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Miquel L, Liotta J, Pivano A, Gnisci A, Netter A, Courbiere B, Agostini A. Ethanol endometrioma sclerotherapy: safety through 8 years of experience. Hum Reprod 2024; 39:733-741. [PMID: 38327007 DOI: 10.1093/humrep/deae014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 01/06/2024] [Indexed: 02/09/2024] Open
Abstract
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.
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Affiliation(s)
- L Miquel
- Department of Obstetrics Gynecology and Reproductive Medicine, Pôle femmes parents enfants, La Conception University Hospital, Marseille, France
| | - J Liotta
- Department of Obstetrics Gynecology and Reproductive Medicine, Pôle femmes parents enfants, La Conception University Hospital, Marseille, France
| | - A Pivano
- Department of Obstetrics Gynecology and Reproductive Medicine, Pôle femmes parents enfants, La Conception University Hospital, Marseille, France
| | - A Gnisci
- Department of Obstetrics Gynecology and Reproductive Medicine, Pôle femmes parents enfants, La Conception University Hospital, Marseille, France
| | - A Netter
- Department of Obstetrics Gynecology and Reproductive Medicine, Pôle femmes parents enfants, La Conception University Hospital, Marseille, France
- Department of Mediterranean Institute of marine and terrestrial Biodiversity and Ecology, Aix Marseille Univ, Avignon Université, CNRS, IRD, IMBE, Marseille, France
| | - B Courbiere
- Department of Obstetrics Gynecology and Reproductive Medicine, Pôle femmes parents enfants, La Conception University Hospital, Marseille, France
- Department of Mediterranean Institute of marine and terrestrial Biodiversity and Ecology, Aix Marseille Univ, Avignon Université, CNRS, IRD, IMBE, Marseille, France
| | - A Agostini
- Department of Obstetrics Gynecology and Reproductive Medicine, Pôle femmes parents enfants, La Conception University Hospital, Marseille, France
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Miquel L, Preaubert L, Gnisci A, Resseguier N, Pivano A, Perrin J, Courbiere B. Endometrioma ethanol sclerotherapy could increase IVF live birth rate in women with moderate-severe endometriosis. PLoS One 2020; 15:e0239846. [PMID: 32986747 PMCID: PMC7521758 DOI: 10.1371/journal.pone.0239846] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 09/14/2020] [Indexed: 01/04/2023] Open
Abstract
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.
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Affiliation(s)
- Laura Miquel
- Department of Obstetrics Gynecology and Reproductive Medicine, Pôle femmes parents enfants, IVF Unit/ CECOS, AP-HM La Conception University Hospital, Marseille, France
| | - Lise Preaubert
- Department of Obstetrics Gynecology and Reproductive Medicine, Pôle femmes parents enfants, IVF Unit/ CECOS, AP-HM La Conception University Hospital, Marseille, France
| | - Audrey Gnisci
- Department of Obstetrics Gynecology and Reproductive Medicine, Pôle femmes parents enfants, IVF Unit/ CECOS, AP-HM La Conception University Hospital, Marseille, France
| | - Noémie Resseguier
- Research Unit EA 3279, Department of Public Health, Aix-Marseille University, Marseille, France
| | - Audrey Pivano
- Department of Obstetrics Gynecology and Reproductive Medicine, Pôle femmes parents enfants, IVF Unit/ CECOS, AP-HM La Conception University Hospital, Marseille, France
| | - Jeanne Perrin
- Department of Obstetrics Gynecology and Reproductive Medicine, Pôle femmes parents enfants, IVF Unit/ CECOS, AP-HM La Conception University Hospital, Marseille, France
- Aix Marseille Univ, Avignon Université, CNRS, IRD, IMBE, Marseille, France
| | - Blandine Courbiere
- Department of Obstetrics Gynecology and Reproductive Medicine, Pôle femmes parents enfants, IVF Unit/ CECOS, AP-HM La Conception University Hospital, Marseille, France
- Aix Marseille Univ, Avignon Université, CNRS, IRD, IMBE, Marseille, France
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Garcia-Tejedor A, Martinez-Garcia JM, Candas B, Suarez E, Mañalich L, Gomez M, Merino E, Castellarnau M, Regueiro P, Carreras M, Martinez-Franco E, Carrarrach M, Subirats N, Barbera J, Gonzalez S, Climent M, Fernández-Montolí E, Ponce J. Ethanol Sclerotherapy versus Laparoscopic Surgery for Endometrioma Treatment: A Prospective, Multicenter, Cohort Pilot Study. J Minim Invasive Gynecol 2020; 27:1133-1140. [PMID: 32272240 DOI: 10.1016/j.jmig.2019.08.036] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 08/14/2019] [Accepted: 08/26/2019] [Indexed: 12/29/2022]
Abstract
STUDY OBJECTIVE To compare the cost-effectiveness of ultrasound (US)-guided aspiration and ethanol sclerotherapy versus laparoscopic surgery for benign-appearing ovarian endometrioma. DESIGN Prospective, cohort pilot study. SETTING Multiple centers, Spain. PATIENTS Forty patients with suspected ovarian endometrioma identified by US, with a maximum diameter of 35 to 100 mm, of whom 33 met inclusion criteria. INTERVENTIONS The study group (n = 17) underwent US-guided aspiration plus sclerotherapy with ethanol, and the control group (n = 14) underwent laparoscopic cystectomy. MEASUREMENTS AND MAIN RESULTS Recurrence, complications, and direct costs were compared. One of 17 sclerotherapy patients recurred (5.9%) compared with 4 of 14 laparoscopic surgery patients (28.6%) (odds ratio 0.18, 0.01-1.53). No serious adverse effects (Clavien-Dindo ≥ III) were observed in the sclerotherapy group; 1 patient in the surgery group had a Clavien-Dindo IIIb complication. Median hospital direct costs were significantly lower in the sclerotherapy group than those in the surgery group-266 euros versus 2189 euros. CONCLUSION Ethanol sclerotherapy seems to be cost-effective for endometrioma and also appears to reduce complications. In this pilot study, recurrence was not higher than with conventional surgery.
