of tubal infertility
• Pregnancy , Implantation, Live birth rates : reduced to half
• Miscarriage rate: doubled
MANAGEMENT
 Aim: eliminating the hydro salpingeal fluid before starting IVF

 Methods:
1- Salpingectomy:
• Surgical removal of fallopian tubes
• Recommended particularly for those with ultrasound-visible hydrosalpinxes
• Surgical intervention doubled the clinical pregnancy rate
• Laparoscopic salpingectomy doubled live birth rate
• Carries a potential risk of damaging vascular and nervous supply to the ovary
• However, ovarian response to COS after salpingectomy not significantly
impaired
Advantages:
 Removes the chronically infected hydrosalpinx,
 Decreasing the risk of infection after oocyte retrieval
2- Tubal occlusion
• Permanent blocking of the proximal part of the tube
• Indicated in severe adhesions: salpingectomy is difficult with risk of ovarian damage
• Done through laparoscopy
• Done through hysteroscopic route if laparoscopy is risky or contraindicated
• Significant increase in clinical pregnancy rate

3- Transvaginal aspiration of the hydrosalpingeal fluid

a- At the time of oocyte retrieval:
• Doubled biochemical pregnancy rate
• Increase clinical pregnancy but not statistically significant

b- An option during ovarian stimulation:

• If fluid develops and hydrosalpinx becomes visible on the ultrasound scan .

ART TREATMENT CYCLE IN CASE of HYDEROSALPINEX
:Initial consultation & assessment -1
 Accurate infertility workup is important
 Discuss prognosis and treatment options with the patient if hydrosalpinx is
detected or even suspected
 The patient may not be prepared to undergo salpingectomy prior to her first IVF
cycle but the discussion can be renewed after a failed cycle if appropriate.
 Prior to a laparoscopy discuss potential findings and associated surgical
procedures thoroughly to avoid a repeat procedure
 surgical interventions, will increase her chances of conception considerably
2- Pretreatment adjuvant strategies:
 Surgical interventions

3- Pituitary down regulation

4- Controlled ovarian hyper stimulation:
 Transvaginal aspiration of the collected hydrosalpingeal fluid is an option
5- Final follicular maturation trigger
6- Oocyte and sperm retrieval
7- Embryology process (IVF/ICSI)
8- Monitoring of embryos
9- Intrauterine embryo transfer
10- Luteal phase support
N.B: Interventional ultrasound guided sclerotherapy before IVF is an
effective and less invasive prophylactic intervention alternative to
salpingectomy with hydrosalpinx.
(Clin Exp Reprod Med. 2012 Dec; 39(4): 182–186. )
 ART IN PATIENT WITH ENDOMETRIOSIS
BACKGROUND:
 Endometriosis: chronic disease characterized by presence of
endometrial-like tissue outside the lining of the uterus which induces
inflammatory reaction
 Causes: exact cause is unknown (disease of theories)
 Sites:
1- Pelvic:
• Ovary: 44% commonest (Endometrioma)
• Peritoneum: 34% 2nd most common (Douglas pouch)
2- Extra pelvic
 Lesions:
1- Deep lesions :
• Penetrations of greater than 5 mm
• Represent a more progressive form of the disease
2- Superficial implant
• Lesions on peritoneal surfaces, including the ovary
• Represent a less progressive form of the disease

 Diagnosis:
1- Gynecological symptoms : cyclic pelvic pain, infertility
2- Clinical examination: is predictive (nodules of rectovaginal wall if deep)
3- Specific medical technologies: Laparoscopy, TVS, MRI,3D U/S
Classification and Staging Systems:
1- Revised classification of the American Society for Reproductive Medicine
(ASRM):
• Reflects the extent of endometriotic disease
• Stages: I: Minimal , II: Mild , III: Moderate , IV: Severe

2- Endometriosis Fertility Index:

• Based on historical and surgical factors
• The EFI score: 0-10, with 0 representing the poorest and 10 the best prognosis

3- Enzian Classification:
• Based on anatomic location of the deep lesions & the depth of invasion
• It consists of four stages, which are further subdivided into three groups

4- World Endometriosis Society:

•
IMPACT OF ENDOMETRIOSIS ON FERTILITY
 Incidence:
• 30% to 45% in women with infertility
• 20-40% women undergoing ART
• Endometrioma present in around 5% of IVF patients
 Mechanisms:
1- Physiologic Defects:
• Anovulation – Reduced ovarian reserve- Luteal Dysfunction
• Endometrial abnormality – Local E production and P resistance
• Balstomere/Sperm toxicity – Inflammatory changes in Peritoneal fluid
2- Anatomical Defects: Peri tubal Adhesions - Tubal block
3- Associations: Dyspareunia- Hyperprolactinemia
IVF & ENDOMETRIOSIS
 Indication:
 Tubal function is compromised – AFS/ASRM stage III/IV or
 If there is male factor infertility, and/or
 If Other treatments have failed
 Patients failing to conceive spontaneously after the initial surgery (more
effective than repeat surgery)

