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Zhou JJ, Yu K, Mao HY, Li C. Comparison of ovarian preservation versus oophorectomy on fertility outcomes in patients with endometriosis post-laparoscopic surgery: A prospective study. World J Clin Cases 2024; 12:4652-4660. [PMID: 39070836 PMCID: PMC11235484 DOI: 10.12998/wjcc.v12.i21.4652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 05/23/2024] [Accepted: 06/07/2024] [Indexed: 06/30/2024] Open
Abstract
BACKGROUND Endometriosis is a chronic inflammatory condition affecting a significant proportion of women of reproductive age. Although laparoscopic surgery is commonly the preferred treatment, the decision to preserve or remove the ovaries remains controversial. Previous studies have yielded inconsistent results regarding the impact of ovarian preservation vs oophorectomy on fertility outcomes and disease recurrence. This prospective study aimed to address this knowledge gap by comparing the effects of these surgical approaches on spontaneous pregnancy rates, time to pregnancy, recurrence rates, and postoperative pain in patients with endometriosis. AIM To compare the reproductive outcomes and recurrence rates between ovarian preservation and oophorectomy in women undergoing laparoscopic surgery for endometriosis. METHODS This study was conducted at a tertiary care hospital between January 2019 and December 2023. A total of 312 women aged 18 to 40 years, diagnosed with endometriosis and undergoing laparoscopic surgery, were included. The patients were categorized into the ovarian preservation group (n = 204) and the oophorectomy group (n = 108). The primary outcome measure was the achievement of spontaneous pregnancy within 24 months post-surgery. Secondary outcomes included time to spontaneous pregnancy, recurrence rates, and postoperative pain scores. RESULTS The ovarian preservation group exhibited a significantly higher spontaneous pregnancy rate than that in the oophorectomy group (43.6% vs 28.7%, P = 0.006). Moreover, the median time to spontaneous pregnancy was shorter in the ovarian preservation group (8.2 months vs 11.4 months, P = 0.018). Nonetheless, endometriosis recurrence was more prevalent in the ovarian preservation group (22.1% vs 11.1%, P = 0.014). The postoperative pain scores demonstrated similar improvements in both groups, with no significant differences observed. Subgroup analyses indicated that the benefit of ovarian preservation on spontaneous pregnancy rates was more evident among younger women (≤ 35 years) and those with advanced-stage endometriosis. CONCLUSION Ovarian preservation is associated with a high spontaneous pregnancy rate and a short time to pregnancy. However, because of the increased risk of recurrence, the decision should be based on age, fertility aspirations, and disease severity.
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Affiliation(s)
- Jin-Jin Zhou
- Department of Gynecology, Affiliated Hospital of Yangzhou University, Yangzhou 225001, Jiangsu Province, China
| | - Ke Yu
- Department of Gynecology, Affiliated Hospital of Yangzhou University, Yangzhou 225001, Jiangsu Province, China
| | - Hai-Yan Mao
- Department of Oncology, Affiliated Hospital of Yangzhou University, Yangzhou 225001, Jiangsu Province, China
| | - Cen Li
- Department of Gynecology, Affiliated Hospital of Yangzhou University, Yangzhou 225001, Jiangsu Province, China
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Mathyk BA, Cetin E, Youssef Y, Imudia AN, Encalada Soto D, Mikhail E, Moawad G. Beyond the surface: Does stage I-II endometriosis impact fertility? Exploring the challenges of mild disease. Best Pract Res Clin Obstet Gynaecol 2024:102501. [PMID: 38760260 DOI: 10.1016/j.bpobgyn.2024.102501] [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: 03/05/2024] [Revised: 04/21/2024] [Accepted: 05/02/2024] [Indexed: 05/19/2024]
Abstract
Endometriosis is one of the most common gynecologic conditions that women face throughout their lives. Despite advances in technology, diagnosis and treatment of this relapsing and remitting condition is still challenging for many women. This review focuses on literature pertaining to minimal/mild (stage I/II) endometriosis and its impact on fertility. The effectiveness of medical interventions to improve infertility and obstetric outcomes in both natural and assisted reproductive technologies cycles remains debated. The recent ESHRE guidelines suggests that operative laparoscopy could be considered for rASRM stage I/II endometriosis as it improves ongoing pregnancy rates.
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Affiliation(s)
- Begum Aydogan Mathyk
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine, Tampa, FL, USA.
| | - Esra Cetin
- Department of Obstetrics and Gynecology, Hurley Medical Center, Michigan State University, 1 Hurley Plaza, Flint, MI, 48503, USA
| | - Youssef Youssef
- Division of Minimally Invasive Gynecology, Department of Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, NY, 11220, USA
| | - Anthony N Imudia
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Diana Encalada Soto
- Division of Gynecologic Subspecialties, Department of Obstetrics and Gynecology, University of South Florida, Morsani College of Medicine, Tampa, FL, USA
| | - Emad Mikhail
- Division of Gynecologic Subspecialties, Department of Obstetrics and Gynecology, University of South Florida, Morsani College of Medicine, Tampa, FL, USA
| | - Gaby Moawad
- Department of Obstetrics and Gynecology, George Washington University, Washington, DC, 20037, USA; The Center for Endometriosis and Advanced Pelvic Surgery, Washington, DC, 22101, USA
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3
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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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Dabi Y, Ebanga L, Favier A, Kolanska K, Puchar A, Jayot A, Ferrier C, Touboul C, Bendifallah S, Darai E. Discoid excision for colorectal endometriosis associated infertility: A balance between fertility outcomes and complication rates. J Gynecol Obstet Hum Reprod 2024; 53:102723. [PMID: 38211693 DOI: 10.1016/j.jogoh.2024.102723] [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: 12/30/2023] [Accepted: 01/04/2024] [Indexed: 01/13/2024]
Abstract
OBJECTIVE The objective of our study was to study the impact of discoid excision for deep endometriosis (DE) with colorectal involvement on fertility outcomes. METHODS 49 patients with a desire for pregnancy treated with discoid excision for colorectal endometriosis in our endometriosis expert center between January 2015 and August 2020 were selected from our prospectively maintained database. Indications for surgery were either infertility and / or pelvic pain. Postoperative complications were graded according to the Clavien-Dindo classification. Fertility outcomes, both spontaneous and post-ART pregnancies, were analyzed. RESULTS Among the 49 patients who underwent discoid excision exclusively (no other digestive resection) with a desire to conceive, 25 had a pregnancy after surgery and 24 did not. Double discoid excision was performed in 6.1 % of the cases (3/49). A colpectomy was performed in 12.2 % of the patients (6/49), and a protective stoma in 12.2 % (6/49). Fenestration of endometriomas was performed in 28.6 % of the patients (14/49), and parametrectomy in 40.8 % (20/49). The postoperative complication rate was 24.5 % (12/49) including 10.2 % (5/49) grade I, 12.2 % (6/49) grade II, and 2 % (1/49) grade III. Prior to surgery, 28 (57.1 %) patients had infertility including 13 (52 %) that successfully conceived following surgery and 15 (62.5 %) that remain infertile. Spontaneous pregnancy was achieved in 60 % (15/25) of infertile patients' prior surgery. The live-birth rate in patients conceiving spontaneously was 75 % (12/16). CONCLUSION Our results support that discoid excision is safe and associated with good fertility outcomes. Whether first-line surgery using discoid excision is superior to first-line ART remains to be determined.
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Affiliation(s)
- Yohann Dabi
- Sorbonne University, Tenon Hospital, Department of Gynecology, Obstetrics and Reproductive Medicine, Assistance Publique des Hôpitaux de Paris (AP-HP), Paris, France.
| | - Lea Ebanga
- Sorbonne University, Tenon Hospital, Department of Gynecology, Obstetrics and Reproductive Medicine, Assistance Publique des Hôpitaux de Paris (AP-HP), Paris, France
| | - Amélia Favier
- Sorbonne University, Tenon Hospital, Department of Gynecology, Obstetrics and Reproductive Medicine, Assistance Publique des Hôpitaux de Paris (AP-HP), Paris, France
| | - Kamila Kolanska
- Sorbonne University, Tenon Hospital, Department of Gynecology, Obstetrics and Reproductive Medicine, Assistance Publique des Hôpitaux de Paris (AP-HP), Paris, France
| | - Anne Puchar
- Sorbonne University, Tenon Hospital, Department of Gynecology, Obstetrics and Reproductive Medicine, Assistance Publique des Hôpitaux de Paris (AP-HP), Paris, France
| | - Aude Jayot
- Sorbonne University, Tenon Hospital, Department of Gynecology, Obstetrics and Reproductive Medicine, Assistance Publique des Hôpitaux de Paris (AP-HP), Paris, France
| | - Clément Ferrier
- Sorbonne University, Tenon Hospital, Department of Gynecology, Obstetrics and Reproductive Medicine, Assistance Publique des Hôpitaux de Paris (AP-HP), Paris, France
| | - Cyril Touboul
- Sorbonne University, Tenon Hospital, Department of Gynecology, Obstetrics and Reproductive Medicine, Assistance Publique des Hôpitaux de Paris (AP-HP), Paris, France; GRC-6 Sorbonne University: Centre Expert en Endométriose (C3E), Paris, France; Unité INSERM UMR S 938, Sorbonne University, Paris, France
| | - Sofiane Bendifallah
- Sorbonne University, Tenon Hospital, Department of Gynecology, Obstetrics and Reproductive Medicine, Assistance Publique des Hôpitaux de Paris (AP-HP), Paris, France; GRC-6 Sorbonne University: Centre Expert en Endométriose (C3E), Paris, France; Unité INSERM UMR S 938, Sorbonne University, Paris, France
| | - Emile Darai
- Sorbonne University, Tenon Hospital, Department of Gynecology, Obstetrics and Reproductive Medicine, Assistance Publique des Hôpitaux de Paris (AP-HP), Paris, France; GRC-6 Sorbonne University: Centre Expert en Endométriose (C3E), Paris, France; Unité INSERM UMR S 938, Sorbonne University, Paris, France
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Shafrir AL, Wallace B, Laliberte A, Vitonis AF, Sieberg CB, Terry KL, Missmer SA. Pelvic pain symptoms and endometriosis characteristics in relation to oxidative stress among adolescents and adults with and without surgically-confirmed endometriosis. F1000Res 2024; 13:34. [PMID: 38495219 PMCID: PMC10940847 DOI: 10.12688/f1000research.141793.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/25/2023] [Indexed: 03/19/2024] Open
Abstract
Background: While the majority of reproductive-aged females will experience pelvic pain during their lives, biological mechanisms underlying pelvic pain are not well understood. We investigated associations between pelvic pain symptoms and oxidative stress among people with and without surgically-confirmed endometriosis. Methods: Using an enzyme-linked immunosorbent assay, we measured 8-Hydroxy-2'-deoxyguanosine (8-OHdG) in urine samples and corrected for creatinine levels in 434 surgically-confirmed endometriosis participants compared to 605 participants never diagnosed with endometriosis. At enrollment, participants reported details of their pelvic pain symptoms. Linear regression was used to compute geometric mean (GM) creatinine-corrected 8-OHdG levels with 95% confidence intervals (CI) among all participants and those with and without endometriosis separately, adjusting for potential confounders. Interactions by surgically-confirmed endometriosis status were tested by Wald statistics. Results: No trends in 8-OHdG were observed among those with or without endometriosis for severity or frequency of dysmenorrhea, acyclic pelvic pain, dyspareunia or pain with bowel movements. Among endometriosis participants, lower 8-OHdG levels were observed for participants with any white, blue/black, or brown lesions (GM=76.7 versus 82.9 ng/mg; p=0.10), which was primarily driven by lower levels of 8-OHdG for any blue/black lesions (GM=72.8 versus 81.6 ng/mg; p=0.05). Conclusion: While no associations were observed between 8-OHdG and pelvic pain symptoms, future research is needed to assess how other pathways of oxidative damage, e.g. through proteins or lipids, may affect endometriosis-associated symptoms. Additionally, further research is needed to understand differences in oxidative stress among endometriosis lesion sub-phenotypes.
