FOGSI FOCUS Endometriosis: Current Trends
FOGSI FOCUS Endometriosis: Current Trends
Editor-in-Chief Nandita Palshetkar MD FCPS FICOG FRCOG (UK)
President of FOGSI 2019 Scientific Director, Bloom IVF Professor of Obstetrics and Gynecology Dr DY Patil Medical College, Hospital and Research Centre
Navi Mumbai, Maharashtra, India
Editor Kuldeep Jain MD Fellow ART (Singapore)
IVF Consultant and Gynae Laparoscopic Surgeon Director, KJIVF and Laparoscopy Centre, Delhi Chairperson, Endometriosis Committee
Co-Editors Sudha Prasad MBBS MS FICOG FICMCH
IVF Coordinator at IVF and Reproductive Biology Centre Department of Obstetrics and Gynecology Lok Nayak Hospital and Maulana Azad Medical College
Delhi, India
T Ramani Devi MD DGO FICS FICOG
Consultant, Obstetrician & Gynaecologist and Reproductive Medicine Vice President Elect, South Zone FOGSI 2020 Department of Obstetrics and Gynaecology Ramakrishna Medical Centre LLP
Trichy, Tamil Nadu, India
Louis T Fessy DGO DNB FAGE MNAMS DPS MICOG FICOG
Senior Consultant and Associate Professor Department of Reproductive Medicine and Surgery Amrita Fertility Centre, AIMS Amrita Institute of Medical Sciences
Kochi, Kerala, India
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FOGSI FOCUS Endometriosis: Current Trends
First Edition: 2020
9789389188844
Printed at
Office Bearers of Team FOGSI 2019 | |
President Secretary General Vice President (West Zone) Vice President (West Zone) Vice President (North Zone) Vice President (East Zone) Vice President (South Zone) Deputy Secretary General Treasurer Joint Treasurer Joint Secretary lmmediate Past President President Elect | Dr Nandita Palshetkar Dr Jaydeep Tank Dr Rajendrasingh Pardeshi Dr Haresh Doshi Dr Sudha Prasad Dr Rajat Mohanty Dr Aswath Kumar Dr Madhuri Patel Dr Suvarna Khadilkar Dr Parikshit Tank Dr Ameya Purandare Dr Jaideep Malhotra Dr Alpesh Gandhi |
Chairpersons of the Committees | |
Adolescent Health Clinical Research Endocrinology Endometriosis Endoscopic Surgery Ethics and Medicolegal Family Welfare Food Drugs Medico Surgical Equipment Genetics and Fetal Medicine HIV/AIDS Imaging Science Infertility International Academic Exchange MTP Medical Education Medical Disorders in Pregnancy Midlife Management Oncology Perinatology Practical Obstetrics Public Awareness Quiz Safe Motherhood Breast Sexual Medicine Urogynaecology Young Talent Promotion | Dr Girish Mane Dr Meena Samant Dr Pratik Tambe Dr Kuldeep Jain Dr B Ramesh Dr Geetendra Sharma Dr Shobha Gudi Dr Vidya Thobbi Dr Mandakini Pradhan Dr Mrutyunjay Mohapatra Dr Meenu Agarwal Dr Asha Baxi Dr Varsha Baste Dr Bharti Maheshwari Dr Abha Singh Dr Komal Chavan Dr Rajendra Nagarkatti Dr Bhagyalaxmi Nayak Dr Vaishali Chavan Dr Sanjay Das Dr Kalyan Barmade Dr Sebanti Goswami Dr N Palaniappan Dr Sneha Bhuyar Dr Sudha Tandon Dr Nita Thakre Dr Vinita Singh |
- Abha Majumdar MS
- Director and Head
- Centre of IVF and Human Reproduction
- Institute of Obstetrics and Gynaecology
- Sir Ganga Ram Hospital
- New Delhi, India
- Asha R Rao MD
- Chief Consultant
- Department of Infertility
- RAO Hospital
- Coimbatore, Tamil Nadu, India
- Bharti Jain DNB Fellowship in ART
- Senior Radiologist and ART Consultant
- Department of Reproductive Medicine
- KJIVF and Laparoscopy Centre
- Delhi, India
- Damodar R Rao MS
- Associate Director and Senior Consultant
- Department of Endogynaecology
- RAO Hospital
- Coimbatore, Tamil Nadu, India
- Dhivya Sethuraman MD
- Associate Professor
- Department of Obstetrics and Gynaecology
- SRM Medical College
- Trichy, Tamil Nadu, India
- Fessy Louis T MBBS DGO Dip NB FICOG
- Senior Consultant & Associate Professor
- Department of Reproductive Medicine
- Amrita Institute of Medical Science
- Kochi, Kerala, India
- Kuldeep Jain MD Fellow ART (Singapore)
- IVF Consultant and Gynae Laparoscopic Surgeon
- Director, KJIVF and Laparoscopy Centre, Delhi
- Chairperson, Endometriosis Committee
- Delhi, India
