Reproductive performance in infertile women with rectovaginal endometriosis: is surgery worthwhile?

Impact of surgery on reproductive outcomes in women with deep endometriosis and proven presurgical infertility: Facts and controversies

In women with proven infertility and deep endometriosis (DE), optimal management is controversial. To date, there is no clear evidence on the association between infertility and different stages of rASRM, nor is there clear guidance from leading scientific societies for surgical treatment of DE patients. A comprehensive literature search was conducted on the main databases for English-language trials describing the effectiveness of surgery for DE in patients with proven infertility; 16 studies were deemed eligible for inclusion in this systematic review (CRD42024498888). Quantitative analysis was not possible because of the heterogeneity of the data. A descriptive summary of the results according to location of pathology, surgical technique used, and whether assisted reproductive technology (ART) was needed or not was provided. A total of 947 infertile women were identified, 486 of whom became pregnant, with an average pregnancy rate of 51.3%. Our review suggests that surgery can be of valuable help in improving reproductive outcomes by improving the results of ART. It has not been possible to reach robust conclusions on the outcomes of surgery based on the location of DE because of the heterogeneity of evidence available to date. Overall, although some data encourage first-line surgical management, further investigation is needed to determine its effective application before or after ART failure.

Surgical treatment of deep endometriosis: Impact on spontaneous conception

Deep endometriosis (DE) is the most severe form of endometriosis and is commonly associated with infertility. Surgical treatment of DE appears to increase chances of spontaneous conception in appropriately selected patients wishing to conceive. Identifying, however, the exact impact of DE, and its surgical removal, on natural conception is highly challenging. The surgical approach should be favoured in symptomatic patients with pregnancy intention. Limited data from infertile patients suggest that outcomes may not differ from patients without known infertility. Complex DE surgery carries a risk of serious complications, therefore, it should be performed in centers of expertise. Such complications may, however, not have a significant negative impact on fertility outcomes, according to limited available data. Data on obstetric outcomes of spontaneous conceptions after DE surgery are too scarce. In asymptomatic, infertile patients the debate between primary surgery or Artifial Reproductive Technology is ongoing, until randomized studies report their results.

Fertility Preservation in Women with Endometriosis

Several mechanisms have been implicated in the pathogenesis of endometriosis-related infertility. For patients considering surgery, the risk of iatrogenic injury is among the most important factors in the context of fertility preservation, along with age and individual reproductive goals. In the case of endometrioma excision, evidence overwhelmingly demonstrates the negative impact of surgery on ovarian reserve, with significant reductions in antimullerian hormone (up to 30% in unilateral versus up to 44% in bilateral endometriomas). The surgical endometriosis patient should be thoroughly counseled regarding fertility preservation and discussion should include tissue, embryo, and oocyte cryopreservation options. For the latter, data support cryopreservation of 10-15 oocytes in women ≤35 years and over 20 for those >35 years for a realistic chance to achieve one or more live births. When performing surgical interventions for endometriosis, reproductive surgeons should employ fertility-conserving surgical methods to reduce the likelihood of postoperative iatrogenic diminished ovarian reserve.

Minimally invasive surgery for ovarian endometriosis as a mean of improving fertility: Cystectomy vs. CO2 fiber laser ablation what do we know so far?

Minimally invasive surgery emerged in the 1980s as a safe and effective technique which requires smaller incisions and, usually, a shorter hospital stay compared to traditional surgery. Since then, minimally invasive surgery has expanded in many surgical specialties. One of its newest application in gynecology stands in the infertility management of young women with unexplained infertility or suspected endometriosis. In these cases, laparoscopy allows to diagnose and treat the disease aiming to increase at best the chances of spontaneous pregnancy or trough assisted reproductive technology. Nowadays, minimally invasive surgical approach of ovarian endometriosis consists of either laparoscopic cystectomy or ablative techniques such as laparoscopic CO2 fiber laser vaporization. Although cystectomy represents the gold standard according to the latest Cochrane review, some endometriosis experts are worried about its detrimental effect on healthy ovarian parenchyma and suggest preferring a less aggressive approach such as CO2 fiber laser vaporization. The aim of this review is to give an overview of the available evidences about the impact of the two surgical procedures on ovarian reserve markers and pregnancy outcome.

Impact of surgery on fertility among patients with deep infiltrating endometriosis

OBJECTIVE

The aim of the study was to investigate pregnancy and live birth rate after surgical resection of rectosigmoid deep infiltrating endometriosis (DIE), and study if complications affect these rates.

STUDY DESIGN

Historical case series. 193 patients with rectosigmoid DIE and pregnancy intention undergoing a rectosigmoid resection for DIE from January 2009 to May 2019. All operations were performed at the Department of Obstetrics and Gynecology, Aarhus University Hospital, Denmark. Surgical and fertility outcome data were obtained through patient files. Anonymized data was analyzed statistically. Normally distributed continuous variables are stated as means, categorical data as percentages and time to pregnancy as Kaplan-Meier failure function. Live birth rates stratified on complications were tested with chi2 test.

RESULTS

117 patients became pregnant postoperatively with a pregnancy and live birth rate of 60.6% and 53.9%, respectively. 39 patients (20.2%) became pregnant spontaneously and 78 patients (40.4%) by intrauterine insemination or assisted reproductive technologies. Median time to pregnancy after surgery was 12.4 months (range: 0.4-58). Clavien-Dindo complication grade III (none grade IV) was registered among 16.6%. These patients had pregnancy and live birth rates of 50%, not statistically significantly different from those without complications.

CONCLUSIONS

Postoperative pregnancy and live birth rates after resection of rectosigmoid endometriosis in this study are in line with conservative treatment, when comparing with the literature. Interestingly, complications (Clavien-Dindo grade III) did not affect live birth rate or time to pregnancy.

