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Etrusco A, Chiantera V, Serra P, Stabile G, Margioula-Siarkou C, Della Corte L, Giampaolino P, Török P, Baldini GM, Ghezzi F, D'Amato A, Laganà AS. Impact of surgery on reproductive outcomes in women with deep endometriosis and proven presurgical infertility: Facts and controversies. Best Pract Res Clin Obstet Gynaecol 2024:102524. [PMID: 38910100 DOI: 10.1016/j.bpobgyn.2024.102524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Revised: 02/09/2024] [Accepted: 06/18/2024] [Indexed: 06/25/2024]
Abstract
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.
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Affiliation(s)
- Andrea Etrusco
- Unit of Obstetrics and Gynecology, "Paolo Giaccone" Hospital, 90127, Palermo, Italy; Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90127, Palermo, Italy.
| | - Vito Chiantera
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90127, Palermo, Italy; Unit of Gynecologic Oncology, National Cancer Institute - IRCCS - Fondazione "G. Pascale", 80131, Naples, Italy.
| | - Pietro Serra
- Unit of Obstetrics and Gynecology, "Paolo Giaccone" Hospital, 90127, Palermo, Italy; Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90127, Palermo, Italy.
| | - Guglielmo Stabile
- Department of Medical and Surgical Sciences, Institute of Obstetrics and Gynecology, University of Foggia, 71122, Foggia, Italy.
| | - Chrysoula Margioula-Siarkou
- 2(nd)Academic Department of Obstetrics and Gynecology, Hippokration General Hospital, Aristotle University of Thessaloniki, 54643, Thessaloníki, Greece.
| | - Luigi Della Corte
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, 80126, Naples, Italy.
| | - Pierluigi Giampaolino
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, 80126, Naples, Italy.
| | - Péter Török
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Debrecen, 4032, Debrecen, Hungary.
| | | | - Fabio Ghezzi
- Department of Obstetrics and Gynecology, Filippo Del Ponte Hospital, University of Insubria, 21100, Varese, Italy.
| | - Antonio D'Amato
- Department of Interdisciplinary Medicine (DIM), Unit of Obstetrics and Gynecology, University of Bari "Aldo Moro", Policlinico of Bari, Piazza Giulio Cesare 11, 70124, Bari, Italy.
| | - Antonio Simone Laganà
- Unit of Obstetrics and Gynecology, "Paolo Giaccone" Hospital, 90127, Palermo, Italy; Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90127, Palermo, Italy.
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Bourdon M, Peigné M, Maignien C, de Villardi de Montlaur D, Solignac C, Darné B, Languille S, Bendifallah S, Santulli P. Impact of Endometriosis Surgery on In Vitro Fertilization/Intracytoplasmic Sperm Injection Outcomes: a Systematic Review and Meta-analysis. Reprod Sci 2024; 31:1431-1455. [PMID: 38168857 DOI: 10.1007/s43032-023-01421-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 12/04/2023] [Indexed: 01/05/2024]
Abstract
Endometriosis-related infertility remains a therapeutic challenge. A burning issue in this field of research is determining whether pre-assisted reproductive technology (ART) surgery may be of some benefit in terms of reproductive outcomes. This systematic review and meta-analysis aimed at comparing ongoing pregnancy rates (OPR) and/or live birth rates (LBR) in patients who underwent endometriosis surgery before ART (IVF/ICSI) in comparison with patients who underwent first-line ART (IVF/ICSI). Searches were conducted from January 1990 to June 2021 on PubMed, Embase, and Cochrane Library using the following search terms: endometriosis, surgery, reproductive outcomes, and IVF/ICSI. The primary outcomes were OPR or LBR. A total of 19 studies were included in the meta-analysis. No statistically significant differences in LBR [0.91[0.63, 1.30]; I2 = 66%; n = 11], OPR [1.28[0.66, 2.49]; I2 = 60%; n = 3], and early pregnancy loss rate [0.88[0.62, 1.25]; I2 = 0%; n = 7] per cycle were found when comparing patients who underwent endometriosis surgery before IVF/ICSI and those who did not. After the exclusion of the studies with high risks of bias, the LBR per cycle was significantly reduced in the case of surgical treatment before IVF/ICSI [0.53[0.33, 0.86]; I2 = 30%; n = 4]. These data urge the clinician to carefully weigh the pros and cons before referring infertile patients with endometriosis to surgery before IVF, highlighting the key role of multidisciplinary referral centers.
