*nsanlar, nerede kuvvet grrse hak orada sanr, oysa hak ile g pek az birleirler Joseph Rouse

ENDOMETROSS EVRELEME SSTEMLERNN KRTK ANALZDr. Kutay BiberogluGazi niversitesi Tp Fakltesi Kadn Hastalklar ve Doum Anabilim Dalreme Endokrinolojisi ve nfertilite Bilim Dal

Sunu Ak PlanGemiten bugne evreleme sistemleri

Neden halen evreleme sistemi aray iindeyiz?

Gelecekteki olas snflamalar

Evrelemenin klinik uygulamaya etkileri

Gemiten bugne evreleme sistemlerilk evreleme sistemi nerisi 19791 AFS (ASRM) Hastaln iddetinin cerrahi tedavi baarsn ngrecei varsaymyla drt evre 2Srekli revizyonlar & yeni sistem araylarAFSrASRMAFS. Classification of endometriosis. Fertil Steril 1979;32:633634Adamson GD. Curr Opin Obstet Gynecol 2011; 23: 213220

19801985199019952000200520102015

*Histolojik dorulama : krmz - %100, siyah - %92, beyaz - %31 Mettler L. 2003CPP/infertilite/karma renk/>5mm derin/>10 mm geni - %75 Wanyonyi SZ. 2011

*Gemiten bugne evreleme sistemlerilk evreleme sistemi nerisi 19791 AFS (ASRM) Hastaln iddetinin cerrahi tedavi baarsn ngrecei varsaymyla drt evre 2Srekli revizyonlar & yeni sistem araylarAFSrASRMENZIANrENZIANAFS. Classification of endometriosis. Fertil Steril 1979;32:633634Adamson GD. Curr Opin Obstet Gynecol 2011; 23: 213220

19801985199019952000200520102015

*FI rekto sigmoid dnda intestinal infiltrasyon FA Uterin adenomyosis FB derin mesane tutulumu FU intrinsik reteral infiltrasyon a : douglas & vajina b : uterosakral lig. & kardinal lig. c : rektum, rektosigmoid FO dier lokalizasyonlarF EKSTERNAL HASTALIK E ENDOMETRIOSIS (iddet 1-4)Haas D et al. Fertil Steril 2011;95:15748

Haas D. et al. Arch Gynecol Obstet 2013; 287:941945

*Gemiten bugne evreleme sistemlerilk evreleme sistemi nerisi 19791 AFS (ASRM) Hastaln iddetinin cerrahi tedavi baarsn ngrecei varsaymyla drt evre 2Srekli revizyonlar & yeni sistem araylarAFSrASRMENZIANrENZIANEFIAFS. Classification of endometriosis. Fertil Steril 1979;32:633634Adamson GD. Curr Opin Obstet Gynecol 2011; 23: 213220

19801985199019952000200520102015

*Adamson GD. Curr Opin Obstet Gynecol 2013, 25:186192

*Neden rASRM evresi ile ar semptomu arasnda zayf bir korelasyon var?OyunuzAr ile evre arasnda korelasyon yokturrASRM hastal yeterince hassas olarak yanstmaz??

*rASRMEn yaygn ve sk kullanlan sistemTan iin gvenilir1almalarda sk kullanmPeritonda yzeyel lezyonlar evrelemeye dahil

AMA, klinik gereklilii sorgulamada:Ar-evre arasnda korelasyon yok DIE or organ tutulumu gstermiyorTedaviyi ynlendirmiyor, prognozu ngrmyor Schliep KC et al. Obstet Gynecol 2012;120:10412

Dier alternatifler nelerdir?ENZIANDIE ve retroperitoneal yaplar iin rASRM evreleme sistemine destekAr & fertilite iin yetersizKomplike / yaygn kullanm yok1

EFIinde rASRM var3 almada valide edilmi24EFI skoru ile non-ART gebelik iin geen sre korele4Tedavi plannda yardmcAdamson GD. Curr Opin Obstet Gynecol 2011; 23: 213220Wei DM et al. Zhonghua Fu Chan Ke Za Zhi 2011; 46:806808Yacoub A et al. World Congress Endometriosis. Montpelier, France. S#10-4. 7 September 2011Tomassetti C et al. Hum Reprod.2013;28(5):1280-8p=0.00012Cerrahi sonras