Endometriosis-associated infertility diagnosis based on saliva microRNA signatures

RESEARCH QUESTION

Can a saliva-based miRNA signature for endometriosis-associated infertility be designed and validated by analysing the human miRNome?

DESIGN

The prospective ENDOmiARN study (NCT04728152) included 200 saliva samples obtained between January 2021 and June 2021 from women with pelvic pain suggestive of endometriosis. All patients underwent either laparoscopy, magnetic resonance imaging, or both. Patients diagnosed with endometriosis were allocated to one of two groups according to their fertility status. Data analysis consisted of identifying a set of miRNA biomarkers using next-generation sequencing, and development of a saliva-based miRNA signature of infertility among patients with endometriosis based on a random forest model.

RESULTS

Among the 153 patients diagnosed with endometriosis, 24% (n = 36) were infertile and 76% (n = 117) were fertile. Small RNA-sequencing of the 153 saliva samples yielded approximately 3712 M raw sequencing reads (from ∼13.7 M to ∼39.3 M reads/sample). Of the 2561 known miRNAs, the feature selection method generated a signature of 34 miRNAs linked to endometriosis-associated infertility. After validation, the most accurate signature model had a sensitivity, specificity and area under the curve of 100%.

CONCLUSION

A saliva-based miRNA signature for endometriosis-associated infertility is reported. Although the results still require external validation before using the signature in routine practice, this non-invasive tool is likely to have a major effect on care provided to women with endometriosis.

Surgery vs. hormone-based treatment for pain control in deep infiltrating endometriosis: a retrospective cohort study

OBJECTIVE

To evaluate the outcome of surgical or hormone-based pharmacological treatment for deep infiltrating endometriosis (DIE) in patients with pain symptoms.

STUDY DESIGN

A retrospective cohort study of 122 women with DIE of the bowel was conducted: 61 women underwent surgical treatment due to poor pain control and 61 received hormone-based treatment alone for at least six months. Chronic pelvic pain, dysmenorrhea, deep dyspareunia, dyschezia and dysuria were evaluated by a visual analog scale (VAS) to measure pain on a scale from 0 to 10. Dyspareunia was further evaluated using the Deep Dyspareunia Scale (scores of 0-3).

RESULTS

Surgery (n = 61 women) was performed at a mean of 3.3 ± 1.6 years previously, while hormone-based treatment alone (n = 61 women) was used for a mean of 3.0 ± 1.41 years. After surgery, women without a desire to procreate received hormone-based treatment. Before treatment, the most intense endometriosis-related pain in the surgical treatment group and hormone-based treatment group alone were chronic pelvic pain (VAS = 9.48 ± 1.49; 8.57 ± 2.22), dysmenorrhea (VAS = 9.61 ± 1.45; 9.02 ± 1.35) and deep dyspareunia (VAS = 8.04 ± 2.82; 7.47 ± 3.21, respectively), all with mean pain scores of around 8 (0-10) in both groups. Both treatments were effective at reducing all symptoms (p < .001). The surgical treatment proved to be more effective and more enduring at improving chronic pelvic pain (p < .001), dyschezia (p = .003) and deep dyspareunia (p < .001). Regarding deep dyspareunia, using the deep dyspareunia scale, ∼70% of surgically treated women scored 0 or 1 (absent or mild deep dyspareunia) after treatment, compared to scores 2 or 3 (intense dyspareunia) in about 70% of the group using hormone-based treatment (p < .001).

CONCLUSION

Both types of treatment, surgical and pharmacological, effectively improved pain symptoms associated with DIE. However, improvement in chronic pelvic pain, dyschezia and deep dyspareunia was greater and longer-lasting after surgery.

Treating Deep Endometriosis in Infertile Patients before Assisted Reproductive Technology

Deep endometriosis (DE) causes infertility and pelvic pain. Surgical management of DE has become a topic of increasing interest in gynecological surgery. In women desirous of pregnancy, optimal management such as surgery versus first-line assisted reproductive technology (ART) for patients with severe endometriosis is strongly debated. Current guidelines and literature including retrospective and prospective studies in English available on DE surgery, infertility, and pregnancy outcomes following surgery were searched in Cochrane Library with DE, DIE, Infertility, "DE surgery and pregnancy outcomes," and "Deep infiltrating endometriosis and assisted reproduction" as keywords. The purpose was to find evidence to answer the following clinical questions: How does DE affect fertility and pregnancy? What are the possible benefits of primary surgery for DIE before in vitro fertilization (IVF)? Several studies have recently concluded that surgical removal of DE nodules might actually have a favorable impact on IVF outcomes. This is in contradiction to European Society of Human Reproduction and Embryology statement which stated that there was no evidence supporting surgical management of DE prior to ART to improve pregnancy rate; several studies have suggested that the surgical removal of DE nodules might actually have a favorable impact on IVF outcomes. Treatment of DE affecting the rectovaginal septum or bowel requires complex surgery with considerable risk of complications. This review article tries to analyze the rationale of surgical treatment of DE before ART. A balance must be struck between exposing the patient to surgical risk and improvement in pain and fertility potential. Decisions should be tailored according to the individual needs of each woman and most importantly on the ability of the surgeons.

Laparoscopic "Shaving" for Infiltrative External Adenomyosis of Bowel Muscularis and Concomitant Deep Infiltrating Endometriosis

Deep infiltrating endometriosis (DIE) is a common finding in patients diagnosed with adenomyosis. Women commonly present with severe, incapacitating dysmenorrhea. We report a case of severe dysmenorrhea and lower abdominal tightness for 4 years, diagnosed with posterior adenomyosis. The patient underwent surgery and DIE involving the rectosigmoid and coexisting uterocervical adenomyosis infiltrating bowel muscularis successfully diagnosed and treated using laparoscopic “shaving” technique. Dysmenorrhea significantly resolved after surgery. Laparoscopic surgical “shaving” technique for external adenomyosis infiltrating Rectosigmoid muscularis is feasible, where uterine preservation is desired.

