Endométriose: Quand passer la main?
Transcription
Endométriose: Quand passer la main?
Endométriose: Quand passer la main? Dr David HAMID Strasbourg Rappels § 25à50%despa,entessuiviespourinfer,litéontune endométriose § 30à50%despa,entesayantuneendométrioseaurontun problèmed’infer,lité § Prévalencedel’endométriose:5à40%desfemmesenâgede procréer § Tauxdefécondabilitémensuelledelapa,enteendométriosique 0,02à0,045%vs0,15à0,2(ASRM) § Chancedegrossesseà0,73vs1,57pourstérilitétubaire,1,19pour lesinfer,litésmasculines,2,64pourlesinfer,litésinexpliquées (EijkermansetcolHumReprod2008) 2 Mécanismephysiopathologique § Théoriedel’implanta,on(Sampson): § Régurgita,onparlestrompesdeFallope § Implanta,onparphénomèned’adhésionet proliféra,on § Théoriedelamétaplasie(Fuji): § localisa,onatypique:prostate,ombilic § Théoriedescellulessouchesendométriales (Sasson) § Cellulessouchescirculantessetransformanten cellulesendométriosiques reflux du sang et des cellules endométriales dans la cavité péritonéale <1>, défaillance de la défense immunitaire du péritoine <2>, adhésion des cellules endométriales au péritoine <3>, envahissement du mésothélium <4>, prolifération <5> et angiogénèse <6> (Louse et al., 2009) Figure 1 : théorie du reflux et de la transplantation de cellules endométriales La théorie du reflux est la plus admise aujourd’hui (9), même si elle explique mal les localisations extra pelviennes atypiques (cérébrale (8) par exemple). Le reflux est observé Mécanisme développe par conséquent sous l’influence d’autres facteurs. physiopathologique chez 90 % des femmes. (12) Ce chiffre ne correspond pas à la prévalence de la maladie qui se Concernant les anomalies des systèmes d’épuration, plusieurs études ont démontré que le liquide péritonéal des femmes endométriosiques diffère de celui des femmes saines.http://www.saintluc.be/services/medicaux/gynecologie/endometriose.php Endométriomes:physiopathologie 1 : ovaire 2 : trompe 3 : ligament rond 4 : ligament large a, b : accumulation des débris menstruels c, d : inversion et invagination du cortex ovarien Figure 11 : constitution d’un kyste endométriosique (Roman et al. EMC gynecol 2009) L’endométriose superficielle voit ses localisations les plus fréquentes au niveau du cul de sac de Douglas et du ligament large. Les lésions se retrouvent également au niveau du cul de sac vésical, du dôme utérin, du dôme vésical (et possiblement, comme dit Mécanismereliantl’endométrioseetl’infer,lité § Modifica,onsanatomiques:adhérencesperi-tubairesetperiovariennes,séquellesinflammatoirestubaires § Stadeextrême:pelvisgelé Mécanismereliantl’endométrioseet l’infer,lité § Altéra,ondelafonc,onpéritonéale: concentra,ondes prostaglandines,protéasesetcytokinesdansleliquide péritonéal § Altéra,ondel’endomètrepouvantaffecterl’implanta,on embryonnaire: IgG,IgAetlymphocytes § Dysovula,oneteffetsdélétèressurl’ovocyte ENDOMETRIOSE ET INFERTILITE Quelle place pour la coeliochirurgie face à l’A.M.P ? EndométrioseetFIV Effets de l’endométriose sur les résultats de la F.I.V.E.T Méta-analyse évaluant les résultats de la F.I.V dans l’endométriose 22 publications Comparaison : endométriose vs infertilité tubaire Barnhart. IVF in endometriosis-associated infertility.Fertil Steril 2002 Taux de Grossesses cliniques selon L’indication en FIV EndométrioseetFIV FIVNAT 2006 StadeAFS-R § Baséesurlésionsanatomiques § § § § Stade1:1à5 stade2:6à15 Stade3:16à40 Stade4:>40 § Stade1et2:22%grossesseà1an (Parazzini1999) § Stade4:3%grossesseà1an (Adamson1997) § CorrélaEonexcellenteentrestadeet hypoferElité,pasdecorrélaEonavec ladouleur Figure 3. Staging: American Society for Reproductive Medicine Revised Classification of Endometriosis STAGE I (MINIMAL) PERITONEUM Superficial Endo — 1–3cm L. OVARY Superficial Endo — <1cm Filmy Adhesions — <1/3 TOTAL POINTS STAGE II (MILD) -2 -1 -1 4 STAGE III (MODERATE) PERITONEUM Superficial Endo — >3cm L. TUBE Dense Adhesions — <1/3 L. OVARY Deep Endo — <1cm Dense Adhesions — <1/3 R. TUBE Filmy Adhesions — <1/3 R. OVARY Filmy Adhesions — <1/3 TOTAL POINTS PERITONEUM Deep Endo — >3cm L. OVARY Superficial Endo — <1cm Filmy Adhesions — <1/3 R. OVARY Superficial Endo — <1cm TOTAL POINTS STAGE III (MODERATE) -6 -1 -1 -1 9 STAGE IV (SEVERE) -3 -16* -4 -4 PERITONEUM Superficial Endo — >3cm L. OVARY Deep Endo — 1–3cm Dense Adhesions — <1/3 L. TUBE Dense Adhesions — <1/3 TOTAL POINTS -1 -1 29 *Point assignment changed to 16 **Point assignment doubled PERITONEUM Deep Endo — >3cm CULDESAC Partial Obliteration L. OVARY Deep Endo — 1–3cm TOTAL POINTS -6 -4 -16 26 STAGE IV (SEVERE) -3 -32** -8** -8** 51 PERITONEUM Deep Endo — >3cm CULDESAC Complete Obliteration R. OVARY Deep Endo — 1–3cm Dense Adhesions — >1/3cm L. TUBE Dense Adhesions — >2/3cm L. OVARY Deep Endo — 1–3cm Dense Adhesions — >2/3cm TOTAL POINTS -6 -40 -16 -4 -16 -16 -16 114 Images 2012 © Jespersen & Associates, LLC. -function score and the Endometriosis Fertility Index. Note: The Tab «Forcesenprésence» RPC COLLÈGE NATIONAL DES GYNÉCOLOGUES ET OBSTÉTRICIENS FRANÇAIS 2006 PRISE EN CHARGE DE L’ENDOMÉTRIOSE RECOMMANDATIONS POUR LA PRATIQUE CLINIQUE (Texte court) CNGOF ,RPC 2006/2010: Infertilité RPC2006 Arguments en faveur d’une endométriose NON: 3 à 4 IIU avec stimulation ovarienne OUI: COELIOSCOPIE DIAGNOSTIQUE Lésions extensives avec risques de complications chirurgicales LESIONS TRAITABLES PAR COELIOSCOPIE Facteurs péjoratifs: âge, OATS, adhérences, atteinte tubaire Agonistes de la LHRH Pas de facteurs péjoratifs Essai de G spontanée 6 à 12 mois Récidive FECONDATION IN VITRO Echec Pas de récidive: 3 à 4 IIU avec stim ov Placedelachirurgiechezlapa,ente endométriosiqueinfer,le Quandgarderlamain? AMPetendométriosedestadeI/II EndometriosisandFerElity:acommiteeopinion.FerElandSteril2012 EndométriosedeStadeI/II • • • • • MarcouxetcolNEngJMed1997 ParazzinietcolHumReprod1994 AdamsonetcolSeminReprodEndoc1997 Chirurgie>absten,on Increased fertility after treatment in infertile women with endometriosis? Chirurgie>traitementmédical JACOBSON ET AL, COCHRANE DATABASE SYST REV, 2002 Chirurgie versus abstention Marcoux et al (341 cas) OR = 1,95 (1,18 – 3,22) OR = 0,85 (0,32 – 2,28) Parazzini et al (96 cas) OR = 1,64 (1,05 – 2,57) Synergiechirurgie/AMP Reproductive BioMedicine Online (2010) 21, 179– 185 www.sciencedirect.com www.rbmonline.com ARTICLE Endometriosis-associated infertility: surgery and IVF, a comprehensive therapeutic approach Pedro N Barri *, Buenaventura Coroleu, Rosa Tur, Pedro N Barri-Soldevila, Ignacio Rodrı́guez of Reproductive Medicine, Department of Obstetrics, Gynecology and Reproduction, Institut Universitari Dexeus, • Service 825pa,entesde20à40ansde2001à2008 Gran Via Carles III 71–75, 08028 Barcelona, Spain • Duréemoyenned’infer,litéde3,2ans * Corresponding author. E-mail address: [email protected] (PN Barri). Dr Pedro N Barri was born in Barcelona in 1949. He graduated from the Faculty of Medicine in Barcelona in 1971 and completed his doctorate in 1993 with a thesis entitled ‘‘Respuesta Anómala a la Estimulación de la Maduración Folicular en Fecundación In Vitro’’ with qualification Cum Laude. He is Director of the Department arian reserve and response to stimulation P < 0.03) than the 93 patients suffering from unilateral affection. Synergiechirurgie/AMP e ovarian reserve of the whole population of 825 patients fore undergoing any treatment was compared with that served in a simultaneous control group, made up of 334 tients who were going to have IVF for male factor infertiland adjusted for age. Patients with endometriosis had sal follicle-stimulating hormone concentrations on cycle Table 1 <35 years !35 years Total Among the 144 patients who went on to IVF after not becoming pregnant post surgery, 32 presented recurrence Endometriosis-associated infertility: pregnancy rates after surgery and/or IVF. Group 1a (surgery) (n = 483) Age Can IVF be attempted in a patient previously operated on for endometriosis who has a recurrence? Group 1b (surgery and IVF) (n = 144)a Group 2 (IVF first option) (n = 173)b Pregnancyc Time (Months) Pregnancyc Pregnancyc 229/372 (61.6) 33/111 (29.7) 262/483 (54.2) 12.5 ± 12 (1–66) 6.6 ± 7.2 (1–14) 11.8 ± 12.1 (1–66) 34/99 (34.3) 22/85 (25.9) 56/184 (30.4) 51/143 (35.7) 17/68 (25.0) 68/211 (32.2) Values are number/total (%) or mean ± SD (range). a 184 IVF cycles. b 211 IVF cycles. c P < 0.05. BarrietcolReprodBiomedOnline2010 Synergiechirurgie/AMP Figure 1 Table 2 Age influence on pregnancy rate after surgery for endometriosis. Endometriosis-associated infertility: pregnancy rate according to different treatment strategies. Pregnancies after surgery (n) Pregnancies after IVF (n) Total pregnancies Final clinical pregnancy rate (%) Group Group Group Group Group 1a (surgery) (n = 483) Group 1b (surgery and IVF) (n = 483) Group 2 (IVF first option) (n = 173) Group 3 (no treatment) (n = 169) 262 – 262 54.2 262 56 318 65.8 – 68 68 32.2 – – 20 (spontaneous) 11.8 I-a versus Group I-b: P < 0.0001. I (a–b) versus Group II: P < 0.0001. I (a–b) versus Group III: P < 0.0001. II versus Group III: P < 0.0001. Table 3 IVF outcomes in patients with endometriosis or male factor infertility after IVF BarrietcolReprodBiomedOnline2010 treatment. Endometriosis (n = 317) Male factor infertility (n = 334) P-value Barrietcol 182 Figure 1 Age influence on pregnancy rate after surgery for endometriosis. PN Barri et al. Barrietcol • Absencederandomisa,onmais Chirurgie FIV • MieuxvautFIVa>37ans Chirurgie+FIV Tauxdegrossesse >35ans 29,7% 25% 25,9% Tauxdegrossesse <35ans 61,6% 35,7% 34,3% BarrietcolReprodBiomedOnline2010 ZiegleretcolLancet2010 FIV>37ans Spécificitédel’endométriome Opéreroupasopérerencas d’infer,lité? Endométriomesetinfer,lité • Tsoumpouetcol:FerElSteril2009 «Surgicalmanagementofendometriomashasno significanteffectsonIVFpregnancyrateandovarian responssEmulaEoncomparedwithnotreatment» • Garci-Velascoetcol:HumanReprod2009 «Responsivenesstogonadotrophinsa]erovarian cystectomyisreduced.Surgeryshouldbeenvisaged onlyinpresenceoflargeortotreatpainsymptoms, orwhenmalignancycanbesuspected» Absten,onchirurgicale