 May be considered:

 In infertile women undergoing laparoscopy and found to be AFS/ASRM

stage I/II endometriosis
MANAGEMENT
 IVF & surgical management of endometriosis:
 ASRM stage I/II:
Surgery may be considered prior to ART to improve live birth rate,
although the benefit is not well established

 ASRM stage III/IV:

Surgery not recommended prior to ART to promote fertility or increase
pregnancy rates

 Ovarian endometrioma:
Surgery not recommended before IVF unless indication is PAIN or to allow
accessibility for oocyte retrieval (risks of reduced ovarian function and the
possible loss of the ovary after surgery , not increase fertility outcome)
 IVF & Medical therapy in infertile women with endometriosis:
GnRH agonists is recommended for 3 to 6 months prior to ART
improve clinical pregnancy rates

Medical therapy while waiting for fertility treatment is not

recommended as routine however, this may sometimes be required for
symptomatic control
ART TREATMENT CYCLE IN CASE OF ENDOMETRIOSIS
:Initial consultation & assessment -1
 Accurate infertility workup is important
 Establish outcomes of previous surgical and/or medical treatments
 Check ovarian reserve (FSH, AMH, AFC).
2- Pretreatment adjuvant strategies:
 OFFER GnRH agonists for 3-6 consecutive months before the IVF cycle.
 Consider laparoscopic excision if large endometrioma (>3 cm or >4cm).
3- Pituitary down regulation:
 GnRH agonist's long luteal protocol: prefeed in adequate reserve
• Prolonged down regulation
• Better metaphase II eggs and embryos
 GnRH Antagonist protocol: has comparable clinical pregnancy outcome with
long agonist protocol, especially in those with diminished ovarian reserve, the
higher available embryo rate can be achieved.

4- Controlled ovarian hyper stimulation:

 AMH levels can be used to individualize control ovarian stimulation
in endometriosis patients.
5- Final follicular maturation trigger
6- Oocyte and sperm retrieval:
 Avoid puncturing or draining the endometrioma during oocyte retrieval.
 Give intravenous antibiotics at oocyte retrieval
7- Embryology process (IVF/ICSI)
8- Monitoring of embryos
9- Intrauterine embryo transfer
10- Luteal phase support
Intrauterine insemination in women with endometriosis
IUI is performed with controlled ovarian stimulation:
 Recommended instead of expectant management: increases live birth rates
 Recommended instead of IUI alone: it increases pregnancy rates
 Within 6 months after surgical treatment of stage I/II endometriosis
 ART IN PATIENT WITH PCOS
BACKGROUND:
 PCOS:
 Heterogeneous, multifactorial endocrinopathy
 Characterized by a combination of
• Androgen excess (secretion or activity)
• Ovulatory dysfunction and/or
• Polycystic ovaries

 Diagnostic classification:
 Rotterdam diagnostic criteria 2003 (ESHRE/ASRM Consensus)
IMPACT OF PCOS ON FERTILITY
 Incidence:
 PCOS is the most common cause of Anovulation (80-90 % of cases).
 PCOS is presented by Infertility in 50%

 Mechanisms:
 Hormonal imbalance interferes with ovulation & implantation
ART TREATMENT CYCLE IN CASE OF PCOS
:Initial consultation & assessment -1
 Baseline pelvic ultrasound provides morphologic appearance
 Baseline endocrine profile aids choice of appropriate regimen.
 Assessment of glucose tolerance is important if overweight.
 Counsel for increased obstetric risk if overweight (gestational
diabetes, pre-eclampsia and fetal morbidity)
 Treatment plan aimed to minimize risk of OHSS.

2- Pretreatment adjuvant strategies:

 Metformin therapy for women with PCOS: significantly decreases the risk
OHS
3- Pituitary down regulation:
 Use low dose stimulation in either a long protocol or short GnRH-antagonist
protocol
4- Controlled ovarian hyper stimulation:
 Starting FSH dose of no more than 50–150 IU, depending on age and other
factors (AMH).
 Metformin therapy may reduce risk of OHSS (dose 850 mg twice daily from the
start of down-regulation to the day of oocyte retrieval).
5- Final follicular maturation trigger: Strategies to minimize the risk of OHSS
 Avoidance of HCG for the final maturation trigger
 GnRH agonist → physiological release of endogenous GnH→ significant risk↓
 GnRH agonist with small dose of HCG (1500 IU): dual trigger no ↑ in OHSS
risk
7- Embryology process (IVF/ICSI)

8- Monitoring of embryos

9- Intrauterine embryo transfer

10- Luteal phase support:

 Use progestogens and not hCG for luteal support