*Var olan sistemlerin zeti

rASRMrENZIANEFIPeritonealOvarian/OMA DIEFertilitePainTedavi ynlendirme?Basit

Neden endometriosisi evreleme abalarna devam edelim?yi bir evreleme sistemi:

Ayn dilde konumay salar

Tan spesifisitesi salar

Karlatrmalar standardize eder

Aratrmalar hzlandrr / kolaylatrr

Tedavi plan ynlendirir ve monitorize eder

Hastaln yaygnln & ar / infertilite ilikisini yanstmalUygulamas kolay olmalNon-invaziv olmalTedavi plann ynlendirmeli:

Prognozu ngrmeli (medikal ve operatif)Rekrens riskini ngrmeliTedavi prognozunu monitorize etmelideal bir evreleme sistemi

Gelecekteki olas sistemlerAAGLProje 2007 ylnda AAGL endometriosis cerrahi ilgi grubu tarafndan balatldOtoriteler ar & infertilite asndan nemli grdkleri anatomik faktrleri skorlamaya baladlar

Hipotez: Eer hastalk doru ekilde tanmlanabilirse en sonunda bu tanmlarn analizinden pratik bir evreleme sistemi doabilir

30 otoritenin verileri analiz edilerek skorlandrldBu verilere gre AAGL yeni bir sistem nerecekn sonular ar, infertilite ve cerrahi glk ile korele gibi.. Endometriosis Classification Committee, Ad Hoc Committee of the AAGL. 2007Martin DC et al. AAGL Annual Meeting. Orlando, Florida. 17 November 2009

Gelecekteki olas sistemlerSemptomlar & rASRM ile korele serolojik belirtelerCA-125, TNF, IL-1, IL-6, IL-8 AMH serum dzeyleri ve hastaln iddeti ile ilikiUS ile grlemeyen endometriosis tansnda %81-90 duyarllk & % 63-81 zgnlk ile Annexin V, VEGF, CA-125 & sICAM-1/veya glycodelin Vimercati A et al. Ultrasound Obstet Gynecol 2012; 40: 592603 Coccia ME, Rizzello F. Ann N Y Acad Sci 2011; 1221:6169 Socolov R et al. Eur J Obstet Gynecol Reprod Biol 2011; 154:215217 Shebl O et al. Gynecol Endocrinol 2009; 25:713716 Vodolazkaia A et al.Hum Reprod 2012; 27:26982711 Borghese B et al. Mol Endocrinol 2010; 24:18721885Genome-wide profil endometriosiste subtelomerik hipermetilasyon Transvajinal sonografi & DIE iin kontrastl magnetik rezonans-kolonografi

Bugn hastalarmz nasl ynetelim?Var olan sistemler gereksinimleri karlamyor & tan iin laparoskopik ilem gerektiriyor

Pragmatik, hasta odakl bir ynetim plan:

Evrelemeyi klinik almalara snrlayalmSadece tedavi edici cerrahi gerekiyorsa evrelemeyi dnelimEer cerrahinin amac fertiliteyi dzeltmek ise EFI kullanalm Arl hastalarda & baka endikasyon yoksa evreleme gerekli olmayabilirVAS / B&B & US ile monitorizasyon ve lm yeterli olabilir

*ZETu anda elimizdeki evreleme sistemleri hastal hassas ve gvenilir ekilde yanstmyor

Yeni ve gelecekte olas sistemler (EFI & AAGL) mit vadediyor

imdilik hastal deil hastay, pragmatik bir yaklamla tedavi etmeliyiz

*Further information:

AFS:First introduced in 19791Classifies disease into 4 stages based on site & distribution of lesionsPremise that severity of disease would determine the success of surgery2Revised last in 1996, rASRM (AFS became ASRM) which included illustrations and pictures as guides3