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Affiliation(s)
- Amy L Shafrir
- Boston Center for Endometriosis, Boston Children's Hospital and Brigham and Women's Hospital, Boston, Massachusetts, 02115, USA
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA, 02115, USA
| | - Britani Wallace
- Boston Center for Endometriosis, Boston Children's Hospital and Brigham and Women's Hospital, Boston, Massachusetts, 02115, USA
- Department of Obstetrics, Gynecology, and Reproductive Biology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, 02115, USA
| | - Ashley Laliberte
- Boston Center for Endometriosis, Boston Children's Hospital and Brigham and Women's Hospital, Boston, Massachusetts, 02115, USA
- Department of Obstetrics, Gynecology, and Reproductive Biology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, 02115, USA
| | - Allison F Vitonis
- Boston Center for Endometriosis, Boston Children's Hospital and Brigham and Women's Hospital, Boston, Massachusetts, 02115, USA
- Department of Obstetrics, Gynecology, and Reproductive Biology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, 02115, USA
| | - Christine B Sieberg
- Department of Pyschiatry, Harvard Medical School, Boston, MA, 02115, USA
- Pain & Affective Neuroscience Center, Department of Anesthesiology, Boston Children's Hospital, Boston, MA, 02115, USA
- Biobehavioral Pain Innovations Lab, Department of Psychiatry & Behavioral Sciences, Boston Children's Hospital, Boston, MA, 02115, USA
| | - Kathryn L Terry
- Boston Center for Endometriosis, Boston Children's Hospital and Brigham and Women's Hospital, Boston, Massachusetts, 02115, USA
- Department of Obstetrics, Gynecology, and Reproductive Biology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, 02115, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, 02115, USA
| | - Stacey A Missmer
- Boston Center for Endometriosis, Boston Children's Hospital and Brigham and Women's Hospital, Boston, Massachusetts, 02115, USA
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA, 02115, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, 02115, USA
- Department of Obstetrics, Gynecology, and Reproductive Biology, College of Human Medicine, Michigan State University, Grand Rapids, MI, 49503, USA
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6
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McGrath IM, Montgomery GW, Mortlock S. Genomic characterisation of the overlap of endometriosis with 76 comorbidities identifies pleiotropic and causal mechanisms underlying disease risk. Hum Genet 2023; 142:1345-1360. [PMID: 37410157 PMCID: PMC10449967 DOI: 10.1007/s00439-023-02582-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 06/23/2023] [Indexed: 07/07/2023]
Abstract
Comorbid conditions can be driven by underlying pleiotropic and causal mechanisms that can provide insights into shared molecular and biological processes contributing to disease risk. Endometriosis is a chronic condition affecting one in nine women of reproductive age and poses many challenges including lengthy diagnostic delays and limited treatment efficacy owing to poor understanding of disease aetiology. To shed light on the underlying biological mechanisms and to identify potential risk factors, we examine the epidemiological and genomic relationship between endometriosis and its comorbidities. In the UK Biobank 292 ICD10 codes were epidemiologically correlated with endometriosis diagnosis, including gynaecological, immune, infection, pain, psychiatric, cancer, gastrointestinal, urinary, bone and cardiovascular traits. A subset of the identified comorbidities (n = 76) underwent follow-up genetic analysis. Whilst Mendelian randomisation suggested causality was not responsible for most comorbid relationships, 22 traits were genetically correlated with endometriosis, including pain, gynaecological and gastrointestinal traits, suggestive of a shared genetic background. Pleiotropic genetic variants and genes were identified using gene-based and colocalisation analysis. Shared genetic risk factors and potential target genes suggest a diverse collection of biological systems are involved in these comorbid relationships including coagulation factors, development of the female reproductive tract and cell proliferation. These findings highlight the diversity of traits with epidemiological and genomic overlap with endometriosis and implicate a key role for pleiotropy in the comorbid relationships.
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Affiliation(s)
- Isabelle M McGrath
- The Institute for Molecular Bioscience, The University of Queensland, Brisbane, QLD, 4072, Australia
| | - Grant W Montgomery
- The Institute for Molecular Bioscience, The University of Queensland, Brisbane, QLD, 4072, Australia
| | - Sally Mortlock
- The Institute for Molecular Bioscience, The University of Queensland, Brisbane, QLD, 4072, Australia.
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Predictive value of preoperative MRI using the #ENZIAN classification score in patients with deep infiltrating endometriosis. Arch Gynecol Obstet 2023; 307:215-220. [PMID: 35239004 DOI: 10.1007/s00404-022-06451-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 02/10/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE The aim of this study is to investigate the correlation between the magnetic resonance imaging (MRI) and intraoperative findings of deep infiltrating endometriosis using the #ENZIAN score. METHODS This retrospective study included 64 patients who underwent surgery for deep infiltrating endometriosis between January 2017 and August 2020. Preoperative abdominopelvic MRI assessment was evaluated and scored using the #ENZIAN classification. Operative scores were considered the gold standard, and the sensitivity, specificity, and positive and negative predictive values (PPV and NPV) of MRI for each category were calculated. RESULTS MRI has higher sensitivity and specificity in showing the lesions of the compartments O (ovarian lesions), A (rectovaginal septum and posterior vaginal fornix), and B (uterosacral ligaments and parametrium) (100-100%, 100-100%, and 97-100%, respectively, p < 0.001) compared to the other compartments. The lowest sensitivity, specificity, accuracy, and PPV of the MRI was found in compartment P (14%, 76%, 70%, and 7%, respectively). CONCLUSION We demonstrated that the #ENZIAN classification in MRI reports has significant sensitivity and specificity in compartments A, B (uterosacral ligaments and parametrium), and O. Furthermore, the determination of peritoneal lesions via MRI is inadequate.
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8
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Fruscalzo A, Dayer A, Londero AP, Guani B, Khomsi F, Ayoubi JM, Feki A. Endometriosis and Infertility: Prognostic Value of #Enzian Classification Compared to rASRM and EFI Score. J Pers Med 2022; 12:jpm12101623. [PMID: 36294762 PMCID: PMC9605607 DOI: 10.3390/jpm12101623] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 09/17/2022] [Accepted: 09/22/2022] [Indexed: 11/16/2022] Open
Abstract
This study’s objective was to compare the predictive validity of the three most utilized classification scores for endometriosis, #Enzian, EFI, and rASRM, in achieving a spontaneous pregnancy or pregnancy via assisted reproductive technology (ART) after surgery for endometriosis. The monocentric retrospective study was carried out from January 2012 to December 2021 at the gynaecology department of the cantonal hospital of Fribourg. Patients consulting for infertility and operated on for endometriosis with histological confirmation were included. The predictive value of #Enzian, rASRM, and EFI was evaluated and compared concerning the prediction of fertility after surgery, both spontaneous and ART, during the following 12 months. A total of 58 women (mean age 33.1 ± 4.57 years) were included. Overall, 30 women achieved a pregnancy, seven spontaneously. Among all women who achieved a pregnancy, there was a lower prevalence of rASRM stage III−IV (16.67% vs. 39.29%, p = 0.054). Women achieving a pregnancy had a significantly higher EFI score than others (p < 0.05). No significant differences were observed concerning the #Enzian score. In conclusion, the revised #Enzian score is not correlated with pregnancy achievement; EFI score is the only score significantly associated with the pregnancy outcome in women affected by endometriosis.
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Affiliation(s)
- Arrigo Fruscalzo
- Clinic of Obstetrics and Gynaecologz, HFR—Hòpital Fribourgeois, Chemin des Pensionnats 2-6, 1708 Fribourg, Switzerland
- Faculty of Medicine, University of Münster, Domagkstraße 3, 48149 Münster, Germany
- Correspondence:
| | - Arnaud Dayer
- Clinic of Obstetrics and Gynaecologz, HFR—Hòpital Fribourgeois, Chemin des Pensionnats 2-6, 1708 Fribourg, Switzerland
| | - Ambrogio Pietro Londero
- Academic Unit of Obstetrics and Gynaecology, Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Infant Health, University of Genova, 16132 Genova, Italy or
- Ennergi Research (Non-Profit Organization), 33050 Lestizza, Italy
| | - Benedetta Guani
- Clinic of Obstetrics and Gynaecologz, HFR—Hòpital Fribourgeois, Chemin des Pensionnats 2-6, 1708 Fribourg, Switzerland
| | - Fathi Khomsi
- Clinic of Obstetrics and Gynaecologz, HFR—Hòpital Fribourgeois, Chemin des Pensionnats 2-6, 1708 Fribourg, Switzerland
| | - Jean-Marc Ayoubi
- Department of Obstetrics and Gynecology and Reproductive Medicine, Hopital Foch–Faculté de Médecine Paris, 92150 Suresnes, France
| | - Anis Feki
- Clinic of Obstetrics and Gynaecologz, HFR—Hòpital Fribourgeois, Chemin des Pensionnats 2-6, 1708 Fribourg, Switzerland
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9
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Harada T, Taniguchi F, Kitajima M, Kitawaki J, Koga K, Momoeda M, Mori T, Murakami T, Narahara H, Osuga Y, Yamaguchi K. Clinical practice guidelines for endometriosis in Japan (The 3rd edition). J Obstet Gynaecol Res 2022; 48:2993-3044. [PMID: 36164759 PMCID: PMC10087749 DOI: 10.1111/jog.15416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 08/11/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Tasuku Harada
- Department Obstetrics and Gynecology, Tottori University
| | | | | | - Jo Kitawaki
- Department Obstetrics and Gynecology, Kyoto Prefectural University of Medicine
| | - Kaori Koga
- Department Obstetrics and Gynecology, The University of Tokyo
| | - Mikio Momoeda
- Department Obstetrics and Gynecology, Aiiku Hospital
| | - Taisuke Mori
- Department Obstetrics and Gynecology, Kyoto Prefectural University of Medicine
| | - Takashi Murakami
- Department Obstetrics and Gynecology, Shiga University of Medical Science
| | | | - Yutaka Osuga
- Department Obstetrics and Gynecology, The University of Tokyo
| | - Ken Yamaguchi
- Department of Gynecology and Obstetrics, Kyoto University Graduate School of Medicine
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Demir E, Soyman Z, Kelekci S. Outcomes between non-IVF and IVF treatment after laparoscopic conservative surgery of advanced endometriosis with Endometriosis Fertility Index score >3. Medicine (Baltimore) 2022; 101:e30602. [PMID: 36123931 PMCID: PMC10662901 DOI: 10.1097/md.0000000000030602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Accepted: 08/16/2022] [Indexed: 11/25/2022] Open
Abstract
Surgical excision of advanced endometriosis has been demonstrated to improve women's pain symptoms and quality of life in women in randomized placebo-controlled trials, but there is no strong evidence regarding the live birth rate. The revised American Fertility Society (r-AFS) classification for endometriosis has a limited predictive ability for fertility outcomes after surgery; therefore, EFI scoring has been advised for predicting conception after endometriosis surgery. No randomized controlled trials have investigated fertility outcomes in patients with advanced endometriosis after surgery. This study aimed to determine the outcomes of in vitro fertilization (IVF) or non-IVF treatments after conservative surgery for advanced endometriosis in patients with good prognosis Endometriosis Fertility Index (EFI) scores (>3). This prospective cohort study was conducted between April 2014 and April 2019 at a tertiary research hospital. In total, 113 women with suspected preoperative advanced endometriosis were enrolled in this study. A total of 90 women with advanced endometriosis underwent laparoscopic surgery. Fourteen patients with EFI score of ≤3 and 3 of them who had bilateral tubal occlusion were also excluded. Seventy-three women were included in this study. The remaining 30 women in the non-IVF group and 32 women in the IVF group were analyzed. The main outcome measures were cumulative pregnancy rates and live birth rates in both groups. Women who underwent IVF treatment were older than women (30 ± 3.41) who had non-IVF treatment (26.5 ± 3.07) after laparoscopic surgery (P < .001). The remaining baseline characteristics of the patients in both groups were similar. Clinical pregnancy, abortion, and live birth rates were similar in both the groups after 36 months of follow-up. This study demonstrated that cumulative pregnancy and live birth rates were similar to those of non-IVF or IVF treatments after conservative surgery for advanced endometriosis, if patients had good prognosis EFI scores. Furthermore, non-IVF treatments resulted in nearly the same clinical pregnancy results as IVF treatment within 1 year after surgery.
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Affiliation(s)
- Emine Demir
- İzmir Katip Celebi University, Department of Obstetrics and Gynecology, İzmir, Turkey
| | - Zeynep Soyman
- İstanbul Education and Researh Hospital, Department of Obstetrics and Gynecology, İstanbul, Turkey
| | - Sefa Kelekci
- İzmir Katip Celebi University, Department of Obstetrics and Gynecology, İzmir, Turkey
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11
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Lee J, Kang J, Lee HJ. Effect of Surgical Findings on Prediction of Postoperative Ovarian Reserve in Patients with Ovarian Endometrioma. Int J Womens Health 2022; 14:1127-1136. [PMID: 36032056 PMCID: PMC9401609 DOI: 10.2147/ijwh.s373135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 08/10/2022] [Indexed: 11/23/2022] Open
Abstract
Objective Revised American Society for Reproductive Medicine (rASRM) classification for endometriosis is considered to have limited ability to predict fertility after surgery. This study evaluated the effect of surgical findings described by the rASRM classification on postoperative change in serum Anti-Müllerian hormone (AMH) in endometriosis. Study Design We retrospectively analyzed 112 patients with endometrioma who underwent laparoscopic ovarian cystectomy. The ovarian score was defined as the sum of the endometrioma score from the size and depth of endometrioma and the adhesion score from the extent and types of ovarian adhesion described in the rASRM classification. The ovarian score was correlated with the AMH levels before surgery (AMH0), 3 (AMH3), and 6 months (AMH6) after surgery. To design a model for predicting AMH6, using ovarian score and AMH0, we calculated the unstandardized predictive value of AMH6/AMH0 (UPV) by linear regression analysis. The predicted AMH6 (pAMH6) could be calculated by multiplying the UPV by AMH0. When AMH6 is less than 1.0 ng/mL, it was defined as a poor ovarian reserve group (PORG), and the accuracy of the predictive model was validated. Results The level of AMH declined more in rASRM stage IV compared to stage III after surgery. The ovarian score had a significant variable in the linear regression analysis with the ratio of AMH6/AMH0 (p = 0.001). The UPV was correlated with ovarian score negatively. The pAMH6 correlated with AMH6 positively and with age negatively. The pAMH6 showed sensitivity 0.564, specificity 0.909, positive predictive rate 0.786, and negative predictive rate 0.800 in the prediction of PORG (p < 0.001). Conclusion The pAMH6 predicted the PORG at 6 months after surgery. Based on the results of our study, the surgical findings, including the size and depth of the endometrioma and extent and types of adhesion could be useful indicators for ovarian reserve after surgery.
