Repeat transvaginal ultrasound-guided aspiration of ovarian endometrioma in infertile women with endometriosis

Treatment after endometrioma recurrence: a narrative review

INTRODUCTION

Ovarian endometrioma is a common subtype of endometriosis with a prevalence between 17 and 44%. The reported average recurrence of endometrioma after surgical management is 21.5% after 2 years and 40-50% after 5 years. The aim of this narrative review was to summarize the existing literature focusing on treatment options after endometrioma recurrence in order to provide an evidence-based approach for the clinical practice.

EVIDENCE ACQUISITION

Three electronic databases (MEDLINE, EMBASE and Cochrane) were searched until September 2022 for eligible studies.

EVIDENCE SYNTHESIS

The available studies showed that repeated surgery has a negative impact on ovarian function, without improving the fertility outcomes. Transvaginal aspiration as an alternative option for surgery has a high rate of recurrence, which varies from 8.20 to 43.5% depending on the technique used and on the study population. Pregnancy related outcomes were similar between transvaginal aspiration groups and no intervention groups in patients with endometrioma recurrence. Regarding medical treatments, only four studies were found, showing that progestins reduce the pain and the diameter of the ovarian cyst.

CONCLUSIONS

Recurrent endometrioma is a challenging condition which could be encountered during the care of women with endometriosis. The decision about the treatment-strategy has to be individualized considering family planning status, age, ovarian reserve and transvaginal ultrasound findings. Well-designed randomized clinical trials are needed to export safer conclusions about the most appropriate treatment in each specific condition after endometrioma recurrence.

Exploring the Impact of Endometrioma Aspiration and Dienogest Combination Therapy on Cyst Size, Inflammatory Cytokines in Follicular Fluid and Fertility Outcomes

Endometriomas (chocolate cysts) are cystic lesions that can develop on ovaries, and are characterized by the presence of ectopic endometrial tissue or similar tissue. Such lesions can cause a decline in the number and quality of oocytes, and lead to implantation failure. In this study, we retrospectively assessed the efficacy of repeated endometrioma aspiration and dienogest combination therapy in patients suffering endometriosis-associated infertility with endometriomas. A comparison was made between a treated group that underwent combination therapy followed by controlled ovarian hyperstimulation (COH) (n = 30) and a control group that did not undergo treatment (n = 40), at the IVF Osaka Clinic from September 2019 to September 2021. There were no differences in patient background between the two groups. A reduction in endometrioma size continued for 12 months after treatment. The numbers of follicles that developed to 15 mm or greater in size following COH and mature oocytes were significantly lower in the treated group compared to those in the control group. The levels of inflammatory cytokines in the follicular fluid significantly decreased in the treated group (p < 0.05). In patients in the treated group who underwent a second ova retrieval, the results were compared between those in the first ova retrieval (immediately after the end of treatment) and those in the second ova retrieval (four months after the first retrieval). The numbers of follicles following COH, retrieved, mature and fertilized ova were significantly increased in the second ova retrieval.

Efficacy of ablation and sclerotherapy for the management of ovarian endometrioma: A narrative review

Ovarian cystectomy is the preferred technique for the surgical management of ovarian endometrioma. However, other techniques such as ablation or sclerotherapy are also commonly used. The aim of this review is to summarize information regarding the efficacy of ablation and sclerotherapy compared to cystectomy in terms of ovarian reserve, the recurrence rate, and the pregnancy rate. Several studies comparing ablation versus cystectomy or sclerotherapy versus cystectomy in terms of the serum anti-Müllerian hormone (AMH) decrement, endometrioma recurrence, or the pregnancy rate were identified and summarized. Both ablation and cystectomy have a negative impact on ovarian reserve, but ablation results in a smaller serum AMH decrement than cystectomy. Nonetheless, the recurrence rate is higher after ablation than after cystectomy. More studies are needed to demonstrate whether the pregnancy rate is different according to whether patients undergo ablation or cystectomy. The evidence remains inconclusive regarding whether sclerotherapy is better than cystectomy in terms of ovarian reserve. The recurrence rates appear to be similar between sclerotherapy and cystectomy. There is not yet concrete evidence that sclerotherapy helps to improve the pregnancy rate via in vitro fertilization in comparison to cystectomy or no sclerotherapy.