Effects of postoperative medical treatment and expectant treatment on dysmenorrhea after conservative laparoscopic surgery for deep-infiltrating endometriosis accompanied by dysmenorrhea

Objective

To compare the efficacy of postoperative adjuvant treatment (gonadotropin-releasing hormone agonists [GnRHas] and oral contraceptives [OCs]) and expectant treatment in preventing recurrent dysmenorrhea following conservative laparoscopic surgery for deep infiltrating endometriosis (DIE) with dysmenorrhea.

Methods

A prospective cohort study was conducted in Shanghai, China. In total, 147 patients with dysmenorrhea who underwent conservative laparoscopic surgery for DIE were enrolled. Following surgery, patients received either postoperative adjuvant therapy (GnRHa or OCs) for 6 months or expectant treatment according to a shared medical decision-making approach. The primary outcome was the postoperative recurrence of dysmenorrhea. The secondary outcomes included reproductive outcomes and drug-induced side effects.

Results

The generalized estimating equation analysis illustrated that the visual analog scale for dysmenorrhea was significantly higher in the adjuvant treatment group than in the expectant treatment group. Kaplan–Meier analysis and the log-rank test demonstrated that the cumulative recurrence rate was higher in the expectant treatment group than in the adjuvant treatment group, but no difference was noted between the two hormonal treatments. Similar cumulative 24-month clinical pregnancy rates were observed among the three groups.

Conclusions

Compared with expectant management, postoperative medical treatment more effectively relieved symptoms and prevented the recurrence of dysmenorrhea.

Fertility in patients with untreated rectosigmoid endometriosis

RESEARCH QUESTION

Several studies have investigated reproductive outcomes following surgical treatment of colorectal endometriosis, mainly segmental colorectal resection. This study examines pregnancy and live birth rates of women with rectosigmoid endometriosis not treated by surgery.

DESIGN

A retrospective analysis of data collected between May 2009 and January 2020 related to 215 women affected by rectosigmoid endometriosis wishing to conceive. Patients had a diagnosis of rectosigmoid endometriosis by transvaginal ultrasonography and magnetic resonance imaging enema. Patients with estimated bowel stenosis >70% at computed tomographic colonography and/or subocclusive/occlusive symptoms were excluded.

RESULTS

During the median length of follow-up of 31 months (range 13-63 months), the total pregnancy and live birth rates of the study population were 47.9% and 45.1%, respectively. Sixty-two women had a live birth after natural conception (28.8%; 95% confidence interval [CI] 22.8-35.6%) with a median time required to conceive of 10 months (range 2-34 months). Eighty-three women underwent infertility treatments (38.6%, 95% CI 32.1-45.5%); among these, 68 patients underwent IVF either directly (n = 51) or after intrauterine insemination (IUI) failure (n = 17). Time to conception was significantly higher in women having conceived by IVF than in those having conceived naturally (P < 0.001) or by IUI (P = 0.006). In patients undergoing IVF cycles, a worsening of some pain and intestinal symptoms was observed.

CONCLUSIONS

At median follow-up of 31 months, women with rectosigmoid endometriosis have a 48% pregnancy rate. However, these patients must be referred to centres specialized in managing endometriosis to properly assess symptoms and degree of bowel stenosis.

Carbon dioxide (CO2) laser ablation of symptomatic vaginal endometriosis: a pilot study

Deep dyspareunia affects almost half of the women with endometriosis and is associated with vaginal endometriotic lesions. Our pilot study's objective is to assess the feasibility and effectiveness of CO₂-laser ablation under colposcopic guidance for the treatment of symptomatic vaginal endometriosis. A non-comparative pilot study has been performed. Only women with histologically proven vaginal endometriosis, who declared the presence of moderate or severe deep dyspareunia, resistant to at least 6 months of conventional hormonal treatment, were deemed eligible for the study. All treatments were performed in an outpatient setting with a colposcopic-guided, hand-directed CO₂-laser. Variation in pain symptoms was measured with a 0- to 10-point numerical rating scale (NRS), in sexual functioning with the Female Sexual Function Index (FSFI), in psychological status with the Hospital Anxiety and Depression Scale (HADS), and in quality of life with the Short Form-12 questionnaire (SF-12). Satisfaction with treatment was evaluated according to a five-category scale (very satisfied, satisfied, neither satisfied nor dissatisfied, dissatisfied, very dissatisfied). Nineteen women were enrolled. No complications occurred. At 12-month follow-up, significant improvements were observed in deep dyspareunia and dyschezia scores, in FSFI, HADS, and in the physical component summary scores of SF-12, whereas the mental component score of SF-12 did not vary substantially. Most women (84%) were satisfied with the treatment received. CO₂-laser ablation for vaginal endometriosis could represent a valuable alternative option for women with symptomatic lesions, both in terms of amelioration of pain symptoms and improvement in quality of life and sexual function.

Crossroad decisions in deep endometriosis treatment options: a qualitative study among patients

OBJECTIVE

To study the experiences, considerations, and motivations of patients with endometriosis in the decision-making process for deep endometriosis (DE) treatment options.

DESIGN

Qualitative study using semi-structured in-depth focus group methodology.

SETTING

University medical center.

PATIENT(S)

A total of 19 Dutch women diagnosed with DE between 27 and 47 years of age.

INTERVENTION(S)

Not applicable.