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Affiliation(s)
- Jisun Lee
- Department of Obstetrics and Gynecology, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, Republic of Korea
| | - Juyeon Kang
- Department of Obstetrics and Gynecology, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, Republic of Korea
| | - Hyun Jung Lee
- Department of Obstetrics and Gynecology, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, Republic of Korea
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12
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Sorrentino F, DE Padova M, Falagario M, D'Alteri O MN, DI Spiezio Sardo A, Pacheco LA, Carugno JT, Nappi L. Endometriosis and adverse pregnancy outcome. Minerva Obstet Gynecol 2022; 74:31-44. [PMID: 34096691 DOI: 10.23736/s2724-606x.20.04718-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
INTRODUCTION Endometriosis is a gynecologic disease affecting approximately 10% of reproductive age women, around 21-47% of women presenting subfertility and 71-87% of women with chronic pelvic pain. Main symptoms are chronic pelvic pain, dysmenorrhea, dyspareunia and infertility that seem to be well controlled by oral contraceptive pill, progestogens, GnRh antagonists. The aim of this review was to illustrate the modern diagnosis of endometriosis during pregnancy, to evaluate the evolution of endometriotic lesions during pregnancy and the incidence of adverse outcomes. EVIDENCE ACQUISITION Published literature was retrieved through searches of the database PubMed (National Center for Biotechnology Information, US National Library of Medicine, Bethesda, MD, USA). We searched for all original articles published in English through April 2020 and decided to extract every notable information for potential inclusion in this review. The search included the following MeSH search terms, alone or in combination: "endometriosis" combined with "endometrioma," "biomarkers," "complications," "bowel," "urinary tract," "uterine rupture," "spontaneous hemoperitoneum in pregnancy" and more "adverse pregnancy outcome," "preterm birth," "miscarriage," "abruption placentae," "placenta previa," "hypertensive disorder," "preeclampsia," "fetal grow restriction," "small for gestation age," "cesarean delivery." EVIDENCE SYNTHESIS Pregnancy in women with endometriosis does not always lead to disappearance of symptoms and decrease in the size of endometriotic lesions, but it may be possible to observe a malignant transformation of ovarian endometriotic lesions. Onset of complications may be caused by many factors: chronic inflammation, adhesions, progesterone resistance and a dysregulation of genes involved in the embryo implantation. As results, the pregnancy can be more difficult because of endometriosis related complications (spontaneous hemoperitoneum [SH], bowel complications, etc.) or adverse outcomes like preterm birth, FGR, hypertensive disorders, obstetrics hemorrhages (placenta previa, abruptio placenta), miscarriage or cesarean section. Due to insufficient knowledge about its pathogenesis, currently literature data are contradictory and do not show a strong correlation between endometriosis and these complications except for miscarriage and cesarean delivery. CONCLUSIONS Future research should focus on the potential biological pathways underlying these relationships in order to inform patients planning a birth about possible complications during pregnancy.
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Affiliation(s)
- Felice Sorrentino
- Department of Medical and Surgical Sciences, Institute of Obstetrics and Gynecology, University of Foggia, Foggia, Italy
| | - Maristella DE Padova
- Department of Medical and Surgical Sciences, Institute of Obstetrics and Gynecology, University of Foggia, Foggia, Italy
| | - Maddalena Falagario
- Department of Medical and Surgical Sciences, Institute of Obstetrics and Gynecology, University of Foggia, Foggia, Italy
| | - Maurizio N D'Alteri O
- Division of Gynecology and Obstetrics, Department of Surgical Sciences, University of Cagliari, Cagliari, Italy
| | - Attilio DI Spiezio Sardo
- School of Medicine, Department of Public Health, University of Naples Federico II, Naples, Italy
| | - Luis A Pacheco
- Unit of Gynecologic Endoscopy, Gutenberg Center, Xanit International Hospital, Málaga, Spain
| | - Jose T Carugno
- Miller School of Medicine, Department of Obstetrics and Gynecology, University of Miami, Miami, FL, USA
| | - Luigi Nappi
- Department of Medical and Surgical Sciences, Institute of Obstetrics and Gynecology, University of Foggia, Foggia, Italy -
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13
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Hudelist G, Valentin L, Saridogan E, Condous G, Malzoni M, Roman H, Jurkovic D, Keckstein J. What to choose and why to use - a critical review on the clinical relevance of rASRM, EFI and Enzian classifications of endometriosis. Facts Views Vis Obgyn 2021; 13:331-338. [PMID: 35026095 PMCID: PMC9148714 DOI: 10.52054/fvvo.13.4.041] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Endometriosis is a common benign gynaecological disease that affects pelvic structures and causes adhesions. Endometriosis outside the pelvis exists but is rarer. Deep endometriosis may affect organs such as the urinary bladder, ureters, bowel and sacral roots. Adenomyosis (growth of endometrium in the myometrium, sometimes explained by disruption of the uterine junctional zone) frequently co-exists with deep endometriosis. Over the past decades, multiple attempts have been made to describe the anatomical extent of endometriosis. Out of approximately 20 classification systems suggested and published so far, three have gained widespread acceptance. These are the rASRM (American Society of Reproductive Medicine) classification, the Endometriosis Fertility Index (EFI) and the Enzian classification. Ideally, a classification system should be useful both for describing disease extent based on surgical findings and results of imaging methods (ultrasound, magnetic resonance imaging). OBJECTIVES To highlight the advantages and disadvantages of the three classification systems. METHODS This is a narrative review based on selected publications and experience of the authors. We discuss the current literature on the use of the rASRM, EFI and Enzian classification systems for describing disease extent with imaging methods and for prediction of fertility, surgical complexity, and risk of surgical complications. We underline the need for one universally acceptable terminology to describe the extent of endometriosis. CONCLUSIONS A useful classification system for endometriosis should describe the sites and extent of the disease, be related to surgical complexity and to disease-associated symptoms, including subfertility and should satisfy needs of both, imaging specialists for pre-operative classification and surgeons. The need for such a system is obvious and is provided by the #Enzian classification. Future research is necessary to test its validity.
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14
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Salliss ME, Farland LV, Mahnert ND, Herbst-Kralovetz MM. The role of gut and genital microbiota and the estrobolome in endometriosis, infertility and chronic pelvic pain. Hum Reprod Update 2021; 28:92-131. [PMID: 34718567 DOI: 10.1093/humupd/dmab035] [Citation(s) in RCA: 75] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 08/25/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Endometriosis is a chronic, burdensome condition that is historically understudied. Consequently, there is a lack of understanding of the etiology of the disease and its associated symptoms, including infertility and chronic pelvic pain (CPP). Endometriosis development is influenced by estrogen metabolism and inflammation, which are modulated by several factors including the microbiome and the estrobolome (the collection of genes encoding estrogen-metabolizing enzymes in the gut microbiome). Therefore, there is increasing interest in understanding the role of microbiota in endometriosis etiology. OBJECTIVE AND RATIONALE To date, there is no cure for endometriosis and treatment options often are ineffective. This manuscript will review the potential relationship between the microbiome and endometriosis, infertility and CPP and highlight the available data on the microbiome in relation to endometriosis and its related symptoms. The overarching goal of this manuscript is to inform future microbiome research that will lead to a deeper understanding of the etiology of the disease and possible diagnostic modalities and treatments. The potential impact of the microbiome on estrogen regulation modulated by the estrobolome, as well as inflammation and other endometriosis-promoting mechanisms within the genital tract, will be reviewed. The methodological limitations of microbiome-related studies will be critically assessed to provide improved guidelines for future microbiome and clinical studies. SEARCH METHODS PubMed databases were searched using the following keywords: endometriosis AND microbiome, infertility AND microbiome, pelvic pain AND microbiome, IVF (in-vitro fertilization) AND microbiome, endometriosis AND infertility. Clinical and preclinical animal trials that were eligible for review, and related to microbiome and endometriosis, infertility or CPP were included. All available manuscripts were published in 2002-2021. OUTCOMES In total, 28 clinical and 6 animal studies were included in the review. In both human and animal studies, bacteria were enriched in endometriosis groups, although there was no clear consensus on specific microbiota compositions that were associated with endometriosis, and no studies included infertility or CPP with endometriosis. However, bacterial vaginosis-associated bacteria and Lactobacillus depletion in the cervicovaginal microbiome were associated with endometriosis and infertility in the majority (23/28) of studies. Interpretation of endometrial studies is limited owing to a variety of methodological factors, discussed in this review. In addition, metadata outlining antibiotic usage, age, race/ethnicity, menopausal status and timing of sample collection in relation to diagnosis of endometriosis was not consistently reported. Animal studies (6/6) support a bidirectional relationship between the gut microbiota and endometriosis onset and progression. WIDER IMPLICATIONS There is evidence that a dysbiotic gut or genital microbiota is associated with multiple gynecologic conditions, with mounting data supporting an association between the microbiome and endometriosis and infertility. These microbiomes likely play a role in the gut-brain axis, which further supports a putative association with the spectrum of symptoms associated with endometriosis, including infertility and CPP. Collectively, this review highlights the demand for more rigorous and transparent methodology and controls, consistency across the field, and inclusion of key demographic and clinical characteristics of disease and comparison participants. Rigorous study designs will allow for a better understanding of the potential role of the microbiome in endometriosis etiology and the relationship to other disorders of the female reproductive tract.
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Affiliation(s)
- Mary E Salliss
- Department of Obstetrics and Gynecology, University of Arizona-College of Medicine, Phoenix, AZ, USA.,Department of Biology and Biochemistry, Bath University, Bath, UK
| | - Leslie V Farland
- Department of Epidemiology and Biostatistics, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ, USA.,Department of Obstetrics and Gynecology, University of Arizona-College of Medicine Tucson, Tucson, AZ, USA
| | - Nichole D Mahnert
- Department of Obstetrics and Gynecology, University of Arizona-College of Medicine, Phoenix, AZ, USA.,Department of Obstetrics and Gynecology, Banner-University Medical Center Phoenix, Phoenix, AZ, USA
| | - Melissa M Herbst-Kralovetz
- Department of Obstetrics and Gynecology, University of Arizona-College of Medicine, Phoenix, AZ, USA.,Department of Basic Medical Sciences, University of Arizona-College of Medicine, Phoenix, AZ, USA
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15
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Vermeulen N, Abrao MS, Einarsson JI, Horne AW, Johnson NP, Lee TTM, Missmer S, Petrozza J, Tomassetti C, Zondervan KT, Grimbizis G, De Wilde RL. Endometriosis Classification, Staging and Reporting Systems: A Review on the Road to a Universally Accepted Endometriosis Classification. J Minim Invasive Gynecol 2021; 28:1822-1848. [PMID: 34690085 DOI: 10.1016/j.jmig.2021.07.023] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 07/08/2021] [Accepted: 07/08/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVE In the field of endometriosis, several classification, staging and reporting systems have been developed. Which endometriosis classification, staging and reporting systems have been published and validated for use in clinical practice? DATA SOURCES A systematic PUBMED literature search was performed. Data were extracted and summarized. METHODS OF STUDY SELECTION na TABULATION, INTEGRATION AND RESULTS: Twenty-two endometriosis classification, staging and reporting systems have been published between 1973 and 2021, each developed for specific, and different, purposes. There still is no international agreement on how to describe the disease. Studies evaluating the different systems are summarized showing a discrepancy between the intended and the evaluated purpose, and a general lack of validation data confirming a correlation with pain symptoms or quality of life for any of the current systems. A few studies confirm the value of the ENZIAN system for surgical description of deep endometriosis. With regards to infertility, the endometriosis fertility index has been confirmed valid for its intended purpose. CONCLUSION Of the 22 endometriosis classification, staging and reporting systems identified in this historical overview, only a few have been evaluated for the purpose for which they were developed. The literature search was limited to PUBMED. Unpublished classification, staging or reporting systems, or those published in books were not considered. It can be concluded that there is no international agreement on how to describe endometriosis or how to classify it, and that most classification/staging systems show no or very little correlation with patient outcomes. This overview of existing systems is a first step in working towards a universally accepted endometriosis classification.
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Affiliation(s)
- Nathalie Vermeulen
- ESHRE, Central office (Dr. Vermeulen), Meerstraat 60, Grimbergen, BE 1852, Belgium
| | - Mauricio S Abrao
- Disciplina de Ginecologia, Departamento de Obstetricia e Ginecologia (Dr. Abrao), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil; Gynecologic Division, BP - A Beneficencia Portuguesa de Sao Paulo, Sao Paulo, Brazil
| | - Jon I Einarsson
- Brigham and Women's Hospital, Department of Obstetrics and Gynecology, Division of Minimally Invasive Gynecologic Surgery (Dr. Einarsson), Boston, MA, USA
| | - Andrew W Horne
- University of Edinburgh, MRC Centre for Reproductive Health (Dr. Horne), QMRI, 49 Little France Crescent, Edinburgh, UK EH16 4TJ
| | - Neil P Johnson
- Repromed Auckland, 105 Remuera Road, Remuera, Auckland (Dr. Johnson), New Zealand 1050
| | - Ted T M Lee
- Magee Womens Hospital of UPMC, Department of Obstetrics, Gynecology and Reproductive Sciences (Dr. Lee), Pittsburgh, PA, USA
| | - Stacey Missmer
- Michigan State University College of Human Medicine, Department of Obstetrics, Gynecology and Reproductive Biology (Dr. Missmer), East Lansing, MI, USA; Harvard University T H Chan School of Public Health, Department of Epidemiology, Boston, MA, USA; World Endometriosis Research Foundation, WERF, London, UK
| | - John Petrozza
- Massachusetts General Hospital Fertility Center, Department of Obstetrics and Gynecology (Dr. Petrozza), Boston, MA, USA
| | - Carla Tomassetti
- University Hospital Leuven, Department of Obstetrics and Gynaecology, Leuven University Fertility Centre (Dr. Tomassetti), Leuven, Belgium
| | - Krina T Zondervan
- University of Oxford, Oxford Endometriosis CaRe Centre, Nuffield Department of Women's & Reproductive Health (Dr. Zondervan), Oxford, Oxfordshire, UK; University of Oxford, Wellcome Centre for Human Genetics, Oxford, Oxfordshire, UK
| | - Grigoris Grimbizis
- Medical School, Aristotle University of Thessaloniki (Dr. Grimbizis), 1st Dept Obstet Gynecol, Tsimiski 51 Street, Thessaloniki, Greece 54623
| | - Rudy Leon De Wilde
- Carl von Ossietzky Universitat Oldenburg, University Hospital for Gynecology (Dr. De Wilde), Oldenburg, Germany.