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Affiliation(s)
- M Bourdon
- Department of Gynecology Obstetrics II and Reproductive Medicine (Professor Chapron), Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, Université de Paris Cité, Faculté de Santé, Paris, France
- Department 3I "Infection, Immunité Et Inflammation", Institut Cochin, INSERM U1016, Paris, France
| | - M Peigné
- Department of Reproductive Médecine and Fertility Preservation, AP-HP, Hopital Jean Verdier, Université Sorbonne Paris Nord, Faculté de Santé, Bondy, France
| | - C Maignien
- Department of Gynecology Obstetrics II and Reproductive Medicine (Professor Chapron), Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, Université de Paris Cité, Faculté de Santé, Paris, France
| | | | - C Solignac
- Gedeon Richter France, 75008, Paris, France
| | - B Darné
- Monitoring Force, 78600, Maisons-Laffitte, France
| | - S Languille
- Monitoring Force, 78600, Maisons-Laffitte, France
| | - S Bendifallah
- Department of Gynecology Obstetrics and Reproductive Medicine, AP-HP, Hôpital Tenon, Hôpitaux Universitaires Est Parisien, Faculté de Santé, Paris, France
| | - Pietro Santulli
- Department of Gynecology Obstetrics II and Reproductive Medicine (Professor Chapron), Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, Université de Paris Cité, Faculté de Santé, Paris, France.
- Department 3I "Infection, Immunité Et Inflammation", Institut Cochin, INSERM U1016, Paris, France.
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3
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Maignien C, Hachem RE, Bourdon M, Marcellin L, Chalas C, Patrat C, Gonzàlez-Foruria I, Chapron C, Santulli P. Oocyte donation outcomes in endometriosis patients with multiple IVF failures. Reprod Biomed Online 2023; 47:103236. [PMID: 37390602 DOI: 10.1016/j.rbmo.2023.05.008] [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: 05/05/2023] [Accepted: 05/17/2023] [Indexed: 07/02/2023]
Abstract
RESEARCH QUESTION What are the reproductive outcomes and the prognostic factors of live birth rates in patients with endometriosis referred to oocyte donation after multiple IVF failures? DESIGN Observational cohort study including all women with endometriosis-related infertility and two or more failed IVF/intracytoplasmic sperm injection (ICSI) cycles referred to oocyte donation between January 2013 and June 2022. Endometriosis was diagnosed based on published imaging criteria, and was confirmed histologically in women who had a history of surgery for endometriosis. The main outcome measured was the cumulative live birth rate (CLBR). The characteristics of women who had a live birth were compared with those who did not using univariate and multivariate analysis to identify determinant factors of fertility outcome. RESULTS Fifty-seven patients underwent 90 oocyte donation cycles after 244 failed autologous IVF cycles. The mean ± SD age of the population was 36.8 ± 3.3 years, with a mean duration of infertility of 3.6 ± 2.2 years, and a mean number of autologous IVF/ICSI cycles of 4.4 ± 2.3 cycles per patient. Three patients (5.3%) had superficial peritoneal endometriosis, two patients (3.5%) had ovarian endometriomas, and 52 patients (91.2%) had deep infiltrating endometriosis, among which 30 patients (57.7%) had bowel lesions. Thirty patients (52.6%) had associated adenomyosis. Overall, CLBR per patient was 36/57 (63.2%). After multivariate analysis, only being nulligravida (P=0.002) remained an independent negative predictive factor of the live birth rate. Previous surgery did not impact reproductive outcomes. CONCLUSION This study suggests that oocyte donation appears to be a viable option to optimize the live birth rate in women with endometriosis-related infertility and recurrent IVF failures.