ENZIAN:First introduced in 2005,4 and revised in 2011 (rENZIAN)5To supplement rASRM staging, particularly in DIE, retroperitoneal structures & intestine, ureter, bladder etc.Not widely recognised, but used in Germany

EFI:Developed by Adamson & Pasta in 20106Predicts non-IVF fertility rates after surgeryUses rASRM as part of scoring systemValidated in three studies up to 201379

AAGLInitiated in 2007 to document disease accurately30 individuals responded with weighted score for different anatomical factors they thought were important with respect to pain and infertility (based on analysis of data from their own patients collected in the form)The same surgeons are now seeing if they can retrospectively apply scores & predict outcome Expected to propose a classifications system soon10,11

References:AFS. Classification of endometriosis. Fertil Steril 1979;32:633634Adamson GD. Curr Opin Obstet Gynecol 2011; 23: 213220Revised ASRM classification of endometriosis. Fertil Steril 1996; 67:817821Tuttlies F. et al. Zentralbi Gynakol 2005; 127:275281Haas D. et al. Arch Gynecol Obstet 2013; 287:941945Adamson GD, Pasta DJ. Fertil SAteril 2010; 94: 16091615Wei DM et al. Zhonghua Fu Chan Ke Za Zhi 2011; 46:806808Yacoub A et al. World Congress Endometriosis. Montpelier, France. S#10-4. 7 September 2011Tomassetti C et al. Hum Reprod.2013;28(5):1280-8Endometriosis Classification Committee, Ad Hoc Committee of the AAGL. 2007Martin DC et al. AAGL Annual Meeting. Orlando, Florida. 17 November 2009

*Further information:

AFS:First introduced in 19791Classifies disease into 4 stages based on site & distribution of lesionsPremise that severity of disease would determine the success of surgery2Revised last in 1996, rASRM (AFS became ASRM) which included illustrations and pictures as guides3

ENZIAN:First introduced in 2005,4 and revised in 2011 (rENZIAN)5To supplement rASRM staging, particularly in DIE, retroperitoneal structures & intestine, ureter, bladder etc.Not widely recognised, but used in Germany

EFI:Developed by Adamson & Pasta in 20106Predicts non-IVF fertility rates after surgeryUses rASRM as part of scoring systemValidated in three studies up to 201379

AAGLInitiated in 2007 to document disease accurately30 individuals responded with weighted score for different anatomical factors they thought were important with respect to pain and infertility (based on analysis of data from their own patients collected in the form)The same surgeons are now seeing if they can retrospectively apply scores & predict outcome Expected to propose a classifications system soon10,11

References:AFS. Classification of endometriosis. Fertil Steril 1979;32:633634Adamson GD. Curr Opin Obstet Gynecol 2011; 23: 213220Revised ASRM classification of endometriosis. Fertil Steril 1996; 67:817821Tuttlies F. et al. Zentralbi Gynakol 2005; 127:275281Haas D. et al. Arch Gynecol Obstet 2013; 287:941945Adamson GD, Pasta DJ. Fertil SAteril 2010; 94: 16091615Wei DM et al. Zhonghua Fu Chan Ke Za Zhi 2011; 46:806808Yacoub A et al. World Congress Endometriosis. Montpelier, France. S#10-4. 7 September 2011Tomassetti C et al. Hum Reprod.2013;28(5):1280-8Endometriosis Classification Committee, Ad Hoc Committee of the AAGL. 2007Martin DC et al. AAGL Annual Meeting. Orlando, Florida. 17 November 2009

*Further information:

AFS:First introduced in 19791Classifies disease into 4 stages based on site & distribution of lesionsPremise that severity of disease would determine the success of surgery2Revised last in 1996, rASRM (AFS became ASRM) which included illustrations and pictures as guides3

ENZIAN:First introduced in 2005,4 and revised in 2011 (rENZIAN)5To supplement rASRM staging, particularly in DIE, retroperitoneal structures & intestine, ureter, bladder etc.Not widely recognised, but used in Germany