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16
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Vermeulen N, Abrao MS, Einarsson JI, Horne AW, Johnson NP, Lee TTM, Missmer S, Petrozza J, Tomassetti C, Zondervan KT, Grimbizis G, De Wilde RL. Endometriosis classification, staging and reporting systems: a review on the road to a universally accepted endometriosis classification . Hum Reprod Open 2021; 2021:hoab025. [PMID: 34693032 PMCID: PMC8530712 DOI: 10.1093/hropen/hoab025] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 06/11/2021] [Indexed: 12/14/2022] Open
Abstract
STUDY QUESTION Which endometriosis classification, staging and reporting systems have been published and validated for use in clinical practice? SUMMARY ANSWER Of the 22 endometriosis classification, staging and reporting systems identified in this historical overview, only a few have been evaluated, in 46 studies, for the purpose for which they were developed. WHAT IS KNOWN ALREADY In the field of endometriosis, several classification, staging and reporting systems have been developed. PARTICIPANTS/MATERIALS, SETTING, METHODS A systematic PUBMED literature search was performed. Data were extracted and summarized. MAIN RESULTS AND THE ROLE OF CHANCE Twenty-two endometriosis classification, staging and reporting systems have been published between 1973 and 2021, each developed for specific, and different, purposes. There still is no international agreement on how to describe the disease. Studies evaluating the different systems are summarized showing a discrepancy between the intended and the evaluated purpose, and a general lack of validation data confirming a correlation with pain symptoms or quality of life for any of the current systems. A few studies confirm the value of the ENZIAN system for surgical description of deep endometriosis. With regards to infertility, the endometriosis fertility index has been confirmed valid for its intended purpose. LARGE SCALE DATA NA. LIMITATIONS, REASONS FOR CAUTION The literature search was limited to PUBMED. Unpublished classification, staging or reporting systems, or those published in books were not considered. WIDER IMPLICATIONS OF THE FINDINGS It can be concluded that there is no international agreement on how to describe endometriosis or how to classify it, and that most classification/staging systems show no or very little correlation with patient outcomes. This overview of existing systems is a first step in working toward a universally accepted endometriosis classification. STUDY FUNDING/COMPETING INTEREST(S) The meetings and activities of the working group were funded by the American Association of Gynecologic Laparoscopists, European Society for Gynecological Endoscopy, European Society of Human Reproduction and Embryology and World Endometriosis Society. A.W.H. reports grant funding from the MRC, NIHR, CSO, Wellbeing of Women, Roche Diagnostics, Astra Zeneca, Ferring, Charles Wolfson Charitable Trust, Standard Life, Consultancy fees from Roche Diagnostics, AbbVie, Nordic Pharma and Ferring, outside the submitted work. In addition, A.W.H. has a patent Serum biomarker for endometriosis pending. N.P.J. reports personal fees from Abbott, Guerbet, Myovant Sciences, Vifor Pharma, Roche Diagnostics, outside the submitted work; he is also President of the World Endometriosis Society and chair of the trust board. S.M. reports grants and personal fees from AbbVie, and personal fees from Roche outside the submitted work. C.T. reports grants, non-financial support and other from Merck SA, non-financial support and other from Gedeon Richter, non-financial support from Ferring Pharmaceuticals, outside the submitted work and without private revenue. K.T.Z. reports grants from Bayer Healthcare, MDNA Life Sciences, Roche Diagnostics Inc, Volition Rx, outside the submitted work; she is also a Board member (Secretary) of the World Endometriosis Society and World Endometriosis Research Foundation, Research Advisory Board member of Wellbeing of Women, UK (research charity), and Chair, Research Directions Working Group, World Endometriosis Society. The other authors had nothing to disclose. TRIAL REGISTRATION NUMBER NA.
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Affiliation(s)
| | | | - Mauricio S Abrao
- Disciplina de Ginecologia, Departamento de Obstetricia e Ginecologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, Brazil.,Gynecologic Division, BP - A Beneficencia Portuguesa de Sao Paulo, Sao Paulo, SP, Brazil
| | - Jon I Einarsson
- Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA, USA
| | - Andrew W Horne
- University of Edinburgh, MRC Centre for Reproductive Health, QMRI, Edinburgh, UK
| | | | - Ted T M Lee
- Department of Obstetrics, Gynecology and Reproductive Sciences, Magee Womens Hospital of UPMC, Pittsburgh, PA, USA
| | - Stacey Missmer
- Department of Obstetrics, Gynecology and Reproductive Biology, Michigan State University College of Human Medicine, East Lansing, MI, USA.,Department of Epidemiology, Harvard University T H Chan School of Public Health, Boston, MA, USA.,World Endometriosis Research Foundation, WERF, London, UK
| | - John Petrozza
- Department of Obstetrics and Gynecology, Massachusetts General Hospital Fertility Center, Boston, MA, USA
| | - Carla Tomassetti
- Department of Obstetrics and Gynaecology, University Hospital Leuven, Leuven University Fertility Centre, Leuven, Belgium
| | - Krina T Zondervan
- Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford Endometriosis CaRe Centre, Oxford, Oxfordshire, UK.,University of Oxford, Wellcome Centre for Human Genetics, Oxford, UK
| | - Grigoris Grimbizis
- 1st Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Rudy Leon De Wilde
- Carl von Ossietzky Universitat Oldenburg, University Hospital for Gynecology, Oldenburg, Germany
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17
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Vermeulen N, Abrao MS, Einarsson JI, Horne AW, Johnson NP, Lee TTM, Missmer S, Petrozza J, Tomassetti C, Zondervan KT, Grimbizis G, De Wilde RL. Endometriosis classification, staging and reporting systems: a review on the road to a universally accepted endometriosis classification. Facts Views Vis Obgyn 2021; 13:305-330. [PMID: 34672508 PMCID: PMC9148706 DOI: 10.52054/fvvo.13.3.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background In the field of endometriosis, several classification, staging and reporting systems have been developed. However, endometriosis classification, staging and reporting systems that have been published and validated for use in clinical practice have not been systematically reviewed up to now. Objectives The aim of the current review is to provide a historical overview of these different systems based on an assessment of published studies. Materials and Methods A systematic Pubmed literature search was performed. Data were extracted and summarised. Results Twenty-two endometriosis classification, staging and reporting systems have been published between 1973 and 2021, each developed for specific and different purposes. There is still no international agreement on how to describe the disease. Studies evaluating different systems are summarised showing a discrepancy between the intended and the evaluated purpose, and a general lack of validation data confirming a correlation with pain symptoms or quality of life for any of the current systems. A few studies confirm the value of the Enzian system for surgical description of deep endometriosis. With regards to infertility, the endometriosis fertility index has been confirmed valid for its intended purpose. Conclusions Of the 22 endometriosis classification, staging and reporting systems identified in this historical overview, only a few have been evaluated, in 46 studies, for the purpose for which they were developed. It can be concluded that there is no international agreement on how to describe endometriosis or how to classify it, and that most classification/staging systems show no or very little correlation with patient outcomes. What is new? This overview of existing systems is a first step in working towards a universally accepted endometriosis classification.
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18
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Bougie O, McClintock C, Pudwell J, Brogly SB, Velez MP. Long-term follow-up of endometriosis surgery in Ontario: a population-based cohort study. Am J Obstet Gynecol 2021; 225:270.e1-270.e19. [PMID: 33894154 DOI: 10.1016/j.ajog.2021.04.237] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 04/02/2021] [Accepted: 04/17/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Endometriosis is a chronic gynecological disease affecting approximately 10% of reproductive aged females and leads to decreased quality of life and productivity. Despite effective medical options, many women do require surgery for endometriosis. There is limited literature examining long term outcomes of endometriosis surgery. OBJECTIVE This study aimed to characterize the long-term outcomes, including recurrence of symptoms, fertility outcomes, and need for reoperation, of patients who underwent surgical management for endometriosis. STUDY DESIGN This was a population-based cohort study in which the universal coverage health database for the province of Ontario, Canada, was used to identify women aged 18 to 50 years who underwent surgery for endometriosis from April 1, 2002, through March 31, 2018. Surgery was classified as diagnostic laparoscopy, conservative or uterine preserving (minor or major, with and without ovarian preservation), or hysterectomy (with and without ovarian preservation). The outcomes were evaluated from 30 days after the index surgery to the end of the study period or at censoring. Cox proportional hazard regression models were used to estimate the hazard ratios between exposures and outcomes following adjustment for confounders. RESULTS A total of 84,885 women 2,718 (3.2%) diagnostic laparoscopy, 21,594 (25.4%) minor conservative surgery, 28,484 (33.6%); major conservative with ovarian preservation, 2,102 (2.5%) major conservative without ovarian preservation, 21,609 (25.5%) hysterectomy with ovarian preservation, and 8,378 (9.9%) hysterectomy without ovarian preservation) were included in the cohort and followed for a median of 10 years (interquartile range, 6-13 years). In the first postoperative year, women who underwent diagnostic laparoscopy were significantly more likely to require repeat surgery (adjusted hazard ratio, 1.68; 95% confidence interval, 1.51-1.87), whereas those who underwent major conservative surgery were significantly less likely to require repeat surgery (with ovarian preservation: adjusted hazard ratio, 0.44; 95% confidence interval, 0.41-0.48; without ovarian preservation: adjusted hazard ratio, 0.05; 95% confidence interval, 0.03-0.09). Among women who did not receive repeat surgery in the first year, those who underwent a diagnostic laparoscopy (adjusted hazard ratio, 0.85; 95% confidence interval, 0.76-0.95) and major conservative surgery without ovarian preservation were less likely to undergo repeat surgery (adjusted hazard ratio, 0.12; 95% confidence interval, 0.09-0.18) than those who initially had minor surgery. Compared with those who initially underwent minor surgery, patients who underwent other treatment modalities were less likely to undergo a hysterectomy (diagnostic laparoscopy: adjusted hazard ratio, 0.85; 95% confidence interval, 0.75-0.96; major surgery with ovarian preservation: adjusted hazard ratio, 0.60; 95% confidence interval, 0.57-0.64; major surgery without ovarian preservation: adjusted hazard ratio, 0.05; 95% confidence interval, 0.03-0.08). Following minor and major conservative with ovarian preservation surgery, 8,331 (38.6%) and 9,498 (33.3%) of patients sought an infertility consult within 1 year, respectively. By 5 years after the index surgery, 5,290 (29.4%) of patients who had minor conservative surgery and 4,528 (20.7%) of those who had major conservative with ovarian preservation surgery had given birth at least once. CONCLUSION Our study suggests that only a few endometriosis patients who undergo hysterectomy surgery require repeat surgery; however, up to 1 in 4 who undergo minor surgery and 1 in 5 who undergo major conservative surgery with ovarian preservation require additional endometriosis surgery. Up to 1 in 3 patients who had uterine sparing endometriosis surgery subsequently sought an infertility assessment. These findings may inform preoperative counseling in terms of recurrence of symptoms, fertility outcomes, and need for reoperation of women seeking surgical management for endometriosis. Future studies should consider the outcomes of patient satisfaction and quality of life based on the current practices for management of endometriosis.
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Affiliation(s)
- Olga Bougie
- Department of Obstetrics and Gynaecology, Queen's University, Kingston Health Sciences Centre, Kingston, Ontario, Canada.
| | - Chad McClintock
- Institute for Clinical Evaluative Sciences, Queen's University, Kingston, Ontario, Canada
| | - Jessica Pudwell
- Department of Obstetrics and Gynaecology, Queen's University, Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Susan B Brogly
- Institute for Clinical Evaluative Sciences, Queen's University, Kingston, Ontario, Canada; Department of Surgery, Queen's University, Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Maria P Velez
- Department of Obstetrics and Gynaecology, Queen's University, Kingston Health Sciences Centre, Kingston, Ontario, Canada; Institute for Clinical Evaluative Sciences, Queen's University, Kingston, Ontario, Canada
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19
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Tapmeier TT, Rahmioglu N, Lin J, De Leo B, Obendorf M, Raveendran M, Fischer OM, Bafligil C, Guo M, Harris RA, Hess-Stumpp H, Laux-Biehlmann A, Lowy E, Lunter G, Malzahn J, Martin NG, Martinez FO, Manek S, Mesch S, Montgomery GW, Morris AP, Nagel J, Simmons HA, Brocklebank D, Shang C, Treloar S, Wells G, Becker CM, Oppermann U, Zollner TM, Kennedy SH, Kemnitz JW, Rogers J, Zondervan KT. Neuropeptide S receptor 1 is a nonhormonal treatment target in endometriosis. Sci Transl Med 2021; 13:13/608/eabd6469. [PMID: 34433639 DOI: 10.1126/scitranslmed.abd6469] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 02/25/2021] [Accepted: 08/06/2021] [Indexed: 12/28/2022]
Abstract
Endometriosis is a common chronic inflammatory condition causing pelvic pain and infertility in women, with limited treatment options and 50% heritability. We leveraged genetic analyses in two species with spontaneous endometriosis, humans and the rhesus macaque, to uncover treatment targets. We sequenced DNA from 32 human families contributing to a genetic linkage signal on chromosome 7p13-15 and observed significant overrepresentation of predicted deleterious low-frequency coding variants in NPSR1, the gene encoding neuropeptide S receptor 1, in cases (predominantly stage III/IV) versus controls (P = 7.8 × 10-4). Significant linkage to the region orthologous to human 7p13-15 was replicated in a pedigree of 849 rhesus macaques (P = 0.0095). Targeted association analyses in 3194 surgically confirmed, unrelated cases and 7060 controls revealed that a common insertion/deletion variant, rs142885915, was significantly associated with stage III/IV endometriosis (P = 5.2 × 10-5; odds ratio, 1.23; 95% CI, 1.09 to 1.39). Immunohistochemistry, qRT-PCR, and flow cytometry experiments demonstrated that NPSR1 was expressed in glandular epithelium from eutopic and ectopic endometrium, and on monocytes in peritoneal fluid. The NPSR1 inhibitor SHA 68R blocked NPSR1-mediated signaling, proinflammatory TNF-α release, and monocyte chemotaxis in vitro (P < 0.01), and led to a significant reduction of inflammatory cell infiltrate and abdominal pain (P < 0.05) in a mouse model of peritoneal inflammation as well as in a mouse model of endometriosis. We conclude that the NPSR1/NPS system is a genetically validated, nonhormonal target for the treatment of endometriosis with likely increased relevance to stage III/IV disease.
