Author: Eleni Pap.

Endometriosis Treatment

Endometriosis is a major health issue in women of reproductive age, and makes no racial, social or financial distinctions. It is characterized by endometrial-like tissue that develops and spreads to other body organs, structures and tissues outside the uterus, causing a chronic inflammatory reaction.

As regards its prevalence, endometriosis, affects 6-10% of reproductive-aged women, and the rate is 38% (20-50%) in childless women and 71-78% in women with chronic pelvic pain. It is a chronic gynecological condition and its main manifestations include chronic pelvic pain and infertility. The pathogenesis of the disease seems to be linked to endometrial cells which are being transfered and implanted, and then grow in the peritoneal cavity, as a result of the retrograde flow of menstrual blood over the course of the menstrual cycle.

The clinical manifestations of endometriosis can vary in terms of the way they occur and their duration. Dysmenorrhea, chronic pelvic pain, pain with intercourse, clinical symptoms from the bowel or the bladder with or without abnormal bleeding, and constipation constitute, in brief, the principal clinical symptomatology of the disease.

Women with endometriosis are very frequently faced with two major problems: Chronic pelvic pain and infertility, at the same time or separately. The treatment can be medication, surgery or both. For women with pain and a known history of endometriosis who would like to conceive in the future, the initial treatment consists of several types of medication, such as non-steroidal anti-inflammatory drugs (NSAIDS), contraceptive pills, contraceptive vaginal ring and transdermal patch (estrogens/progesterone).  In addition, progestagen (medroxyprogesterone acetate, dienogest) orally or parenterically, or antiprogestogen (gestrinone) are another quite effective option. Furthermore, GNRH analogues (nafarelin, leuprolide, triptorelin) are a serious and highly effective alternative in the treatment of chronic pelvic pain. A 3 month regimen is rather established and improves dysmenorrhea significantly. There is, also, the possibility of a longer period of administration (>1 year) supplemented with small doses of progestogen alone or in combination with estrogen (“add-back” therapy).

Levonorgestrel intrauterine system insertion has also proven its effectiveness in the reduction of pelvic pain. Danazole is a testosterone derivative that has been used with many side-effects, such as acne and androgenic effects (excessive hair growth). Finally, one should also note the use of aromatase inhibitors (anastrozole, letrozole) with co-administration of progesteronoids or combined contraceptives.

Besides medication, laparoscopy is the established method for the treatment of endometriotic lesions (thermal destruction – burn-off), removal of adhesions and uterosacral nerve interruption or even ablation (presacral neurectomy/LUNA). As regards the surgical treatment of endometriotic lesions, laparoscopic ovarian cystectomy is characterized by lower rates of relapsed pain, as well as higher rates of spontaneous pregnancy in the future. Finally, total hysterectomy with oophorectomy and total resection of all visible foci of disease in women who have achieved their desired family size is a radical solution when other conservative methods have failed.

Ovarian function suppression with hormone therapy is not recommended as part of the treatment of endometriosis–related Infertility, in order to improve fertility, but rather laparoscopic ablation and destruction of endometriotic lesions, cystectomy and adhesiolesis, so as to resolve the distortion of pelvic anatomy.

In conclusion, endometriosis is a pathological entity with social and financial implications, but also with severe consequences for the daily life of modern women. Our goal should be to have a better management and knowledge of the disease, in order to reduce both the personal and the social cost of the disease.

Hysteroscopy before IVF treatment

Prior to the IVF treatment, a number of preliminary screening tests are available for early detection of possible uterine abnormalities that might interfere in the process of successful implantation and have an impact on the final pregnancy outcome. In the last decade, specific modern endoscopic techniques have gained increasing acceptance, as the most reliable diagnostic tests for infertility, mainly hysteroscopy which allows direct inspection of the endo-cervix, the endometrial cavity and the internal fallopian os.

The procedure is simple and relatively painless. It is generally performed between the 6^th and 10th day of the menstrual cycle. Mild anaesthetic may be used, only if needed. The woman herself can watch the procedure on a screen, if she wishes.

Hysteroscopy is performed by placing a hysteroscope into the uterine cavity (a thin long tube with 2.8mm diameter), usually without the need for cervical dilatation. Dilatation fluid is pumped into the uterus to facilitate the visualization first of the cervical canal and through that the uterine cavity and the internal os of the fallopian tubes, on the screen in real time.

The main advantage of hysteroscopy is the possibility it offers to inspect the endometrial cavity and diagnose pathologies e.g. polyps, adhesions, fibroids, uterine septae, intrauterine congenital malformations etc. These pathological conditions, not infrequently, are detected in women undergoing IVF treatment and may compromise the final treatment outcome.

The efficacy of hysteroscopy prevails over other alternative, non-invasive methods available for assessing the uterine cavity, including Hysterosalpingography (HSG) and Hysterosonogram  (HSN) where a small amount of normal saline is infused through the cervix and an ultrasound examination is performed to assess the uterus.

The other big advantage of hysteroscopy that should be emphasized is that the above mentioned pathologies can be diagnosed and treated in one single procedure. An operative hysteroscopy can be performed simultaneously by utilizing advanced micro-instruments inserted through the hysteroscope. These pathologies are often the cause of an IVF failure and miscarriage, with considerable psychological impact on the couple.

According to recent studies, endometrial ablation performed during hysteroscopy (scratching), even at the absence of definite pathological conditions, improves endometrial receptivity, implantation and pregnancy rates, especially in women with recurrent implantation failure (RIF), which remains a major challenge in IVF.

It is evident that both diagnostic and operative hysteroscopy are particularly effective in the management of infertility, used routinely of selectively

The European Society of Human Reproduction and Embryology (ESHRE) recommends the use of hysteroscopy to confirm and treat intrauterine pathologies, but not as a routine procedure.

In conclusion, hysteroscopy is a simple and safe method for the diagnosis of uterine pathological conditions related to infertility, through direct visualization and treatment in a single procedure. In addition to improving IVF/ICSI treatment outcome, it reduces miscarriage

Aristidis Kainantidis

MD, PhD

Obstetrician – Gynecologist, Scientific Fellow, FIVI Fertility & IVF Center, European Interbalkan Medical Center