Laparoscopic evaluation of infertile patients with chronic pelvic pain

An Overview of Postoperative Intraabdominal Adhesions and Their Role on Female Infertility: A Narrative Review

Postoperative intraabdominal adhesions can occur after more than 90% of gynecologic surgeries. They not only cause chronic pelvic pain and small bowel obstruction, but are also one of the main reasons for infertility. Adhesions are not only a burden for the affected patients, but are also a burden for the healthcare system, since the treatment of adhesion-associated complications costs a considerable amount of money. The gold standard for the diagnosis of adhesions is by laparoscopy, although other methods, such as transvaginal hydro-laparoscopy, are being discussed as better alternatives. Ideally, adhesions are avoided inherently, by operating carefully and by using microsurgical principles. If this is not possible, gel barriers have been shown to be successful in reducing postoperative adhesions.

Negative laparoscopy unveiled

Introduction:

Studies indicate a variable proportion of laparoscopies done for the management of non-acute pelvic pain that do not identify visible pathology and are called negative laparoscopies. Possible explanations have included undetected endometriosis, observer error, and/or neural tissues in the endometrium acting as nociceptive input. The goal was to compare demographic and pain testing measures between women with negative laparoscopies and confirmed endometriosis in a cohort of women presenting with chronic pelvic pain.

Methods:

Women with chronic pelvic pain (n = 255) provided written consent for the study prior to entry. Data were collected at the time of clinic visit and entered contemporaneously into SPSS. Pain sensitization was identified as the presence of cutaneous allodynia. Clinical, pain, and pain sensitization variables were compared using Student’s t-test.

Results:

The frequency of negative laparoscopy was 13.7% (35 cases) and that of confirmed endometriosis was 27.1% (69 cases). There were no differences between women with a negative laparoscopy and women with confirmed endometriosis in clinical, dysmenorrhea, or pain testing measurements.

Conclusion:

The data suggest in the absence of endometriotic tissue in the pelvis, chronic visceral pain may result from a uterine origin and result in a generalized pattern of pain and pain sensitization.

Noninvasive diagnostic tools for pelvic congestion syndrome: a systematic review

Introduction

In the work‐up of patients with suspected pelvic congestion syndrome, venography is currently the gold standard. Yet if non‐invasive diagnostic tools are found to be accurate, invasive venography might no longer be indicated as necessary.

Material and methods

A literature search in Pubmed and EMBASE was performed from inception until 6 May 2017. Studies comparing non‐invasive diagnostic tools to a reference standard in the work‐up of patients with (suspected) pelvic congestion syndrome were included. Relevant data were extracted and methodological quality of individual included studies was assessed by the Quality Assessment of Diagnostic Accuracy Studies (QUADAS‐2) tool.

Results

Nine studies matched our inclusion criteria. Six studies compared ultrasonography to venography and three studies described a magnetic resonance imaging technique. In using transvaginal ultrasonography, the occurrence of a vein greater than five mm crossing the uterine body had a specificity of 91% (95% CI; 77–98%) and occurrence of pelvic varicoceles a sensitivity and specificity of 100% (95% CI; 89–100%) and 83–100% (95% CI; 66–93%), respectively. In transabdominal ultrasonography, reversed caudal flow in the ovarian vein accounted for a sensitivity of 100% (95% CI; 84–100%). Detection of pelvic congestion syndrome with magnetic resonance imaging techniques resulted in a sensitivity varying from 88 to 100%.

Conclusions

The sensitivity of ultrasonography and magnetic resonance imaging seem to be adequate, which indicates a role for both tests in an early stage of the diagnostic workup. However, due to methodological flaws and diversity in outcome parameters, more high standard research is necessary to establish a clear advice for clinical practice.

Stages of endometriosis: does it affect in vitro fertilization outcome

OBJECTIVE

Women with endometriosis often need in vitro fertilization (IVF) to conceive. There are conflicting data on the results of IVF in patients with endometriosis. The present study was undertaken to investigate whether or not the stage of endometriosis affects the IVF outcome in order to give the best patient counseling

MATERIALS AND METHODS

We compared IVF outcome measures between 40 patients with surgically confirmed minimal and mild endometriosis (American Society for Reproductive Medicine Stage I/II) and 38 patients with moderate and severe endometriosis (Stage III/IV). Each group was also compared with a control group of 157 patients with tubal factor infertility. Outcome measures included number of follicles, number of oocytes, mean number of ampoules of gonadotropins, cumulative pregnancy, and live birth rates

RESULTS

Higher cancelation rates, higher total gonadotropin requirements, and lower oocyte yield were found in women with endometriosis Stage III and IV compared with both the Stage I/II and control groups. The fertilization rate was higher in Stage III/IV endometriosis compared to Stage I/II. Clinical pregnancy and live birth rates were comparable between patients with endometriosis Stage I/II and control group, whereas they were significantly lower in patients with endometriosis Stage III/IV compared to other two groups.

