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Treatment options

Details the condition endometriosis and the current types of endometriosis treatment.


Management options for women with endometriosis

There is no cure for endometriosis but there are several treatment options available for infertile patients suffering from endometriosis. Treatment should be tailored to individual women. It is worth remembering that there is a considerable spontaneous pregnancy rate in infertility associated with minimal and mild endometriosis. Treatments for endometriosis may include one of the following techniques: surgery, intrauterine insemination and IVF.

Medical treatment

There are a number of drug therapies including: pain killers such as non steroidal anti inflammatory drugs (NSAIDs) and drugs that allows the endometriosis to “dry up” and heal. The latter are taken for several months. Each drug therapy has its own advantages and side effects. Some of the commonly used drugs include: contraceptive pills (birth control pills), progesterone, danazol and GnRh agonist e.g. nafareline, buserelin (these drugs need to be taken every day, without a break). Long-acting GnRh agonists such as zoladex can be given as a monthly implant. These drugs put a temporary stop to the production of certain monthly hormones. Obviously while the patient is taking the medication she can not get pregnant, but the aim of the treatment is to reduce the extent of endometriosis in the hope that the patient will conceive soon after she stops the medication. The main problems associated with suppressive drug therapy include: the length of time it takes (about 6 months), which could be a problem especially in infertile women. Treating endometriosis with drugs has its own limitations; large chocolate cysts are less likely to respond to medication and drugs will not remove scar tissues. In addition, there are unpleasant side effects. It is important to use cap or condoms for contraception while taking the GnRH agonist or Danozol, since pregnancy is not advised. There is no evidence to support the use of ovarian suppression drugs in the treatment of endometriosis-associated infertility. NICE guidelines in the United Kingdom do not recommend medical treatment of minimal and mild endometriosis because it does not enhance fertility (2013) However, medical treatment is generally successful for the relief of pain associated with endometriosis. (RCOG guidelines 2006). Insertion of MIRENA IUS device is an option for women with heavy painful periods and who do not wish to conceive.

Surgical treatment

To destroy visible endometriotic nodules and divide adhesions (scar tissues) by either burning them using a fine metal electrode or laser them. This usually improves the fertility in the subfertile women with mild/minimal endometriosis (NICE Fertility Guidelines, UK, 2004; RCOG guidelines 2006, NICE 2013, ESHRE 2014).

In women with severe endometriosis who have large ovarian endometriotic cysts (4cm or more in diameter). Surgery allow easier monitoring, may improve access for egg collection and the chance of pregnancy if IVF is considered. The procedure is done under a general anesthetic and can be done by laparoscopy and in certain cases by laparotomy (open surgery which involves a a larger cut in the belly). The procedure involves the endometriosis being cut away or burned, the adhesions divided. Chocolate cysts are removed (ovarian cysectomy) or opened and drained and their lining destroyed (coagulated) to prevent the cyst from reforming. There is evidence that ovarian cystectomy is better than drainage and coagulation (RCOG guidelines 2006, ESHRE 2014). There is a risk of damaging ovarian reserve by surgically treating ovarian endometriomas especially in women who had previous surgery to their ovaries (Ferrero et al 2014). The risk of ovarian failure following bilateral ovarian cystectomy is about 2-3%.

Post-operative medical treatment does not improve pregnancy rates in women with moderate to severe endometriosis and so is not usually recommended (NICE Fertility Guidelines, UK, 2004; RCOG Guidelines, 2006, ESHRE 2014).

Unlike drug treatment, the patient can try for a baby within two to three weeks of the operation and thus it is usually a better option for older women.


How often does endometriosis recur after surgery?

Recurrence of endometriosis after surgery is common. Approximately 20% to 30% within one year of laparoscopic surgery

IUI

The technique intrauterine insemination with ovulation induction is effective treatment but only suitable for young women with healthy Fallopian tubes who ovulate regularly, have a minimal or mild endometriosis and where there is no severe male factor infertility. Up to 6 cycles of intrauterine insemination should be offered because this increases the chance of pregnancy (NICE Fertility Guidelines, UK, 2004, ESHRE 2014).

IVF

The technique IVF is an effective treatment in all stages of endometriosis and is the treatment of choice in women with severe or moderate endometriosis. If the fallopian tubes are damaged or there is also a male factor infertility. There is evidence that IVF pregnancy rates are lower in women with endometriosis than those with tubal infertility (Barnhart et al. Fertility and Sterility, 2002). There is also evidence that treatment with GnRH agonist for 3-6 months before IVF treatment in women with severe endometriosis increases the rate of clinical pregnancy (Marcus et al. American Journal of Obstetrics & Gynecology 1994; RCOG Guidelines, 2006, ESHRE 2014). IVF treatment does not increase endometriosis recurrence rate.

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