Alcoolisation endometriome version courte - CICE - … endometriome version... · –Especially if...
Transcript of Alcoolisation endometriome version courte - CICE - … endometriome version... · –Especially if...
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ALCOOLISATION DES ENDOMETRIOMESETHANOL SCLEROTHERAPY (EST)
Dr Anne Sophie GREMEAU,
Pr Jean‐Luc POULY, Dr DEJOU BOUILLET lydie,
Pr CANIS, Dr COMPAN Clara, Dr CHAUFFFOUR Candice.
Diplôme d’endoscopie en GynécologieJanvier 2015
– HUGHESTON (1957)/ BROSENS (1994)
The OE have their origin in superficial peritoneal implants of
ovarian fossas. An accumulation of cyclic micro‐
haemorrhages is responsible for the accumulation of blood
and debris with progressive invagination al inside the ovary.
– NISOLLE ET DONNEZ (1996)
OE are due to an invagination of the mesothelium to the
surface of the ovaries followed by coeliomicmetaplasia of
the invaginated tissue. This explains the OE having no
contact with the fossa and OE multilocular formation
– JAIN 1999 et VERCELLINI (2009)
Colonization of functional ovarian cyst by endometriosis
implants.
OVARIAN ENDOMETRIOMA (OE): How it occurs? 3 theories
ENDOMETRIOMA: How it occurs?
Choco
late
fluid
Internal
laye
r
Cortex and follicu
les
Med
ulla
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ENDOMETRIOMA And FERTILITY:CurrentTrends
• Negative impact of endometriosis on fertility: if> 2‐3 cm
– Shubert B et al, Human reprod, 2005: histological evaluation of ovarian cortex surrounding the EO shows a
direct negative effect of the cyst on the on the follicular adjacent capital
– Benaglia et al 2009: The physiologicalmechanisms leading to ovulation are deranged in ovaries withOE.
• Improving spontaneous conception rates after surgery: VERCELLINI et al, 2009
But cystectomy can also be deleterious to ovarian reserve
• Cystectomy negative effect on fertility:
– Alteration of ovarian Reserve (decrease in l’AMH level, poor response to COH)
– Especially if second surgeries, multiple or large endometriomas.
MORE OVER NO NEGATIVE IMPACT OF EO ON IVF RESULTSNo cyctectomy if ART required
Laparoscopic excision of OE
Recognizable ovarian tissue adjacent to OC wall
OMAs 14/26 (54%)< 0.005
Non OMAs 1/16 (6%)
Serous 0/7 (0%)
Dermoid 1/6 (17%)
Mucinous 0/3 (0%)
Muzii et al., Fertil Steril (2002)
Oma cyst wall: no follicule
Oma cyst wall: Scanty primordial follicule
Oma cyst wall: Two primordial follicule
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OE SURGERY and AMH
Streuli et al, Human Reprod 2012In women with endometriosus AMH
levels are decreased only in those with previous endometrioma surgery
Raffi et al., JCEM (2012)Negatif impact of excision of OEon ovarian reserve
But new study VIGNALI 2015 showing that AMH level increaseOne year after cystectomy
Cystectomy: YES but,
GOOD WRONG
The crucial question with the useof the surgical treatment of OETHECLEAVAGE PLANE
Liquide ch
oco
lat
Paroi d
u kyste
Cortex et follicu
les
Med
ulla
2 MAJORS RISK forTHE FERTILITY‐A part of normal cortex is removed in 59% of the cases vs 5 % for other cyst.‐Risk of ovarian devascularization due to intensive coagulation for hemostasis.
No negative impact of endometrioma on IVF results
To treat or not to treat?
2 SITUATIONS: NO ART or ART REQUIRED
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Sociétés Savantes (1)….
• L’endométriose peut être responsable d’une hypofertilité, la chirurgie première est
possible avec un délai de 6 à 12 mois derrière pour obtenir une grossesse spontanée
– La ponction écho‐guidée n’est pas le traitement de première intention
– Le drainage percoelioscopique n’est pas recommandé car il conduit à une récidive immédiate
– KIP coelio si > 3cm (infertilité, douleur ou masse annexielle)
– Traitement médical en préopératoire non recommandé.
• Les endométriomes n’ont pas d’impact sur les résultats de l’AMP
– . Ne pas interrompre une FIV si découverte d’un EO en cours de traitement
– Pour les EO < 6cm, ni le traitement chirurgical, ni la ponction des EO ne sont recommandés avant la FIV.
2006
• Laparoscopic cystectomy for OE greater than 4 cm improved fertility compared to cyst drainage
and coagulation which is associated with a high risk of recurrence.
• A possible adverse consequence is the loss of viable ovarian cortex.
• After the first infertility operation, additional surgery has only rarely increased fecundability, and
these patients may be better servec by usingART.
