1
|
Roman H, Chanavaz-Lacheray I, Mircea O, Berby B, Dehan L, Braund S, Verspyck E, Puscasiu L. Large ovarian endometriomas are associated with high pre-operative anti-Müllerian hormone concentrations. Reprod Biomed Online 2020; 42:158-164. [PMID: 33060013 DOI: 10.1016/j.rbmo.2020.09.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 09/02/2020] [Accepted: 09/08/2020] [Indexed: 12/27/2022]
Abstract
RESEARCH QUESTION Are large ovarian endometriomas associated with high pre-operative anti-Müllerian hormone (AMH) concentrations? DESIGN Data from 332 women who underwent AMH measurement before surgery for endometriosis were prospectively recorded in a large database. Univariate analysis compared AMH concentrations in terms of the patients' baseline characteristics. A multivariate model was used to identify variables having an independent relationship with AMH concentration. RESULTS Among 332 women included in the study, 47.6% were aged 18-30 years, 67.8% were infertile and 85.5% were nulliparous. A total of 66.3% had ovarian endometriomas, and 10.8% had cysts measuring over 6 cm. Bilateral cysts over 3 cm were recorded in 24.7% of the women. Univariate analysis identified two variables that had a statistically significant relationship with AMH concentration: the woman's age (P = 0.01) and cyst size (P < 0.001). Multivariate analysis revealed that ages of 36-40 years and over 40 years showed a significant association with lower AMH concentrations (P = 0.02 and P = 0.009, respectively), while a cyst size of over 6 cm was statistically associated with high AMH concentrations (P < 0.001), after adjustment for smoking, parity, rectosigmoid endometriotic nodules and a bilateral location of endometriomas. CONCLUSIONS Pre-operative AMH concentration was significantly increased in women with large endometriomas of over 6 cm, independent of their age or the presence of bilateral endometriomas. This is relevant for both surgeons and patients when planning surgery in women with an intention to conceive post-operatively.
Collapse
Affiliation(s)
- Horace Roman
- Endometriosis Centre, Clinique Tivoli-Ducos, Bordeaux, France; Department of Gynaecology and Obstetrics, University Hospital Aarhus, Aarhus, Denmark.
| | | | - Oana Mircea
- Department of Gynecology and Obstetrics, University of Medicine, Pharmacy, Science and Technology, TarguMures, Romania
| | - Benoit Berby
- Expert Center in Diagnosis and Management of Endometriosis, Department of Gynecology and Obstetrics, Rouen University Hospital, Rouen, France
| | - Lise Dehan
- Expert Center in Diagnosis and Management of Endometriosis, Department of Gynecology and Obstetrics, Rouen University Hospital, Rouen, France
| | - Sophia Braund
- Expert Center in Diagnosis and Management of Endometriosis, Department of Gynecology and Obstetrics, Rouen University Hospital, Rouen, France
| | - Eric Verspyck
- Expert Center in Diagnosis and Management of Endometriosis, Department of Gynecology and Obstetrics, Rouen University Hospital, Rouen, France
| | - Lucian Puscasiu
- Department of Gynecology and Obstetrics, University of Medicine, Pharmacy, Science and Technology, TarguMures, Romania
| |
Collapse
|
2
|
Pluchino N, Roman H. Oocyte vitrification offers more space for a tailored surgical management of endometriosis. Reprod Biomed Online 2020; 41:753-755. [PMID: 32819840 DOI: 10.1016/j.rbmo.2020.07.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 07/01/2020] [Accepted: 07/13/2020] [Indexed: 10/23/2022]
Abstract
Oocyte vitrification is an attractive and efficient option in the long-term management of endometriosis patients. Which women would benefit from banked oocytes when pregnancy is attempted, and whether oocyte vitrification should be carried out before or after the surgical management of endometriosis, is still debated. On the basis of recent data, and in the absence of cost-effective modelling, a personalized strategy should assess crucial variables, such as type of surgery, effect on oocyte yield and the huge heterogeneity of the clinical scenarios possibly requiring surgery. Research into a more tailored approach to maximize the result of each available intervention, e.g. hormones, surgery, assisted reproductive technology or their combination to prevent infertility and reduce the actual burden of personal and societal cost of the disease, is recommended.
Collapse
Affiliation(s)
- Nicola Pluchino
- Division of Obstetrics and Gynecology, University Hospital of Geneva and Faculty of Medicine, Bd de la Cluse 30, 1205 Geneva, Switzerland.