MAIN OUTCOME MEASURE(S)

Focus group topics were disease impact and motives for treatment, expectations of the treatment process, and important factors in the decision process.

RESULT(S)

Women reported that pain, fertility, and strong fear of complications are important decisive factors in the treatment process. The goal of conceiving a child is considered important, however, sometimes doctors emphasize this topic too much. It emerged that complication counseling is frequently about surgical complications, whereas side effects of hormonal treatments are neglected. Shared decision making and information about treatment options, complications, and side effects are not always optimal, making it difficult to make a well-considered choice. Despite negative experiences encountered after surgery, the positive effect of surgery ensures that most women do not regret their choice.

CONCLUSION(S)

In the treatment decision process for patients with DE, pain is almost always the most important decisive factor. The wish to conceive and strong fear of complications can change this choice. Doctors should understand the importance of fertility for the majority of women, but, also, if this is not considered paramount, respect that view. To improve shared decision making, exploration of treatment goals, training of healthcare providers, and better patient information provision are desirable.

Spontaneous pregnancy rate following surgery for deep infiltrating endometriosis in infertile women: The impact of the learning curve

OBJECTIVES

To determine whether the surgical learning curve impact the spontaneous pregnancy rate in infertile patients undergoing removal of deep infiltrating endometriosis MATERIAL AND METHODS: Single center retrospective study including the first 50 consecutive infertile women suffering from deep infiltrating endometriosis and referred to a single surgeon. All patients underwent laparoscopic removal of deep endometriosis lesions. The study population was stratified in two subgroups, namely the early group (including the first 25 cases) and the late group (comprising the 25 subsequent cases). Pregnancy and live birth rates, surgical morbidity and clinical recurrence rate were compared between study groups.

RESULTS

Overall, spontaneous pregnancy rate (40 % in the early group versus 56 % in the late group, p = 0.25), live birth rate (40 % versus 44 %, p = 0.77) and clinical recurrence rate (16 % versus 4%, p = 0.16) did not significantly differ between the study groups. Logistic regression analysis revealed that ASRM stage, EFI score, and body mass index were the only significant prognostic factors of postoperative spontaneous fertility.

CONCLUSION

Surgical resection of deep infiltrating endometriosis in infertile women is associated with high spontaneous pregnancy and live birth rates. The surgeon's learning curve does not impact postoperative fertility outcomes.

Pregnancy and delivery outcomes in women with rectovaginal endometriosis treated either conservatively or operatively

OBJECTIVE

To study reproductive outcomes, and pregnancy and delivery complications after conservative or operative treatment of rectovaginal endometriosis during long-term follow-up.

DESIGN

Retrospective cohort study.

SETTING

University hospital.

PATIENT(S)

Women with rectovaginal endometriosis referred to hospital due to any indication from 2004 to 2013 (N = 543) who were treated initially either conservatively (group CONS, n = 183), or operatively (OPER, n = 360) either with resection of rectovaginal nodule (RVR, n = 192) or with concomitant bowel resection (BR, n = 132).

INTERVENTION(S)

Conservative or operative management.

MAIN OUTCOME MEASURE(S)

Clinical pregnancy rate, live-birth rate, and assessment of the complications during pregnancy and delivery.

RESULTS(S)

Between women in the CONS group or OPER group, no differences were found in either clinical pregnancy rate (56%, n = 102 vs. 50%, n = 181) or live-birth rate (48%, n = 87 vs. 42%, n = 153). Of the pregnancies, 64% (n = 65) and 49% (n = 89), respectively, started after medically assisted reproduction. No differences emerge in the subanalysis of women <40 years-old who wished to conceive. The most common pregnancy complication was preterm birth: 15% (n = 13) in the CONS group and 20% (n = 30) in the OPER group. The cesarean delivery rate also was high (46%, n = 40 vs. 49%, n = 76). Complications emerged in 21% (n = 10) versus 29% (n = 23) of vaginal deliveries and 45% (n = 18) versus 53% (n = 40) of cesarean deliveries. The most common delivery complication was excessive bleeding. The follow-up period was 4.9 years in the CONS group and 5.6 years in the OPER group.

CONCLUSION(S)

Women with rectovaginal endometriosis have comparable and good reproductive prognosis regardless of the treatment method.

Negative Sliding Sign during Dynamic Ultrasonography Predicts Low Endometriosis Fertility Index at Laparoscopy

STUDY OBJECTIVE

Endometriosis fertility index (EFI) is a robust tool to predict the pregnancy rate in patients with endometriosis who are attempting non-in vitro fertilization conception. However, EFI calculation requires laparoscopy. Newly established imaging techniques such as sliding sign, which is used to diagnose pouch of Douglas obliteration, could provide a promising alternative. The objective of this study was to investigate the practicality of using ultrasound data to predict a low EFI (score ≤6).

DESIGN

Observational study from a prospective registry (Endometriosis Pelvic Pain Interdisciplinary Cohort, clinicaltrials.gov #NCT02911090). Analyzed data were captured from December 2013 to June 2017.

SETTING

Tertiary referral center at British Columbia Women's Hospital.

PATIENTS

We analyzed data for 2583 participants from the Endometriosis Pelvic Pain Interdisciplinary Cohort. In this cross-sectional study, we included 86 women aged <40 years.

INTERVENTIONS

Dynamic ultrasonography for the sliding sign testing and EFI calculation during laparoscopic surgery.