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Affiliation(s)
- Amparo Garcia-Tejedor
- Departments of Gynaecology (Drs. Garcia-Tejedor, Martinez-Garcia, Climent, Fernández-Montolí, and Ponce), Barcelona.
| | - Jose M Martinez-Garcia
- Departments of Gynaecology (Drs. Garcia-Tejedor, Martinez-Garcia, Climent, Fernández-Montolí, and Ponce), Barcelona
| | - Beatriz Candas
- Biochemistry and Molecular Biology, Clinical Laboratory (Dr. Candas), Barcelona
| | - Elena Suarez
- Hospital Universitari Bellvitge, Hospitalet de Llobregat Idibell, the Department of Gynaecology, Hospital Universitari Vall d'Hebron (Drs. Suarez and Mañalich), Barcelona
| | - Laura Mañalich
- Hospital Universitari Bellvitge, Hospitalet de Llobregat Idibell, the Department of Gynaecology, Hospital Universitari Vall d'Hebron (Drs. Suarez and Mañalich), Barcelona
| | - Maria Gomez
- Department of Gynaecology, Hospital Universitari Joan XXIII, Tarragona (Dr. Gomez), Barcelona
| | - Elisabet Merino
- Department of Gynaecology, Hospital Universitari Doctor Josep Trueta, Girona (Dr. Merino), Barcelona
| | - Marta Castellarnau
- Department of Gynaecology, Consorci Sanitari Integral, Hospitalet de Llobregat (Drs. Castellarnau and Regueiro), Barcelona
| | - Purificacion Regueiro
- Department of Gynaecology, Consorci Sanitari Integral, Hospitalet de Llobregat (Drs. Castellarnau and Regueiro), Barcelona
| | - Manuel Carreras
- Department of Gynaecology, Hospital de Sant Joan de Déu de Sant Boi, Sant Boi de Llobregat (Drs. Carreras and Martinez-Franco), Barcelona
| | - Eva Martinez-Franco
- Department of Gynaecology, Hospital de Sant Joan de Déu de Sant Boi, Sant Boi de Llobregat (Drs. Carreras and Martinez-Franco), Barcelona
| | - Marta Carrarrach
- Department of Gynaecology, Hospital de Viladecans, Viladecans (Dr. Carrarrach), Barcelona
| | - Neus Subirats
- Department of Gynaecology, Hospital Verge de La Cinta, Tortosa, Tarragona (Drs. Subirats and Barbera), Spain
| | - Judith Barbera
- Department of Gynaecology, Hospital Verge de La Cinta, Tortosa, Tarragona (Drs. Subirats and Barbera), Spain
| | - Santiago Gonzalez
- Department of Gynaecology, Hospital de Sant Joan de Déu d'Esplugues, Esplugues de Llobregat, Barcelona (Dr. Gonzalez), Spain
| | - Maite Climent
- Departments of Gynaecology (Drs. Garcia-Tejedor, Martinez-Garcia, Climent, Fernández-Montolí, and Ponce), Barcelona
| | - Eulalia Fernández-Montolí
- Departments of Gynaecology (Drs. Garcia-Tejedor, Martinez-Garcia, Climent, Fernández-Montolí, and Ponce), Barcelona
| | - Jordi Ponce
- Departments of Gynaecology (Drs. Garcia-Tejedor, Martinez-Garcia, Climent, Fernández-Montolí, and Ponce), Barcelona
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Martel-Billard C, Pellerin M, Hummel M, Pirrello O. [Ethanol sclerotherapy: a treatment option for ovarian endometriomas before ovarian stimulation]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2019; 47:387-389. [PMID: 30819505 DOI: 10.1016/j.gofs.2019.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2018] [Indexed: 06/09/2023]
Affiliation(s)
- C Martel-Billard
- Service de gynécologie, centre médicochirurgical et obstétrical, hôpitaux universitaires de Strasbourg, 19, rue Louis-Pasteur, 67300 Schiltigheim, France.
