Contemporary Surgical Management for Endometriosis Related to Infertility

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Mark Perloe, MD: “I’m Mark Perloe, I’m here at the American Society of Reproductive Medicine with Professor Togas Tulandi who is Professor of Obstetrics and Gynecology, and the Milton Leong Chair in Reproductive Medicine at McGill University. You had a presentation today on the contemporary surgical management of endometriosis. Can you share your findings with our viewers?”

Togas Tulandi, MD: “Treatment of endometriosis could be medical or surgical. For surgical treatment, laparoscopy is the answer. It has been shown that removal of mild and minimal endometriosis either with laser or electro-cautery or by excision improves the pregnancy rate. For endometriomas the best treatment is excision. Some people do fenestration and coagulation, which means they just open up a cyst, drain it and they burn the inner side of the cyst. The excision is superior because the recurrence rate is much lower, and we published it in Fertility and Sterility two years ago.”

Mark Perloe, MD: “Let me go back, I think you hit on two areas I want to cover. One of the criticisms of the Endocan study has been that many of these patients had adhesions and that the treatment of adhesions may have contributed to the success, rather than just the excision of the endometriosis. And the other comment that people have is that the control group pregnancy rates appear significantly lower than historical studies have shown. How would you comment on those criticisms?”

Togas Tulandi, MD: “The Endocan study is the first and the only randomised clinical trial for infertile women with endometriosis. There are no other trials so far. In terms of adhesions, I don’t believe that they had a lot of adhesions in the endometriosis group; in fact, they were only stage one and two endometriosis, so they had no or minimal adhesions. Supposedly they had adhesions, the same thing would be in the control group as well.”

Mark Perloe, MD: “So based on that study do you believe that in the patient with unexplained infertility there is still a role for diagnostic laparoscopy?”

Togas Tulandi, MD: “Oh, there is a role in diagnostic laparoscopy; in fact that study tells us if you do laparoscopy and you see endometriosis, stage one or two, you should burn it or laser it or remove it. It will increase the pregnancy rate. The diagnosis of unexplained infertility is established after a negative laparoscopy.”

Mark Perloe, MD: “The other item that you mentioned was the treatment of the endometriomas. I think many reports have discussed recurrence rates with inadequate treatments, such as ablation, drainage, irrigation, fenestration. What about IVF success rates? In some patients you cannot excise an endometrioma and you are forced to open it and ablate the interior. Do you risk damage to the ovary and damage to fertility? And based on that how would you decide which endometriomas to remove prior to doing IVF?”

Togas Tulandi, MD: “We remove endometriomas if there is symptomatic; pelvic pain or the presence of large endometrioma – three centimetres or larger. If the patient has a frozen pelvis, then she should just go to IVF. The only concern is, if you puncture that endometrioma trans-vaginally, people have reported more abscess formation. In view of IVF pregnancy rate, some studies have shown that pregnancy rate is the same, others reported that the pregnancy rate is lower in the presence of an endometrioma.”

Mark Perloe, MD: “Now many patients who have had a diagnosis of endometriosis or peritoneal endometriosis and adhesions related to that, who are destined for IVF, asked for a laparoscopy to remove the endometriosis prior to undergoing IVF. Do you believe, or do you have evidence that would support surgical treatment of endometriosis other than endometriomas in the patient going to IVF?”

Togas Tulandi, MD: “I don’t think there is any evidence at all, in fact the IVF will bypass the problem in the pelvis.”

Mark Perloe, MD: “Okay. Any other comments from your presentation that you would like to share?”

Togas Tulandi, MD: “Some people believe that excision of endometrioma decreases ovarian reserve. We have evaluated it by histopathology and it is not the case. The best study comes from Italy, by Beretta et al. In a randomised study, they found that the pregnancy rate was higher with excision compared to fenestration.”

Mark Perloe, MD: “Now you’ve opened up this ovary and you have removed the cyst wall. Haemostasis provided as needed. During the healing phase you are obviously going to have different inflammatory cytokines and inflammatory infiltrate at the site of the healing process. Do you believe there is any period of time necessary following surgery to get that ovary working as well as it might at other times? Is there a pre-determined time we’ve got to wait after excising endometriomas to proceed to IVF?”

Togas Tulandi, MD:  “Empirically, they just wait a month or two. I don’t think there is any study whatsoever.”

Mark Perloe, MD: “Thank you so much visiting with us.”

Togas Tulandi, MD:  “Thank you.”