MEASUREMENTS AND MAIN RESULTS

Logistic regression was used to obtain receiver operating characteristic area under the curve (AUC) for the prediction models. Significance was p <.05. Patients with a negative sliding sign were older and had severe endometriosis and longer duration of infertility. Patients with a negative sliding sign had significantly lower total EFI scores and lower surgical factors scores than patients with a positive sliding sign. Logistic regression showed that a negative sliding sign and EFI historic factors score can predict an EFI score ≤6 (sensitivity = 87.9%, specificity = 81.1%, AUC = 0.93 [95% confidence interval, 0.88-0.98]). Adding the diagnosis of endometrioma to the previous prediction model resulted in AUC = 0.95 (95% confidence interval, 0.90-0.995), sensitivity = 84.8%, and specificity = 92.5%.

CONCLUSION

The sliding sign could be a potential alternative to the EFI surgical factors, and it could be used in combination with EFI historic factors and the diagnosis of endometrioma to predict an EFI score ≤6 for patients who are not scheduled for immediate surgery.

Pregnancy Rates After Surgical Treatment of Deep Infiltrating Endometriosis in Infertile Patients With at Least 2 Previous In Vitro Fertilization or Intracytoplasmic Sperm Injection Failures

STUDY OBJECTIVE

To assess the postoperative probabilities of pregnancy in patients with deep infiltrating endometriosis (DIE) and ≥2 previous in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) failures.

DESIGN

Retrospective study using data prospectively recorded in the North-West Inter Regional Female Cohort for Patients with Endometriosis (CIRENDO) database.

SETTING

University tertiary referral center.

PATIENTS

Infertile patients under the age of 43 years, having undergone ≥2 previous IVF or ICSI failures, who were surgically managed for DIE.

INTERVENTIONS

Complete excision of DIE.

MEASUREMENTS AND MAIN RESULTS

The pregnancy rate after surgery was assessed. One hundred and four infertile patients had surgery in 7 different centers participating in the database. Seventy-seven women intended to get pregnant postoperatively. Four patients who got pregnant by oocyte donation were excluded, resulting in a sample of 73 women. The mean patient age was 31.9 years (standard deviation [SD], 4.1), and the mean length of history of infertility was 48.4 months (SD, 26.5). Stage III and IV endometriosis were recorded in 83.6% of patients. The mean postoperative follow-up was 46.6 months (SD, 20.5). The postoperative pregnancy rate was 43.8% with a mean time from surgery to pregnancy of 11.1 months. 21.8% of pregnancies were spontaneous, 31.2% were obtained by IVF, 21.8% by frozen embryo transfer, 18.7% by IVF-ICSI, and 3.1% by intrauterine insemination. Multivariate analysis revealed that ovarian surgery, age ≥35 years old, and stage II endometriosis was associated with the probability of conception.

CONCLUSION

Infertile women with ≥2 IVF-ICSI failures may be referred for surgery as it appears related to reasonable postoperative pregnancy rates, particularly when endometriomas surgery is either not required or not performed. Surgery for DIE does not routinely delay conception, as it usually occurs during the year following surgery.

Fertility Preservation in Women With Endometriosis

Infertility affects 30% to 50% of women with endometriosis. Women with endometriosis are at risk of decreased ovarian reserve, both because of the pathophysiology of the disease and iatrogenic injury resulting from surgical intervention. Fertility preservation must occur at multiple levels, including careful selection of surgical candidates, avoidance of repeat procedures, and meticulous surgical technique. Fertility preservation with oocyte or ovarian tissue cryopreservation may be considered on an individual basis for women with endometriosis, particularly those at risk of bilateral ovarian injury, such as women with bilateral endometriomas.

High postoperative fertility rate following surgical management of colorectal endometriosis

STUDY QUESTION

What are fertility outcomes in patients surgically managed for large deep endometriosis infiltrating the rectum who intend to get pregnant postoperatively?

SUMMARY ANSWER

Surgical management for rectal endometriosis is followed by high pregnancy rates, with a majority of natural conceptions.

WHAT IS KNOWN ALREADY

Optimal management such as surgery versus first-line ART for patients with severe deep endometriosis who desire pregnancy is not defined.

STUDY DESIGN, SIZE, DURATION

The study included the patients enrolled in ENDORE randomized trial who attempted pregnancy after the surgery. From March 2011 to August 2013, we performed a two-arm randomized trial, enrolling 60 patients with deep endometriosis infiltrating the rectum up to 15 cm from the anus, measuring more than 20 mm in length, involving at least the muscular layer in depth, and up to 50% of rectal circumference. Postoperative follow-up was prolonged in 55 patients recruited at Rouen University Hospital, and varied from 50 to 79 months. No women were lost to follow-up.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Patients had either conservative surgery by shaving or disc excision, or radical rectal surgery by segmental resection. One gynecologist experienced in deep endometriosis surgery performed all the procedures, assisted when required by three general surgeons experienced in colorectal surgery. Institutional review board approval was obtained to extend postoperative follow-up to 10 years after the surgery. Among patients enrolled at Rouen University Hospital, women who intended to get pregnant after surgery were selected and followed up postoperatively every 6 months for 2 years, then every year. Pregnancy intention, fertility outcomes, conception mode, endometriosis recurrences and digestive and urinary outcomes were rigorously recorded. The primary outcome was postoperative pregnancy rate. Secondary outcomes were conception mode, the delay to conception from the day of surgery and the day when hormonal treatment was stopped, and delivery rate. Kaplan Meier curves were used to estimate the probability of conception after surgery.

