Treatment of recurrent chocolate cysts by transvaginal aspiration and tetracycline sclerotherapy

Ethanol endometrioma sclerotherapy: safety through 8 years of experience

STUDY QUESTION

What are the complications of transvaginal ethanol sclerotherapy for the treatment of endometriomas?

SUMMARY ANSWER

Sclerotherapy is a reliable, minimally invasive method applicable in outpatient procedures but with specific and potential life-threatening complications that need to be identified and prevented.

WHAT IS KNOWN ALREADY

There are currently few data on the use of transvaginal ethanol sclerotherapy, and we mainly note septic complications.

STUDY DESIGN, SIZE, DURATION

A retrospective observational cohort study was carried out. The study was conducted at an academic hospital and included 126 women aged 31.9 ± 5.5 years (mean ± SD), between November 2013 and June 2021. We analyzed a total of 157 ethanol sclerotherapy treatment (EST), treated by 131 EST procedures, in 126 women.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The study included women with an indication for transvaginal ethanol sclerotherapy. Indications were women with at least one endometrioma over 10 mm, isolated or associated with other endometriosis locations, requiring treatment for pain or infertility before assisted reproductive treatment. We followed a standardized transvaginal ethanol sclerotherapy procedure consisting of an ultrasound-guided transvaginal puncture of one or more endometriomas under general anesthesia. The cyst content was completely removed and flushed with saline solution. Ethanol (96%) was injected at 60% of the initial volume of the endometrioma, remained in the cyst for 10 min and was then completely removed. Ethanol loss was defined as a loss of 5 ml or more than 10% of the initial volume of the injected ethanol. Failure was defined by the contraindication of endometrioma puncture because of interposition of the digestive tract, ethanol loss in the previous endometrioma treated (in case of multiple ESTs), failure to aspirate the endometriotic fluid, contraindication to start ethanol injection owing to saline solution leakage, or contraindication to continue ethanol injection owing to suspicions of ethanol leakage at sonography. Intraoperative complications were defined by ethanol loss, positive blood alcohol level, and ethanol intoxication. Postoperative complications were defined by fever, biological inflammatory syndrome, and ovarian abscess. Complications were classified according to the Clavien and Dindo surgical classification, which is a system for classifying postoperative complications in five grades of increasing severity.

MAIN RESULTS AND THE ROLE OF CHANCE

We reported a total of 17/157 (10.8%) transvaginal ethanol sclerotherapy failures during 14/131 (10.7%) transvaginal ethanol sclerotherapy procedures in 13/126 (10.3%) women. In the same sets of data, complication was reported for 15/157 (9.5%) transvaginal ethanol sclerotherapy in 13/131 (9.9%) transvaginal ethanol sclerotherapy procedures in 13/126 (10.3%) women. Nine of 126 women (7.1%) had a grade I complication, one (0.8%) had a grade II complication (medical treatment for suspicion of pelvic infection), two (1.6%) had a grade III complication (ovarian abscess) and one (0.8%) had a grade IV complication (ethanol intoxication). We did not observe any grade V complications.

LIMITATIONS, REASONS FOR CAUTION

This was a retrospective study and pain assessment not considered. The benefit-risk balance of endometrioma transvaginal ethanol sclerotherapy was not evaluated.

WIDER IMPLICATIONS OF THE FINDINGS

Our study is the first to evaluate the complications of transvaginal ethanol sclerotherapy with such a large cohort of women in a standardized protocol. Transvaginal ethanol sclerotherapy seems to be an effective alternative to laparoscopic surgery in the management of endometriomas and limits the alteration of ovarian reserve. Transvaginal ethanol sclerotherapy is a reliable, minimally invasive method applicable on an outpatient basis. The majority of complications are Clavien-Dindo ≤IV, for which preventative measures, or at least early diagnosis and treatment, can be easily performed. The risk of ethanol intoxication is rare, but it is a life-threatening risk that must be avoided by appropriate implementation and promotion of the sclerotherapy procedures.

STUDY FUNDING/COMPETING INTEREST(S)

None.

TRIAL REGISTRATION NUMBER

Aix Marseille University's ethics committee registration number 2021-06-03-01.