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Affiliation(s)
- Thomas T Tapmeier
- Oxford Endometriosis CaRe Centre, Nuffield Department of Women's & Reproductive Health, University of Oxford, Women's Centre, John Radcliffe Hospital, Oxford OX3 9DU, UK. .,Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria 3168, Australia
| | - Nilufer Rahmioglu
- Oxford Endometriosis CaRe Centre, Nuffield Department of Women's & Reproductive Health, University of Oxford, Women's Centre, John Radcliffe Hospital, Oxford OX3 9DU, UK.,Wellcome Centre for Human Genetics, University of Oxford, Oxford OX3 7BN, UK
| | - Jianghai Lin
- Oxford Endometriosis CaRe Centre, Nuffield Department of Women's & Reproductive Health, University of Oxford, Women's Centre, John Radcliffe Hospital, Oxford OX3 9DU, UK.,Institute of Life and Health Engineering, College of Life Science and Technology, Jinan University, Guangzhou, Guangdong 510632, PR China
| | - Bianca De Leo
- Bayer AG Pharmaceuticals, Research & Development, Building S107, 13342 Berlin, Germany
| | - Maik Obendorf
- Bayer AG Pharmaceuticals, Research & Development, Building S107, 13342 Berlin, Germany
| | | | - Oliver M Fischer
- Bayer AG Pharmaceuticals, Research & Development, Building S107, 13342 Berlin, Germany
| | - Cemsel Bafligil
- Nuffield Department of Orthopedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Oxford OX3 7LD, UK
| | - Manman Guo
- Nuffield Department of Orthopedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Oxford OX3 7LD, UK
| | - Ronald Alan Harris
- Human Genome Sequencing Center, Baylor College of Medicine, Houston, TX 77030, USA
| | - Holger Hess-Stumpp
- Bayer AG Pharmaceuticals, Research & Development, Building S107, 13342 Berlin, Germany
| | - Alexis Laux-Biehlmann
- Bayer AG Pharmaceuticals, Research & Development, Building S107, 13342 Berlin, Germany
| | - Ernesto Lowy
- Wellcome Centre for Human Genetics, University of Oxford, Oxford OX3 7BN, UK
| | - Gerton Lunter
- MRC Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DS, UK
| | - Jessica Malzahn
- Nuffield Department of Orthopedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Oxford OX3 7LD, UK
| | - Nicholas G Martin
- QIMR Berghofer Medical Research Institute, Brisbane, Queensland 4006, Australia
| | - Fernando O Martinez
- Faculty of Health and Medical Sciences, University of Surrey, Guildford GU2 7YH, UK
| | - Sanjiv Manek
- Department of Pathology, Oxford University Hospitals Foundation Trust, Oxford OX3 9DU, UK
| | - Stefanie Mesch
- Bayer AG Pharmaceuticals, Research & Development, Building S107, 13342 Berlin, Germany
| | - Grant W Montgomery
- QIMR Berghofer Medical Research Institute, Brisbane, Queensland 4006, Australia.,Institute for Molecular Bioscience, University of Queensland, Brisbane, Queensland 4072, Australia
| | - Andrew P Morris
- Wellcome Centre for Human Genetics, University of Oxford, Oxford OX3 7BN, UK.,Division of Musculoskeletal and Dermatological Sciences, University of Manchester, Manchester M13 9PL, UK
| | - Jens Nagel
- Bayer AG Pharmaceuticals, Research & Development, Building S107, 13342 Berlin, Germany
| | - Heather A Simmons
- Wisconsin National Primate Research Center, University of Wisconsin-Madison, Madison, WI 53715, USA
| | - Denise Brocklebank
- Wellcome Centre for Human Genetics, University of Oxford, Oxford OX3 7BN, UK
| | - Catherine Shang
- Oxford Endometriosis CaRe Centre, Nuffield Department of Women's & Reproductive Health, University of Oxford, Women's Centre, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Susan Treloar
- QIMR Berghofer Medical Research Institute, Brisbane, Queensland 4006, Australia
| | - Graham Wells
- Nuffield Department of Orthopedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Oxford OX3 7LD, UK
| | - Christian M Becker
- Oxford Endometriosis CaRe Centre, Nuffield Department of Women's & Reproductive Health, University of Oxford, Women's Centre, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Udo Oppermann
- Nuffield Department of Orthopedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Oxford OX3 7LD, UK
| | - Thomas M Zollner
- Bayer AG Pharmaceuticals, Research & Development, Building S107, 13342 Berlin, Germany
| | - Stephen H Kennedy
- Oxford Endometriosis CaRe Centre, Nuffield Department of Women's & Reproductive Health, University of Oxford, Women's Centre, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Joseph W Kemnitz
- Wisconsin National Primate Research Center, University of Wisconsin-Madison, Madison, WI 53715, USA.,Department of Cell & Regenerative Biology and Wisconsin National Primate Research Center, University of Wisconsin-Madison, Madison, WI 53706, USA
| | - Jeffrey Rogers
- Human Genome Sequencing Center, Baylor College of Medicine, Houston, TX 77030, USA.,Wisconsin National Primate Research Center, University of Wisconsin-Madison, Madison, WI 53715, USA.,Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX 77030, USA
| | - Krina T Zondervan
- Oxford Endometriosis CaRe Centre, Nuffield Department of Women's & Reproductive Health, University of Oxford, Women's Centre, John Radcliffe Hospital, Oxford OX3 9DU, UK. .,Wellcome Centre for Human Genetics, University of Oxford, Oxford OX3 7BN, UK
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20
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Tomassetti C, Bafort C, Vanhie A, Meuleman C, Fieuws S, Welkenhuysen M, Timmerman D, Van Schoubroeck D, D'Hooghe T. Estimation of the Endometriosis Fertility Index prior to operative laparoscopy. Hum Reprod 2021; 36:636-646. [PMID: 33367865 DOI: 10.1093/humrep/deaa346] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 11/12/2020] [Indexed: 11/13/2022] Open
Abstract
STUDY QUESTION Can the Endometriosis Fertility Index (EFI) be estimated accurately before surgery? SUMMARY ANSWER The EFI can be estimated accurately based on mere clinical/ultrasound information, with some improvement after adding data from diagnostic laparoscopy. WHAT IS KNOWN ALREADY The EFI is a validated clinical instrument predicting the probability of pregnancy after endometriosis surgery without the use of ART. Being an end-of-surgery-score, it implies the decision for operative laparoscopy to be made in advance-hence, its role in the pre-surgical decision-making process remains to be established. STUDY DESIGN, SIZE, DURATION Single-cohort prospective observational study in 82 patients undergoing complete endometriosis excision (between June and December 2016). Two methods were used to estimate the final EFI: type A based on non-surgical clinical/ultrasound findings only, and type B based on the combination of non-surgical clinical/ultrasound findings and diagnostic laparoscopy data. To calculate EFI type A, an algorithm was created to translate non-surgical clinical/imaging information into rASRM (revised American Society of Reproductive Medicine)-and EFI points. EFI type A and type B estimates were assessed for their clinical and numerical agreement with the final EFI score. Agreement was defined as clinical if EFI scores were within the same range (0-4, 5-6, 7-10), and numerical if their difference was ≤1. PARTICIPANTS/MATERIALS, SETTING, METHODS All 82 patients underwent complete laparoscopic CO2-laser excision of any rASRM stage of endometriosis in the Leuven University Fertility Centre (LUFC) of University Hospitals Leuven, a tertiary referral centre for both endometriosis and infertility. An anonymized clinical research file was created. For each patient, three different data sets were created, in order to allow the estimation of the (surgical part) EFI and of the rASRM scores, defined as follows: 'Estimated type A' contained only non-surgical clinical/imaging data, 'Estimated type B' included type A information plus the information of the diagnostic laparoscopy and 'Final EFI' included information of type A, type B and all intra-operative information required to calculate the final EFI. To calculate EFI type A without surgical information, a set of rules was used to translate pre-surgical clinical/imaging information into (rASRM and EFI points). Scoring was done by one person (C.T.), with a time interval of 4 weeks between sessions for each EFI type. Next to the EFI, also rASRM score and stage were calculated. MAIN RESULTS AND THE ROLE OF CHANCE Agreement rate between estimated EFI type A and final EFI was high for both the clinical (0.915; 95% CI 0.832-0.965) and numerical definition (0.878; 95% CI 0.787-0.940). Agreement rates between estimated EFI type B and final EFI were even higher (clinical (0.988; 95% CI 0.934-1.000), numerical (0.963; 95% CI 0.897-0.992)). LIMITATIONS, REASONS FOR CAUTION Type A estimation is dependent on high-level gynaecological ultrasound expertise, which may not be available in all clinics. A small number of patients had no prior clinical, ultrasound (hard markers) or surgical confirmation of the diagnosis of endometriosis. When applying the estimated EFI type A in clinical practice, a priori assumptions of the presence or absence of endometriosis will need to be made in adjunct to the estimation of the estimated type A EFI when counselling patients on the potential benefit of an (at least diagnostic) laparoscopy. The level of agreement for type A or B should also be taken into account when counselling patients on the type of efforts undertaken to attempt to diagnose or rule out endometriosis. WIDER IMPLICATIONS OF THE FINDINGS As this study reports, the EFI can be estimated accurately based on clinical/ultrasound data only without the need for any surgical data. This means that the EFI could be used as an instrument to guide joint physician-patient decision-making between surgery, ART or other fertility management options for the individualized treatment of women with endometriosis-related infertility. STUDY FUNDING/COMPETING INTEREST(S) During this study period, C.T. was supported by FWO (Research Fund Flanders, Grant number 1700816N) and UZ Leuven KOF (University Hospitals Leuven, Klinisch Onderzoeksfonds).The LUFC received unrestricted research grants from Ferring Pharmaceuticals and Merck SA. Gedeon Richter and MSD sponsored travel to and attendance at scientific meetings. C.M. received consultancy fees from Lumenis (paid to KU Leuven, no private revenue). T.D. has been vice-president and head of global medical affairs infertility for the multinational pharmaceutical company Merck (Darmstadt, Germany) since 1 October 2015. He continues his academic appointment on a part-time basis as Professor of Reproductive Medicine at the University of Leuven (KU Leuven). T.D. has been vice-president and head of global medical affairs infertility for the multinational pharmaceutical company Merck (Darmstadt, Germany) since October 2015. He is also a Guest Professor in Reproductive Medicine and Biology at the Department of Development and Regeneration, Group Biomedical Sciences, KU Leuven (University of Leuven), Belgium, and an Adjunct Professor at the Department of Obstetrics and Gynecology in the University of Yale, New Haven, USA. This work was initiated before he joined Merck KGaA in October 2015, and completed during the subsequent years. TRIAL REGISTRATION NUMBER study registration number at UZ Leuven Clinical Trial Centre: S59221.
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Affiliation(s)
- C Tomassetti
- Department of Obstetrics and Gynaecology, Leuven University Fertility Centre, University Hospitals Leuven, Leuven 3000, Belgium.,Department of Development and Regeneration, KU Leuven, Leuven 3000, Belgium
| | - C Bafort
- Department of Obstetrics and Gynaecology, Leuven University Fertility Centre, University Hospitals Leuven, Leuven 3000, Belgium.,Department of Development and Regeneration, KU Leuven, Leuven 3000, Belgium
| | - A Vanhie
- Department of Obstetrics and Gynaecology, Leuven University Fertility Centre, University Hospitals Leuven, Leuven 3000, Belgium.,Department of Development and Regeneration, KU Leuven, Leuven 3000, Belgium
| | - C Meuleman
- Department of Obstetrics and Gynaecology, Leuven University Fertility Centre, University Hospitals Leuven, Leuven 3000, Belgium.,Department of Development and Regeneration, KU Leuven, Leuven 3000, Belgium
| | - S Fieuws
- Department of Public Health, Interuniversity Centre for Biostatistics and Statistical Bioinformatics, KU Leuven, Leuven 3000, Belgium
| | - M Welkenhuysen
- Department of Obstetrics and Gynaecology, Leuven University Fertility Centre, University Hospitals Leuven, Leuven 3000, Belgium
| | - D Timmerman
- Department of Obstetrics and Gynaecology, Leuven University Fertility Centre, University Hospitals Leuven, Leuven 3000, Belgium.,Department of Development and Regeneration, KU Leuven, Leuven 3000, Belgium
| | - D Van Schoubroeck
- Department of Obstetrics and Gynaecology, Leuven University Fertility Centre, University Hospitals Leuven, Leuven 3000, Belgium
| | - T D'Hooghe
- Department of Development and Regeneration, KU Leuven, Leuven 3000, Belgium
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21
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Marlin N, Rivas C, Allotey J, Dodds J, Horne A, Ball E. Development and Validation of Clinical Prediction Models for Surgical Success in Patients With Endometriosis: Protocol for a Mixed Methods Study. JMIR Res Protoc 2021; 10:e20986. [PMID: 33818394 PMCID: PMC8056291 DOI: 10.2196/20986] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 11/18/2020] [Accepted: 11/24/2020] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Endometriosis is a chronic inflammatory condition affecting 6%-10% of women of reproductive age and is defined by the presence of endometrial-like tissue outside the uterus (lesions), commonly affecting the pelvis and ovaries. It is associated with debilitating pelvic pain, infertility, and fatigue and often has devastating effects on the quality of life (QoL). Although it is as common as back pain, it is poorly understood, and treatment and diagnosis are often delayed, leading to unnecessary suffering. Endometriosis has no cure. Surgery is one of several management options. Quantifying the probability of successful surgery is important for guiding clinical decisions and treatment strategies. Factors predicting success through pain reduction after endometriosis surgery have not yet been adequately identified. OBJECTIVE This study aims to determine which women with confirmed endometriosis benefit from surgical improvement in pain and QoL and whether these women could be identified from clinical symptoms measured before laparoscopy. METHODS First, we will carry out a systematic search and review and, if appropriate, meta-analysis of observational cohort and case-control studies reporting one or more risk factors for endometriosis and postsurgical treatment success. We will search PubMed, Embase, and Cochrane databases from inception without language restrictions and supplement the reference lists by manual searches. Second, we will develop separate clinical prediction models for women with confirmed and suspected diagnoses of endometriosis. A total of three suitable databases have been identified for development and external validation (the MEDAL [ISRCTN13028601] and LUNA [ISRCTN41196151] studies, and the BSGE database), and access has been guaranteed. The models will be developed using a linear regression approach that links candidate factors to outcomes. Third, we will hold 2 stakeholder co-design workshops involving eight clinicians and eight women with endometriosis separately and then bring all 16 participants together. Participants will discuss the implementation, delivery, usefulness, and sustainability of the prediction models. Clinicians will also focus on the ease of use and access to clinical prediction tools. RESULTS This project was funded in March 2018 and approved by the Institutional Research Ethics Board in December 2019. At the time of writing, this study was in the data analysis phase, and the results are expected to be available in April 2021. CONCLUSIONS This study is the first to aim to predict who will benefit most from laparoscopic surgery through the reduction of pain or increased QoL. The models will provide clinicians with robustly developed and externally validated support tools, improving decision making in the diagnosis and treatment of women. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/20986.