MAIN RESULTS AND THE ROLE OF CHANCE

Among the 55 patients enrolled at Rouen University Hospital, 25 had conservative and 30 had radical surgery, and their postoperative follow-up varied from 50 to 79 months. No patient was lost to follow-up. Among the 55 patients, 36 intended to get pregnant after surgery, 23 of whom had unsuccessfully attempted to conceive for more than 12 months before surgery (63%). At the end of follow-up, 29 patients achieved pregnancy (81%), and natural conception was recorded in 17 of them (59% of conceptions). As several women had more than 1 pregnancy (range: 0–3), we recorded 37 pregnancies, 24 natural conceptions (65%) and 29 deliveries (78%). The probabilities of achieving pregnancy at 12, 24, 36 and 48 months postoperatively were 33.4% (95% CI: 20.6–51.3%), 60.6% (44.8–76.8%), 77% (61.5–89.6%) and 86.8% (72.8–95.8%), respectively. Women who had been advised to attempt natural conception achieved pregnancy significantly earlier than patients referred for ART (P = 0.008). In infertile patients, the postoperative pregnancy rate was 74%, and 53% of conceptions were natural.

LIMITATIONS, REASONS FOR CAUTION

The main outcomes of the original trial were related to digestive function and not to fertility. Several factors impacting fertility could not be revealed due to small sample size. The study included a high percentage of young women with an overall satisfactory prognosis for fertility, as patients’ median age was 28 years. The inclusion of only large infiltrations of the rectum does not allow the extrapolation of conclusions to small nodules of <2 cm in length. Only one skilled gynecologic surgeon performed all the procedures.

WIDER IMPLICATIONS OF THE FINDINGS

First-line surgery can be considered in patients with deep endometriosis infiltrating the rectum and pregnancy intention. Patients receiving advice from experienced surgeons on conception modes were more likely to conceive faster after surgery.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by a grant from the clinical research program for hospitals (PHRC) in France. The authors declare no competing interests related to this study.

TRIAL REGISTRATION NUMBER

The original randomized trial is registered with ClinicalTrials.gov (number NCT 01291576).

Surgery and Endometriosis

Care of the endometriosis patient today can be complex and difficult. Once medical management has been exhausted and symptoms persist patients desire further treatment options. This chapter takes an evidence-based approach at discussion of patient surgcical options for treatment of endometriosis symptoms. Surgical techniques, success rates, patient satisfaction, and risks must be discussed and understood at depth before planning patient surgical intervention. This chapter provides reference to current surgical management options and symptom relief following those interventions.

[Deeply infiltrating endometriosis and infertility: CNGOF-HAS Endometriosis Guidelines]

Deeply infiltrating endometriosis is a severe form of the disease, defined by endometriotic tissue peritoneal infiltration. The disease may involve the rectovaginal septum, uterosacral ligaments, digestive tract or bladder. Deeply infiltrating endometriosis is responsible for disabling pain and infertility. The purpose of these recommendations is to answer the following question: in case of deeply infiltrating endometriosis associated infertility, what is the best therapeutic strategy? First-line surgery and then in vitro fertilization (IVF) in case of persistent infertility or first-line IVF, without surgery? After exhaustive literature analysis, we suggest the following recommendations: studies focusing on spontaneous fertility of infertile patients with deeply infiltrating endometriosis found spontaneous pregnancy rates about 10%. Treatment should be considered in infertile women with deeply infiltrating endometriosis when they wish to conceive. First-line IVF is a good option in case of no operated deeply infiltrating endometriosis associated infertility. Pregnancy rates (spontaneous and following assisted reproductive techniques) after surgery (deep lesions without colorectal involvement) varie from 40 to 85%. After colorectal endometriosis resection, pregnancy rates vary from 47 to 59%. The studies comparing the pregnancy rates after IVF, whether or not preceded by surgery, are contradictory and do not allow, to date, to conclude on the interest of any surgical management of deep lesions before IVF. In case of alteration of ovarian reserve parameters (age, AMH, antral follicle count), there is no argument to recommend first-line surgery or IVF. The study of the literature does not identify any prognostic factors, allowing to chose between surgical management or IVF. The use of IVF in the indication "deep infiltrating endometriosis" allows satisfactory pregnancy rates without significant risk, regarding disease progression or oocyte retrieval procedure morbidity.

[Bowel endometriosis and infertility: Do we need to operate?]

Endometriosis is a benign chronic inflammatory disease, whose pathogenesis is still unclear. Endometriosis is responsible for infertility and/or pelvic pain. One of the most important features of the disease is the heterogeneity (clinical and anatomical: superficial peritoneal, ovarian and/or deep infiltrating lesions). Bowel involvement constitutes one particularly severe form of the disease, affecting 8-12% of women with deep endometriosis. In case of associated infertility, bowel endometriosis constitutes a real therapeutic challenge for gynecologists. Indeed, while complete resection of the lesions alleviates pain and seems to improve spontaneous fertility, surgery remains technically challenging and may cause severe complications. Reverting to assisted Reproductive Technology (ART) is another valuable therapeutic option regarding pregnancy rates. Thus, the choice between surgical management or ART is still debated. Benefits and risks of these two options should be considered and discussed before planning treatment. In the present study, we aimed to answer the question: Bowel endometriosis and infertility: do we need to operate?

Endometriosis and Infertility: A Systematic Review

Endometriosis is one of the most common gynaecological conditions affecting 6% to 12% of women in the reproductive age group. It can be found in 35% to 45% of women who are trying to conceive and are infertile. Infertility is one of the most common problems associated with endometriosis. This review will look at the evidence that endometriosis may lead to infertility and the data looking at whether surgical correction of endometriosis may improve fertility outcomes.

Spontaneous fertility after expectant or surgical management of rectovaginal endometriosis in women with or without ovarian endometrioma: a retrospective analysis

OBJECTIVE

To investigate spontaneous pregnancy rate (SPRs) of women with rectovaginal endometriosis (RV) with/without ovarian endometrioma (OMA) and treated with the use of expectant or surgical management.

DESIGN

Retrospective study.

SETTING

University hospital.