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Affiliation(s)
- Chloé Maignien
- Université Paris Cité, Faculté de Santé, 12 Rue de l'Ecole de Médecine, 75006 Paris, France; Department of Gynaecology Obstetrics II and Reproductive Medicine, Assistance Publique-Hôpitaux de Paris, Hôpital Universitaire Paris Centre, Centre Hospitalier Universitaire Cochin, 123 Boulevard de Port Royal, 75014 Paris, France
| | - Rami El Hachem
- Université Paris Cité, Faculté de Santé, 12 Rue de l'Ecole de Médecine, 75006 Paris, France; Department of Gynaecology Obstetrics II and Reproductive Medicine, Assistance Publique-Hôpitaux de Paris, Hôpital Universitaire Paris Centre, Centre Hospitalier Universitaire Cochin, 123 Boulevard de Port Royal, 75014 Paris, France
| | - Mathilde Bourdon
- Université Paris Cité, Faculté de Santé, 12 Rue de l'Ecole de Médecine, 75006 Paris, France; Department of Gynaecology Obstetrics II and Reproductive Medicine, Assistance Publique-Hôpitaux de Paris, Hôpital Universitaire Paris Centre, Centre Hospitalier Universitaire Cochin, 123 Boulevard de Port Royal, 75014 Paris, France; Department of Development, Reproduction and Cancer, Cochin Institute, INSERM U1016, Paris, France
| | - Louis Marcellin
- Université Paris Cité, Faculté de Santé, 12 Rue de l'Ecole de Médecine, 75006 Paris, France; Department of Gynaecology Obstetrics II and Reproductive Medicine, Assistance Publique-Hôpitaux de Paris, Hôpital Universitaire Paris Centre, Centre Hospitalier Universitaire Cochin, 123 Boulevard de Port Royal, 75014 Paris, France; Department of Development, Reproduction and Cancer, Cochin Institute, INSERM U1016, Paris, France
| | - Céline Chalas
- Université Paris Cité, Faculté de Santé, 12 Rue de l'Ecole de Médecine, 75006 Paris, France; Department of Histology and Reproductive Biology, Assistance Publique-Hôpitaux de Paris, Hôpital Universitaire Paris Centre, Centre Hospitalier Universitaire Cochin, 123 Boulevard de Port Royal, 75014 Paris, France
| | - Catherine Patrat
- Université Paris Cité, Faculté de Santé, 12 Rue de l'Ecole de Médecine, 75006 Paris, France; Department of Histology and Reproductive Biology, Assistance Publique-Hôpitaux de Paris, Hôpital Universitaire Paris Centre, Centre Hospitalier Universitaire Cochin, 123 Boulevard de Port Royal, 75014 Paris, France
| | - Iñaki Gonzàlez-Foruria
- Department of Obstetrics, Gynaecology and Reproductive Medicine, Dexeus Mujer - Dexeus University Hospital, 08028 Barcelona, Spain; NatuVitro, Travessera de les Corts, 322, 08029 Barcelona, Spain
| | - Charles Chapron
- Université Paris Cité, Faculté de Santé, 12 Rue de l'Ecole de Médecine, 75006 Paris, France; Department of Gynaecology Obstetrics II and Reproductive Medicine, Assistance Publique-Hôpitaux de Paris, Hôpital Universitaire Paris Centre, Centre Hospitalier Universitaire Cochin, 123 Boulevard de Port Royal, 75014 Paris, France; Department of Development, Reproduction and Cancer, Cochin Institute, INSERM U1016, Paris, France
| | - Pietro Santulli
- Université Paris Cité, Faculté de Santé, 12 Rue de l'Ecole de Médecine, 75006 Paris, France; Department of Gynaecology Obstetrics II and Reproductive Medicine, Assistance Publique-Hôpitaux de Paris, Hôpital Universitaire Paris Centre, Centre Hospitalier Universitaire Cochin, 123 Boulevard de Port Royal, 75014 Paris, France; Department of Development, Reproduction and Cancer, Cochin Institute, INSERM U1016, Paris, France.