| | - Horace Roman
- Endometriosis Center, Clinique Tivoli-Ducos, rue Mandron 220, 33000 Bordeaux, France; Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Palle Juul-Jensens Boulevard 99, Denmark
| |
Collapse
|
3
|
Post-operative management and follow-up of surgical treatment in the case of rectovaginal and retrocervical endometriosis. Arch Gynecol Obstet 2020; 302:957-967. [PMID: 32661754 PMCID: PMC7471187 DOI: 10.1007/s00404-020-05686-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 07/04/2020] [Indexed: 12/17/2022]
Abstract
Introduction Deep infiltrating endometriosis (DIE) affects between 3.8% and 37% of all endometriosis patients, mostly affecting rectovaginal septum or retrocervical space and characterized by the severe endometriosis-related complaints. Nowadays, generally managed with surgery. However, this is associated with a risk of postoperative complications. To better evaluate intra- and postoperative complications and outcomes for rectovaginal (RVE) and retrocervical endometriosis (RCE), the preoperative management should be accurately described and compared. Methodology This is a cohort retrospective study performed at the Endometriosis Centre of Charité-University Clinic, Berlin. 34 patients were investigated in their reproductive age, n = 19 with RVE and n = 15 RCE, operated between 2011 and 2015. The surgical approach was divergent in both groups. Single laparoscopy was performed in RCE patients (RCEP) and vaginal assisted laparoscopy in RVE patients (RVEP). Long-term postoperative outcome included complications, fertility rate and recurrence rate. Results The median follow-up time was three years (y). Symptom-free status was revealed in n = 12 RVEP and n = 9 RCEP. Postoperatively, endometriosis-related complaints were presented in n = 7 RVEP and n = 6 RCEP, but with significant pain relief. From n = 8 RVE patients seeking fertility, pregnancy occurred in n = 7 and from n = 9 RCEP pregnancy appeared in n = 5 patients in the meantime of 6 months. Postoperative complications were reported in n = 1 RVEP with early postoperative bleeding, after ureter leakage and n = 1 RCEP with postoperative anastomotic insufficiency. The postoperative recurrence rate was equivalent to zero. Conclusion The appropriate surgical approach for each group, preserving anatomy and functionality of the organs, seems to be very essential and efficient.
Collapse
|
4
|
Breteau P, Chanavaz-Lacheray I, Rubod C, Turck M, Sanguin S, Pop I, Resch B, Roman H. 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. J Minim Invasive Gynecol 2019; 27:1148-1157. [PMID: 31518714 DOI: 10.1016/j.jmig.2019.08.032] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 08/29/2019] [Accepted: 08/31/2019] [Indexed: 10/26/2022]
Abstract
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.
Collapse
Affiliation(s)
- Pauline Breteau
- Expert Center in the Diagnosis and Multidisciplinary Management of Endometriosis, Department of Obstetrics and Gynecology, Rouen University Hospital, Rouen, France (Drs. Breteau, Chanavaz-Lacheray, and Resch)
| | - Isabella Chanavaz-Lacheray
- Expert Center in the Diagnosis and Multidisciplinary Management of Endometriosis, Department of Obstetrics and Gynecology, Rouen University Hospital, Rouen, France (Drs. Breteau, Chanavaz-Lacheray, and Resch)
| | - Chrystele Rubod
- Department of Gynaecology, Hôpital Jeanne de Flandre, CHRU de Lille, Lille, France (Dr. Rubod)
| | - Mélusine Turck
- Department of Gynaecology and Obstetrics, Caen University Hospital, Caen, France (Dr. Turck)
| | - Sophie Sanguin
- Department of Gynaecology and Obstetrics, Amiens University Hospital, Amiens, France (Dr. Sanguin)
| | - Ionut Pop
- Department of Gynaecology and Obstetrics, Dieppe General Hospital, Dieppe, France (Dr. Pop)
| | - Benoit Resch
- Expert Center in the Diagnosis and Multidisciplinary Management of Endometriosis, Department of Obstetrics and Gynecology, Rouen University Hospital, Rouen, France (Drs. Breteau, Chanavaz-Lacheray, and Resch); Department of Gynaecological Surgery, Clinique Mathilde, Rouen, France (Dr. Resch)
| | - Horace Roman
- Endometriosis Centre, Clinique Tivoli-Ducos, Bordeaux, France (Dr. Roman); Department of Gynecology and Obstetrics, Aarhus University Hospital, Aarhus, Denmark (Dr. Roman).
| |
Collapse
|
5
|
Vercellini P, Viganò P, Frattaruolo MP, Borghi A, Somigliana E. Bowel surgery as a fertility-enhancing procedure in patients with colorectal endometriosis: methodological, pathogenic and ethical issues. Hum Reprod 2019; 33:1205-1211. [PMID: 29741687 DOI: 10.1093/humrep/dey104] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Accepted: 04/12/2018] [Indexed: 12/12/2022] Open
Abstract
Bowel surgery for colorectal endometriosis is being promoted to infertile women without severe sub-occlusive symptoms, with the objective of improving the likelihood of conception. Contrary to rectal shaving, bowel surgery involving full-thickness disk excision and segmental resection entails opening of the intestinal lumen thus increasing the risk of postoperative infectious complications. About 1 in 10 patients undergoing colorectal resection for intestinal endometriosis will experience severe sequelae, including anastomotic dehiscence, rectovaginal fistula formation, and bladder and bowel denervation. Similar to other surgical procedures aiming at enhancing fertility in women with endometriosis, bowel surgery has been introduced into clinical practice without adequate evaluation through randomized controlled trials. According to systematic literature reviews based mainly on case series, the incremental gain of adding bowel procedures to standard surgery appears uncertain in terms of pregnancy rate after both natural attempts and IVF. Considering the methodological drawbacks and the high risk of bias in the available observational studies, it is not possible to exclude the suggestion that the benefit of colorectal surgery has been overestimated. Given the risk of harms to women's health and the important ethical implications, less emphasis should be put on strict statistical significance and more emphasis should be placed on the magnitude of the effect size. In this regard, the published data may not be generalizable, as the surgeons publishing their results may not be representative of all surgeons. Until the results of adequately designed and conducted RCTs are available, colorectal surgery with the sole intent of improving the reproductive performance of infertile patients with intestinal endometriosis should be performed exclusively within research settings and by highly experienced surgeons. Women should be informed about the uncertainties regarding the harms and benefits of bowel surgery in different clinical conditions, and preoperative counselling must be conducted impartially with the objective of achieving a truly shared medical decision.