| | - M Pellerin
- Service de gynécologie, centre médicochirurgical et obstétrical, hôpitaux universitaires de Strasbourg, 19, rue Louis-Pasteur, 67300 Schiltigheim, France
| | - M Hummel
- Service de gynécologie, centre médicochirurgical et obstétrical, hôpitaux universitaires de Strasbourg, 19, rue Louis-Pasteur, 67300 Schiltigheim, France
| | - O Pirrello
- Service d'assistance médicale à la procréation, centre médicochirurgical et obstétrical, hopitaux universitaires de Strasbourg, 19, rue Louis-Pasteur, 67300 Schiltigheim, France
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[Surgical management of endometrioma: Different alternatives in term of pain, fertility and recurrence. CNGOF-HAS Endometriosis Guidelines]. ACTA ACUST UNITED AC 2018; 46:278-289. [PMID: 29510964 DOI: 10.1016/j.gofs.2018.02.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Indexed: 11/22/2022]
Abstract
Surgical management of ovarian endometrioma is most often part of a global approach of endometriosis pathology. Isolated endometrioma are rare. Laparoscopic cystectomy is the gold standard for surgical management of endometrioma. Nevertheless, this technique impacts the ovarian function. The hemostasis of the ovarian cyst bed should be performed to conserve the ovarian stroma. Ultrasonography-guided cyst aspiration, laparoscopic drainage and simple bipolar coagulation are not recommended as first line of treatment. Based on the actual literature, we cannot state the place of laser-vaporization and plasma-energy ablation in surgical management. Ethanol sclerotherapy could be an alternative to treat recurrent endometrioma. Uncompleted surgical removal of endometriosis lesions increases the recurrence rate. Endometriosis management should take into account the research and treatment of all the pelvic lesion, especially before surgical management of endometrioma. In this context, the evaluation of ovarian reserve could be useful before surgery.
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Abstract
Preoperative evaluation: clinical examination, and research for associated lesions. Laparoscopic approach. Cystectomy: gold standard, conformed to the endometrioma pathophysiology (3 zones). Laser CO2 Plasmajet® vaporisation: important data lead to legitimate utilisation. Haemostasis: be patient! Use of bipolar energy sparingly. Look for other endometriotic lesions, and systematic treatment. Preoperative medical treatment not always useful. Postoperative treatment: decrease recurrence. Especially for patients with no immediate pregnancy desire.
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Abstract
Background: To evaluate ultrasonographic-guided cyst aspiration and methotrexate injection in the management of simple and endometriotic ovarian cysts in selected patients. Subjects and Methods: This prospective study was conducted in the Department of Obstetrics and Gynaecology in Government Medical College and Hospital, Chandigarh, from November 2007 to October 2009. It included 132 female patients (age range, 15–72 years; mean, 38.7 years) with simple or endometriotic ovarian cysts (3.0–10.6 cm) at ultrasonic examinations. We performed puncture and aspiration followed by methotrexate injection into the cyst. All patients were followed for 12 months. None was lost to follow-up. Results: At follow-up ultrasonography, cysts had disappeared in 120 patients (90.90%) and persisted in 12 patients (9%). No major complications were observed in our study population during or after the procedure. Only 10 patients reported mild pelvic pain, and four others reported dizziness or nausea during or after the procedure. Malignant cells were not found in any of the cases at cytologic examination. We did not observe any cases of infection after the procedure. Conclusion: Ultrasonography-guided transabdominal aspiration of cyst fluid and subsequent methotrexate injection appears to be an alternative treatment for both simple and endometriotic ovarian cysts in selected cases.
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Affiliation(s)
- Pratiksha Gupta
- Department of Gynecology and Obstetrics, PGIMSR, Basai Darapur, New Delhi, India
| | - Anju Huria
- Department of Gynecology and Obstetrics, Government Medical College, Chandigarh, India
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Ethanol sclerotherapy of ovarian endometrioma: a safe and effective minimal invasive procedure. Preliminary results. Eur J Obstet Gynecol Reprod Biol 2015; 187:25-9. [DOI: 10.1016/j.ejogrb.2015.02.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Revised: 01/29/2015] [Accepted: 02/06/2015] [Indexed: 11/20/2022]
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Borghese B, Marzouk P, Santulli P, de Ziegler D, Chapron C. Traitements chirurgicaux des tumeurs ovariennes présumées bénignes. ACTA ACUST UNITED AC 2013; 42:786-93. [DOI: 10.1016/j.jgyn.2013.09.033] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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