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Fertility Outcomes after Surgical Management of Colorectal Endometriosis: A Single-center Retrospective Study. J Minim Invasive Gynecol 2023; 30:230-239. [PMID: 36509394 DOI: 10.1016/j.jmig.2022.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 11/26/2022] [Accepted: 12/03/2022] [Indexed: 12/13/2022]
Abstract
STUDY OBJECTIVE To assess the pregnancy rate after surgery for colorectal endometriosis. DESIGN A retrospective, single-center study performed from January 2014 to December 2019. SETTING A university tertiary referral center. PATIENTS Patients with the intention to get pregnant younger than the age of 43 years, with or without a history of infertility and who were surgically managed for colorectal endometriosis. INTERVENTIONS Complete excision of deeply infiltrating endometriosis. MEASUREMENTS AND MAIN RESULTS The postoperative pregnancy rate was assessed. Seventy-seven patients had surgery; their mean age was 32.5 ± 4.4 years. Preoperative documented infertility was present in 77.9% of patients (n = 60). The mean length of history of infertility was 36.2 ± 24.9 months. The procedure was performed by laparoscopic surgery in 92.2% of patients (n = 71). Nonconservative, conservative, and mixed treatment were performed in 66.2% (n = 51), 29.9% (n = 23), and 3.9% of patients (n = 3), respectively. According to the Clavien-Dindo classification, the 3B complication rate was 6.5% (n = 5). The mean follow-up was 46.7 ± 20.6 months. Clinical pregnancies were defined by the presence of intrauterine pregnancy with an embryo with cardiac activity. The postoperative pregnancy rate was 62.3% (n = 48), and 54.2% (n = 26) were spontaneous. The mean number of pregnancies was 1.2 ± 0.4 per patient. In addition, 18.7% of patients (n = 9) got pregnant twice. The mean time from surgery to pregnancy was 13.8 ± 13.1 months. The live birth rate was 89.1% (n = 41). There were no significant differences concerning the prognostic criteria reported in the literature (antimüllerian hormone level, age, presence of adenomyosis). There were no predictive criteria for live births. CONCLUSION According to this study, surgery for colorectal endometriosis results in a high postoperative pregnancy rate. Studies with a high level of evidence are needed to determine good candidates for this type of surgery.
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Pavlovic ZJ, Vest AN, Imudia AN. Where Does the Reproductive Endocrinology and Infertility Subspecialist Fit in the Spectrum of Gynecologic Surgeries? J Gynecol Surg 2022. [DOI: 10.1089/gyn.2022.0006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Zoran Jason Pavlovic
- Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida Tampa, Florida, USA
| | - Adriana N. Vest
- Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida Tampa, Florida, USA
| | - Anthony N. Imudia
- Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida Tampa, Florida, USA
- Shady Grove Fertility Tampa Bay, Tampa, Florida, USA
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Zhang N, Sun S, Zheng Y, Yi X, Qiu J, Zhang X, Zhang Y, Hua K. Reproductive and postsurgical outcomes of infertile women with deep infiltrating endometriosis. BMC Womens Health 2022; 22:83. [PMID: 35313876 PMCID: PMC8939234 DOI: 10.1186/s12905-022-01666-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 03/15/2022] [Indexed: 11/18/2022] Open
Abstract
Background This study aimed to summarize and analyze clinical characteristics and reproductive outcomes in postoperative deep infiltrating endometriosis (DIE).
Methods This retrospective cohort study included 55 reproductive-aged patients who were diagnosed with DIE, wished to conceive and underwent resection surgery at the Obstetrics and Gynecology Hospital, Fudan University, from January 2009–June 2017. Those with any plausible infertility factor or abnormalities in the partner’s semen analysis were excluded. Patient characteristics, preoperative symptoms, infertility history, intraoperative findings and reproductive outcomes were followed up and recorded. Risk factors for reproductive outcomes were identified for women who became pregnant versus those who did not by univariate logistic regression. Additionally, pre- and postoperative endometriosis health profile questionnaire-30 (EHP-30), Knowles–Eccersley–Scott Symptom questionnaire (KESS), Cox Menstrual Symptom Scale (CMSS) and Female Sexual Function Index (FSFI) scores were used to evaluate the effect of DIE surgery on quality of life. Results The average age was 30.22 ± 3.62 years, with no difference between the pregnancy and nonpregnancy groups. The average follow-up time was 26.57 ± 14.51 months. There were 34 pregnancies (61.82%): 24 (70.59%) conceived spontaneously and 10 (29.41%) by in vitro fertilization (IVF). Twenty-eight patients (82.35%) had term deliveries. The interval between operation and pregnancy was 10.33 ± 5.6 (1–26) months. Univariate analysis showed that a lower endometriosis fertility index (EFI) score (EFI < 8) was a risk factor for infertility (OR: 3.17 (1.15–10.14), p = .044). For patients with incomplete surgery, postoperative gonadotropin-releasing hormone agonist (GnRHa) administration improved the pregnancy rate (p < 0.05). Regarding quality of life, there was significant improvement (p < 0.05) in the postoperative EHP-30, KESS and CMSS scores compared with preoperative scores in both groups. Although there was no obvious difference in FSFI scores, significant improvement in dyspareunia was observed (p < 0.05). Conclusions Overall, the postoperative pregnancy rate of DIE patients was 61.82%. Surgical management of DIE for patients with complaints of pain and with pregnancy intentions was feasible and effective. Long-term expectant treatment should not be advised for patients with lower EFI scores (EFI < 8), and postoperative IVF–ET may be a good choice. More cases should be enrolled for further study, and randomized studies are required.