The effect of surgery or medication on pain and quality of life in women with endometrioma. A systematic review and meta-analysis

For patients with endometrioma it is unclear what treatment: surgery and/or medication, is more effective in reducing pain and improving quality of life (QoL). This systematic review and meta- analysis aimed to provide an overview of the existing evidence on the effects of surgery and/or medication (i.e. analgesics and/or hormonal medication) on pain and QoL. A search through CENTRAL, MEDLINE and Embase was conducted. The study population had to be women treated for endometrioma. Retrospective or prospective studies reporting about QoL and/or the following types of pain were reviewed: dysmenorrhea, dyspareunia, chronic pelvic pain, and pain that was not well defined in the included article (referred to as pain). We performed a meta-analysis on mean visual analogue scale (VAS) scores and proportions of patients experiencing different types of pain over time. QoL was described narratively. Out of 11.515 articles, 76 studies including 7148 patients were included for the systematic review. The meta-analysis consisted of 52 studies including 4556 patients. No studies compared medication with surgery. And there were no studies on analgesics. Meta-analysis showed that surgery and/or medication often reduced VAS scores and proportions of all types of pain over time. Surgery and medication combined seems more effective in reducing VAS scores of pain compared to surgery alone, but not to medication alone (estimated mean difference = 0.17, p < 0.0001 and -0.98, p = 0.0339). QoL improved after medication (follow up ≤ 12 months) and QoL was unchanged or worsened after surgery and medication combined (follow up ≤ 24 months). However, these were results from a total of 5 studies. Both surgery and medication reduce endometriosis-related pain in patients with endometrioma. However, there is lack of uniform, good quality data comparing surgery with medication to draw firm conclusions. For better-informed treatment decisions, further studies including a standardized core-outcome set at fixed follow-up times, are necessary.

Endometrioma ethanol sclerotherapy could increase IVF live birth rate in women with moderate-severe endometriosis

OBJECTIVE

To examine the impact of ethanol sclerotherapy (EST) for endometrioma on in vitro fertilization (IVF) cumulative live birth rates (CLBR) in women with moderate-severe endometriosis.

METHODS

This retrospective cohort study included women with moderate-severe endometriosis (revised American Fertility Society stage III-IV) and endometrioma who underwent IVF with the ultra-long agonist protocol. We compared two groups: women undergoing EST for endometrioma before IVF (EST group), and women whose endometrioma was left in situ during IVF (No-EST group). The primary outcome was the CLBR per IVF cycle, including fresh and frozen embryo transfers. The secondary endpoints included the complication rate, number of mature oocytes retrieved, clinical pregnancy rate and pregnancy loss rate.

RESULTS

Seventy-four women were included in the study, with 37 in the EST group and 37 in the No-EST group, representing 67 and 69 IVF cycles, respectively. The population and cycle characteristics were comparable between the two groups, especially the ovarian response to stimulation. The CLBR was significantly increased in the EST group compared to the No-EST group (31.3% vs. 14.5%, p = 0.03). The clinical and biochemical pregnancy rates were significantly increased in the EST group (37.3% vs. 15.9%, p = 0.01 and 43.3% vs. 23.2%, p = 0.01, respectively). Multivariate analysis revealed a significantly increased chance of live birth in women exposed to EST before IVF with an adjusted OR of 2.68 (95% confidence interval, CI: 1.13-6.36, p = 0.02). In the EST group, we reported one major complication Clavien and Dindo classification grade III, complication involving an ovarian abscess that required a laparoscopic drainage.

CONCLUSIONS

EST is an interesting technique to improve IVF success rates in women with moderate-severe endometriosis. EST could be discussed before IVF in infertile women.

Doxycycline reduces MMP-2 activity and inhibits invasion of 12Z epithelial endometriotic cells as well as MMP-2 and -9 activity in primary endometriotic stromal cells in vitro

BACKGROUND

Matrix metalloproteinases (MMPs), especially the gelatinases MMP-2 and MMP-9, play a crucial role in the pathogenesis of endometriosis by enabling invasion. Doxycycline is a well-tolerated antibiotic and a potent MMP-inhibitor in subantimicrobial doses.

METHODS

Gelatin zymography and activity assays were used to detect latent and active MMP-2 and -9 in cell culture supernatants of immortalized epithelial (12Z) and two isolates of primary endometriotic stromal cells treated with doxycycline. The invasiveness of 12Z endometriotic cells treated with doxycycline was assessed in matrigel-coated invasion chambers. The effect on latent and active MMP-2 expression of the combination of progesterone and doxycycline was tested in 12Z.

RESULTS

Doxycycline significantly reduced the MMP-2 activity and pro-MMP-2 expression in 12Z and the MMP-2 and -9 activity as well as expression of pro-MMP-2 and -9 in primary endometriotic stromal cells. The percentage of 12Z cells invading through a matrigel-coated membrane was reduced to 65 and 22% of the control after treatment with doxycycline at doses of 1 μg/ml and 10 μg/ml, respectively. Furthermore, a combination of progesterone and doxycycline showed an additive effect in low doses on the reduction of MMP-2 activity and pro-MMP2 expression in 12Z endometriotic cells.

