Postoperative danazol therapy in infertility patients with severe endometriosis**Presented at the Thirty-Seventh Annual Meeting of the American Fertility Society, Atlanta Hilton, March 14 to 18, 1981, Atlanta, Georgia

Endometriosis: preoperative and postoperative medical treatment

The quality of the evidence that supports the use of medical treatment before conservative surgery for endometriosis is manifestly poor, and no recommendations can be made based on the results of the published studies. There are practical advantages inherent to this schedule, but whether this translates into better conception rates and reduced pain recurrence rates is unproven. The effect of drug therapy after surgery can be assessed better as data from seven true randomized, controlled trials are available. The results of the current review do not support the notion that suppressing ovarian activity postoperatively increases the long-term pregnancy rate. As far as pelvic pain is concerned, more data are needed to verify the reduced symptoms recurrence rate found in four trials in women who were allocated to postoperative medical therapy, particularly in view of the different results obtained in some of the considered studies. The observed differences among various drugs used before or after surgery are limited in clinical terms and, in the absence of formal randomized comparisons, are difficult to interpret. Because of their tolerable side effects and limited cost, progestins with or without estrogens should be considered strongly as first-line postoperative medical treatment if and when suppression of ovulation after conservative surgery is deemed opportune.

A gonadotrophin-releasing hormone agonist compared with expectant management after conservative surgery for symptomatic endometriosis

OBJECTIVE

To ascertain whether the frequency of pelvic pain recurrence is reduced and time to symptoms recurrence is prolonged in women with symptomatic endometriosis undergoing conservative surgery and post-operative hormonal therapy compared with women treated with surgery only. Pregnancy rates and time to conception in women wanting children were also evaluated.

DESIGN

A multicentre, prospective, randomised controlled study.

SETTING

Nineteen Italian academic departments and teaching hospitals specialising in reparative and reconstructive surgery.

POPULATION

A total of 269 women undergoing conservative surgery for mild to severe symptomatic endometriosis.

METHODS

After surgery the women were assigned to treatment with subcutaneous goserelin depot injections for six months or to expectant management. Dysmenorrhoea, deep dyspareunia, nonmenstrual pain and general discomfort were graded according to a verbal rating scale from 0 (absent) to 3 (severe) and the scores summed to give a total symptoms score. Only patients with at least one preoperative moderate or severe symptom were enrolled. The women were evaluated regularly for two years.

MAIN OUTCOME MEASURES

Post-operative pain recurrences (total symptoms scores > or = 5), time to recurrence, pregnancy rates and time to conception in the two study groups.

RESULTS

At one- and two-year follow up visits, 14/107 (13.1%) and 19/81 (23.5%) patients had moderate or severe symptoms recurrence in the goserelin group compared with, respectively, 22/103 (21.4%) and 27/74 (36.5%) in the expectant management group (P = 0.143 at 1 year and 0.082 at 2 years). Time to symptoms recurrence was significantly longer in the goserelin group according to survival analysis (Wilcoxon test, P = 0.041). Among women wanting children, few conceptions occurred in both the goserelin (8/69, 11.6%) and the expectant management group (14/76, 18.4%). There was no significant difference at survival analysis (Wilcoxon test, P = 0.427).

CONCLUSION

Post-operative treatment with goserelin significantly prolonged the pain-free interval after conservative surgery for symptomatic endometriosis and did not influence reproductive prognosis.

Correlation of fecundability and serum estradiol after danazol treatment in patients with advanced endometriosis

OBJECTIVE

To examine the relationship between pregnancy incidence and the level of serum E2 during danazol therapy.

DESIGN

Danazol was given by 200 mg four times daily for 3 months. Serum E2 level was checked after completing the therapy, but before stopping medication. Patients then were advised to conceive at the appropriate time over a 6-month period.

SETTING

Reproductive and Endocrine Laboratory of the Department of Obstetrics and Gynecology, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan.

PATIENTS

Infertile women with invasive endometriosis receiving conservative surgery and danazol treatment.

INTERVENTIONS

Serum E2 is checked before medication and at the end of danazol therapy, but before stopping medication.

MAIN OUTCOME MEASURES

Whether pregnancy is related to the change of serum E2 caused by danazol therapy.

RESULTS

There were 24 pregnancies in 38 patients with invasive endometriosis after treatment. Pregnant patients had significantly lower serum E2 levels as compared with the nonpregnant patients.

CONCLUSIONS

After conservative surgery for invasive endometriosis associated with infertility, the therapeutic period of danazol treatment could be shortened to 3 months. Because there is significant correlation of fecundability and serum E2 after danazol medication, serum E2 could be a guideline for predicting pregnancy or for prolonging or changing of treatment after danazol therapy.