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Affiliation(s)
- Ning Zhang
- Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University, 128 Shenyang Road, Shanghai, 200090, China.,Shanghai Key Laboratory of Female Reproductive Endocrine Related Disease, 413 Zhaozhou Road, Shanghai, China
| | - Shugen Sun
- Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University, 128 Shenyang Road, Shanghai, 200090, China.,Shanghai Key Laboratory of Female Reproductive Endocrine Related Disease, 413 Zhaozhou Road, Shanghai, China
| | - Yunxi Zheng
- Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University, 128 Shenyang Road, Shanghai, 200090, China.,Shanghai Key Laboratory of Female Reproductive Endocrine Related Disease, 413 Zhaozhou Road, Shanghai, China
| | - Xiaofang Yi
- Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University, 128 Shenyang Road, Shanghai, 200090, China.,Shanghai Key Laboratory of Female Reproductive Endocrine Related Disease, 413 Zhaozhou Road, Shanghai, China
| | - Junjun Qiu
- Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University, 128 Shenyang Road, Shanghai, 200090, China.,Shanghai Key Laboratory of Female Reproductive Endocrine Related Disease, 413 Zhaozhou Road, Shanghai, China
| | - Xiaodan Zhang
- Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University, 128 Shenyang Road, Shanghai, 200090, China.,Shanghai Key Laboratory of Female Reproductive Endocrine Related Disease, 413 Zhaozhou Road, Shanghai, China
| | - Ying Zhang
- Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University, 128 Shenyang Road, Shanghai, 200090, China. .,Shanghai Key Laboratory of Female Reproductive Endocrine Related Disease, 413 Zhaozhou Road, Shanghai, China.
| | - Keqin Hua
- Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University, 128 Shenyang Road, Shanghai, 200090, China. .,Shanghai Key Laboratory of Female Reproductive Endocrine Related Disease, 413 Zhaozhou Road, Shanghai, China.
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Becker CM, Bokor A, Heikinheimo O, Horne A, Jansen F, Kiesel L, King K, Kvaskoff M, Nap A, Petersen K, Saridogan E, Tomassetti C, van Hanegem N, Vulliemoz N, Vermeulen N. ESHRE guideline: endometriosis. Hum Reprod Open 2022; 2022:hoac009. [PMID: 35350465 PMCID: PMC8951218 DOI: 10.1093/hropen/hoac009] [Citation(s) in RCA: 371] [Impact Index Per Article: 185.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Indexed: 12/14/2022] Open
Abstract
STUDY QUESTION How should endometriosis be diagnosed and managed based on the best available evidence from published literature? SUMMARY ANSWER The current guideline provides 109 recommendations on diagnosis, treatments for pain and infertility, management of disease recurrence, asymptomatic or extrapelvic disease, endometriosis in adolescents and postmenopausal women, prevention and the association with cancer. WHAT IS KNOWN ALREADY Endometriosis is a chronic condition with a plethora of presentations in terms of not only the occurrence of lesions, but also the presence of signs and symptoms. The most important symptoms include pain and infertility. STUDY DESIGN SIZE DURATION The guideline was developed according to the structured methodology for development of ESHRE guidelines. After formulation of key questions by a group of experts, literature searches and assessments were performed. Papers published up to 1 December 2020 and written in English were included in the literature review. PARTICIPANTS/MATERIALS SETTING METHODS Based on the collected evidence, recommendations were formulated and discussed within specialist subgroups and then presented to the core guideline development group (GDG) until consensus was reached. A stakeholder review was organized after finalization of the draft. The final version was approved by the GDG and the ESHRE Executive Committee. MAIN RESULTS AND THE ROLE OF CHANCE This guideline aims to help clinicians to apply best care for women with endometriosis. Although studies mostly focus on women of reproductive age, the guideline also addresses endometriosis in adolescents and postmenopausal women. The guideline outlines the diagnostic process for endometriosis, which challenges laparoscopy and histology as gold standard diagnostic tests. The options for treatment of endometriosis-associated pain symptoms include analgesics, medical treatments and surgery. Non-pharmacological treatments are also discussed. For management of endometriosis-associated infertility, surgical treatment and/or medically assisted reproduction are