Tamer Seckin: I am Dr. Tamer Seckin reporting from Osaka, Japan. We are at the Annual Meeting of ISGE. There are many beautiful presentations going on. Among some of them we are proud to present to you and bring it through the internet. And today I have Professor Timur Gurgan from Hacettepe University, Ankara, Turkey. He is going to talk to us with some special questions with respect to endometriomas, whether it is surgery or conservative treatment and its effect on IVF cycles. Timur, it is nice having you here today.
Timur Gurgan: It’s nice to be with you Tamer.
Tamer Seckin: My question is to you, after so many years and the results that we observe on endometriosis treatment without endometrioma first, the effect of laparoscopic excisions is well established, but when it comes to the issue of endometrioma even though we did believe that in the past there was a solid effect, positive effect of endometrioma, removing or devoluming the ovary, on your presentation today you have brought some controversial results reviewing your literature and your current findings, could you just give us a synopsis of what you have said and why and where are we going with the subject?
Timur Gurgan: As a gynecological surgeon know about this, we are just operating the endometriomas if they are big enough to be operated. We consider the size, just more than 3-4 cm, I think we have to think about the operation. But on the other hand if there is really severe pelvic pain and they have to consider the operation is that today, in my presentation, I did not touch to the operational side at all, if there is adnexal mass and the pelvic pain, we are right to operate then, but if fertility is the question we have to be very careful for the operation, since there are some possibilities that we have to think about in advance. The first one is okay, we could operate the patient and after the operation, we could get around 50% of pregnancy rate in a period of time. But we have to give the patients a good advice depending upon their own characteristic that I have said today because we cannot announce easily publicly that okay we could operate and we could get the 50% of pregnancy rate because we have to individualize what we are saying to the patient, this is the first part of my talking. The second one was the debate on if operating the patient we could decrease their IVF chance or not because there is a question in the literature saying that if we operate the patient, you know, remove the endometriomas, we may decrease their potential to produce the eggs on the operated side. So, reviewing all of the literature including our publication, two publications coming from our department, we could say that, okay if a patient has the endometriomas and we diagnosed the endometriomas and we decided for the IVF, the question is when we are going to operate or should we operate those patients just prior to IVF to have a positive impact of their IVF success. Okay and the result is #1, okay we do not have to operate them for sure. If there is no pain and if there is no big endometriomas, and operation cannot improve the pregnancy rate, but negatively if we are not kind enough, if we are just using the bad techniques of removing the cyst wall, not carefully we are just using too much electrical energy to make the hemostasis, there is a possibility to decrease the number of the oocyte on the affected site.
Tamer Seckin: Let’s pause that. This is a endoscopy meeting. I think the most important part of meeting for viewers to understand with the respect of the results what is the right technique for endometrioma surgery.
Timur Gurgan: Yeah.
Tamer Seckin: So, first of all, you probably want the viewers to be aware that we endoscopists do not use an electrical surgery on the ovary and we want to avoid as much as possible.
Timur Gurgan: Right.
Tamer Seckin: We do like to take the cyst wall out because that is an endometriomas secondary endometrial cavity within the abdominal cavity. So, we want to take that without though any coagulation.
Timur Gurgan: You are right there. You know during the discussion period, we had a debate with Jacque Canis from France, we have come to a conclusion that you know if you are an experienced person, if you are going to the experienced surgeon, there is no problem at all. This is very, very important and the surgeon should strip, make a strip of the capsule in the right plane and you do not cause any bleeding at all.
Tamer Seckin: None at all.
Timur Gurgan: You are right, endocoagulation. So, you cannot make it hard to the oocyte which is retrieved after the IVF, but the important thing is and we all know that the recurrence rate of the removed endometriomas is a little bit higher up to 30% percent and at least we have to give the patient that they should not be operated again and again, repeat it.
Tamer Seckin: Repeat operations are, patients with repeated operations are bad candidates for.
Timur Gurgan: Yeah, but the important thing is if it is the bilateral repeated operation there is a chance of reduced oocytye. On the other hand, if there is no problem of small endometriomas, we do not have to operate them in advance just prior to IVF.
Tamer Seckin: And last question for the sake of this meeting, I think do you reapproximate the ovarian tissue after removing endometriomas larger than 5 cm, let’s put it that way?
Timur Gurgan: Yeah, but there are some publication in our hand. It depends upon the size of the endometriomas. If they are not big enough you do not put any suture, you do not make anything and there are some surgical techniques and you could put very less amount of the electrocauterization, make the diversion of the ovarian cortex, if it is your selection and preference, if it is a big area and we may put very fine sutures one or two one, two. It could just only the approximation.
Tamer Seckin: Approximations. Do you suspend ovaries at times of severe pelvic sidewall adhesions?
Timur Gurgan: Yeah, but I do not do it, you know, surgeon doing too much, very extensive operations, but you know and there is a question if we should prepare the ovaries just prior to IVF to get.
Tamer Seckin: Technically it’s difficult.
Timur Gurgan: To get Oocyte we do not need them very often.
Tamer Seckin: Thank you very much.
Timur Gurgan: Thank you very much, Dr. Tamer.