Management of stage III and IV endometriosis: a 10-year experience

A retrospective analysis is reported of the management of 117 cases of infertility associated with Stage III and IV endometriosis. Combined medico-microsurgical treatment was selected in 75.3% of Stage III cases and in 83.3% of those on Stage IV. Medication consisted of medroxyprogesterone acetate in 26 patients and danazol in the remaining 64. Microsurgery alone was utilized in 24.7% of Stage III patients and in 16.6% of those on Stage IV. Both surgery alone and the combined therapy had a profound positive effect on subjective symptoms: dysmenorrhea, dyspareunia and pelvic pain. Following combined therapy, pregnancy was achieved in 34.4% of all women. Respective figures are 30.7% for medroxyprogesterone acetate (29.4% Stage III and 33.3% Stage IV) and 35.9% for danazol (37.7% Stage III and 27.2% Stage IV). In the group of patients treated by surgery alone, pregnancy occurred in 25.9%. Of the pregnancies in women with Stage III endometriosis, 25 were carried to term and 6 ended with a spontaneous abortion; figures for Stage IV women are 5 and 2, respectively. Second-look laparoscopy was performed in 49 of the 79 patients who failed to conceive, at 12-36 months after treatment; persistent genital pathology, to which infertility could be attributed, was found in 77.5% of them.

Endometriosis and infertility

The relationship of endometriosis, the most common benign gynaecological disease during reproductive life, to infertility is generally ill understood. The association between infertility and minimal to mild endometriosis, when no anatomical defect is evident, may be explained by the following possible mechanisms: alternations in peritoneal fluid (macrophages - immunoglobulins, Interleukin-1, protease inhibitors, prostanoids, an ovum capture inhibitor), ovulatory dysfunctions (anovulation, LUF syndrome), luteal phase defect, disturbed implantation, and spontaneous abortion. These possibilities are discussed. The latest prospective controlled studies offer strong evidence that endometriosis per se is not a direct cause of infertility. On the other hand, the disease usually deteriorates if not treated, and therefore medical or surgical interventions are often needed when expectant treatment or other infertility therapies, e.g., ovulation induction, fail to result in pregnancy. Women with minimal to mild endometriosis only should be diagnosed as having unexplained infertility, which today may be treated by in vitro fertilization.

Surgical treatment of symptomatic colorectal endometriosis

The approach to the treatment of bowel endometriosis has varied greatly. In this paper we present 77 consecutive patients with deep colorectal endometriosis treated with a full-thickness resection. Gynecologic procedures included conservative laparotomies for preserving fertility (39 patients); hysterectomy with bilateral salpingo-oophorectomy (29 patients); bilateral salpingo-oophorectomy (2 patients); left salpingo-oophorectomy (1 patient) and resection of pelvic endometriosis in patients with previous ablative surgery (6 patients). A low anterior bowel resection was performed in 68 patients (88.3%); a disc excision of the anterior rectal wall in 5 (6.5%); sigmoid resection in 3 (3.9%), and partial cecal resection in 1 (1.3%). The postoperative febrile morbidity was 10.4%, with no apparent anastomotic leaks. Of 33 patients who attempted to conceive postoperatively, 13 achieved a term pregnancy (39.4%). Complete relief of pelvic symptoms was obtained in 38 patients (49.4%); improvement in 30 (39%); no improvement in 8 (10.4%); and worsening of symptoms in 1 (1.2%). There has been no recurrence of symptomatic bowel endometriosis during 1 to 9 years of follow-up. Full-thickness resection of the colon for the treatment of deep bowel endometriosis is a safe procedure with low morbidity, good postoperative relief of symptoms, and favorable pregnancy rates.

Danazol and medroxyprogesterone acetate inefficacious in the treatment of infertility in endometriosis

Danazol (200 mg three times a day) and medroxyprogesterone acetate (MPA, 100 mg a day) were compared with placebo in the treatment of infertility of patients with endometriosis. Twenty-seven patients had medical therapy alone for 6 months, and 22 patients received it after conservative surgery. The clinical characteristics of the patients in the danazol group (n = 18), the MPA group (n = 17), and the placebo group (n = 14) were comparable to each other. The follow-up time was 30 months. The cumulative pregnancy rates, 33% in the danazol group (n = 6), 42% in the MPA group (n = 7), and 46% in the placebo group (n = 6), did not differ significantly from each other. The time to pregnancy after the start of therapy was 17.7 +/- 8.4 (standard deviation [SD]) months in the danazol group, 18.0 +/- 9.0 months in the MPA group and 10.0 +/- 5.8 months in the placebo group with no significant difference between the groups. The abortion rate was 26%, and there was no significant difference among the groups. Cox multivariant analysis did reveal ovarian endometriosis a prognostically significant negative indicator as regards fecundation in endometriosis (P less than 0.05). In summary, correction of infertility alone does not appear to be an indication for the use of danazol or MPA in the treatment of endometriosis, and ovarian endometriotic lesions but not peritoneal ones do make a worse prognosis as regards fecundation in endometriosis.