feasible. While most of the more recent studies confirm previous ESHRE recommendations, there are five topics in which significant changes to recommendations were required and changes in clinical practice are to be expected. LIMITATIONS REASONS FOR CAUTION The guideline describes different management options but, based on existing evidence, no firm recommendations could be formulated on the most appropriate treatments. Also, for specific clinical issues, such as asymptomatic endometriosis or extrapelvic endometriosis, the evidence is too scarce to make evidence-based recommendations. WIDER IMPLICATIONS OF THE FINDINGS The guideline provides clinicians with clear advice on best practice in endometriosis care, based on the best evidence currently available. In addition, a list of research recommendations is provided to stimulate further studies in endometriosis. STUDY FUNDING/COMPETING INTERESTS The guideline was developed and funded by ESHRE, covering expenses associated with the guideline meetings, with the literature searches and with the dissemination of the guideline. The guideline group members did not receive payments. C.M.B. reports grants from Bayer Healthcare and the European Commission; Participation on a Data Safety Monitoring Board or Advisory Board with ObsEva (Data Safety Monitoring Group) and Myovant (Scientific Advisory Group). A.B. reports grants from FEMaLE executive board member and European Commission Horizon 2020 grant; consulting fees from Ethicon Endo Surgery, Medtronic; honoraria for lectures from Ethicon; and support for meeting attendance from Gedeon Richter; A.H. reports grants from MRC, NIHR, CSO, Roche Diagnostics, Astra Zeneca, Ferring; Consulting fees from Roche Diagnostics, Nordic Pharma, Chugai and Benevolent Al Bio Limited all paid to the institution; a pending patent on Serum endometriosis biomarker; he is also Chair of TSC for STOP-OHSS and CERM trials. O.H. reports consulting fees and speaker's fees from Gedeon Richter and Bayer AG; support for attending meetings from Gedeon-Richter, and leadership roles at the Finnish Society for Obstetrics and Gynecology and the Nordic federation of the societies of obstetrics and gynecology. L.K. reports consulting fees from Gedeon Richter, AstraZeneca, Novartis, Dr KADE/Besins, Palleos Healthcare, Roche, Mithra; honoraria for lectures from Gedeon Richter, AstraZeneca, Novartis, Dr KADE/Besins, Palleos Healthcare, Roche, Mithra; support for attending meetings from Gedeon Richter, AstraZeneca, Novartis, Dr KADE/Besins, Palleos Healthcare, Roche, Mithra; he also has a leadership role in the German Society of Gynecological Endocrinology (DGGEF). M.K. reports grants from French Foundation for Medical Research (FRM), Australian Ministry of Health, Medical Research Future Fund and French National Cancer Institute; support for meeting attendance from European Society for Gynaecological Endoscopy (ESGE), European Congress on Endometriosis (EEC) and ESHRE; She is an advisory Board Member, FEMaLe Project (Finding Endometriosis Using Machine Learning), Scientific Committee Chair for the French Foundation for Research on Endometriosis and Scientific Committee Chair for the ComPaRe-Endometriosis cohort. A.N. reports grants from Merck SA and Ferring; speaker fees from Merck SA and Ferring; support for meeting attendance from Merck SA; Participation on a Data Safety Monitoring Board or Advisory Board with Nordic Pharma and Merck SA; she also is a board member of medical advisory board, Endometriosis Society, the Netherlands (patients advocacy group) and an executive board member of the World Endometriosis Society. E.S. reports grants from National Institute for Health Research UK, Rosetrees Trust, Barts and the London Charity; Royalties from De Gruyter (book editor); consulting fees from Hologic; speakers fees from Hologic, Johnson & Johnson, Medtronic, Intuitive, Olympus and Karl Storz; Participation in the Medicines for Women's Health Expert Advisory Group with Medicines and Healthcare Products Regulatory Agency (MHRA); he is also Ambassador for the World Endometriosis Society. C.T. reports grants from Merck SA; Consulting fees from Gedeon Richter, Nordic Pharma and Merck SA; speaker fees from Merck SA, all paid to the institution; and support for meeting attendance from Ferring, Gedeon Richter and Merck SA. The other authors have no conflicts of interest to declare. DISCLAIMER This guideline represents the views of ESHRE, which were achieved after careful consideration of the scientific evidence available at the time of