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Affiliation(s)
- Nadine Marlin
- Pragmatic Clinical Trials Unit, Centre for Primary Care and Public Health, Queen Mary University of London, London, United Kingdom
| | - Carol Rivas
- UCL Social Research Institute, University College London, London, United Kingdom
| | - John Allotey
- Women's Health Research Unit, Centre for Primary Care and Public Health, Queen Mary University of London, London, United Kingdom
| | - Julie Dodds
- Women's Health Research Unit, Centre for Primary Care and Public Health, Queen Mary University of London, London, United Kingdom
| | - Andrew Horne
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, United Kingdom
| | - Elizabeth Ball
- Women's Health Research Unit, Centre for Primary Care and Public Health, Queen Mary University of London, London, United Kingdom
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22
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Keckstein J, Saridogan E, Ulrich UA, Sillem M, Oppelt P, Schweppe KW, Krentel H, Janschek E, Exacoustos C, Malzoni M, Mueller M, Roman H, Condous G, Forman A, Jansen FW, Bokor A, Simedrea V, Hudelist G. The #Enzian classification: A comprehensive non-invasive and surgical description system for endometriosis. Acta Obstet Gynecol Scand 2021; 100:1165-1175. [PMID: 33483970 DOI: 10.1111/aogs.14099] [Citation(s) in RCA: 105] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Revised: 12/09/2020] [Accepted: 01/11/2021] [Indexed: 12/25/2022]
Abstract
Advances in preoperative diagnostics as well as in surgical techniques for the treatment of endometriosis, especially for deep endometriosis, call for a classification system, that includes all aspects of the disease such as peritoneal endometriosis, ovarian endometriosis, deep endometriosis, and secondary adhesions. The widely accepted revised American Society for Reproductive Medicine classification (rASRM) has certain limitations because of its incomplete description of deep endometriosis. In contrast, the Enzian classification, which has been implemented in the last decade, has proved to be the most suitable tool for staging deep endometriosis, but does not include peritoneal or ovarian disease or adhesions. To overcome these limitations, a comprehensive classification system for complete mapping of endometriosis, including anatomical location, size of the lesions, adhesions and degree of involvement of the adjacent organs, that can be used with both diagnostic and surgical methods, has been created through a consensus process and will be described in detail-the #Enzian classification.
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Affiliation(s)
- Jörg Keckstein
- Scientific Endometriosis Foundation (Stiftung Endometriose-Forschung/ SEF, Westerstede, Germany.,Endometriosis Clinic Dres. Keckstein, Villach, Austria.,University of Ulm, Germany
| | - Ertan Saridogan
- Department of Obstetrics and Gynaecology, University College Hospital, London, UK
| | - Uwe A Ulrich
- Scientific Endometriosis Foundation (Stiftung Endometriose-Forschung/ SEF, Westerstede, Germany.,Department of Obstetrics and Gynecology, Endometriosis Center, Martin Luther Hospital, Berlin, Germany
| | - Martin Sillem
- Scientific Endometriosis Foundation (Stiftung Endometriose-Forschung/ SEF, Westerstede, Germany.,Praxisklinik am Rosengarten, Mannheim, Germany.,Department of Obstetrics and Gynecology, Saarland University Medical School, Homburg, Germany
| | - Peter Oppelt
- Scientific Endometriosis Foundation (Stiftung Endometriose-Forschung/ SEF, Westerstede, Germany.,Department for Gynecology, Obstetrics and Gynecological Endocrinology, Kepler University Hospital Linz, Austria
| | - Karl W Schweppe
- Scientific Endometriosis Foundation (Stiftung Endometriose-Forschung/ SEF, Westerstede, Germany
| | - Harald Krentel
- Scientific Endometriosis Foundation (Stiftung Endometriose-Forschung/ SEF, Westerstede, Germany.,Department of Obstetrics and Gynecology, Bethesda Hospital, Duisburg, Germany
| | - Elisabeth Janschek
- Scientific Endometriosis Foundation (Stiftung Endometriose-Forschung/ SEF, Westerstede, Germany.,Department of Obstetrics and Gynecology, Villach General Hospital, Villach, Austria
| | - Caterina Exacoustos
- Department of Obstetrics and Gynecology, Universita Cattolica del Sacro Cuore, Rome, Italy
| | - Mario Malzoni
- Endoscopica Malzoni - Center for Advanced Endoscopic Gynecological Surgery, Avellino, Italy
| | - Michael Mueller
- Scientific Endometriosis Foundation (Stiftung Endometriose-Forschung/ SEF, Westerstede, Germany.,Department of Obstetrics and Gynecology, Inselspital, University of Bern, Bern, Switzerland
| | - Horace Roman
- Endometriosis Center, Clinique Tivoli-Ducos, Bordeaux, France
| | - George Condous
- Acute Gynaecology, Early Pregnancy and Advanced Endoscopy Surgery Unit, Sydney Medical School Nepean, University of Sydney Nepean Hospital, Sydney, Australia
| | - Axel Forman
- Department of Gynecology and Obstetrics, Aarhus University Hospital, Aarhus, Denmark
| | - Frank W Jansen
- Department of Gynecology, Leiden University Medical Center, Leiden, The Netherlands
| | - Attila Bokor
- Department of Obstetrics and Gynecology, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - Voicu Simedrea
- Department of Obstetrics and Gynecology, Regina Maria Clinic, Timisoara, Romania
| | - Gernot Hudelist
- Scientific Endometriosis Foundation (Stiftung Endometriose-Forschung/ SEF, Westerstede, Germany.,Department of Gynaecology, Center for Endometriosis, Hospital St. John of God, Vienna, Austria
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23
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Dückelmann AM, Taube E, Abesadze E, Chiantera V, Sehouli J, Mechsner S. When and how should peritoneal endometriosis be operated on in order to improve fertility rates and symptoms? The experience and outcomes of nearly 100 cases. Arch Gynecol Obstet 2021; 304:143-155. [PMID: 33537880 PMCID: PMC8164581 DOI: 10.1007/s00404-021-05971-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 01/12/2021] [Indexed: 12/18/2022]
Abstract
Purpose To analyze the follow-up results of patients suffering from symptomatic early-stage endometriosis after a consistent laparoscopic peritoneal stripping of the altered peritoneum (peritoneal endometriosis and surrounding inflamed tissue) was performed. This type of endometriosis is resistant to medical therapy and/or impairs fertility. Methods Using our prospectively maintained database, we were able to identify all symptomatic women with the suspicion of only peritoneal endometriosis who underwent laparoscopy at our endometriosis center over a period of 5 years. All procedures were carried out in a standardized fashion by one single surgeon, who is highly experienced in minimal invasive surgery, and included a suspended hormonal pretreatment for 2 months. Postoperative outcomes including complications, fertility and recurrence rates were analysed. Results Laparoscopic peritonectomy was performed on 94 women. Follow-up data were available in 87% of these cases. At the time of surgery, almost all patients tested showed signs of stage I or II endometriosis (44.7 and 48.9%, respectively). More than three-quarters of the women reported pain relief, inter alia, due to the post-surgical hormonal therapy. About one-third of the patients wanted to have children after the procedure. 62% of them became pregnant and the majority did so without the need for assisted reproductive therapy. In seven women a re-operation was performed. Conclusion According to our data, a consistent excision of altered peritoneum followed by adjuvant hormonal therapy and multimodal concepts results in better outcomes for the patient, particularly in regards to pregnancy and recurrence rates.
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Affiliation(s)
- A M Dückelmann
- Department of Gynecology, Charité-Universitätsmedizin BerlinVirchow Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany
| | - E Taube
- Department of Pathology, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - E Abesadze
- Department of Gynecology, Vivantes Clinic Berlin Hellersdorf, Myslowitzerstr. 45, 12621, Berlin, Germany
| | - V Chiantera
- Department of Gynecologic Oncology, University of Palermo, Piazza Marina, 61, 90133, Palermo, Italy
| | - J Sehouli
- Department of Gynecology, Charité-Universitätsmedizin BerlinVirchow Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany
| | - S Mechsner
- Department of Gynecology, Charité-Universitätsmedizin BerlinVirchow Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany.
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Stamenov GS, Vitale SG, Della Corte L, Vilos GA, Parvanov DA, Nikolova DN, Ganeva RR, Haimovich S. Hysteroscopy and female infertility: a fresh look to a busy corner. HUM FERTIL 2020; 25:430-446. [PMID: 33261529 DOI: 10.1080/14647273.2020.1851399] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Hysteroscopy has evolved from the traditional art of examining the uterine cavity for diagnostic purposes to an invaluable modality to concomitantly diagnose and (see and) treat a multitude of intrauterine pathologies, especially in the field and clinics specialising in female reproduction. This article reviews the literature on the most common cervical, endometrial, uterine and tubal pathologies such as chronic endometritis, endometrial polyps, adenomyosis, endometriosis, endometrial atrophy, adhesions, endometrial hyperplasia, cancer, and uterine malformations. The aim is to determine the efficiency of hysteroscopy compared with other available techniques as a diagnostic and treatment tool and its association with the success of in vitro fertilisation procedures. Although hysteroscopy requires an experienced operator for optimal results and is still an invasive procedure, it has the unique advantage of combining great diagnostic and treatment opportunities before and after ART procedures. In conclusion, hysteroscopy should be recommended as a first-line procedure in all cases with female infertility, and a special effort should be made for its implementation in the development of new high-tech procedures for identification and treatment infertility-associated conditions.
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Affiliation(s)
| | - Salvatore Giovanni Vitale
- Obstetrics and Gynecology Unit, Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy
| | - Luigi Della Corte
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples "Federico II", Naples, Italy
| | - George Angelos Vilos
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Western University, London, Canada
| | | | | | | | - Sergio Haimovich
- Hillel Yaffe Medical Center/Technion - Israel Technology Institute, Hadera, Israel
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Fan J, Qin K, Li K, Li X, Huang Q, Liao Y, Liang H, Xie J, Yang Y, Li Q. Modified endometriosis fertility index is more accurate to predict the non-ART pregnancy rate following surgery: a cohort of Chinese women. Arch Gynecol Obstet 2020; 303:1353-1361. [PMID: 33200306 DOI: 10.1007/s00404-020-05871-1] [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: 06/14/2020] [Accepted: 11/02/2020] [Indexed: 01/10/2023]
Abstract
OBJECTIVE To examine whether a modified endometriosis fertility index (EFI) can better predict the rate of pregnancy without assisted reproductive technologies (ART) after laparoscopic surgery in infertile Chinese women with endometriosis. METHODS 564 infertile women undergoing laparoscopy for endometriosis were retrospectively collected from January 2014 to December 2018. 472 patients were used to modify the EFI based on new, optimal cutoffs for its predictor variables. The predictive accuracy of the modified EFI was examined in the other 92 patients. RESULTS Among the patients for the EFI modification, the multivariable Cox regression results showed that historical factors made more contribution in predicting non-ART pregnancy rate than surgical factors both in modified EFI (C-index: historical factors 0.617 vs surgical factors 0.558) and original EFI (C-index: historical factors 0.600 vs surgical factors 0.549). No significant relationship between the prior pregnancy and post-operative non-ART pregnancy rates was detected by both modified EFI and original EFI (p = 0.530 and 0.802, respectively). To assess the predictive effect of modified EFI, the two versions of modified EFI not only had higher predictive accuracy (C-index: 0.627 and 0.632) for non-ART pregnancy rates than that of the original EFI (C-index: 0.602) in the patients undergoing surgery during 2014-2017, but also higher than that of the original EFI (C-index: 0.638 and 0.612 vs 0.560) in the externally validated population in 2018. CONCLUSIONS A modified EFI based on population-specific optimal cutoffs and weights might be more suitable for estimating the rate of non-ART pregnancy after laparoscopic surgery in infertile women with endometriosis.