• Ovarian endometrioma and IVF
– For women who are found to have an asymptomaticOE ans who are planning to undergo IVF there is
insufficient evidence to suggest that removal of the endometrioma will improve IVF success rate.
– But if the OE is large > 4cm, surgery should be considered to confirm the diagnosis histollogically, to improve
access to follicle duringOCR, and possibly to improve ovarian response.
– The patient should bemade aware that extensive ovarian surgery could compromise ovarian function and
diminish the response to ovarian stimulation.
Sociétés Savantes (2)….
2012
• Surgery for infertility and pain.
– Cyctectomy instead of drainage and coagulation or laser vaporization: less pain (Hart 2011), less
recurrence rate (Carmona et al 2011) In women withOE receiving surgery for infertility or pain,
– Excision of the endometrioma capsule increases the spontaneous post operative pregnancy rate when
compared with drainage and electrocoagulation of the OE wall
– The GDG recommand that clinicians counselled women withOE regarding the risks of reduced ovarian
function after surgery and the possible loss of the ovary.
– THE DECISION TO PROCEED SURGERY SHOULD BE CONSIDERED CAREFULLY IF THE WOMAN HAS
HAD PREVIOUS SURGERY.
• Endometrioma and ART
– Several studies have evaluated the usefullness of cystectomy prior to ART to improve reproductive
outcome in women withOE, but there is limited consistency in the interpretation of the results.
Sociétés Savantes (3)….
2014
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Les sociétés savantes conclusions
OPERER LES ENDOMETRIOMES SI DOULEURS, HYPOFERTILITE sans autres causes ASSOCIEESPREFERER LA KYSTECTOMIE LAPAROSCOPIQUEEXCLURE LE DRAINAGE DE L’ENDOMETRIOME
3CM3CM 4CM
ART AND ENDOMETRIOMA
No surgery if endometrioma< 6cm
Surgery possible if4cm but risque of ovarianfailure
No recommandation
NOTHING ABOUT ENDOMETRIOMA RECURRENCEAnd MULTIPLES ENDOMETRIOMA
OE TREATMENTS: Goals and Methods
• GOALS OF ENDOMETRIOMA TREATMENT– To permit a spontaneous pregnancy if there is no others causes of infertility
– To remove the internal layer of the cyst
– As much as possible to limit the risk of recurrence
– Without destroying the surounding tissue and mainly the oocytes
– Without impairing the ovarian vascularization
– Withoutmissing an hypothetical cancer
• AVAILABLE TREATMENT
– Medical treatment : not for infertility
– Cystectomy: still the gold standard
– Destruction of the internal layer of the cyst
• Laser or plasma jet vaporization
• Sclerotherapy
KYSTECTOMIE: Gold standardRevue COCHRANE HART 2011Comparaison of cystectomy versus excisionLess recurrence of endometriomaLess requirement for further surgeryLess requirement of pelvic painMost subsequent spontaneous conception
BUTTWOMAJOR RISKS‐Risk of removed normal ovarian cortex‐Risk of ovarian devascularization due tointensive coagulation for hemostasis.
ALTERNATIVES METHODS‐ Ablative surgery: CO2, plasmajet‐ Ethanol sclerotherapy
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Endometrioma: The optimal strategy
Surgery: EXCISIONAL or ABLATIVE
‐To Remove endometrioma, check the pelvis (tube adhesion), and to dicrease recurrence rate. (Hart 2011)
‐To get a specimen
‐To expect a natural pregnancy : 40 % deliveries (Hart 2011)
‐Knowledge of the surgeons (Matzuzaki 2009)
No Surgery
‐Lowovarian reserve : AFC and AMH (Somigliani 2012)
‐Multiple endometriomas (busacca 2009: IOP x2,4)
‐Recurrence of endometrioma (Streuli 2012, ferrero 2015)
‐Another pemanent indication of IVF (ASRM, ESHRE)
PLACE OF ETHANOL SCLEROTHERAPY
• What is proven
– No impact of endometrioma on IVF results (Benaglia 2013)
– No benefits to remove the endometrioma before Ivf
• But
– Pains
– Less matures oocytes obtained (Yazbeck 2006, Busacca 2009)
– Difficulty for ovum pick‐up
– Risk of ovarian abscess (Padila 1997, Younis 1993)
OE and IVF: The optimal strategy
PLACE OF ETHANOLSCLEROTHERAPY
IVF must be the option When endometrioma < 3 cm
‐ Direct IVF withoutOE treatment
When endometrioma > 3 cm or multiple or recurrence
‐ Ultralong protocole + sclerotherapy
ETHANOL SCLEROTHERAPY
• ADVANTAGES:
– Simple, fast
– Cheep
– Efficient on pain
– Recurrence rate <15 %
– Can be repeated
– No histological sample
– No evidence of alteration
of the ovarian reserve
Garcia Tejedor 2015 EJOG
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History
• Initial development in pulmonary
tuberculosis and in the treatment of
malignant pleural oncology. Then in
various types of cysts (thyroid, heart,
liver, kidney ..)