OUI, MAIS… 20 ± 10 VOLUME MOYEN DES ENDOMETRIOMES: 20 ±mm 10 OUI, MAIS… 20 ± 10 VOLUME MOYEN DES ENDOMETRIOMES: 20 ±mm 10 EndométriomesetAMP TheimpactofendometriomaonIVF/ICSIoutcomes:a systema,creviewandmeta-analysis Hamdametcol.Humanreprodupdate2015 • Meta-analysede33études(30/33rétrospec,ves). • Pa,entesavecendométriomesvssans endométriomes Résultats Hamdametcol • Différencedetauxdenaissancesvivantesnon significa,ve • Différencedetauxdegrossessesnon significa,ve • 5études(900pa,entes)concluaientàun nombreplusimportantsdefollicules recrutéesaprèschirurgieet5(900)l’inverse • Femmesopéréesounonavaientlemême tauxdenaissancesvivantes Facteursprédic,fs? Aucunmarqueursuffisammentfiableenpré-opératoire Chirurgiedesrécidives d’endométriomes Rôledelatechniqueopératoire? – Trauma,smethermique – Vasculaire – Exérèsedu,ssussain • Placedestechniquesnon-chirurgicalesavant AMP • Yazbecketcol.Reprodbiomed2009 • Onpasselamain… EndométriosedestadeIII/IV Endométrioseviscéraleprofondeet infer,lité Quandpasserlamain..Quandla reprendre? Endométrioseviscérale Endométriose urétérale Endométriose diges,ve Situa,onclinique • Qualitédeviedétériorée • Chirurgieextensivepseudo-carcinologique • Morbiditésévère – Vessieneurologique4à10% – Fistulerecto-vaginale2à10% • «Equipesentrainées» • Neoeaméliora,ondelaqualitédevieaprèschirurgie • Quid/fer,lité? Résultats/Fer,lité Hindawi Publishing Corporation BioMed Research International Volume 2015, Article ID 438790, 7 pages http://dx.doi.org/10.1155/2015/438790 Research Article The Surgical Treatment of Severe Endometriosis Positively Affects the Chance of Natural or Assisted Pregnancy Postoperatively Erin M. Nesbitt-Hawes,1,2 Neil Campbell,1,2 Peta E. Maley,1 Haryun Won,1,2 Dona Hooshmand,2 Amanda Henry,1,2 William Ledger,1,2 and Jason A. Abbott1,2 1 University of New South Wales, Sydney, Australia Royal Hospital for Women, Locked Bag 2000, Barker Street, Randwick, NSW 2031, Australia 2 Correspondence should be addressed to Jason A. Abbott; [email protected] Received 27 September 2014; Accepted 12 January 2015 BioMed Research International Pa,entes (1997-2002) 3 Table 1: Demographic data. Age (median and range) BMI (median and IQR) Previous laparoscopic surgery Smoking Yes Indication for surgery Pain Fertility Both Not stated Prior pregnancy Trying to conceive pre-op Trial ART pre-op Duration of surgery mins (median and IQR) r-ASRM stage III IV Length of stay hours (median and IQR) All participants (𝑛 = 253) Trying to conceive post-op (𝑛 = 142) Pregnancy post-op (𝑛 = 109) 37 (17–55) 24 (21–28) 149 (59%) 37 (26–50) 24 (21–28) 83 (59%) 36 (26–48) 24 (21–28) 58 (53%) 111 (44%) 60 (42%) 46 (42%) 164 (65%) 27 (11%) 58 (23%) 4 (1%) 79 (31%) 114 (45%) 20 (8%) 120 (90–145) 58 (41%) 27 (19%) 55 (39%) 2 (1%) 38 (27%) 95 (67%) 17 (12%) 120 (90–150) 48 (44%) 24 (22%) 35 (32%) 2 (2%) 30 (28%) 67 (62%) 10 (9%) 120 (90–140) 98 (39%) 155 (61%) 44 (29–52) 51 (36%) 91 (64%) 45 (29–51) 42 (39%) 67 (61%) 42 (28–50) SD: standard deviation; IQR: interquartile range; ART: assisted reproductive technology; r-ASRM: revised American Society of Reproductive Medicine. had s 0.0 0 20 40 60 80 Time to conception (months) Erinetcol2015BioMedRes ART Natural conception 100 4. D (%) Pregnancy (%) Surgi has b Figure 2: Postoperative pregnancy (women attempting to con4 BioMed Research International and q