Subtle Uterine Septum : A Diagnostic and Management Dilemma

s Regional Meeting (in alphabetical order) For personal use only. Not to be reproduced without permission of Krause & Pachernegg GmbH. 414 J Reproduktionsmed Endokrinol 2010; 7 (5) IFFS 2010 – Abstracts Regional Meeting IF FS – A b st ra ct s 3 generation AIs have been used in infertility treatment to induce ovulation. Clinical trials showed that transient inhibition of aromatase activity in the early follicular phase results in moderate ovarian hyperstimulation similar to that seen with clomiphene citrate [13, 14]. Additionally, letrozole reduces the gonadotropin dose required to induce follicular maturation especially in poor responders, and adjunctive use of letrozole may form an effective means of low-cost IVF protocol in these patients [15–17]. Approximately half of the patients with chronic pain associated with endometriosis are refractory to currently available treatments that create a hypoestrogenic state including OC, Depo-Provera, oral progestins and GnRH analogs [18–20]. The majority of these patients refuse to be treated with danazol because of its potential androgenic side effects [21]. Conservative surgical removal of endometriosis provides some pain relief. Response to surgical treatment varies extensively and heavily depends on many factors including the experience of the surgeon, previous attempts of treatment, use of adjuvant medical treatment and the definition of the therapeutic endpoint [22–25]. Following conservative surgery, endometriosis often recurs at some point after surgery; and pain is usually more refractory to repeated surgical attempts. The immediate overall response of chronic pain to conservative surgery in an unselected population of women is approximately 50 % [25]. The value of uterosacral nerve ablation or presacral nerve resection has not yet been clearly demonstrated, and the benefits of these adjunctive surgical approaches for endometriosis-associated pain remain controversial [22, 23]. Currently, when no other medical options remain and minimally invasive surgery has failed, women resort to a total hysterectomy with or without bilateral salpingo-oopherectomy. Even after this invasive procedure, their pain may not be relieved [1, 26, 27]. The results of the 5 studies on the effect of hysterectomy on chronic pelvic pain of presumed uterine origin consistently demonstrated that 3–17 % of operated women reported recurrence of pain one year after surgery [28]. Failure of current medical and surgical treatments to relieve pain prompted us and others to target the aromatase molecule in endometriosis using AIs. The rationale was that continued local estrogen production in endometriotic implants during other medical treatments (e. g., GnRH analogs) was, in part, responsible for resistance to these treatments. Anastrozole and letrozole have been successfully used to treat endometriosis [29–35]. The number of clinical trials employing AIs in the treatment of endometriosis strikingly increased after 2004. AIs appear to be the first breakthrough in the medical treatment of endometriosis since the introduction of GnRH agonists in the 80’s. Patients with endometriosis that do not respond to existing treatments appear to obtain significant painrelief from AIs. Most of the AI regimens are fairly simple consisting of taking 1 or 2 tablets a day. Finally, the side effect profiles of the AI regimens (including a progestin or OC add-back) are more favorable compared with treatments using GnRH agonists or danazol. Thus, some of these regimens may potentially be administered over prolonged periods of time. AIs administered in combination with an ovarian suppressant represent promising and novel treatments of premenopausal endometriosis. The requirement for calcium, vitamin D or bisphosphonate supplementation in premenopausal women needs further evaluation. The regimens including combinations of an AI with a progestin or OC will probably gain more popularity over the combination of an AI with a GnRH analog because the former are simpler, cheaper, associated with fewer side effects and may be administered for longer. Randomized clinical trials are needed to establish the efficacy and side effects of these regimens. Lower doses of AIs may also be used potentially in the treatment of pain or infertility associated with endometriosis. We anticipate that many more clinical trials performed over the next decade will provide answers to these questions.