• The simple echo‐guided aspiration has
been promoted first, but the high rate of
recurrence restricted its application
(Giorlandino 1993, Chan 2003) and those
of other sclerotic agents (Chang 1997)
• It was in Japan that has developed in the
ethanol sclerotherapy of endometriomas,
which led to a clear reduction of the
recurrence rate (Okagaki et al, 1999,
Noma and Yoshida 2001, Koide and Al
2002)
• Investigate and test the efficacityof Ethanol sclerotherapy for recurrent endometrioma beforeCOH in infertile patients.
– Cases: n=31 patients with positive histological diagnosis at previoussurgery, recurrent OE between 2 and 6 cm.
– Controls n=26, patients with an history of moderate to severeendometriosis including one conventional laparoscopiccystectomy for recurrent OE.
YAZBECK 2009: Endometrioma EST
Recurrence rate = 12.9%
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3 groups‐Cystectomy‐EST‐Abstention
Same results in term ofLivebirth rate per cycle in the 3 groups
But place for ESTIf huge endometriomaAnd place to abstentionIf small endometrioma
How we do?
• In the AMP unit, we offer ethanol sclerotherapy for women requiringART when:
– Previous surgery of endometriosis and recurrence of OE > 3cm
– Bilateral endometrioma
– Huge endometrioma if ART is indicated for another indication (MRI necessary)
– In extensive stage IV endometriosis with endometriomawhen infertility is the main symptom (no
or moderate pain)
– Abstention is offered if small recurrent endometrioma.
• Sclerotherapy was done during ultra long GNRH agonist suppression protocol
– Just before the second injection
– US control of cysts was done before the controlled ovarian stimulation
Before IVF: Ethanol Sclerotherapyduring ultralong agonist protocols
GNRH ANALOGUEDEPOT
GNRH ANALOGUEDEPOT
GNRH ANALOGUEDEPOT
SCLEROTHERAPY
CONTROLBefore COH
FSH‐HMG
30 DAYS 30 DAYS 20 DAYS
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TECHNIQUE: Materiel
‐ Paracervical block and Sedation
‐ US with Endovaginal probe‐ Transvaginal Needle 17 or 18G‐ Nacl and Ethanol
EST: TECHNIQUE
• ‐Outpatient, oral sedation
• ‐Vagina sterilizedwith povidone iodine
• ‐Transvaginal US guidance and 18 gauge 30 cm single lumen needle
• ‐Cyst aspirated and Flushed with normal saline. Aspirate send for pathological review
• ‐Injection of pure sterile ethanol in an amount equalTo 60% of the aspirated volume
• ‐Ethanol was lef 10min n the cyst and removed in case of important quantity (more than
30cc) and left in situ in case of small quantity (<30cc)
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Our Experience: 2010‐2013
PARAMETRES n=27
AgeFSH (J3)
32,02 (27‐41)8,5 (2,1‐11,8)
INDICATIONS‐Endometriomes recidivants apres KIP‐Endometrioses de stade IV avec mauvais pronostic chirurgical
16 (55,2%)13 (44.8%)
NOMBRES DE KYSTES‐ Patientes avec 1 Kyste‐ Patientes avec 2 kystes‐ Patientes > 3 kystes‐ Endometriomes bilatéraux
5714 (48.3%)10 (34.5%)5 (17.2%)16 (59,3%)
CARACTERISTIQUES DES KYSTES‐Diametre (mm)‐Volume aspiré (ml)‐Volume d’ethanol injecté (ml)‐% volume/alcool
42,5 (10‐90)50,7 (5‐170)31,9 (2‐150)
63%
RESULTATSAMPS‐ Protocoles ultralong‐ Grossesses débutantes par cycles‐ Grossesses evolutives
2111 (35,5%)7 (22,5%)
AMP Results after EST2010‐2015
CASES n=40Sclerotherapy
CONTROLS n=411Endometriosis
p
Age moyen 32,03 34,28
Nombres de ponctions‐ Blanches‐ déprogrammées
512 (3.70%)3 (5.70%)
68511 (1.52%)40 (5.52%)
ns (0.4)ns (0.9)
Résultats ponction‐Nombre ovocytes matures
taux de fecondation FIVtaux de fecondation ICSI
‐Nombre d’Embryons obtenus‐Nombre d’embryons transférés‐moyenne d’emb congelés
4.92 (251)69.7%75,58%
3.53 (180)1.31 (59)0.76 (39)
7.63 (5225)61.34%65.67%
4.74 (3250)1.46 (872)1.11 (762)
0.001
0.001
Grossesses cliniques‐FCS‐GEU‐FCT et ITGAccouchement attendus
15 (29.41%)2 (13,33%)1 (6.67%)0 (0%)
12 (21,57%)
208 (30.36%)45 (21.63)6 (2.88%)5 (2.40%)
152 (19.27%)
ns (0.9)nsnsnsns (0.3)
LIVEBIRTH after EST
GROSSESSESSclerotherapyn= 40 patients
GROSSESSESAll Endometriosisn=425
p
Nb de grossesseAccouchements faits
1511 (27.5%)
208132 (31.05%) ns
TYPE DE GROSSESSE‐Singletons‐Jumeaux‐Triplets
11 (100%)00
116 (87,9%)15 (11,3%)1 (0,6%)
nsnsns
A TERME >37SA‐<32SA‐32 à 37SACESARIENNES
8 (72%)12
6 (54.55%)
112 (75%)41648 (36.36%)
ns
ns
ENFANTS nombre‐Termemoyen‐poids moyen
1135+7SA2965 grammes
14936+5SA2868 grammes
nsns
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COMPLICATIONS after EST (1)
• PELVIC ABCESS (Younis 1997, J Assist Reprod
genetic)
– Preventionwith strict aspesie and the use of sterile
equipment.
