treatment of severe adenomyosis prior to assisted reproductive techniques (art) · 2016-05-23 ·...
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Tips & tricks in endometriosis
Treatment of severe adenomyosis prior to Assisted Reproductive Techniques (ART)
Edgardo SOMIGLIANA, MD-PhD Fondazione Ca’ Granda, Ospedale Maggiore Policlinico
& Università degli Studi di Milano Milan, Italy
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Conflicts of interest
Personal conflicts:
Those related to private practice
Conflicts of the referring ART Unit
Financial supports during the last three years received
from Ferring, Merck-Serono, IBSA and MSD
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Adenomyosis prior to ART
Endometriosis
Age
Adenomyosis Pregnancy
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Adenomyosis prior to ART
v Abnormal uterine bleeding
v Repetitive implantation failure
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Pre-ART treatment: available evidence
Surgery GnRH agonists Progestins
RCTs
Prospective controlled
Retrospective controlled
Case reports / case series
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Retrospective patient-preference study
Frozen-thawed embryo replacement
GnRH agonists (2 months) + HRT versus HRT
Women informed about possible ↑ effectiveness but also ↑ time and costs
339 cycles in women with adenomyosis (US diagnosis) Niu et al., 2013
Pre-ART treatment: comparative studies
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GnRH agonists for adenomyosis Ultralong + HRT HRT
Characteristics n=194 n=145 p Age (years) 32.1 ± 4.0 31.5 ± 4.0 ns BMI (Kg/m2) 21.5 ± 3.0 20.7 ± 2.6 ns Previous pregnancies 82 (42%) 57 (39%) ns Duration of infertility (months) 39 ± 19 42 ± 20 ns Serum FSH (IU/ml) 7.5 ± 2.3 7.2 ± 1.3 ns Indication to IVF ns Tubal 79 (41%) 52 (36%) Male factor 53 (27%) 39 (27%) Endometriosis 15 (8%) 10 (7%) Mixed 47 (24%) 44 (30%)
Niu et al., 2013
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GnRH agonists for adenomyosis
Ultralong + HRT HRT Characteristics n=194 n=145 p
Endometrial thickness (mm) 9.7 ± 1.4 11.6 ± 1.7 0.04
N. Embryos transferrred 2.0 ± 0.4 1.9 ± 0.4 ns
Implantation rate 127 (33%) 45 (16%) <0.01
Clinical pregnancy rate 100 (52%) 36 (25%) 0.04
On-going pregnancy rate 90 (46%) 31 (21%) 0.02
Niu et al., 2013
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Adenomyosis prior to ART
Endometriosis
Age
Adenomyosis Pregnancy
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Sallam et al., 2006
OR=4.28 (95%CI: 2.00-9.15)
Ultralong protocol for endometriosis
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De Ziegler et al., 2010
*
CPR per pick (%)
Oral contraceptive pre-IVF
Ultralong protocol for endometriosis
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Clinical pregnancy: RR=0.72 (95%CI: 0.55-0.95)
Vercellini et al., 2014
Long protocol for adenomyosis
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Long protocol: RR=1.05 (95%CI: 0.75-1.48) Short protocol: RR=0.58 (95%CI: 0.38-0.88)
Vercellini et al., 2014
Long protocol for adenomyosis
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Surgery for adenomyosis
Retrospective patient preference study
65 women with unexplained infertility > 3 years
28 treated surgically (15 also received GnRH analogues for 6 months)
37 treated with GnRH analogues for 6 months
Outcome: natural pregnancy Wang et al., 2009
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Surgery for adenomyosis
Surgery (n=28) GnRHa (n=37) p
Age (years 34.3 ± 2.1 32.7 ± 1.4 0.007
Infertility (years) 3.9 ± 0.9 3.4 ± 0.6 0.04
Max. uterine diameter (mm) 102 ± 9 98 ± 7 ns
Pregnancies (at 3 years) 13 (46%) 4 (11%) 0.002
Deliveries (at 3 years) 9 (32%) 3 (8%) 0.02
Wang et al., 2009
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Conclusions
GnRH agonists may increase the chance of pregnancy in women with adenomyosis
Long protocol should be first considered for fresh cycles in women with adenomyosis
Ultralong protocol (or progestins?) prior to fresh or frozen embryo transfer if: v Abnormal uterine bleeding v Repetitive implantation failure v Very severe sonographic findings
Surgery in skilled hands and for adenomyomas if the other approaches failed
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