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Affiliation(s)
- Jiaying Fan
- Department of Gynecology and Obstetrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No. 9 Jinsui Road, Guangzhou, 510120, China
| | - Kang Qin
- Institute of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Kuanrong Li
- Institute of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Xiaojun Li
- Institute of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Qingsheng Huang
- Institute of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Yunsheng Liao
- Department of Gynecology and Obstetrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No. 9 Jinsui Road, Guangzhou, 510120, China
| | - Huiying Liang
- Institute of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Jingying Xie
- Department of Gynecology and Obstetrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No. 9 Jinsui Road, Guangzhou, 510120, China
| | - Yan Yang
- Department of Gynecology and Obstetrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No. 9 Jinsui Road, Guangzhou, 510120, China
| | - Qingfeng Li
- Department of Gynecology and Obstetrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No. 9 Jinsui Road, Guangzhou, 510120, China.
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Kamath MS, Rikken JFW, Bosteels J. Does Laparoscopy and Hysteroscopy Have a Place in the Diagnosis of Unexplained Infertility? Semin Reprod Med 2020; 38:29-35. [PMID: 33080633 DOI: 10.1055/s-0040-1718942] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The standard fertility workup includes assessment of ovulation, semen analysis, and evaluation of tubal patency. If the fertility workup is found to be normal, a diagnosis of unexplained infertility is made. The role of laparoscopy in fertility workup has been a matter of debate. The current review presents the evidence for and against laparoscopy and hysteroscopy during fertility workup and subsequently prior to fertility treatment. After appraising the literature, we found the role of diagnostic laparoscopy in fertility workup is limited and is dependent on factors like prevalence of pelvic infection, setting, and availability of expertise. Moreover, whenever a laparoscopy is planned as a part of the fertility workup, the preparation should include ability to carry out simultaneous therapeutic intervention to maximize the benefit. Similarly, the routine use of hysteroscopy in women with unexplained infertility cannot be recommended. There is a need to investigate the impact of choice of tubal test on chances of spontaneous conception and treatment outcomes in women with unexplained infertility. Our future research agenda should also include high-quality multicenter randomized trials assessing the cost-effectiveness of screening and operative hysteroscopy prior to intrauterine insemination or in vitro fertilization.
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Affiliation(s)
- Mohan S Kamath
- Department of Reproductive Medicine, Christian Medical College, Vellore, India
| | - Judith F W Rikken
- Center for Reproductive Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Jan Bosteels
- Department of Obstetrics and Gynaecology, Imelda Hospital, Bonheiden, Belgium.,Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium.,Department of Development and Regeneration, Gent University, Gent, Belgium
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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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Sen S, Singh K, Agarwal J, Sen G. A Massive Primary Ovarian Abscess within an Endometrioma in a Young Nullipara – An Unusual Case and Review of Literature. FERTILITY & REPRODUCTION 2020. [DOI: 10.1142/s266131822030007x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Primary ovarian abscess without the involvement of the fallopian tube is a rare complication of an underlying endometrioma. Surgical interventions like ultrasound guided oocyte retrieval in in vitro fertilization and endometrioma aspiration may be a possible source of infection. De novo primary ovarian abscess within an endometrioma in the absence of a risk factor is even rarer. Decreased natural killer cell activity leads to a failure to clear out the ectopic endometrial tissue and the collected blood acts as a potential culture medium for the growth of pathogenic microorganisms. Infected ovarian endometrioma is a surgical emergency and preserving the fertility in a nullipara is a challenge. We report an unusual case of a massive de novo ovarian abscess masking an endometrioma in a young nulliparous woman with no risk factors. We have summarized current literature and evaluated the etiopathogenesis and the risk factors leading to abscess formation within an endometrioma.
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Affiliation(s)
- Shashwati Sen
- Department of Reproductive Medicine and Surgery, Mohak Superspeciality Hospital, Prayagraj, India
| | - Kamal Singh
- Department of Reproductive Medicine and Surgery, Mohak Superspeciality Hospital, Prayagraj, India
| | - Jyotima Agarwal
- Department of Pathology, Cytocare Pathology Centre, Prayagraj, India
| | - Gautam Sen
- Department of Radiology, North Central Railway Hospital, Prayagraj, India
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Ferrier C, Boujenah J, Poncelet C, Chabbert-Buffet N, Mathieu D'Argent E, Carbillon L, Grynberg M, Darai E, Bendifallah S. Use of the EFI score in endometriosis-associated infertility: A cost-effectiveness study. Eur J Obstet Gynecol Reprod Biol 2020; 253:296-303. [PMID: 32920265 DOI: 10.1016/j.ejogrb.2020.08.031] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 08/06/2020] [Accepted: 08/21/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND The management of endometriosis-related infertility is still under debate. The Endometriosis Fertility Index (EFI) score is performant to predict the occurrence of a spontaneous pregnancy following surgery, but was not evaluated in a cost-effectiveness perspective. Our objective was to quantify fertility outcomes, and costs of different care pathways for endometriosis-associated infertility after primary surgery, with a stratification on the EFI score. STUDY DESIGN We conducted a cost-effectiveness analysis based on a decision-tree model in a Tertiary-care university hospital. Extracted form a prospectively maintained database, 608 patients with endometriosis-associated infertility, who underwent laparoscopic treatment with an evaluation of the EFI score, were discriminated between different strategies: natural conception, immediate IVF-ICSI, delayed IVF-ICSI. The pregnancy rate and the live birth rate were the effectiveness outcomes. We considered direct and indirect costs in each strategies. The analysis was stratified according to the EFI score. RESULTS After surgery, 163 women with immediate IVF-ICSI (strategy I) were compared with 445 women who had natural conception attempts during a year (strategy II). After a year failure of natural conception attempts, 133 women continuing natural conception attempts (strategy III) were compared with 168 women who had delayed IVF-ICSI (strategy IV). The respective PR and LBR were 62.6 % and 52.1 % for strategy I, and 32.4 % and 23.8 % for strategy II. Compared to strategy II, strategy I was more costly and more effective (Incremental Cost Effectiveness Ratio (ICER): 31,469 €/pregnancy and 33,568 €/live birth)). No added benefit was observed for patients in strategy I with an EFI score [0-3] after two IVF-ICSI cycles. Strategy III was strongly dominant versus strategy IV for patients with an EFI score [9-10]. Compared to strategy III, strategy VI was more costly and more effective (ICER: 79,674 €/pregnancy, 53,188 €/pregnancy and 27,748 €/pregnancy respectively for patients with an EFI score [7-8], [4-6] and [0-3]). CONCLUSION Immediate IVF-ICSI after surgery is effective but associated with substantial costs for the healthcare system. Taking into account healthcare costs, the EFI is a useful score for helping a couple decide between different care pathways -natural conception, immediate or delayed IVF-ICSI- after surgery for endometriosis-associated infertility.
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Affiliation(s)
- Clément Ferrier
- Department of Gynaecology and Obstetrics, Tenon University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Faculty of Medicine Pierre and Marie Curie, Sorbonne University, Paris, France; Groupe de Recherche Clinique GRC6-UPMC: Centre Expert En Endométriose (C3E), France.
| | - Jérémy Boujenah
- Department of Obstetrics, Gynecology and Assisted Reproductive Technologies Centers, Hôpitaux Universitaires Paris Seine Saint-Denis, Assistance Publique-Hôpitaux de Paris, Bondy, France; Faculty Paris 13, UFR SMBH Leonard de Vinci, Sobonne Paris Cité, Bobigny, France
| | - Christophe Poncelet
- Department of Gynaecology and Obstetrics, Centre Hospitalier René Dubos, Pontoise, France; Faculty Paris 13, UFR SMBH Leonard de Vinci, Sobonne Paris Cité, Bobigny, France
| | - Nathalie Chabbert-Buffet
- Department of Gynaecology and Obstetrics, Tenon University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Faculty of Medicine Pierre and Marie Curie, Sorbonne University, Paris, France; Groupe de Recherche Clinique GRC6-UPMC: Centre Expert En Endométriose (C3E), France
| | - Emmanuelle Mathieu D'Argent
- Department of Gynaecology and Obstetrics, Tenon University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Faculty of Medicine Pierre and Marie Curie, Sorbonne University, Paris, France; Groupe de Recherche Clinique GRC6-UPMC: Centre Expert En Endométriose (C3E), France
| | - Lionel Carbillon
- Department of Obstetrics, Gynecology and Assisted Reproductive Technologies Centers, Hôpitaux Universitaires Paris Seine Saint-Denis, Assistance Publique-Hôpitaux de Paris, Bondy, France; Faculty Paris 13, UFR SMBH Leonard de Vinci, Sobonne Paris Cité, Bobigny, France
| | - Michael Grynberg
- Faculty Paris 13, UFR SMBH Leonard de Vinci, Sobonne Paris Cité, Bobigny, France; Department of Reproductive Medicine and Fertility Preservation, Hôpital Antoine Béclère, Hôpitaux Universitaires Paris Sud, Assistance Publique - Hôpitaux de Paris, Clamart 92140, France; Université Paris-Sud, Université Paris Saclay, Le Kremlin Bicêtre, 94276, France
| | - Emile Darai
- Department of Gynaecology and Obstetrics, Tenon University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Faculty of Medicine Pierre and Marie Curie, Sorbonne University, Paris, France; Groupe de Recherche Clinique GRC6-UPMC: Centre Expert En Endométriose (C3E), France
| | - Sofiane Bendifallah
- Department of Gynaecology and Obstetrics, Tenon University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Faculty of Medicine Pierre and Marie Curie, Sorbonne University, Paris, France; Groupe de Recherche Clinique GRC6-UPMC: Centre Expert En Endométriose (C3E), France
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Schippert C, Witte Y, Bartels J, Garcia-Rocha GJ, Jentschke M, Hillemanns P, Kundu S. Reproductive capacity and recurrence of disease after surgery for moderate and severe endometriosis - a retrospective single center analysis. BMC Womens Health 2020; 20:144. [PMID: 32660473 PMCID: PMC7358195 DOI: 10.1186/s12905-020-01016-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 07/07/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Endometriosis can be associated with considerable pain and sterility. After surgical excision of moderate or severe endometriosis lesions, the rate of recurrence reaches up to 67%. The objective of this retrospective study was to establish the recurrence and pregnancy rates following surgical resection of stage III/IV endometriosis lesions. Indications for operation were endometriosis symptoms, sonographic findings and/or infertility. METHODS A total of 456 patients who underwent stage III/IV endometriosis surgery between 2004 and 2014 were sent a questionnaire relating to their postoperative medical treatment, pregnancies, relief of symptoms and recurrence. Responses of 206 patients (45.2%) and their clinical data were analysed for this study. RESULTS A total of 66.5% (N = 137) of patients had stage III disease, and 33.5% (N = 69) had stage IV disease. The average age was 37 years (17-59). A total of 63.1% (N = 130) of surgeries were performed by laparoscopy, 21.8% (N = 45) were performed by laparotomy and 15% (N = 31) were performed by conversion. Complete resection of endometriosis lesions was achieved in 90.8% of patients (N = 187). After surgery, 48.5% (N = 100) of the women did not receive hormonal treatment; the main reason was the desire for children in 53%. Complete or partial relief in complaints was achieved in 93.2% (N = 192). The rate of recurrence was 21.8% (N = 45). The statistically significant factors that was associated with a higher risk to develop recurrence was an age < 35 (p < 0.005). After surgery, 65.8% (79/120) of patients who wished to have children became pregnant. There was a statistically significant association among a higher postoperative pregnancy rate and age < 35 (p < 0.003) in multivariate logistic regression analysis and laparoscopic surgical access in univariate logistic regression analysis (p < 0.01). CONCLUSION We assessed the high percentage of complete or partial relief of symptoms of 93.2%, the high postoperative pregnancy rate of 65.8% and the low rate of recurrence of 21.8% compared to international literature to be very encouraging for women suffering from moderate and severe endometriosis. Though laparoscopy is considered the 'gold standard'of endometriosis surgery, laparotomy still may be indicated in patients with extensive endometriosis especially to preserve reproductive function.
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Affiliation(s)
- Cordula Schippert
- Department of Obstetrics and Gynaecology, Hanover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany.
| | - Yvonne Witte
- Department of Obstetrics and Gynaecology, Hanover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Janina Bartels
- Department of Obstetrics and Gynaecology, Hanover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Guillermo-José Garcia-Rocha
- Department of Obstetrics and Gynaecology, Hanover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Matthias Jentschke
- Department of Obstetrics and Gynaecology, Hanover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Peter Hillemanns
- Department of Obstetrics and Gynaecology, Hanover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Sudip Kundu
- Department of Obstetrics and Gynaecology, Hanover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
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Harris A, McCaughey T, Tsaltas J, Davies-Tuck M, Ratner R, Najjar H, Barel O. Endometriosis-related pelvic pain following laparoscopic surgical treatment. JOURNAL OF ENDOMETRIOSIS AND PELVIC PAIN DISORDERS 2020. [DOI: 10.1177/2284026520926038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction: Endometriosis is a common, often-debilitating disease, affecting women of reproductive age. Pain is a common symptom of the disease and is commonly treated by surgery, medical therapy, or a combination of the two. This study aimed to evaluate the rates of ongoing pain post laparoscopic excision and the risk factors for ongoing pain symptoms. Methods: This retrospective cohort study analyzed the medical records of all patients who underwent laparoscopic surgery for endometriosis in a large tertiary healthcare service in Australia between January 2009 and September 2016. Results were analyzed using SPSS statistics version 11. Results: A total of 972 patients met the inclusion criteria; of these, 398 had follow-up at our hospital network and were included in the final analysis. The median age was 34.5 years, 69.6% were of Caucasian ethnicity, and the median body mass index was 25.9; 70.6% of our patients reported decreased pain after surgery. Patients who suffered from chronic pain were twice as likely to experience ongoing pain, while patients with stage 3–4 endometriosis were found to have 65% reduced odds of pain at follow-up (95% confidence interval = 0.22–0.61, p < 0.001). In univariate analysis of non-Caucasian patients, those who had a specialist endometriosis surgeon perform the surgery had significantly higher incidence of symptom improvement (58% reduced odds of recurrent pain and 40% reduced odds, p < 0.05, accordingly). Conclusion: The prevalence and severity of pain associated with endometriosis mandates a thorough understanding of the effectiveness of current management. Our article highlights the utility of laparoscopic surgery in treating endometriosis-associated pain.