CONCLUSION

The American Society for Reproductive Medicine classification of endometriosis is useful in predicting IVF outcome. Advanced endometriosis means a worse prognosis for IVF treatment compared to milder stages or tubal factor infertility. The decreased fertilization rate in Stage I/II endometriosis might be a cause of subfertility in these women, as a result of a hostile environment caused by the disease.

Targeting mast cells in endometriosis with janus kinase 3 inhibitor, JANEX-1

Endometriosis (EMS) is a chronic inflammatory disease of multifactorial etiology characterized by implantation and growth of endometrial glands and stroma outside the uterine cavity. EMS is a significant public health issue as it affects 15-20% of women in their reproductive age. Clinical symptoms may include pelvic pain, dysmenorrhea, dyspareunia, pelvic/abdominal masses, and infertility. Symptomatic treatments such as surgical resection and/or hormonal suppression of ovarian function and analgesics are not as effective as desired. Consequently, there is an enormous unmet need to develop effective medical therapy capable of preventing the occurrence and recurrence of EMS without undesirable side-effects. EMS-associated intra-abdominal bleeding episodes, local inflammation, adhesions, and i.p. immunologic dysfunction leads to pelvic nociception and pelvic pain. Increasing evidence supports the involvement of allergic-type inflammation in EMS. Invasion of mast cells, degranulation, and proliferation of interstitial component are observed in endometriotic lesions. Presence of activated and degranulating mast cells within the nerve structures can contribute to the development of pain and hyperalgesia by direct effects on primary nociceptive neurons. Therefore, treatments targeting endometrial mast cells may prove effective in preventing or alleviating EMS-associated symptoms. The Janus kinase 3 (JAK3) is abundantly expressed in mast cells and is required for the full expression of high-affinity IgE receptor-mediated mast cell inflammatory sequelae. JANEX-1/WHI-P131 is a rationally designed novel JAK3 inhibitor with potent anti-inflammatory activity in several cellular and in vivo animal models of inflammation, including mouse models of peritonitis, colitis, cellulitis, sunburn, and airway inflammation with favorable toxicity and pharmacokinetic profile. We hypothesize that JAK3 inhibitors, especially JANEX-1, may prove useful to prevent or alleviate the symptoms of EMS.

Surgical outcome and long-term follow up after laparoscopic rectosigmoid resection in women with deep infiltrating endometriosis

The aim of this study was to assess the long-term outcome of treating severely symptomatic women with deep infiltrating intestinal endometriosis by laparoscopic segmental rectosigmoid resection. Detailed intraoperative and postoperative records and questionnaires (preoperatively, 1 month postoperatively and every 6 months for 3 years) were collected from 22 women. The estimated blood loss during surgery was 290 +/- 162 ml (range 180-600), and average hospital stay was 8 days (range 6-19). One woman required blood transfusion after surgery. Two cases were converted to laparotomy. One woman had early dehiscence of the anastomosis. Six months after surgery, there was a significant reduction of symptom scores (greater than 50% for most types of pain) related to intestinal localisation of endometriosis (P < 0.05). Score improvements were maintained during the whole period of follow up. Noncyclic pelvic pain scores showed significant reductions (P < 0.05) after 6 and 12 months, but there was a high recurrence rate later. Dysmenorrhoea and dyspareunia improved in 18/21 and 14/18 women with preoperative symptoms, respectively. Constipation, diarrhoea and rectal bleeding improved in all affected women for the whole period of follow up. Laparoscopic segmental rectosigmoid resection seems safe and effective in women with deep infiltrating colorectal endometriosis resulting in significant reductions in painful and dysfunctional symptoms associated with deep bowel involvement.

Impact of ovarian endometrioma on assisted reproduction outcomes

The effects of ovarian endometrioma on fertility outcomes with IVF and embryo transfer have been causally related to poor outcomes. The objective of this meta-analysis was to evaluate the ovarian reserve and ovarian responsiveness to ovarian stimulation and assisted reproduction outcomes in patients with ovarian endometrioma. The odds for clinical pregnancy were not affected significantly in patients with ovarian endometrioma compared with controls, with an overall odds ratio of 1.07 from three studies [95% CI: (0.63, 1.81), P = 0.79]. The overall pregnancy rate was similar with an estimated odds ratio of 1.17 [95% CI: (0.85, 1.60), P = 0.34]. Decreased ovarian responsiveness to ovarian stimulation in patients with ovarian endometrioma may be due to a reduced number of follicles in these patients compared with controls (P = 0.002). Prospective randomized controlled trials are needed to assess whether surgical treatment versus no surgical treatment improves pregnancy outcomes in patients with ovarian endometrioma undergoing assisted reproduction cycles.