Page 22 - Journal of WALS

Puneet K Kochhar, Pranay Ghosh

often involves considerable dissection. It is, thus, necessary compared with that of women undergoing IVF for other
to establish precisely the impact on fertility of this type of indications. Laparoscopic excision of endometrioma before IVF
surgery (Fig. 7). reduces the risk of worsening endometriosis during ovarian
Either laser or aqua dissection can be used, separately or stimulation, reduces the risk of infection during oocyte retrieval
combined. Dissection must be performed with care to avoid and allows histological diagnosis avoiding occult malignancy.
any injury to organs, such as the rectum or ureters. In some Thus, laparoscopic diagnosis and treatment of
cases it may be safer to catheterize the ureter in order to facilitate endometriosis is believed to be useful in increasing the
this dissection. probability of conception either spontaneously or with IVF
treatment.
POSTSURGICAL FERTILITY OUTCOMES
STRATEGY OF MANAGEMENT IN INFERTILITY
A 50% pregnancy rate was obtained after laparoscopic
management in a series of 814 women with endometriomas. 33 Three different situations may be encountered: 24
The removal or destruction of endometriomas may provide more i. Clinical diagnosis of endometriosis is suspected. Diagnostic
benefit than simply restoring the normal anatomy and ovarian laparoscopy, staging and treatment are performed in the
structure. same operative sitting.
In another study, CO laser was used laparoscopically for ii. Clinical diagnosis of endometriosis is suspected. Diagnostic
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removal of endometriotic implants. Of 102 infertile patients, laparoscopy reveals extensive endometriosis for which
60.7% conceived within 24 months after laparoscopy. The rates laparoscopic treatment appears extremely difficult. Medical
of conception after surgery were: 75% for patients with mild treatment may be administered for 3 to 6 months, followed
endometriosis, 62% for moderate endometriosis, and 42.1% for by laparoscopic surgery performed as a second step.
patients with severe endometriosis. iii. When severe endometriosis can be diagnosed without
However, it has been suggested that ovarian surgery for laparoscopy according to clinical findings or ultrasound
endometriomas could be deleterious for the residual normal scan, medical therapy is given before laparoscopic treatment.
ovarian tissue, either by removing ovarian stroma with oocytes In the last two situations, GnRH analogs are prescribed for
together with the capsule or by thermal damage provoked by 3 to 6 months prior to laparoscopic treatment.
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coagulation. However, a recent histological analysis revealed In women with stage I/II endometriosis-associated infertility,
that the ovarian tissue surrounding the cyst wall in expectant management or superovulation/IUI after laparoscopic
endometriomas is morphologically altered and possibly not excision or ablation of all visible disease can be considered for
functional. Thus, a functional disruption may already be present younger patients. Women, 35 years of age or older, should be
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before surgery. Therefore, the decreased ovarian response treated with superovulation/IUI or IVF-ET. In women with stage
observed in patients previously treated for a large ovarian III/IV endometriosis-associated infertility, conservative surgical
endometrioma, may also be a consequence of the disease. therapy with laparoscopy and possible laparotomy are
indicated. 11
EFFECT OF ENDOSCOPIC Based on a literature review, the most realistic intrauterine
SURGERY ON IVF CYCLES
pregnancy rate achieved is ~ 40%.
With advances in IVF, a number of patients opt for IVF without There is no advantage of repeating surgery within a short
undergoing adequate surgical treatment of endometriosis. The interval as this may reduce ovarian reserve and increase the
success rate of IVF in women with endometriosis is lower risk of a poor response to ovarian hyperstimulation for IVF.
CONCLUSION

Current evidence suggests that laparoscopic excision or
ablation, either by electrocautery or laser improves pregnancy
rates. The dissection technique and energy source required
depends on the type and constituency of the tissue and the
extent of the lesions. The ideal dissection technique requires a
modality that can accomplish meticulous hemostasis and will
be tissue selective without causing inadvertent tissue damage.
In actual practice, a combination of energy forms is applied
with selection of the most appropriate one at each particular
phase of the operation.
ACKNOWLEDGMENT
Fig. 7: Excision of deep rectovaginal endometriosis with bipolar We are very thankful to Dr RK Mishra, World Laparoscopy
electrocautery and scissors. Harmonic scalpel or CO laser may
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be used alternatively Hospital, for his support.
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