Could surgeon’s expertise resolve the debate about surgery effectiveness in treatment of endometriosis-related infertility?

Pelvic MRI in the diagnosis and staging of pelvic endometriosis: added value of structured reporting and expertise

PURPOSE

To compare the diagnostic characteristics of routine-read (RR), structured-reported read (SR), and structured expert-read pelvic (SER) MRI for staging of pelvic endometriosis in a tertiary care academic center.

METHODS

Of 530 patients with endometriosis (2013-2018), 59/530 (11.1%) were staged surgically and underwent pelvic MRI. Radiology reports were considered RR; MRI studies were independently reassessed by SR and SER. Involvement was recorded by compartment [anterior (AC), middle (MC), posterior (PC), adnexal (AX), and other (OC)]. Diagnostic discrepancy between review methods was assessed with McNemar's test. Interobserver agreement was assessed using Cohen's unweighted kappa.

RESULTS

Of 295 compartments in 59 women (mean age = 38.8 years; range 20-69), 147/295 (49.8%) had confirmed endometriosis. Overall sensitivity: RR = 42.9%; SR = 86.4%; SER = 74.2%. SR's increased sensitivity was significant for PC (p < 0.001), MC (p < 0.001), AC (p = 0.001), AX (p = 0.038). Higher sensitivity by SER was significant for PC (p < 0.001), MC (p = 0.004) and AC (p < 0.001), but not AX (p > 0.05). Overall specificity: RR = 95.3%; SR = 45.9%; SER = 81.8%. SER specificity was no different than RR for PC or AX (p > 0.5). RR sensitivity relied heavily on detection of AX involvement, whereas SR and SER showed additional sites of disease while maintaining comparable specificity for SER. Overall agreement between SR and SER was fair [k = 0.342 (95% CI 0.25, 0.44)].

CONCLUSIONS

Even at a tertiary care academic center, SER outperforms both SR and RR in the assessment of pelvic endometriosis. Although lack of expertise may negatively impact specificity, use of structured reporting is significantly more sensitive than RR. Therefore, its use can be of assistance in surgical planning and patient counseling.

Salpingectomy before assisted reproductive technologies: a systematic literature review

Salpingectomy is largely used in case of hydrosalpinx in infertile women scheduled for assisted reproductive technologies (ART), whereas there is no consensus on its role in absence of hydrosalpinx. The current is a systematic literature review to collate all available evidence regarding salpingectomy as fertility enhancement procedure before ART in infertile patients. Our primary endpoint was to assess the impact of the surgical procedure on ovarian reserve, and secondary outcomes were to evaluate its benefits and harms on ART outcomes. We identified 29 papers of which 16 reporting data on the impact of tubal surgery on ovarian reserve and 24 (11 previously included) on ART outcomes. Available data suggested an absence of variation in ovarian reserve markers after unilateral salpingectomy while contradictory results were reported for bilateral surgery. Considering ART outcomes, data reported a significant improvement in ongoing pregnancy/live-birth rate in treated subjects without significant reduction in ovarian response to gonadotropin stimulation. In case of tubal disease, a surgical approach based on unilateral salpingectomy may be considered safe, without negative effects on ovarian reserve and ovarian response to controlled ovarian stimulation whilst having a positive effect on pregnancy rate. Data regarding bilateral salpingectomy and ovarian reserve are conflicting. Further trials are needed to confirm both the benefits of salpingectomy before ART and the safety of bilateral salpingectomy on ovarian reserve, and to clarify the role of uni- or bilateral surgery in case of tubal blockage without hydrosalpinx.

Clinical management of endometriosis-associated infertility

Endometriosis is a common chronic benign disease that affects reproductive age women and causes chronic pelvic pain and infertility. Despite its prevalence, the exact mechanisms of the pathogenesis of endometriosis-associated infertility are unknown, and precise standards of management have not yet been established. Medical and surgical treatments for endometriosis have different effects on the chance of conception, either spontaneously or via assisted reproductive technologies (ART). In this manuscript, we review the literature from years 1979 to 2015 to report on the proposed mechanism of endometriosis-associated infertility, the staging system of endometriosis for pregnancy outcomes and the current management of patients with endometriosis-associated infertility.

Ovarian damage due to cyst removal: a comparison of endometriomas and dermoid cysts

INTRODUCTION

Surgical treatment of endometriomas and potential damage to the ovary have been debated. Studies have described the inconsistent risk of unintended removal of ovarian tissue when a cystectomy of an endometrioma is performed. We evaluated the risk of inadvertently removed ovarian tissue during surgery by comparing specimens of endometriomas and dermoid cysts removed laparoscopically.

MATERIAL AND METHODS

The material included 326 women in a retrospective cohort study at Rigshospitalet, University hospital in Copenhagen, Denmark from 2011 to 2013. Surgery was performed laparoscopically for 393 benign cysts with a diagnosis of either endometrioma (n = 294) or dermoid cyst (n = 99). The microscopic existence of ovarian tissue in the cystectomy specimens were compared and correlation between CA 125 and size of cysts was examined.

RESULTS

In total, 80.3% endometrioma cystectomies disclosed ovarian stroma compared with 17.2% of the resected dermoid cysts (p < 0.001). The difference was found despite skilled laparoscopic surgeons performing the procedure in the endometriosis cohort. A significant positive correlation between the size of endometriomas and the value of CA 125 was found (p < 0.009).

CONCLUSION

The risk of removal of ovarian tissue during laparoscopic surgery is significantly higher for endometriomas than for dermoid cysts.