CONCLUSIONS

In conclusion, the MMP-inhibiting features of subantimicrobial-dose doxycycline may be further evaluated as a well-tolerable additional therapeutic approach, e.g. in combination with progestins such as dienogest, in patients with infiltrative endometriosis with insufficient response to current medical treatment options.

Value of Transvaginal Two-Dimensional Contrast-Enhanced Ultrasonography in Diagnosing Atypical Ovarian Corpus Luteum Hematoma

Objective

To evaluate the value of transvaginal two-dimensional contrast-enhanced ultrasonography (2D-CEUS) in the diagnosis of atypical ovarian corpus luteum hematoma (AT-OCLH).

Methods

A prospective study was performed on 53 consecutive patients with suspected AT-OCLH, and the diagnostic results by transvaginal 2D-CEUS were statistically compared with the gold standard. The gold standard results were confirmed by surgical pathology or long-term follow-up.

Results

The characteristic perfusion patterns of AT-OCLH in 2D-CEUS showed no contrast agent perfusion within the tumor mass, and the capsule wall showed rapid, annular, high enhancement perfusion; perfusion patterns could be classified into type Ia and type IIa. AT-OCLH can be distinguished from ovarian tumors based on perfusion characteristics and perfusion pattern type, which can be diagnosed based on the significantly stronger cystic wall perfusion intensity, earlier arrival time, and thicker cystic wall than nonluteal cystic foci (P<0.05). The sensitivity of 2D-CEUS for diagnosing AT-OCLH was 95.7%, with a specificity of 96.6%. A 2D-CEUS scoring system for AT-OCLH was established. Lesions with scores >17.5 were diagnosed as AT-OCLH.

Conclusion

2D-CEUS is an effective method for diagnosing AT-OCLH.

Ultrasound sclerotherapy pretreatment could obtain a similar effect to surgical intervention on improving the outcomes of in vitro fertilization for patients with hydrosalpinx

AIM

The aim of this study was to compare the clinical outcomes of in vitro fertilization (IVF) for patients with hydrosalpinx between ultrasound sclerotherapy and surgical intervention.

METHODS

The data of 482 IVF/intracytoplasmic sperm injection (ICSI) cycles were divided into three groups according to different intervention protocols before IVF/ICSI. Group A included 265 cycles in which ultrasound sclerotherapy pretreatment was carried out before controlled ovarian hyperstimulation. Group B included 109 cycles in which hydrosalpinx aspiration was carried out under ultrasound guidance on the day of oocyte retrieval. Croup C included 108 cycles in which bilateral salpingectomy was carried out before IVF/ICSI.

RESULTS

The rates of embryo implantation, biochemical pregnancy, clinical pregnancy, multiple pregnancy, and early abortion showed no significant differences between groups A and C (P > 0.05); whereas the rates of embryo implantation, biochemical pregnancy, and clinical pregnancy in group B were significantly lower than those in groups A and C (P < 0.05), and that of early abortion in group B was significantly higher than that in groups A and C (P < 0.05).

CONCLUSION

Ultrasound sclerotherapy on patients with hydrosalpinx before IVF-embryo transfer could obtain a similar clinical outcome to surgical intervention.

Comparison of success rates of 'transvaginal aspiration and tetracycline sclerotherapy' versus 'only aspiration' in the management of non-neoplastic ovarian cysts

AIM

To investigate the value of tetracycline sclerotherapy for management of recurrent or persisting non-neoplastic ovarian cysts in comparison to the aspiration without sclerotherapy.

MATERIAL AND METHODS

Ninety-six patients with proven non-neoplastic ovarian cysts were randomized into two groups. Group 1 patients underwent cyst aspiration together with tetracycline sclerotherapy (n=48). Group 2 patients underwent only cyst aspiration without tetracycline sclerotherapy (n=48). Then, all patients were followed up monthly with ultrasonography for 12months. The procedure was considered to have failed if the recurring cyst, detected by ultrasound, was 4cm in size or greater.

RESULTS

There were no differences between the two groups regarding demographic data, initial cyst volume and tumor markers. Recurrence rates within 12months were 14.6% in group 1 and 50% in group 2 (P<0.001).

CONCLUSION

Based on the recurrence rates, we suggest transvaginal aspiration together with tetracycline sclerotherapy rather than only simple transvaginal aspiration in the management of non-neoplastic ovarian cysts.

Endometrioma and ART: Does the Needle Work?