preparation. In the absence of scientific evidence on certain aspects, a consensus between the relevant ESHRE stakeholders has been obtained. Adherence to these clinical practice guidelines does not guarantee a successful or specific outcome, nor does it establish a standard of care. Clinical practice guidelines do not replace the need for application of clinical judgement to each individual presentation, nor variations based on locality and facility type. ESHRE makes no warranty, express or implied, regarding the clinical practice guidelines and specifically excludes any warranties of merchantability and fitness for a particular use or purpose (Full disclaimer available at www.eshre.eu/guidelines.).
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Affiliation(s)
- Christian M Becker
- Nuffield Department of Women’s and Reproductive Health, Endometriosis CaRe
Centre, University of Oxford, Oxford, UK
| | - Attila Bokor
- Department of Obstetrics and Gynecology, Semmelweis University,
Budapest, Hungary
| | - Oskari Heikinheimo
- Department of Obstetrics & Gynecology, University of Helsinki and Helsinki
University Hospital, Helsinki, Finland
| | - Andrew Horne
- EXPPECT Centre for Endometriosis and Pelvic Pain, MRC Centre for Reproductive
Health, University of Edinburgh, Edinburgh, UK
| | - Femke Jansen
- EndoHome—Endometriosis Association Belgium, Belgium
| | - Ludwig Kiesel
- Department of Gynecology and Obstetrics, University Hospital
Muenster, Muenster, Germany
| | | | - Marina Kvaskoff
- Paris-Saclay University, UVSQ, Univ. Paris-Sud, Inserm, Gustave Roussy,
“Exposome and Heredity” Team, CESP, Villejuif, France
| | - Annemiek Nap
- Department of Gynaecology and Obstetrics, Radboudumc, Nijmegen,
The Netherlands
| | | | - Ertan Saridogan
- Department of Obstetrics and Gynaecology, University College London
Hospital, London, UK
- Elizabeth Garrett Anderson Institute for Women’s Health, University College
London, London, UK
| | - Carla Tomassetti
- Department of Obstetrics and Gynaecology, Leuven University Fertility Center,
University Hospitals Leuven, Leuven, Belgium
- Faculty of Medicine, Department of Development and Regeneration, LEERM (Lab of
Endometrium, Endometriosis and Reproductive Medicine), KU Leuven, Leuven,
Belgium
| | - Nehalennia van Hanegem
- Department of Reproductive Medicine and Gynecology, University Medical Center
Utrecht, Utrecht, The Netherlands
| | - Nicolas Vulliemoz
- Department of Woman Mother Child, Fertility Medicine and Gynaecological
Endocrinology, Lausanne University Hospital, Lausanne, Switzerland
| | - Nathalie Vermeulen
- European Society of Human Reproduction and Embryology,
Strombeek-Bever, Belgium
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8
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Donnez O. Conservative Management of Rectovaginal Deep Endometriosis: Shaving Should Be Considered as the Primary Surgical Approach in a High Majority of Cases. J Clin Med 2021; 10:5183. [PMID: 34768704 PMCID: PMC8584847 DOI: 10.3390/jcm10215183] [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: 10/10/2021] [Revised: 10/29/2021] [Accepted: 11/03/2021] [Indexed: 12/12/2022] Open
Abstract
Deep endometriosis infiltrating the rectum remains a challenging situation to manage, and it is even more important when ureters and pelvic nerves are also infiltrated. Removal of deep rectovaginal endometriosis is mandatory in case of symptoms strongly impairing quality of life, alteration of digestive, urinary, sexual and reproductive functions, or in case of growing. Extensive preoperative imaging is required to choose the right technique between laparoscopic shaving, disc excision, or rectal resection. When performed by skilled surgeons and well-trained teams, a very high majority of cases of deep endometriosis nodule (>95%) is feasible by the shaving technique, and this is associated with lower complication rates regarding rectal resection. In most cases, removing a part of the rectum is questionable according to the risk of complications, and the rectum should be preserved as far as possible. Shaving and rectal resection are comparable in terms of recurrence rates. As shaving is manageable whatever the size of the lesions, surgeons should consider rectal shaving as first-line surgery to remove rectal deep endometriosis. Rectal stenosis of more than 80% of the lumen, multiple bowel deep endometriosis nodules, and stenotic sigmoid colon lesions should be considered as indication for rectal resection, but this represents a minority of cases.
