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Hum. Reprod. Advance Access published online on June 19, 2006
Human Reproduction, doi:10.1093/humrep/del179
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© The Author 2006. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org
Received February 20, 2006
Revised April 19, 2006
Accepted April 25, 2006

Article

Tumour necrosis factor-{alpha} blockers: potential limitations in the management of advanced endometriosis? A Case Report

Khashayar Shakiba 1 and Tommaso Falcone 1 *

1 Department of Obstetrics and Gynecology, Cleveland Clinic Foundation, Cleveland, OH, USA

* To whom correspondence should be addressed.
Tommaso Falcone, E-mail: falcont{at}ccf.org


  Abstract

Several studies have shown that tumour necrosis factor (TNF)-{alpha} levels are increased in the peritoneal fluid of women with endometriosis, with correlation between TNF-{alpha} concentrations and the degree of disease. It is also likely that elevation of peritoneal fluids’ TNF-{alpha} levels may play a role in the pathogenesis of infertility associated with endometriosis. Use of drugs such as etanercept, a TNF-{alpha} receptor immunoglobulin fusion protein which inhibits TNF-{alpha} activity, showed in an animal study to reduce the severity of the disease, and the size of endometriotic foci. TNF-{alpha} blockers were recommended as a possible new line of therapy for endometriosis. Our case involved a 35-year-old Para 0, with rheumatic arthritis and stage 4 endometriosis. After 6 years of constant use of etanercept, she showed no improvement of endometriosis as demonstrated at laparoscopy. However, she underwent a successful IVF after the first attempt. TNF-{alpha}-blocker medications might not be beneficial for patients with advanced endometriosis. However, we cannot exclude the possible effect of these medications on early-stage endometriosis, and further study is required. Some of the immunologic abnormalities in the pelvis of patients with endometriosis could be the consequence of the disease and not the cause, and possibly suppression of immune cells and their products may not have a major effect on endometriotic lesions at an advanced stage. This also could explain why suppression of TNF-{alpha} showed no effect on infertility. However, use of TNF-{alpha}-blockers before IVF might increase the success rate in advanced endometriosis.

Keywords: endometriosis/medical therapy/tumor necrosis factor.
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