Aim and Objectives

The aim of this study was to see if the fertility outcome improved when IVF/ICSI was done after administration of GnRH analogs and cyst aspiration in comparison with patients in whom either only cyst aspiration or only GnRh analogs were administered.

Materials and methods

This was a prospective study done in a tertiary level ART center which included 30 patients over a span of 5 years from 2004 to 2009. All of them had endometriomas and underwent assisted reproductive techniques (ART) either after cyst aspiration with or without GnRH analog pretreatment or only GnRH analog pretreatment.

Depending on the pretreatment received, they were classified into three groups:

• Group B: Both GnRH analog and cyst aspiration

• Group C: Only cyst aspiration

• Group G: Only GnRH analog.

The patients were not randomized.

The number of days required for stimulation, total dose of stimulation required, number of oocytes obtained, quality of embryos, and the pregnancy rates for each group were tabulated for comparison.

Statistical analysis

The significance of the difference in ART outcome after the different modalities of pretreatment, which was estimated in terms of pregnancy rates was evaluated by calculating the p-value.

Observations and results

Significant difference was observed between the pregnancy rates in the three groups, with the maximum pregnancy rate in group B, followed by the group G and then the group C. The p-value showed a trend, though not statistically significant, indicating the need for larger prospective studies with greater number of subjects.

Conclusion

Pretreating endometriomas by aspirating the cysts and administering three doses of GnRH analog depot preparation prior to IVF/ICSI seems to be better than administering GnRH analog depot preparation alone or aspirating the cysts alone in terms of the number of days required for stimulation, the number of oocytes obtained, and the clinical pregnancy rates.

Ethanol sclerotherapy: a treatment option for ovarian endometriomas before ovarian stimulation

Several surgical treatment modalities have been described in cases of isolated or multiple ovarian endometriotic cysts. The aim of this preliminary study was to investigate and test the efficacy of ethanol sclerotherapy (EST) for recurrent endometriotic cysts, before ovarian stimulation in infertile patients with an adequate ovarian status. In the setting of a prospective comparative study, EST was proposed to 31 infertile patients with recurrence of ovarian endometriomas before inclusion in assisted reproduction cycles. Reproductive outcome was compared with that of patients who had previous laparoscopic cystectomy for recurrent endometriomas. The mean size of endometriomas treated with sclerotherapy was 38.6 +/- 11.2 mm in diameter. Ovarian cysts recurred in 12.9% of cases; at a mean time of 10 months after EST. Ovarian reserve and ovarian response to stimulation were better in the EST group than in the control group. Consequently, clinical and cumulative pregnancy rates of the study group were higher than those of the control group (48.3% versus 19.2%, P = 0.04; and 55.2% versus 26.9%, P = 0.03, respectively). Ethanol sclerotherapy may be a good alternative to surgical management of recurrent endometriotic cysts before assisted reproductive treatment. It could be advised for selected infertile patients.

Effectiveness of ultrasound-guided aspiration and sclerotherapy with 95% ethanol for treatment of recurrent ovarian endometriomas

OBJECTIVE

To evaluate the effectiveness of transvaginal ultrasound aspiration and ethanol sclerotherapy in patients with recurrent ovarian endometriomas.

DESIGN

Retrospective study.

SETTING

Teaching hospital affiliated with Chang Gung University, Taipei.

PATIENT(S)

Patients (n = 108) with recurrent ovarian endometriomas >or=3 cm.

INTERVENTION(S)

Preoperative evaluation of previous pathology, midcycle serum CA-125 level, and color Doppler ultrasonography to exclude possibility of malignancies. After aspiration, sclerotherapy with 95% ethanol irrigation of the cystic cavity was performed (group 1, n = 78, 0-10 minutes of retention; group 2, n = 30, ethanol left in situ [retention]).

MAIN OUTCOME MEASURE(S)

Ultrasonography was performed at 3, 6, 9, and 12 months to determine persistence and size of cysts and the number of antral follicles. Pelvic pain score was also determined at those time points.

RESULT(S)

The 1-year recurrence rate for group 2 patients was significantly lower than for group 1 patients (13.3% vs. 32.1%). Antral follicle count was increased and pain score was decreased in both groups to a similar level. No significant change in CA-125 was observed.

CONCLUSION(S)

Ultrasound-guided sclerotherapy with 95% ethanol is an effective therapy for ovarian endometriomas. Retention of ethanol is more effective than irrigation only.