Effects of ovarian endometrioma aspiration on in vitro fertilization-intracytoplasmic sperm injection and embryo transfer outcomes: a systematic review and meta-analysis

PURPOSE

To evaluate the effect of ovarian endometrioma aspiration on IVF/ICSI outcomes.

METHODS

The PubMed, EMBASE, Web of Science, China National Knowledge Infrastructure, and Wanfang databases were searched to identify studies related to the treatment of endometrioma up to October 1, 2020, and the data of 1207 patients from 10 studies were analyzed using STATA.

RESULTS

The 10 studies in our analysis included 7 comparing aspiration and surgery and 6 comparing aspiration with no intervention. In the aspiration versus surgery groups, live birth rate [OR 0.97 (95% CI 0.51, 1.85), P = 0.925] and clinical pregnancy rate [OR 1.30 (95% CI 0.95, 1.80), P = 0.105] showed no significant difference between the two groups. Abortion rate [OR 4.26 (95% CI 1.38, 13.08), P = 0.011], the number of oocytes retrieved [mean difference 1.95 (95% CI 0.10, 3.81), P = 0.039], and the estradiol peak on hCG day [mean difference 392.16 (95% CI 230.14, 554.18), P < 0.001] were significantly higher in the aspiration group compared to the surgical group. In the aspiration versus the no intervention group, live birth rate [OR 0.84 (95% CI 0.45, 1.59), P = 0.602] and clinical pregnancy rate [OR 1.25 (95% CI 0.88, 1.77), P = 0.206] were not significantly different between the two groups. The abortion rate [OR 0.31 (95% CI 0.11, 0.88), P = 0.028] and the number of gonadotropin ampoules [mean difference - 3.13 ampoules (95% CI - 4.90, - 1.37), P < 0.001] were significantly lower in the aspiration group compared to the no intervention group.

CONCLUSION

Compared with surgical treatment or no intervention treatment, aspiration has less effect on ovarian response, ovarian reserve, and pregnancy outcomes.

Contrast-enhanced ultrasound evaluation of a refractory ovarian endometrial cyst and ultrasound-guided aspiration sclerotherapy using urokinase and lauromacrogol

Endometriosis is one of the most common diseases that happen in reproductive women. The main symptoms include ovarian endometrial cyst, pelvic pain, and so on. We report a case of a 23-year-old woman with a refractory long-course ovarian endometrial cyst (OEC). The patient was previously identified to have a hypoechoic mass sized 9.7 cm in diameter on ultrasound (US) in the right ovary and was tentatively diagnosed as OEC in another tertiary hospital, who was then subjected to US-guided cyst sclerotherapy while the procedure was failed since only a very small amount of viscous and sticky fluid can be aspirated. The patient was then referred to our hospital for further treatment. Pretreat contrast-enhanced ultrasound (CEUS) showed non-enhancement of the mass with a thin cyst wall and a cyst-in-cyst pattern was observed. The possibility of ovarian malignancy was ruled out and the initial diagnosis of OEC was confirmed. The patient was then subjected to US-guided cyst sclerotherapy with lauromacrogol. The interventional procedure was eventful that no fluid was aspirated as what happened in the previous hospital. Thus urokinase was used to dissolve the old, viscious and sticky blood and finally, all the fluid was aspirated. The total consumption of urokinase was 60,000 U. Then lauromacrogol as a sclerosant was injected into the cyst cavity and the cyst wall was flushed repeatedly with lauromacrogol until the aspirated fluid became light red. Finally, 20 mL lauromacrogol was reserved in the cyst and the interventional procedure cost 2 hours The post-procedure course was uneventful without any discomfort, and the volume reduction rate of the cyst was 54%at 3-month follow-up. The visual analogue scale for the pain decreased from 4 before treatment to 1 after treatment, indicating a successful and effective outcome for the refractory long-course OEC.