PATIENT(S)

The study included patients with RV with or without OMA who tried to conceive spontaneously for 1 year either without undergoing surgery (group E; n = 284) or after surgery (group S; n = 221). The study population was further divided into four subgroups: women with RV without OMA who directly tried to conceive (group eRV; n = 121) or tried to conceive after surgery (group sRV; n = 96), and women with RV with OMA who directly tried to conceive (group eOMA; n = 163) or tried to conceive after surgery (group sOMA; n = 125).

INTERVENTIONS(S)

Expectant or surgical management.

MAIN OUTCOME MEASURE(S)

Crude and cumulative SPRs.

RESULT(S)

At 1 year, crude and cumulative SPRs were lower in group E (17.3% and 23.8%, respectively) than in group S (35.7% and 39.5%). Similarly, crude and cumulative SPRs were lower in group eRV (24.8% and 30.6%) than in group sRV (42.7% and 45.7%, respectively) and in group eOMA (11.7% and 18.0%) than group sOMA (30.4% and 34.5%). At 1 year, crude and cumulative SPRs were higher in group eRV (24.8% and 30.6%) than in group eOMA (11.7% and 18.0%), and in group sRV (42.7% and 45.7%) than in group sOMA (30.4% and 34.5%).

CONCLUSION(S)

Crude and cumulative SPRs are lower in women treated with the use of expectant rather than surgical management. The presence of OMAs decreases SPRs independently from the treatment modality adopted.

To operate or not to operate on women with deep infiltrating endometriosis (DIE) before in vitro fertilization (IVF)

Deep infiltrating endometriosis (DIE) can cause infertility and pelvic pain. There is little evidence of a clear connection between DIE and infertility, and the absolute benefits of surgery for DIE have not been established. This paper aimed to review the current literature on the effect of surgery for DIE on fertility, pregnancy, and IVF outcomes. Clinicians should bear in mind that a comprehensive clinical history is useful to identify patients at risk for endometriosis, although many women remain asymptomatic. Imaging can be useful to plan surgery. The effect of surgery on the fertility of women with DIE remains unanswered due to the heterogeneous nature of the disease and the lack of trials with enough statistical power and adequate follow-up. Surgery is not recommended when the main goal is to treat infertility or to improve IVF results. Decisions should be tailored according to the individual needs of each woman. Patients must be provided information on the potential benefits, harm, and costs of each treatment alternative, while the medical team observes factors such as presence of pelvic pain, patient age, lesion location, and previous treatments. In this scenario, management by a multidisciplinary endometriosis team is a key step to achieving successful outcomes.

Trauma and endometriosis. A review. May we explain surgical phenotypes and natural history of the disease?

OBJECTIVE

The study was performed to evaluate whether trauma is an initial event of development of endometriosis.

METHOD

Using Medline database from January 1960 up to December 2014, a systematic review was made of all published studies using the keywords trauma, healing, injury, infection, hyperperistaltism, stretch and endometriosis, adenomyosis and trauma. Studies and review articles written in French and/or in English related to the topic were included and reviewed independently by two authors.

RESULTS

The role of trauma is well-established for endometriotic lesions diagnosed in surgical scars. Various traumas including delivery, uterine curettage or incision, intraperitoneal hemorrhage, or occult pelvic inflammatory diseases could be involved to explain other localizations of the disease. Many data suggested that the healing process, particularly growth factors and the associated estrogen production, may facilitate the implantation and the growth of ectopic endometrial cells. After the initial, a traumatic event, the phenotype of the disease would depend on the tissue in which the endometriotic lesion grows.

CONCLUSIONS

The present literature review may support a potential role of a trauma as an initial event of endometriosis.

Deep infiltrating endometriosis affecting the urinary tract-surgical treatment and fertility outcomes in 2004-2013

Urinary tract endometriosis (UTE) is a rare form of deep infiltrating endometriosis. We studied the operative treatment of UTE and evaluated postoperative recurrences and fertility outcomes. This is a retrospective cohort study of 53 women who underwent operative treatment for UTE in 2004–2013 at Helsinki University Hospital, and were followed-up until the end of 2014. The data were gathered from the hospital’s electronic database. The main outcome measures were complications, reoperations, postoperative pregnancies, and deliveries. Preoperative diagnosis was accurate in 72 % with bladder endometriosis and in 93 % with ureteral disease. Thirty-one (58 %) of the 53 operations were performed via laparoscopy. Postoperative complications requiring re-intervention occurred in five cases (9 %). Five reoperations were performed in four cases due to endometriosis recurrence, only two due to recurrence of UTE (4 %). Twenty-eight women wished for pregnancy; 18 (64 %) of them conceived. Infertility treatment was needed in 20 (71 %) cases. Twelve (75 %) women delivered via cesarean section; intraoperative difficulties occurred in ten (83 %). The complication rate with UTE operations is acceptable and recurrences are rare. Infertility is common, but 57 % of those who wished for a child succeeded. A majority of the deliveries involved unplanned and complicated cesarean section.

Laparoscopic Surgery for Rectovaginal Endometriosis: A Retrospective Descriptive Study from a Single Centre

Introduction

Rectovaginal endometriosis is a form of deep infiltrating endometriosis and accounts for 5%-10% of cases. It is a very difficult to treat and can be associated with severe complications.

Objectives

The aim was to document the outcomes of patients undergoing laparoscopic surgery for rectovaginal endometriosis.

Methods

A retrospective audit of 112 consecutive women undergoing laparoscopic surgery for rectovaginal endometriosis at Vincent Pallotti's Aevitas Fertility Clinic was undertaken. Women were identified from a surgical database using medical aid coding and a review of case notes. Patients were telephonically contacted to gather missing information and to assess further outcomes.