Collapse
Affiliation(s)
- Paolo Vercellini
- Gynaecological Surgery and Endometriosis Departmental Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, Via Commenda 12, Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Via Festa del Perdono 7, Milan, Italy
| | - Paola Viganò
- Reproductive Sciences Laboratory, Division of Genetics and Cell Biology, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, Milan, Italy
| | - Maria Pina Frattaruolo
- Gynaecological Surgery and Endometriosis Departmental Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, Via Commenda 12, Milan, Italy
| | - Alessandra Borghi
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Via Festa del Perdono 7, Milan, Italy
| | - Edgardo Somigliana
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Via Festa del Perdono 7, Milan, Italy.,Infertility Departmental Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Via Fanti 6, Milan, Italy
| |
Collapse
|
6
|
[The Rouen Expert center in the diagnosis and multidisciplinary management of endometriosis: A French pilot experiment]. ACTA ACUST UNITED AC 2018; 46:563-569. [PMID: 29937108 DOI: 10.1016/j.gofs.2018.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To retrospectively describe the activity of the Diagnosis and Multidisciplinary Management of Endometriosis Expert Center of Rouen-Normandy, before and after official identification by French Health Authorities. METHODS Retrospective study of the main activities of an Expert Center, from January 2013 to March 2018. RESULTS The Endometriosis Expert Center of Rouen-Normandy is a regional network, organised as a pyramid with a Referral Center at the top (the Rouen University Hospital) leading a network of public and private Expertise Centers below in Normandy. Ten to 11 Multidisciplinary Team meetings per year were organised, allowing the study of 15 to 20 cases by physicians coming from up to 17different places (hospital, clinic or private practice). 2066patients diagnosed with endometriosis were hospitalised in the Referral Center, among them 615were operated for colorectal endometriosis, among which 607by laparoscopy (97%). The surgical team was multidisciplinary in 444surgeries (72.2%). 50cycles of fertility preservation (oocyte freezing) were led. Research activity allowed the publication of 76scientific articles, among which 41 (53.9 %) in a journal of rank SIGAPS A or B. Medical training was organised for active health professionals as well as students, including school nurses. CONCLUSION The Endometriosis Expert Center of Rouen-Normandy pilot project has helped improving the diagnosis and better management of the disease in Normandy. This experiment could be exported to all the other regions of France, in order to unit health professionals with the aim of a national fight program against endometriosis.
Collapse
|
7
|
Abstract
Colorectal surgeons often participate in the multidisciplinary management of young females with endometriosis. Complications of endometriosis as well as its management often result in infertility since they can involve all pelvic organs including the procreative organs: uterus, ovaries and fallopian tubes. Complete excision of all endometriotic lesions should not be performed at the expense of irreversible destruction of the procreative organs; definitive infertility should not be the price to pay in order to obtain an improvement of the painful symptoms caused by endometriosis. Surgery for ovarian endometriomas should be specifically adapted to the patient's desire for future conception and to her preoperative ovarian reserve. Two main techniques are used to treat ovarian endometriomas: ovarian cystectomy excises the wall of the cyst while ablation consists of destruction of the internal surface of the cyst. The use of mono polar or biolar coagulation for cyst ablation is strongly contra-indicated. Ablation using laser or plasma energy has resulted in comparable rates of post-operative pregnancy to those obtained by ovarian cystectomy. Patients who wish to delay their attempt to conceive for some period of time, should be placed on long-term oral contraception with prevention of menstruation to reduce the risk of recurrent endometriosis. When surgery for colorectal endometriosis is necessary, the laparoscopic approach increases the chances of spontaneous conception compared to laparotomy. Surgery for deep-seated endometriosis has been accompanied by a high rate of spontaneous conception and successful pregnancy and does not seem to decrease the chances for conception by in vitro fertilization.
Collapse
Affiliation(s)
- H Roman
- Clinique gynécologique et obstétricale, centre expert de diagnostic et prise en charge multidisciplinaire de l'endométriose, CHU de Rouen, 1, rue de Germont, 76031 Rouen, France.
| |
Collapse
|