- Maansi Jain MS Fellowship in Reproductive Medicine and Surgery (Singapore)
- Consultant, ART
- Department of Reproductive Medicine
- KJIVF and Laparoscopy Center
- Delhi, India
- Meenakshi Dua MD
- Senior Consultant
- Southend Fertility and IVF
- New Delhi, India
- M Preethi MS
- Resident Fellowship in Endogynaecology
- Department of Endogynaecology
- RAO Hospital
- Coimbatore, Tamil Nadu, India
- Nandita Palshetkar MD FCPS FICOG
- Medical Director
- Bloom IVF
- Mumbai, Maharashtra, India
- President, FOGSI (2019)
- President, IAGE (2017-18)
- Chairperson, MSR (2017-18)
- Vice President, AMOGS (2016-18)
- Neeti Tiwari MD FICOG
- Consultant
- Centre of IVF and Human Reproduction
- Institute of Obstetrics and Gynaecology
- Sir Ganga Ram Hospital
- New Delhi, India
- Nutan Jain MS
- Director
- Department of Obstetrics & Gynae
- Vardhman Trauma & Laparoscopy Centre Pvt Ltd
- Muzaffarnagar, UP, India
- Parul Kotdawala MD Dip Pelviscopy FICOG FICMCH
- Consultant
- Zydus Hospital
- Endoscopy Surgeon
- Department of Obstetrics and Gynecology
- VS Hospital & NHL Municipal Medical College
- Ahmedabad, Gujarat, India
- Parvathy T MS Mch
- Assistant Professor
- Department of Reproductive Medicine
- Amrita Institute of Medical Science
- Kochi, Kerala, India
- Pratik Tambe MD FICOG
- ART Consultant and Gynaec Endoscopic Surgeon
- Chairperson, FOGSI Endocrinology Committee (2017–19)
- Managing Council Member, MOGS
- Managing Council Member, MSR, AMC, IAGE (2015–18)
- Mentor, MOGS Youth Council
- Mumbai, Maharashtra, India
- Riddhi Desai MS PGDMLS Dip in Endoscopy (Pune) Dip in Office Hysteroscopy (Italy)
- Consultant
- Advanced Multispecialty Hospital
- Mumbai, Maharashtra, India
- Rohan Palshetkar MS
- Consultant Fertility Specialist
- Bloom IVF
- Mumbai, Maharashtra, India
- Santwan B Mehta MS FMAS FRM
- Endoscopic Surgeon
- Zydus Hospital
- Ahmedabad, Gujarat, India
- Saumya Prasad MS
- Senior Resident
- Department of Obstetrics and Gynecology
- Maulana Azad Medical College
- New Delhi, India
- Sonia Malik DGO MD FICOG FIAMS
- Director and HOD
- Southend Fertility & IVF
- New Delhi, India
- Sudha Prasad MS FICOG FICMCH
- IVF Coordinator at IVF and Reproductive Biology Centre
- Department of Obstetrics and Gynecology
- Lok Nayak Hospital and Maulana Azad Medical College
- New Delhi, India
- Surveen Ghumman MD
- Director and Head
- Department of IVF & Reproductive Medicine
- Max Multispeciality Hospitals
- New Delhi, India
- T Ramani Devi MD DGO FICS FICOG
- Consultant
- Obstetrician and Gynaecologist and Reproductive Medicine
- Vice President Elect, South Zone FOGSI 2020
- Department of Obstetrics and Gynaecology
- Ramakrishna Medical Centre LLP
- Trichy, Tamil Nadu, India
My Dear FOGSI Members
Greetings from FOGSI !
Endometriosis affects an estimated 10 to 15% of the female population. It has various presentations and degrees of severity. In its most severe form this disease is very debilitating for patients, compromising not just their fertility but also their social, professional, and personal life. It has become a major public health problem associated with high monetary costs and a significant decline in productivity. Endometriosis is not acknowledged in society, and hence is underdiagnosed and so is undertreated.
This FOGSI Focus on endometriosis is a welcome addition to all the literature available on endometriosis. It provides a balanced blend of all aspects of endometriosis like history and a discourse on pathogenesis, along with descriptions of clinical symptomatology, medical and surgical therapeutic approaches, and offers suggestions for holistic care of patients.
The editor of this FOGSI Focus Dr Kuldeep Jain and Co-editors, Dr Sudha prasad, Dr Ramani Devi and Dr Fessy Luice T have compiled a publication on endometriosis which is holistic and will provide us with a practical and evidence-based approach which will be of great value to clinicians and trainees.