Results

The majority of surgeries were performed using the shaving technique, in keeping with international trends, whilst fourteen cases required a segmental resection owing to extensive disease. Complications included rectovaginal fistulas (3 cases), bowel injuries (2 cases), ureteric injury (1 case), a pelvic abscess (1 case), a blood transfusion (1 case) and the need for three urgent re-operations. Of the 71 patients desiring fertility, 39 (54.9%) fell pregnant. Twenty-seven (69.2%) were spontaneous conceptions.

Conclusions

Our outcomes are in keeping with complication rates quoted in the international literature. In trained hands, laparoscopic surgery at our unit is a valid option in the management of rectovaginal endometriosis with similar complication rates and outcomes to international standards.

The Surgical Treatment of Severe Endometriosis Positively Affects the Chance of Natural or Assisted Pregnancy Postoperatively

OBJECTIVE

To report reproductive outcomes following laparoscopic surgical excision of histologically confirmed r-ASRM stage III-IV endometriosis.

STUDY DESIGN

A retrospective cohort study was performed at the Royal Hospital for Women, a university teaching hospital, Sydney, Australia. Women who had fertility-preserving laparoscopic excision of stage III-IV endometriosis from 1997 to 2009 were contacted regarding reproductive outcomes.

RESULTS

In the study period, 355 women underwent surgery for stage III-IV endometriosis. Follow-up data are available for 253/355 (71%) women. Postoperatively, 142/253 (56%) women attempted to conceive with a conception rate of 104/142 (73%). Confidence intervals for pregnancy for women who were attempting conception (including the nonresponders) range from 104/262 (40%) to 224/262 (85%). Median time to conception was 12 months. No positive prognostic factors for pregnancy were identified on regression analyses.

CONCLUSIONS

These data provide information to women with suspected severe disease preoperatively concerning their likely postoperative fertility outcomes. Ours is a population with severe endometriosis, rather than an infertile population with endometriosis, so caution needs to be applied when applying these data to women with fertility issues alone.

Sexual function in women undergoing surgery for deep infiltrating endometriosis: a comparison with healthy women

BACKGROUND

Endometriosis is a chronic and progressive condition of women of reproductive age. It is strongly associated with significant impairment of sexual function.

AIM

To objectively evaluate the impact of laparoscopic excision of endometriosis on sexual function in patients with deep infiltrating endometriosis (DIE) compared to healthy women.

SETTING AND DESIGN

Prospective study, including 250 patients with a diagnosis of DIE scheduled for laparoscopic surgery and 250 healthy women.

METHODS

A sexual activity questionnaire, SHOW-Q (Sexual Health Outcomes in Women Questionnaire), was used to collect data pertaining to women's satisfaction, orgasm, desire and pelvic problem interference with sexual function. Women with DIE underwent complete excision of endometriotic lesions. All participants were asked to complete the SHOW-Q questionnaire before and after surgery.

RESULTS

SHOW-Q scores in the endometriosis group before and 6 months after surgery were compared with the healthy group scores. A significant improvement was found between pre- and post-treatment in the scores of the satisfaction scale, desire scale and pelvic problem interference scale of SHOW-Q. The distribution of post-surgery SHOW-Q scores was comparable to healthy women's scores apart from the orgasm scale score, which was unchanged in the post-surgery group.

CONCLUSIONS

The surgical approach to treatment has a positive impact not only on organ impairment but also on sexual function in women affected by DIE.

How to Manage Bowel Endometriosis: The ETIC Approach

A panel of experts in the field of endometriosis expressed their opinions on management options in a 35-year-old patient desiring pregnancy with a history of previous surgery for endometrioma and bowel obstruction symptoms. Many questions that this paradigmatic patient may pose to the clinician are addressed, and various clinical scenarios are discussed. A decision algorithm derived from this discussion is proposed as well.

Treatment of endometriosis in women desiring fertility

Endometriosis is a common condition affecting a significant proportion of women in their reproductive age. Apart from the impact of endometriosis on the quality of life of these patients, it also can have an impact on the potential of these women to have a family. The options for treating women with endometriosis desiring a family include surgery or assisted reproduction techniques. The choice of treatment will depend on the stage of disease and the characteristics of the couple seeking help. We review here the latest evidence on the management of endometriosis in women desiring fertility and describe our current practice.

Focusing on surgery results in infertile patients with deep endometriosis

Infertility is a common problem in patients with endometriosis and the involved mechanisms are still not completely known. The management of infertility in endometriosis patients includes surgery as well as assisted reproductive technology. Laparoscopic surgery has shown better results in infertility patients with endometriosis in comparison to laparotomy procedures. Laparoscopic surgery has proposed benefits in both minimal to moderate diseases. However, while there may be some benefits with severe diseases, there is still not enough evidence to recommend laparoscopic surgery as the recommended surgery when the main goal is to obtain fertility. We performed a MEDLINE search for articles on fertility in women with deep infiltrating endometriosis (DIE) published between 1990 and April 2015 using the following keywords: "endometriosis", "deep infiltrative endometriosis", "infertility", "fertility after surgery", "laparoscopy surgery", "laparotomy", "pregnancy", "fertility outcome", "bladder endometriosis", and "ureteral endometriosis". The aim of this review was to analyze the results of available clinical studies (randomized controlled or not controlled studies; retrospective cohort studies; or case-control and prospective studies) and guidelines on surgical treatment of infertile endometriosis patients, and pregnancy outcomes after surgery.

Employing Laparoscopic Surgery for Endometriosis

Endometriosis is a chronic, multifactorial disease, which can impact significantly on a women's quality of life. It is associated with pelvic pain, dyspareunia and intestinal disorders, and can lead to infertility. The use of laparoscopic surgery in the management of endometriosis is well documented; however, the optimal management of women with deep infiltrating disease remains controversial. This review describes the different surgical strategies for the treatment of endometriosis.