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Affiliation(s)
- Olivier Donnez
- Institut du Sein et de Chirurgie Gynécologique d'Avignon, Polyclinique Urbain V (Elsan Group), 95 Chemin du Pont des 2 Eaux, 84000 Avignon, France
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9
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Benaglia L, Mensi L, DI Gesaro L, Somigliana E. Safety of in-vitro fertilization in women with endometriosis. Minerva Obstet Gynecol 2021; 73:333-340. [PMID: 34008387 DOI: 10.23736/s2724-606x.21.04711-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Management of women with endometriosis in general is complex. It requires a multidisciplinary and tailored approach. The time of in-vitro fertilization (IVF) may be particularly complicated because women with the disease face peculiar additional risks. In particular, oocytes retrieval may be more difficult and women with endometriomas are exposed to a low but consistent risk of infection and ovarian abscess development. There are also concerns regarding progression of deep invasive peritoneal lesions and misdiagnosis of an occult early ovarian cancer. However, evidence on these latter points is more controversial. Taken together, this body evidence is generally reassuring and does not justify prophylactic surgery prior to IVF to shrink these risks. However, given the uncertainties, women with endometriosis must be informed in depth of these peculiar additional risks.
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Affiliation(s)
- Laura Benaglia
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy -
| | - Laura Mensi
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,University of Milan, Milan, Italy
| | - Luca DI Gesaro
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,University of Milan, Milan, Italy
| | - Edgardo Somigliana
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,University of Milan, Milan, Italy
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10
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Moawad GN, Klebanoff JS, Habib N, Bendifallah S. Colorectal endometriosis: ample data without definitive recommendations. Facts Views Vis Obgyn 2021; 13:3-7. [PMID: 33889855 PMCID: PMC8051188 DOI: 10.52054/fvvo.13.1.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The preoperative work-up and optimal surgical approach to colorectal endometriosis is a highly studied topic lacking definitive recommendations. Synthesis of the available data can be extremely challenging for surgeons due to the heterogeneity of existing comparisons, a variety of studied surgical outcomes, and a predominant focus on operative complications. While these considerations are extremely important for surgeons performing such complex gynaecologic surgery there is still much to be desired with regards to evidence based guidelines for the preoperative assessment and surgical technique for colorectal endometriosis. Having an established guideline stating in which clinical situations endometriosis surgeons should performing rectovaginal shaving, versus discoid excision, versus segmental resection would be extremely important for all pelvic surgeons, even those operating in high-volume centres dedicated to the surgical management of complex endometriosis. This perspective highlights the shortcomings of the available data and attempts to create an algorithm surgeons can follow when performing surgery for colorectal endometriosis. This algorithm is based on our expert opinion after synthesising available data.
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Affiliation(s)
- G N Moawad
- Department of Obstetrics and Gynecology, The George Washington University, Washington, DC.,The Center for Endometriosis and Advanced Pelvic Surgery, Washington, DC
| | - J S Klebanoff
- Department of Obstetrics and Gynecology, Main Line Health, Wynewood, PA
| | - N Habib
- Department of Obstetrics and Gynecology, Francois Quesnay Hospital, Mantes-la-Jolie, France
| | - S Bendifallah
- Department of Gynaecology and Obstetrics, Tenon University Hospital, Assistance Publique des Hopitaux de Paris (AP-HP), Sorbonne University, France
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