Nandita Palshetkar
President, FOGSI
Preface
“He who knows Endometriosis, knows Gynecology”
—Sir William Osler
Endometriosis is a common and debilitating condition that can have a significant impact on the quality of life of the sufferer. It is a disease of controversy/complexity, chronic/multi–factorial, progressive/recurrent, not malignant but behaves like one and difficult to diagnose and treat. Once diagnosed clinically and by various imaging modalities, there is a wide variation of interventions available for treatment ranging from ovarian suppression with hormonal agents to radical excisional surgery. This suggests that the condition is heterogeneous and that there is a lack of consensus over optimal management. Laparoscopy remains gold standard and is the best tool for diagnosis, treatment and follow-up evaluation of endometriosis. Endometriosis affects over 176 million women worldwide and 6–10% of women of reproductive age are affected. An incidence of 2.37–2.49/1000 has also been reported with a relative prevalence of 6–8% in the general population. There is a higher incidence of infertile women. 25% of patients undergoing ART are affected and 20–40% of these patients show ovarian endometriosis.
It is estimated that 25–35% of infertile women have endometriosis while 30–50% of women with endometriosis have infertility. Eight per cent of women in ART programs have the primary diagnosis of endometriosis made. In a review of 61 women with endometriosis 48 of which underwent controlled ovarian hyperstimulation showed the need for higher total dose or ampoules of gonadotropins to produce an average of 3 metaphase II eggs, 50% fertilization rate but pregnancy rates were lower in those with moderate to severe disease. Fecundability is 0.20 in unaffected women but 0.02–0.20 in women with endometriosis. Another report indicates a fecundity of 0.15–0.20 per month in normal couples but 0.02–0.10 in untreated women with endometriosis and infertility. Therefore in women with stage III-IV monthly probability to conceive is 2–10% vs. 15–25% in healthy couples.
Choice of management depends on the presenting symptoms, age, fertility history and progression and recurrence. If the primary symptom is pain and fertility is not the issue, definitive surgery with as much cytoreduction is possible is the treatment of choice, however if the fertility is the issue or patient is young, a conservative approach is recommended. Medical treatments that inhibit ovulation have been found to be effective in reducing pain in 80–90% of women. Medical therapy, however, is not cytoreductive and pain recurrence is frequent after treatment withdrawal. Moreover, side effects and costs discourage long-term use and it does not improve pregnancy rates in women with associated infertility.
For generations it has been taught that abdominal hysterectomy and removal of both ovaries is the definitive surgery for endometriosis. However, our understanding of the disease has evolved. Technological advances in camera optics and electrosurgical devices and improved surgical experience, combined with the limitations of medical treatment, now make operative laparoscopy the preferred management choice for a considerable proportion of women.
In vitro fertility (IVF) is the appropriate treatment especially in the presence of tubal function compromise, male factor or failure of other treatments. IVF is an effective treatment in women with infertility and endometriosis. IVF is appropriate treatment especially if there are multiple causes of infertility and/or other treatments have failed. Surgery may have some role in mild endometriosis and cases with large endometriomas as surgical treatment may improve outcomes. IVF is a useful and effective procedure to treat infertile women with endometriosis although its success rate could be impaired by the disease itself. If there is a negative effect, the oocyte quality more than the endometrium seems to be affected, this may explain why outcomes are better in women with endometriosis who have recipient cycles. Some large data bases did not show adverse effect on pregnancy rates (SART and HFEA) in women with endometriosis.
Considering the complex nature of endometriosis, dilemmas debates and controversies involved in the diagnosis, management and follow-up, and newer suggested molecules for medical management as well as changing concepts for improving the fecundity and cumulative pregnancy rates in ART. This edition of FOGSI FOCUS is planned to cover all areas from diagnosis, etiopathology to advances in medical management to managing deep infiltrative endometriosis to different newer stimulation protocols and fertility preservation and decision making in infertile couples, and I am happy that all contributors have put in their best effort to compile various chapters in such a way that they are clinically useful and easy to understand.
I am thankful to FOGSI president Dr Nandita Palshetkar for giving me the opportunity to bring this FOGSI FOCUS in my last working year as chairperson, endometriosis committee. I am also thankful to my Co-editors Dr Sudha Prasad, Dr Ramani Devi and Dr Fessy Louise T for giving there valuable inputs to complete this work in time. I acknowledge the timely submission of very high quality academic material by all contributing authors.
I express my deep appreciation to Dr Prateek Tambe for extending all possible help to bring out this work in time.
I will be only too happy if the chapters in this volume of FOGSI focus are of benefit to all practicing gynecologist of country in helping to treat all endometriosis patients coming to them for help.
Kuldeep Jain