Placebo-controlled comparison of danazol and high-dose medroxyprogesterone acetate in the treatment of endometriosis after conservative surgery

To evaluate the clinical value of postoperative hormone therapy in endometriosis, 60 patients with advanced disease were randomized to receive in a double-blind study danazol (200 mg, 3 times daily), medroxyprogesterone acetate (MPA) (100 mg daily) or placebo post-operatively for 6 months. Treatment efficacy was evaluated clinically and at laparoscopy 6 months after medication. In relation to placebo, danazol and high-dose MPA treatments, which did not differ from each other in efficacy, significantly alleviated pelvic pain. In addition, the peritoneal endometriosis lesions found at 6-months laparoscopy were significantly smaller in the MPA and danazol groups than in the placebo group. Breakthrough bleeding, weight gain and acne complicated danazol treatment but only breakthrough bleeding complicated MPA treatment. These data suggest that postoperative treatment of advanced endometriosis with high-dose MPA or danazol is clinically beneficial.

Ovarian surgery in an infertility patient as an indication for a short-interval second-look laparoscopy: a preliminary study

The usefulness of a short-interval second-look laparoscopy (SLL) after ovarian surgery was examined. In 23 infertile women who had either bilateral wedge resection (BWR) of polycystic ovaries, an oophorocystectomy (OC), or resection of endometriomata (RE), adhesions were graded before and after surgery and before and after laparoscopic lysis for each ovary. At SLL, periovarian adhesions involving at least one ovary were observed in all women. Of the 22 women who wanted to become pregnant, 3 of 3 with BWR, 1 of 3 with OC, and 6 of 16 with RE conceived. In the women with residual adhesive disease in both or the only remaining adnexa after SLL, there were no pregnancies; whereas 67% of the women with at least one adnexa free of disease became pregnant (P = 0.005). This preliminary study indicates that ovarian surgery does result in significant adhesion formation and that SLL offers an opportunity to reassess the pelvis, to lyse adhesions, and to establish a postoperative prognosis.

Endometriosis: a reappraisal of pathogenesis and treatment

The enigmatic disease of endometriosis continues to baffle both the scientist and the clinician. An encompassing theory of pathogenesis has failed to emerge from contemporary understanding of the immunologic manifestations, the hormonal aberrations, or the evasive infertility associated with endometriosis. Similarly unsettling is the failure of medical or conservative surgical maneuvers to eradicate endometriosis in a manner commensurate with castration. It is hoped that further insight into these areas of research will resolve both of these dilemmas.

Recurrent endometriosis: incidence, management, and prognosis

The rate of recurrence of endometriosis after treatment has varied from 2% to 47% in published reports. In order to determine whether a meaningful prognosis for recurrence can be rendered, 423 patients treated with conservative surgical procedures from 1967 to 1982 were followed as outpatients. From among these, 62 patients underwent reoperation. Annual rates of recurrence based on findings at reoperation ranged from 0.9% in the first postoperative year to 13.6% in the eighth postoperative year. The cumulative 3- and 5-year recurrence rates were 13.5% and 40.3%, respectively. Severity of disease was not predictive of recurrence. Pregnancy did not preclude, but did delay, recurrence. Forty-seven percent of infertile patients with recurrent endometriosis conceived after a second conservative operation. Of 20 patients who had a second conservative operation for endometriosis, 20% required a third laparotomy. This is the first study of postoperative recurrent endometriosis to utilize a control group and the first to report annual rates of recurrence and reoperation.

Interim report a study of danazol for the treatment of endometriosis

Ninety-six infertile women with laparoscopically confirmed endometriosis received danazol (800 mg daily) for 6 months. Despite their prevalence, side effects generally were tolerable and did not contraindicate use of the drug. The mean resolution of peritoneal endometriosis, measured in 44 patients, was 63%. However, individual responses varied considerably. The mean resolution of ovarian endometriosis in 28 patients was 45%. Resolution of less than 1 cm involvement (57%) was similar to that of peritoneal endometriosis, but for more extensive ovarian disease it was only 37% to 40%. Preoperative use of danazol facilitated surgical removal of disease and probably reduced the risk of postoperative adhesions. Pregnancy rates, though reported, are not analyzed because of the brevity of follow-up to date.