ART and endometrioma: assessing the outcome

ART and Endometrioma: assessing the outcome Juan A Garcia Velasco IVI - Madrid Disclosure of Interest: Nothing to Disclose

Topics to be discussed

Endometrioma

Endometrioma Where to look for information?

Endometrioma Statement #1 Most effective treatment of ovarian endometriomas?

Endometrioma

Endometrioma Statement #2 Ovarian response to COH?

All cysts are not created equal Risks of having a cyst Ovarian surgery diminishes # eggs

Endometrioma

Endometrioma 60% 53% 55%

All cysts Risks are of not having created a cyst equal Severe damage after surgery Absence of response to COH: not a rare event 13% (7-21%) 0%

Endometrioma Statement #3 IVF results?

Does endometriosis affect outcome? Endometriosis - IVF Barnhart et al, Fertil Steril 2002

Does endometriosis affect outcome? Endometriosis - IVF

Does endometriosis affect outcome? Oocyte donation

Does endometriosis affect outcome?

Does endometriosis affect outcome? Endometriosis - IVF PARACRINE (-) AUTOCRINE (-) ENDOCRINE (-)

Endometrioma Statement #4 Ovarian damage pre or post surgery?

Endometrioma

All cysts Risks are of not having created a cyst equal Damage due to the presence of cyst Unilateral endometrioma w/o surgery

All cysts are not created equal Risks of having a cyst Damage due to the presence of cyst Unilateral endometrioma w/o surgery

Ovarian Assesment Risks recovery of having of ovarian after a cyst Ovarian reserve after surgery reserve

All Assesment cysts Risks are of not having of created ovarian a cyst equal All cysts are not created reserve equal Well-defined ovarian capsule dermoids serous cystadenomas mucinous cystadenomas Endometriomas (margin of ovarian tissue)

All Assesment cysts Risks are of not having of created ovarian a cyst equal All cysts are not created reserve equal Endometrioma cyst wall

All cysts Risks are of not having created a cyst equal All cysts are not created equal Risk of serious damage in bilateral endometrioma resection ovarian artery blood flow changes accidental removal of ovarian tissue severe local inflammation BUT - pain symptoms reduced - 66% pregnant in 24 months Postsurgical ovarian failure 2.4%

Ovarian damage pre/post surgery? Operated ov Non - operated AFC 4.5 7.4 * # oocytes collected 4.3 7.4 * % zero eggs collected 18.7 1.2 *

Ovarian damage pre/post surgery? Serum AMH Overall Unilateral Bilateral Pre Op 3.9 4.1 3.6 Post Op 2.1 2.9 1.2

Ovarian damage pre/post surgery?

Endometrioma Statement #5 Treatment prior to IVF?

Is medical therapy pre-ivf useful?

Should we operate pre-ivf? 200 Pagidas 1996; Loh 1999; Al-Azemi 2000; Tinkanen 2000 Donnez 2001; Canis 2001; Marconi 2002

All cysts are not created equal Risks of having a cyst Should we operate pre-ivf?

All cysts are not created equal Risks of having a cyst Does endometrioma affect IVF? Surgery IVF # patients 49 50

Endometrioma Statement #6 Risks: better surgery than expectant?

Risks of having a cyst Risk of having a cyst

Conclusions Ovarian responsiveness to COH is diminished in women operated of endometriomas Results (PR) seem unaffected suggesting quantitative damage Damage is mainly surgery-mediated Cystectomy does not improve cycle outcome Careful surgery in SYMPTOMATIC women may be required INDIVIDUALIZATION IS CRUCIAL

Thank you! juan.garcia.velasco@ivi.es