Management of ovarian endometrioma

The optimal conservative treatment for endometriotic cysts is unclear, particularly when treated laparoscopically. We performed a systematic analysis of the published literature on ovarian endometrioma especially focused on comparing laparoscopic cystectomy with laparoscopic drainage and coagulation of the cyst with regard to evaluating advantage and disadvantage of each method. We observed that cystectomy was superior in terms of risk of recurrent symptoms, cyst, reoperation, pregnancy: this was true in both prospective and retrospective studies previously published. Given the evidence available, excision of cyst wall in endometrioma is strongly recommended especially in infertile patients.

Endometriosis: New Genetic Approaches and Therapy

Endometriosis is a relatively common condition in women of reproductive age and is associated with considerable morbidity. Despite an extensive literature describing its multiple clinical manifestations, their management, and many aspects of the biology of endometriotic lesions, the pathophysiological mechanisms involved remain poorly understood. A genetic component in endometriosis is now recognized, and several groups have taken up the challenge of using genetic techniques to identify the aberrant molecular and cellular mechanisms in endometriosis with the intention of providing much-needed insights that might, in turn, lead to new therapies. The techniques that have been applied include expression profiling, tumor genetic studies, functional candidate gene studies, and linkage studies that can adopt a hypothesis-free approach. This review describes the current status of these studies and explores the prospects for new therapies.

Sclerotherapy with 5% tetracycline is a simple alternative to potentially complex surgical treatment of ovarian endometriomas before in vitro fertilization

OBJECTIVE

Conventional treatment of endometriosis involves drainage and removal of the cyst wall, which often results in inadvertent resection of normal ovarian tissue. We previously reported that 12 patients were successfully treated with sclerotherapy using 5% tetracycline. We now report our experience with sclerotherapy before in vitro fertilization (IVF) in an additional 20 patients with ovarian endometriomas.

DESIGN

Prospective, cohort.

SETTING

Private practice.

PATIENT(S)

Women (n = 32) with sonographic evidence of an ovarian endometrioma were offered sclerotherapy in lieu of laparoscopy.

INTERVENTION(S)

Sclerotherapy was performed under conscious sedation and transvaginal ultrasound guidance. An 18-gauge, single-lumen needle was inserted into the endometrioma, and the cyst contents were sequentially aspirated and flushed with sterile saline until the aspirated fluid was clear. Tetracycline (5%) (5-10 mL) was then instilled into the cyst. Saline was injected into the cul-de-sac to dilute any tetracycline that may have leaked. The fluid was then removed. Ultrasound was performed 6 weeks later to assess the efficacy of treatment.

MAIN OUTCOME MEASURE(S)

Resolution of endometrioma and subsequent IVF pregnancy rate.

RESULT(S)

Complete resolution was observed in 24 (75%) of 32 patients, at follow-up exam. Repeat aspiration of watery fluid was required in eight patients before resolution. Repeat treatment with tetracycline was needed in two patients. Only one patient did not ultimately respond. In vitro fertilization was performed in 28 patients; an ongoing gestation resulted in 16 (57%) from the next cycle.

CONCLUSION(S)

Sclerotherapy with 5% tetracycline is a simple, effective (and, in our limited series, safe) alternative to surgical intervention for treatment of endometriomas before IVF.

Efficacy of ethanol sclerotherapy for ovarian endometriomas

OBJECTIVE

To evaluate the efficacy and limitations of ethanol sclerotherapy for ovarian endometriomas.

METHODS

Retrospective investigation was made on 83 women with ovarian endometriomas who underwent transvaginal aspiration and ethanol sclerotherapy at Hiroshima City Hospital between 1993 and 1998. Furthermore, 30 who underwent laparoscopic cystectomy for ovarian endometriomas during the same period were investigated.

RESULTS

Of the 74 women who were followed for more than 6 months, 11 (14.9%) had recurrent cysts. The recurrence rate of laparoscopic cystectomy was 3.8% (NS). The recurrence rate of cases instilled for less than 10 min was 62.5% (5/8), and that for 10 or more than 10 min was 9.1% (6/66) (P<0.001). The recurrence rate of cases having one cyst was 7.5% (4/53) and that of cases having two or more cysts was 33.3% (7/21) (P<0.05).

CONCLUSION

Ethanol sclerotherapy is an effective and safe procedure and can be indicated for almost all ovarian endometriomas. Conduct of ethanol instillation for more than 10 min particularly for a case with a single endometrial cyst is considered most effective from the standpoint of recurrence.

Surgical treatment of endometriosis

Surgical resection of endometriosis, previously possible only by means of laparotomy, can now be accomplished through laparoscopic techniques. The requirements for surgery, surgical principles, operative techniques, and results are summarized in this article, with emphasis on the laparoscopic approach.