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Endometriosis

and infertility
Nama: Nia Apryanti
Nim : 03011213
Pembimbing
: dr. Komang Arianto
Sp.OG

Introduction
The presence of endometrial-like tissue
outside the uterus
Induces a chronic inflammatory reaction,
scar tissue, and adhesions
Primarily found in young women
Not related to ethnic and social group
distinctions
Mainly
complain
:
pelvic
pain,
dysmenorrhea, dyspareunia.

Epidemiology
25% - 50% of infertile woman have
endometriosis
30%
50%
of
women
with
endometriosis are infertile

Signs and symptoms


Dysmenorrhea

6080%

Chronic pelvic pain

4050%

Deep dyspareunia

4050%

Infertility

3050%

Severe menstrual pain and irregular flow and/


premenstrual spotting

1020%

Tenesmus, dyschezia, hematoschezia, costiveness, or


diarrhea

1-2%

Dysuria, pollakiuria, micro-macroscopic hematuria

1-2%

Endometriosis and
infertility
Infertile women are 6 to 8 more likely to
have endometriosis than fertile women
Mechanisms : distorted pelvic anatomy,
endocrine and ovulatory abnormalities,
altered peritoneal function, and altered
hormonal and cell-mediated functions in
endometrium.

Pelvic anatomy distortion


Major pelvic adhesions or peritubal adhesions
Disturb the tubo-ovarian liaison and tube
patency

Impair
oocyte
release
from the
ovary

Inhibit
ovum
pickup /
impede
ovum
transport

Endocrine and ovulatory


disorders
Including :
Luteinized unruptured follicle syndrome
Impaired folliculogenesis
Luteal phase defect
Premature or multiple luteinizing hormone
(LH) surges

Altered peritoneal function


Women with endometriosis have an increased
volume of peritoneal fluid with a concentration of
activated macrophages, prostaglandins, IL-1, TNF,
and proteases.
Adverse effects on the function of the oocyte, sperm,
embryo, or fallopian tube.
May alter endometrial
implantation.

receptivity

and

embryo

Treatment of endometriosis-associated
confirmed disease

infertility

in

Medical treatment
Relieving pain associated with endometriosis
There is no evidence that medical therapy improves
fecundity
Comparing medical treatment to no treatment or
placebo, the common odd ratio for pregnancy was 0.85%
In minimal-mild endometriosis : suppression of ovarian
function to improve infertility is not effective
In severe disease : there is no evidence of its
effectiveness

Surgical treatment
In minimal-mild endometriosis : ablation of endometriotic
lesions plus adhesiolysis to improve fertility
In moderate-severe endometriosis : no explanations
available to answer the question whether surgical
excision enhances pregnancy rate
By normalizing pelvic anatomy distortion and by
adhesiolysis, may enhance fertility
After surgery : negative correlation between the stage of
endometriosis
and
the
spontaneous
cumulative
pregnancy rate
Laparoscopic cystectomy for ovarian endometriomas
>4cm diameter improves fertility compared to drainage
and coagulation
Coagulation or laser vaporization of endometriomas
without excision of the pseudocapsule is associated with
a significantly increased risk of cyst reccurrence

Assisted reproduction in endometriosis


IVF if :
Tubal function is compromised
Also male factor infertility
Other treatments have failed
Prolonged treatment with a GnRH agonist before IVF
Laparoscopic ovarian cystectomy :
Ovarian endometrioma >4cm
Confirm the diagnosis histologically
Improve access to follicles and possibly improve
ovarian response

Clinical variables to be considered in women selected for IVF


Characteristics

Favours surgery

Favours
expectant
management

Previous intervention of
endometriosis

None

Ovarian reserve

Intact

Damaged

Pain symptoms

Present

Absent

Bilaterality

Monolateral
disease

Bilateral
disease

Sonographic feature of
malignancy

Present

Absent

Growth

Rapid growth

Stable

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