Long-term outcomes of transvaginal ultrasound-guided aspiration versus traditional conservative surgery as treatment for endometriomas: A retrospective study of cohorts

AIM

To evaluate if the long-term results (on fertility, need of hysterectomy and persistence of endometriosis) after a minimally invasive intervention (transvaginal ultrasound-guided puncture-aspiration [TUGPA]) for endometriomas are significantly different from performing the traditional conservative surgery (CS) by laparoscopy or laparotomy.

METHODS

We performed a retrospective study of cohorts on patients undergoing surgery for ovarian endometriomas between January 1998 and April 2015. Cohort 1 consisted of 75 women whose first intervention for endometriomas had been TUGPA. For the cohort 2, we selected a randomized paired case in which the first operation for endometriomas had been CS by laparoscopic or laparotomy (another set of 75 patients).

RESULTS

There were significantly more recurrences and the time to recurrence and repetition of operations were also significantly shorter in patients with TUGPA. However, there were no significant differences in overall pregnancy/delivery outcomes, in hysterectomy performances, or in endometriosis persistence at the last follow-up visit. There were no significant differences related to the symptoms or to analytical presurgical values but the application of multivariate analysis with binary logistic regression to each dependent variable adjusted for age, symptoms, and presurgical analyses showed a significant risk of recurrence and reoperation of TUGPA versus CS.

CONCLUSIONS

Those patients with endometriomas who underwent TUGPA (with or without associated medications) had a significant increase in recurrence and the need for reoperation. However, in the long-term there were no significant differences in the results of pregnancy/childbirth, need for hysterectomy, or in the clinical or doubtful persistence of endometriosis.

A randomized controlled trial of a new technique for laparoscopic management of ovarian endometriosis preventing recurrence and keeping ovarian reserve

Introduction

Laparoscopic cystectomy provides more favourable outcomes as regards the recurrence and subsequent clinical pregnancy rates. It is associated with significant reduction in the ovarian reserve due to the inevitable removal of unaffected ovarian tissue. The aim of our study was to evaluate the efficiency of Surgicel in preventing recurrence of endometriomas after their laparoscopic conservative management (cystectomy or drainage).

Material and methods

A randomized controlled trial included two hundred women (candidate for conservative laparoscopic management of ovarian endometriomas). They were randomized into four groups; group D in which patients underwent laparoscopic drainage of the endometrioma, group C in which patients underwent laparoscopic cystectomy of the endometrioma, group DS in which patients underwent laparoscopic drainage followed by insertion of Surgicel inside the cyst cavity & group CS in which patients underwent laparoscopic cystectomy of the endometrioma followed by insertion of Surgicel inside the remaining ovarian tissues. All patients were followed up for 2 years & the primary outcome was the recurrence of endometriomas in the ipsilateral ovary & the postoperative ovarian reserve was reassessed as a secondary outcome.

Results

The Surgicel-treated groups had significantly lower hazard of recurrence compared to untreated groups (p = 0.004). Group CS had significantly lower hazard of recurrence compared to Group D & C (p = 0.014, 0.046 respectively). Group DS had significantly lower hazard of recurrence compared to Group D (p = 0.039) but it not significantly different from Group C (p = 0.112). Group DS had the lowest drop of AMH and was significantly lower than the other three groups.

Conclusion

Surgicel reduces effectively the recurrence risk of endometriomas and its use during laparoscopic drainage is an effective alternative for traditional laparoscopic cystectomy with minimal affection of the patient ovarian reserve.

Trial registration

Name of the registry: clinicaltrials.gov. Trial registration number NCT02947724. Date of registration October 28, 2016.