ceive). [7, 18 place or gonadotrophin releasing hormone analogues), or those 100 1.0 repor who had been trying for a pregnancy preoperatively. Thereexcisi 9 were no90differences in pregnancy rates for women who hadmode 16 8 5 endometriomas resected 64/111 (58%); women having a bowelof wo 0.8 80 0 resection 5/9 (55%); or those with2 incomplete resection ofGiven 1 disease7016/35 (46%) compared with those who did not. for ad 2 13 2 13 recorded There were complications. These included availa 0.6 19 60 two major intraoperative complications, one of blood losswom disea >2000 mL 50 requiring a blood transfusion and 4 one unintenM tional trauma to the bladder repaired laparoscopically. There 0.4 40 minor intraoperative complications of uninten-disea were four tional entry into the vagina, with one of these requiringfollow 18 30 a second suturing due 23 to postoperative dehiscence. There19, 27 0.2 37 were one of urinarymode 20 case of pulmonary oedema, two cases 7 retention, one urinary tract infection, and two patients whopregn no m 10 0.0 had swelling or bleeding at a laparoscopic port site. fertili 0 their 0 20 40 60 80 100 <30 ≥40 30–34 35–39 no di Time to conception (months) surge 4. Discussion ART No pregnancy ART be giv Natural conception Unexpected conception Natural conception Surgical excision of moderate-to-severe stage endometriosisto ha 3: Pregnancy distribution age bands (women has been demonstrated to across improve women’s painattemptsymptomsis 12 Figure 2: Postoperative pregnancy (women attempting to con- Figure ing to conceive 𝑛 = 142 and women with unexpected conceptiontrialskeepi and quality of life in randomised placebo controlled ceive). 𝑛 = 5). [7, 18, 26]. For fertility outcomes, the largest randomisedmore placebo controlled trial assessed only stage I-II disease and19]. C 10073%dechanced’êtreenceintespontanémentdansles12mois reported an improvement in live birth rate following surgicalmust was no significant difference (Figure 3). There were no ofprogr excision [14]. No RCTs exist for the reproductive outcomes Cumulative pregnancy rate after ICSI-IVF in patients with colorectal endometriosis: Results of a multicentre study Adénomyose Age Réserve ovarienne From january 2005 to june 2011. 75 patients with colorectal endometriosis and proved infertility for deep infiltrating endometriosis. The CPR per patient after three ICSI-IVF cycles was 68.6% Marcos Ballester and al. Human Reproduction, Vol 27, N°4 pp. 1043-1049, 2012 SérieHUS • CenEnyetcol.Theimpactoflaparoscopicsurgical managementofdeependometriosison pregnancyrate.J MininminvasiveGynecolsept 2015 • 22moisdesuivimoyenpostopératoireavectaux degrossessede54.78%(n=63) • Tauxdenaissancevivantede42.6%(n=49). • 60%detauxdegrossesseglobale: – 38,7%spontanémentet21,4%parAMP • CONCLUSIONS:Résec,onmaximaleaméliorele tauxdegrossessespontanéeetavecAMP Conclusion • EndométriosestadeI/II:chirurgiepremièreau coursdelacoelioscopieexploratrice • Endométriomeovarien: – <35ans?:chirurgiepuisAMP(6-12moisaprès?) – >35ans?:AMP(sclérothérapie?) – Récidive:pasdechirurgie • Endométrioseprofonde: – Chirurgiepremièresuivied’AMP? – AMPetpuischirurgiesiéchec(plussimpleà accepter?)
Documents pareils
endometriose et infertilite
preoperative fertility status and IVF performance was 39% but dropped to 24% in infertile patients who sought
spontaneous conception.