EFI:Developed by Adamson & Pasta in 20106Predicts non-IVF fertility rates after surgeryUses rASRM as part of scoring systemValidated in three studies up to 201379

AAGLInitiated in 2007 to document disease accurately30 individuals responded with weighted score for different anatomical factors they thought were important with respect to pain and infertility (based on analysis of data from their own patients collected in the form)The same surgeons are now seeing if they can retrospectively apply scores & predict outcome Expected to propose a classifications system soon10,11

References:AFS. Classification of endometriosis. Fertil Steril 1979;32:633634Adamson GD. Curr Opin Obstet Gynecol 2011; 23: 213220Revised ASRM classification of endometriosis. Fertil Steril 1996; 67:817821Tuttlies F. et al. Zentralbi Gynakol 2005; 127:275281Haas D. et al. Arch Gynecol Obstet 2013; 287:941945Adamson GD, Pasta DJ. Fertil SAteril 2010; 94: 16091615Wei DM et al. Zhonghua Fu Chan Ke Za Zhi 2011; 46:806808Yacoub A et al. World Congress Endometriosis. Montpelier, France. S#10-4. 7 September 2011Tomassetti C et al. Hum Reprod.2013;28(5):1280-8Endometriosis Classification Committee, Ad Hoc Committee of the AAGL. 2007Martin DC et al. AAGL Annual Meeting. Orlando, Florida. 17 November 2009

*Superficial disease in the peritoneum should be classified with the rASRM Reliable for diagnosis1Moderately reliable for staging1Reliability near perfect when computer-assisted1

But

Wide-ranging and arbitrary scoringLiable to observer errorsesp. in ovary and posterior cul de sac Problematic documentation and identification of endometriomasPoor correlation between the lesion site, type and extent of endometriosis and pelvic pain/infertility except for extensive diseaseDoesnt take DIE and the involvement of other organs into accountDoes not effectively predict outcome of treatment

Further information on Schliep study

Intraoperative photographs taken using digital cameras ; 4 academic & 4 local, specialized expert reviewed rASRM criteria for staging Images sent to clinical raters one at a time per woman through an online system, asked to stage I-IV, then to complete a checklist for location, size / types of lesions / adhesions Outcomes 1) endometriosis + or - ; 2) staging ; 3) computer-assisted staging

Substantial reliability for rASRM endometriosis diagnosis - interrater reliability among 8 surgeons : 0.69 (0.64 0.74) (21% higher for academic vs local specialized expert) Moderate reliability for staging agreement on rASRM staging 61% (5275%) with moderate interrater reliability : 0.44 (0.41 0.47)Almost perfect reliability with computerized-assisted, checklist-based staging : 0.95 (0.89 0.99)

*Further information on EFIIt is required that gametes are functional enough for non-IVF conception Can be used to decide what type of treatment patients should undergo, for how long and at what cost before considering ART following endometriosis surgery Validated recently by three independent investigators2,3,4 Within 3 years after surgery, cumulative pregnancy rates among patients with EFI score 5, 6, 7, 8, 9, 10 were 49.8, 43.9, 41.6, 62.5, 69.8, 81.1%, respectively EFI 810 vs. 57 (71.8 versus 44.4%, P=0.00012 Significant correlation between EFI & the time to non-ART pregnancy4

ReferencesAdamson GD. Curr Opin Obstet Gynecol 2011; 23: 213220Wei DM et al. Zhonghua Fu Chan Ke Za Zhi 2011; 46:806808Yacoub A et al. World Congress Endometriosis. Montpelier, France. S#10-4. 7 September 2011Tomassetti C et al. Hum Reprod.2013;28(5):1280-8

*Project initiated by AAGL special interest group on reproductive surgery and endometriosis in 2007Endometriosis experts give a weighted score to different anatomical factors felt to be important with respect to pain & infertility

Hypothesis: if disease can be described accurately, a practical classification system may eventually be developed from analysis of the descriptions

Data from 30 experts analyzed and scores assignedAAGL is now about to propose a new classification systemPreliminary results correlate with pain, infertility and surgical difficulty