Endometriosis and endometrioma

Endometriosis is a common finding in women of reproductive age. It often presents with pelvic pain, infertility and infertility treatment failures.  Dr Lok being an advanced reproductive laparoscopic surgeon and fertility subspecialist…

About Endometriosis and endometrioma

Endometriosis is a common finding in women of reproductive age. It often presents with pelvic pain and infertility.

For patients with infertility, medical treatment is ineffective in enhancing the fertility while its role as an adjuvant therapy for ART remain debatable.

Earlier studies indicated that women with moderate or severe disease had improved fecundity with the removal of implants.

Increasing studies, including meta-analyses of non-randomised studies and randomised study showed a small but significant increase in fecundity when implants in mild disease were removed.

IVF is effective in the treatment of infertility for most patients with endometriosis, as fertilisation occurs in laboratory and not in the adverse pelvic environment affected by the disease. Although the ART pregnancy rates in patients with

endometriosis in general are comparable to women with tubal disease, the results for the latter may be suboptimal due to presence of hydrosalpinx.

There are reports of poorer ovarian responses to stimulation and poorer outcomes of IVF in women with advanced endometriosis, especially those with endometriomas. There are also studies showing poor implantation hence lower pregnancy rates in some women affected by endometriosis. Corrective surgery should be considered especially in those who fail IVF, when oocyte qualities and implantation may be affected by the diseases.

persistence with unsuccessful IVF treatments should be avoided as the high hormones from ovarian hyper-stimulation during ART cycles worsen the disease and patient’s symptoms. There is also an increased risk of infection during egg collection in presence of endometrioma.

Excision of endometriotic deposits or stripping of the capsule of endometrioma if feasible should be the ideal approach to avoid undiagnosed or under-treated residual infiltrating disease continue to result in pain and compromise fertility.

Careful surgical techniques would also be needed to avoid compromising ovarian reserve and leading to adhesions. For endometrioma, stripping of its capsule would seem reasonable if the capsule is well defined, but with resort to ablation in areas where the cyst wall is densely adherent.  If there is no obvious tissue plane, it may be prudent to consider the use of an ablative procedure either in one or two-stages in conjunction with GnRH-a therapy.

Severe endometriosis can affect nearby vital organs like blood vessels, ureter and bowel, operative complications from these organs can be serious.  Some of the most severe deep infiltrated endometriosis are found in women with no other symptoms apart from infertility particularly those who fail IVF treatment.  Women with symptoms such as pain usually have the disease diagnosed and treated early before the disease become advanced.

Endometriosis surgeries are among the most challenging operations with potential high operative risks.  Careful preoperative assessments (such as utilising specialist ultrasound assessment) and team operation (involving urologist and colorectal surgeon) are critical in avoiding multiple surgeries (the first operation often provide the best opportunity to radically treat the disease before tissue planes being disrupted and disease obscured by earlier incomplete operations) and minimise potentially serious complications.  Dr Lok being a fertility subspecialist commonly deal with these group of women, and with particular interests in reproductive surgeries with certified advanced (AGES Level V-VI) endoscopic skills, performs large number of these operations with dedicated team of specialists and supporting staff.

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