– UnsystematicAntibiotic prophylaxis unsystematic
(OH = bacteriostatic) unless history of pelvic
infection
• ADHERENCES POST EST
– OKAGAKI R et al 1999, Human Reprod Oxf England;
Severe and unusual discoveries adhesions around the
ovaries during laparoscopy post EST (peritoneal
diffusion of ethanol?)
– MUZZI et al 2002: Same adhesions after simple EO
punctures
COMPLICATIONS after EST (2)
• DO NOT KNOW A MALIGNANT HISTOLOGY
– 0.7% estimated risk of malignant disease in women with endometriosis of reproductive age (Nishida et al 2000)
– Endometriosis disease often known before EST: Histology on previous surgery
– Ultrasound imaging or MRI has excellent sensitivity specificity for benin or malignant ovarian tumor.
• PERFORATIONS INTESTINALES, ALCOOLISATION SYSTEMIQUE
– Perforations: non relevée après EST d’endometriome dans la littérature. Précautions d’injection de l’ethanol.
– Alcoolisation systemique (Tei et al 1996, Masui)
• Risque faible, lié a une diffusion sanguine de l’ethanol. Mais précaution systématique, surveillance 6h post ponction et test
d’alcoolémie au moindre doute
AUTRES DONNEES SUR la SCLEROTHERAPIE
• HSIEH and al, fertil steril 2009: Ethanol left in situ
– Group 1: n=78: 10 minutes sclerotherapy
– Group 2: n=30 Ethanol left in situ
– SameAFC and pain score in two groups, less recurrence in group 2 (13,3% vs 32,1%, p<0.005)
• ZHANG and al, AJOG 2014: sclerotherapy of hydrosalpinx prior IVF
– US sclerotherapy on womenwith hydrosalpinx could improve the outcomes of IVF by
improving the blood flow of uterine arcuate artery. No adverse effect on perinatal outcomes
was seen
• FURMAN et al, 2007 UlstrasoundObstet gynecol: case report
– Alcohol sclerotherapy for successful treatment of Focal adenomyosis
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EST and Fertility PRESERVATION
• EST can offer a preservation of mature oocyte by vitrification for patient with severe
endometriosis, before of potentiel important surgery with risk for their ovarian reserve.
• EST makes oocyte pick up easier ans could increase the number of mature oocyte obtained.
Long GNRH AGONIST
SUPPRESSION
CONTROLLEDOVARIANSTIMULATION
OVOCYTERETRIEVAL And VITRIFICATION
EXTENSIVESURGERY
ETHANOLSCLEROTHERAPY
Conclusion 1: OE and ART
Therpeutic options before an ART
SURGERY EST ABSTENTION
Hystory of endometriosissurgery
NO YES YES
Ovarian reserve NORMAL LOW LOW
Pain YES YES/NO NO
Bilateral OE NO YES YES
Size >6CM >3CM <3 CM
Recurrence os OE NO YES YES
Growth FAST STABLE STABLE
Histological doubt YES NO NO
Conclusion 2: EO withoutART
• GOLD STANDARD = CYSTECTOMY.
– Hormonal suppression if no pregnancy desire
– 6 to 12 months for spontaneous conception
• EST CAN BE OFFERED
– In fertility preservation before an extensive surgery (stade
IV avec OE bilat)
– Recurrence of pain
– Recurrences of endometriomawithmultiples previous
surgery
– Complex abdominal surgical history