This article is a translation of a lecture given by a leading expert in the field
We would like to talk about the countermeasures for endometriosis infertility through these four points below, which we can only treat those infertile patients with endometriosis if we are fully aware of them. Laparoscopy and surgery are still the best treatment. Assisted conception techniques are the best treatment. Multiple factors to consider are the best treatment. The individualization of the protocol implemented in each patient should be very necessary. Lu Meiya, Department of Gynecology, Wuxi Hospital of Traditional Chinese Medicine
102 Let’s discuss separately that laparoscopic surgery is the best treatment. From the following points, it is actually understood that only through laparoscopy can we have a clear diagnosis, a good clinical staging, and an assessment of its chances of pregnancy. In addition, laparoscopic surgery allows the separation of adhesions, restoration of anatomy, etc. It has been shown that a conservative laparoscopic procedure alone can achieve a pregnancy rate of 30%, and the literature has confirmed that the pregnancy rate after a true laparoscopic procedure is approximately the same between all levels. If we are talking purely about infertility, repeated surgery is undesirable, and as we said earlier, you can have a second or third surgery, but the undesirability of repeated surgery as we are talking about now, it shows exactly one thing, you have to try to avoid damage to the ovaries when you have a second or third surgery.
103 Personally, I appreciate what the doctor always says, that for an infertile patient with endometriosis, if you want her to get pregnant on her own, you are giving up on her treatment. I think it would be unwise to expect that in a patient with endometriosis infertility, aggressive treatment is to be respected. There is some literature here, and some arguments for this conclusion. If you just expect 6 cycles, the conception rate is not even 25%. If you go and give her aggressive treatment, you’ll find that the conception rate will be about 37% in 3 cycles.
104 This is a picture from the doctor, and laparoscopy alone is not enough, you should add GnRH-a to laparoscopy, and that will be more effective, and that’s what these two sets of experiments later express.
105 Let’s look at the relevance of pharmacological treatment for fertility status. As we can see from much of the literature, both pharmacological and surgical treatment can reduce recurrence and also relieve the symptoms of endometriosis, but it does not improve fertility status. It is worth emphasizing that GnRH-a is the only effective treatment for severe endometriosis and an important option to prepare for assisted conception. For example, if we have severe endometriosis like myometriosis and so on, when you prepare with GnRH-a and then you go for gamete transplantation, the results may be better.
106 ART has made great progress in recent years, and the key progress, I personally believe, is that it has achieved stable results. So, we now consider assisted reproductive technology to be one of the most important and aggressive measures to address endometriosis infertility. The next few pictures are probably to compare the effectiveness of various methods combined to treat endometriosis infertility.
107 One of these articles from Russia suggests that the conception rate with gamete transfer is significantly higher than with ovulation and IUI, and it suggests that one cycle of gamete transfer can yield higher results than six cycles of IUI. In Taiwan, this data set concluded that the best results were obtained with the GnRH-a group, which was the most effective for ovulation and fertility in mild and moderate endometriosis.
108 This group of figures is mainly to compare the pregnancy rate of patients with endometriosis treated with various methods of ovulation promotion.
109 How can we evaluate the use of gamete transfer in patients with endometriosis to obtain a good pregnancy outcome? Let’s see, in a patient with endometriosis, the success rate of gamete transfer is significantly lower than in a patient with tubal incompetence. It may be that the quality of the eggs and embryos is not good, because as we know, patients with endometriosis have a lot of internal changes, so can it be improved by egg donation? Of course there are some ethical issues in the middle of this. There is also the question of whether there is a problem with the endometrium in situ, which may determine whether the treatment of endometriosis itself can be resolved if you make the endometrium in situ in good condition.
110 Let’s look at the success rate after gamete transfer, we can use 20, 30, 40 to make a lineage. The highest success rate for tubal obstruction is 40%. The success rate for those with unknown causes is the next highest, at 30%. And endometriosis has the lowest rate of 20%.
111 In this article, we will briefly look at the main points, which emphasize the considerations when patients with endometriosis go for gamete transplantation, with particular attention to the changes in the internal environment caused by endometriosis, including immunological aspects. You can notice it in the second and third article, all of them.
112 If we look at the staging of endometriosis, stage 1 and stage 2 patients, Dr. Cheng in Taipei proposed some conclusions, one of which is that if these stage 1 and stage 2 patients are treated with GnRH-a for 2 months, plus ovulation, plus artificial insemination, they can get a high pregnancy rate of 25-37%. pregnancy rate. If you do not use GnRH-a and do IUI directly, you may only get a pregnancy rate of 13%. Thus, it seems that mild and moderate endometriosis are better treated with GnRH-a before insemination.
113 For particularly severe endometriosis, let’s see, Dr. Cheng’s treatment principle is probably like this: he thinks that if the coeliac sac is >5cm, a laparoscopy must be done and after the surgery, GnRH-a should be given for at least 2 months. If it is a light patient, she can be directly inseminated, and if it is a heavy patient, she can be directly transplanted with gametes. For recurrent cases, he recommends that you must have the coeliac removed and then come back for gamete transplantation, this is mainly because if there is a coeliac it may interfere with egg retrieval, and also the internal environment is too poor and may cause failure of your pregnancy.
114 Adamsom gave us a preliminary suggestion, of course, we have to discuss again whether it is suitable for the Chinese situation, but in any case, his basic idea, I personally still think it is better. First, laparoscopy as a consultation is necessary, and it should be used first to address anatomic factors. The second is to do a more adequate endocrine investigation to rule out whether there are other factors of infertility and try to exclude interference. The third one is controversial. For moderate and mild endometriosis, he recommends expecting six months, then directing sex, and if unsuccessful, then going for ovulation and IUI, and then unsuccessful again for gamete transplantation, which I think is debatable. I think this is questionable, because such an expectation may lose a good time for the patient’s treatment. The fourth one I am more in favor of, for severe endometriosis, either with GnRH-a for 3 months or going straight to gamete transplantation. I would argue, in conjunction with other people’s material, that for severe endometriosis, it would be worthwhile to add the 2 items together and start with 3 months of GnRH-a and then go straight to gamete transplantation.
115 The concept that 6 months is the golden period after being a GnRH-a treatment is generally accepted, so whether it is gamete transplantation or IUI, it is important to seize the time and try to get a quick fix for our infertility treatment. If you don’t, endometriosis can continue to develop, it can recur, and the longer you delay, the lower the chance of success you may achieve.