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Affiliation(s)
- Amani Harris
- Gynaecological Endoscopy and Endometriosis Surgery Unit, Monash Health and Monash University, Melbourne, VIC, Australia
| | - Tristan McCaughey
- Gynaecological Endoscopy and Endometriosis Surgery Unit, Monash Health and Monash University, Melbourne, VIC, Australia
- The Royal Women’s Hospital, Melbourne, VIC, Australia
| | - Jim Tsaltas
- Gynaecological Endoscopy and Endometriosis Surgery Unit, Monash Health and Monash University, Melbourne, VIC, Australia
- Melbourne IVF, Melbourne, VIC, Australia
| | - Miranda Davies-Tuck
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
| | - Roni Ratner
- Gynaecological Endoscopy and Endometriosis Surgery Unit, Monash Health and Monash University, Melbourne, VIC, Australia
| | - Haider Najjar
- Gynaecological Endoscopy and Endometriosis Surgery Unit, Monash Health and Monash University, Melbourne, VIC, Australia
- Melbourne IVF, Melbourne, VIC, Australia
| | - Oshri Barel
- Obstetrics and Gynecology, Assuta Medical Center, Ben-Gurion University of the Negev, Ashdod, Israel
- Assuta Ashdod University Hospital, Ashdod, Israel
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Abstract
Endometriosis constitutes the presence of ectopic endometrial glands and stroma outside the uterine endometrium, which is hormonally responsive and responds to pregnancy hormones as well. Decidualization is a physiologic process, where the normal endometrium readies itself for optimal accommodation of a pregnancy. A similar hormonal response can be seen with ectopic endometrium as well. As such, ovarian endometriomas and deep endometriosis implants can undergo decidualization. Overall, the progestational state of pregnancy favors an improvement in endometriosis, however, decidualization can lead to findings that can lead to increased size of endometriomas and deep infiltrative endometriosis implants, changes in imaging appearance and even complications, such as spontaneous hemoperitoneum in pregnancy. Awareness of this process can help prevent misdiagnosis of decidualized endometriomas as ovarian malignancy and recognize common imaging manifestations of hormonal effects of pregnancy on endometriosis.
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Fertility Outcomes After Laparoscopic Cystectomy in Infertile Patients with Stage III-IV Endometriosis: a Cohort with 6-10 years of Follow-up. Adv Ther 2020; 37:2159-2168. [PMID: 32200536 DOI: 10.1007/s12325-020-01299-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Ovarian endometriosis is the most common type of endometriosis (EM), affecting more than 40% of women with EM. Currently, surgical intervention is still controversial in infertile patients with ovarian endometriosis, especially in those with stage III-IV EM. Very few studies have been done to analyze long-term pregnancy results in patients with endometrioma more than 5 years after surgery. Therefore, the aim of this study was to explore the pregnancy outcomes and the related factors in patients with endometrioma and stage III-IV endometriosis during a long-term follow-up postoperatively. METHODS We collected 347 patients with ovarian endometriosis, which included 59 infertile patients with stage III-IV endometriosis who had a minimum of 5 years of postoperative follow-up after undergoing laparoscopic excision of ovarian endometriomas performed by a single doctor at the Peking Union Medical College Hospital from January 2009 to April 2013. RESULTS A total of 59 infertile patients were recruited. The mean age was 31.8 ± 3.6 years. The mean size of the endometriomas was 6.8 ± 3.3 cm. Before surgery, dysmenorrhea was present in 88.1% (52/59) of the cases, while chronic pelvic pain was reported in nine cases (15.3%). A total of 20.3% (12/59) of cases were concurrent with leiomyoma, 52.5% (31/59) with deep infiltrating endometriosis (DIE), and 39.0% (23/59) with adenomyosis. During laparoscopy, 21 cases were diagnosed as stage III (35.6%) and 38 as stage IV (64.4%) EM according to the revised American Fertility Society (AFS) classification. After laparoscopic cystectomy, 38 (64.4%) patients became successfully pregnant by the 5th year. All the patients were divided into two groups according to the postoperative pregnancy outcomes. In univariate analysis, the higher mean age and concurrent diagnosis of adenomyosis were seen to be related to poor postoperative pregnancy outcomes (p < 0.05). In multivariate analysis, however, the mean age, chronic pelvic pain (CPP), and adenomyosis were independent risk factors of pregnancy outcomes between the two groups (p < 0.05). With a minimum follow-up of 6 years, 23.7% (14/59) of recurrence was observed in the entire study cohort. CONCLUSION Infertile patients with endometrioma and stage III-IV EM may have lower pregnancy rates after laparoscopic cystectomy if they are older and present with CPP and adenomyosis. Our data showed a lower rate of recurrence but a higher rate of pregnancy after surgery.
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Sekulovski N, Whorton AE, Shi M, MacLean JA, Hayashi K. Endometriotic inflammatory microenvironment induced by macrophages can be targeted by niclosamide†. Biol Reprod 2020; 100:398-408. [PMID: 30329025 DOI: 10.1093/biolre/ioy222] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 09/17/2018] [Accepted: 10/16/2018] [Indexed: 01/09/2023] Open
Abstract
Endometriosis causes severe chronic pelvic pain and infertility. We have recently reported that niclosamide treatment reduces growth and progression of endometriosis-like lesions and inflammatory signaling (NF${\rm \small K}$B and STAT3) in a mouse model. In the present study, we examined further inhibitory mechanisms by which niclosamide affects endometriotic lesions using an endometriotic epithelial cell line, 12Z, and macrophages differentiated from a monocytic THP-1 cell line. Niclosamide dose dependently reduced 12Z viability, reduced STAT3 and NF${\rm \small K}$B activity, and increased both cleaved caspase-3 and cleaved PARP. To model the inflammatory microenvironment in endometriotic lesions, we exposed 12Z cells to macrophage conditioned media (CM). Macrophages were differentiated from THP-1 cells using 12-O-tetradecanoylphorbol-13-acetate as M0, and then M0 macrophages were polarized into M1 or M2 using LPS/IFNγ or IL4/IL13, respectively. Conditioned media from M0, M1, or M2 cultures increased 12Z viability. This effect was blocked by niclosamide, and cell viability returned to that of CM from cells treated with niclosamide alone. To assess proteins targeted by niclosamide in 12Z cells, CM from 12Z cells cultured with M0, M1, or M2 with/without niclosamide were analyzed by cytokine/chemokine protein array kits. Conditioned media from M0, M1, and/or M2 stimulated the secretion of cytokines/chemokines from 12Z cells. Production of most of these secreted cytokines/chemokines in 12Z cells was inhibited by niclosamide. Knockdown of each gene in 12Z cells using siRNA resulted in reduced cell viability. These results indicate that niclosamide can inhibit the inflammatory factors in endometriotic epithelial cells stimulated by macrophages by targeting STAT3 and/or NF${\rm \small K}$B signaling.
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Affiliation(s)
- Nikola Sekulovski
- Department of Physiology, Southern Illinois University School of Medicine, Carbondale, Illinois, USA
| | - Allison E Whorton
- Department of Physiology, Southern Illinois University School of Medicine, Carbondale, Illinois, USA
| | - Mingxin Shi
- Department of Physiology, Southern Illinois University School of Medicine, Carbondale, Illinois, USA
| | - James A MacLean
- Department of Physiology, Southern Illinois University School of Medicine, Carbondale, Illinois, USA
| | - Kanako Hayashi
- Department of Physiology, Southern Illinois University School of Medicine, Carbondale, Illinois, USA
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Lee D, Kim SK, Lee JR, Jee BC. Management of endometriosis-related infertility: Considerations and treatment options. Clin Exp Reprod Med 2020; 47:1-11. [PMID: 32088944 PMCID: PMC7127898 DOI: 10.5653/cerm.2019.02971] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 07/10/2019] [Accepted: 09/05/2019] [Indexed: 02/06/2023] Open
Abstract
Endometriosis is a common inflammatory disease in women of reproductive age and is one of the major causes of infertility. Endometriosis causes a sustained reduction of ovarian reserve through both physical mechanisms and inflammatory reactions, which result in the production of reactive oxygen species and tissue fibrosis. The severity of endometriosis is related to ovarian reserve. With regard to infertility treatment, medical therapy as a neoadjuvant or adjuvant to surgical therapy has no definite beneficial effect. Surgical treatment of endometriosis can lead to ovarian injury during the resection of endometriotic tissue, which leads to the deterioration of ovarian reserve. To overcome this disadvantage, a multistep technique has been proposed to minimize the reduction of ovarian reserve. When considering surgical treatment of endometriosis in patients experiencing infertility, it should be kept in mind that ovarian reserve can be reduced both due to endometriosis itself and by the process of removing endometriosis. In cases of mild- to moderate-stage endometriosis, intrauterine insemination with ovarian stimulation after surgical treatment may increase the likelihood of pregnancy. In cases of severe endometriosis, the characteristics of the patient should be considered in a multidisciplinary manner to determine the prioritization of treatment modalities, including surgical treatment and assisted reproduction methods such as in vitro fertilization. The risk of cancer, complications after pregnancy, and infection during oocyte retrieval should also be considered when making treatment decisions.
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Affiliation(s)
- Dayong Lee
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Seul Ki Kim
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
| | - Jung Ryeol Lee
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
| | - Byung Chul Jee
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
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van Barneveld E, Veth VB, Sampat JM, Schreurs AMF, van Wely M, Bosmans JE, de Bie B, Jansen FW, Klinkert ER, Nap AW, Mol BWJ, Bongers MY, Mijatovic V, Maas JWM. SOMA-trial: surgery or medication for women with an endometrioma? Study protocol for a randomised controlled trial and cohort study. Hum Reprod Open 2020; 2020:hoz046. [PMID: 33033754 PMCID: PMC7528444 DOI: 10.1093/hropen/hoz046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 10/31/2019] [Indexed: 11/14/2022] Open
Abstract
STUDY QUESTIONS The objective of this study is to evaluate the effectiveness and cost-effectiveness of surgical treatment of women suffering from pain due to an ovarian endometrioma when compared to treatment with medication (analgesia and/or hormones). The primary outcome is defined as successful pain reduction (-30% reduction of pain) measured by the numeric rating scale (NRS) after 6 months. Secondary outcomes include successful pain reduction after 12 and 18 months, quality of life, affective symptoms, cost-effectiveness, recurrence rate, need of adjuvant medication after surgery, ovarian reserve, adjuvant surgery and budget impact. WHAT IS KNOWN ALREADY Evidence suggests that both medication and surgical treatment of an ovarian endometrioma are effective in reducing pain and improving quality of life. However, there are no randomised studies that compare surgery to treatment with medication. STUDY DESIGN SIZE DURATION This study will be performed in a research network of university and teaching hospitals in the Netherlands. A multicentre randomised controlled trial and parallel prospective cohort study in patients with an ovarian endometrioma, with the exclusion of patients with deep endometriosis, will be conducted. After obtaining informed consent, eligible patients will be randomly allocated to either treatment arm (medication or surgery) by using web-based block randomisation stratified per centre. A successful pain reduction is set at a 30% decrease on the NRS at 6 months after randomisation. Based on a power of 80% and an alpha of 5% and using a continuity correction, a sample size of 69 patients in each treatment arm is needed. Accounting for a drop-out rate of 25% (i.e. loss to follow up), we need to include 92 patients in each treatment arm, i.e. 184 in total. Simultaneously, a cohort study will be performed for eligible patients who are not willing to be randomised because of a distinct preference for one of the two treatment arms. We intend to include 100 women in each treatment arm to enable standardization by inverse probability weighting, which means 200 patients in total. The expected inclusion period is 24 months with a follow-up of 18 months. PARTICIPANTS/MATERIALS SETTING METHODS Premenopausal women (age ≥ 18 years) with pain (dysmenorrhoea, pelvic pain or dyspareunia) and an ovarian endometrioma (cyst diameter ≥ 3 cm) who visit the outpatient clinic will make up the study population. Patients with signs of deep endometriosis will be excluded. The primary outcome is successful pain reduction, which is defined as a 30% decrease of pain on the NRS at 6 months after randomisation. Secondary outcomes include successful pain reduction after 12 and 18 months, quality of life and affective symptoms, cost-effectiveness (from a healthcare and societal perspective), number of participants needing additional surgery, need of adjuvant medication after surgery, ovarian reserve and recurrence rate of endometriomas. Measurements will be performed at baseline, 6 weeks and 6, 12 and 18 months after randomisation. STUDY FUNDING/COMPETING INTERESTS This study is funded by ZonMw, a Dutch organization for Health Research and Development, project number 80-85200-98-91041. The Department of Reproductive Medicine of the Amsterdam UMC location VUmc has received several research and educational grants from Guerbet, Merck KGaA and Ferring not related to the submitted work. B.W.J. Mol is supported by a NHMRC Practitioner Fellowship (GNT1082548) and reports consultancy for ObsEva, Merck KGaA and Guerbet. V. Mijatovic reports grants from Guerbet, grants from Merck and grants from Ferring outside the submitted work. All authors declare that they have no competing interests concerning this publication. TRIAL REGISTRATION NUMBER Dutch Trial Register (NTR 7447, http://www.trialregister.nl). TRIAL REGISTRATION DATE 2 January 2019. DATE OF FIRST PATIENT’S ENROLMENT First inclusion in randomised controlled trial October 4, 2019. First inclusion in cohort May 22, 2019.
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Affiliation(s)
- E van Barneveld
- Department of Obstetrics and Gynaecology, Máxima Medical Centre, Veldhoven, the Netherlands
- Research School Grow, Maastricht University, Maastricht, the Netherlands
| | - V B Veth
- Department of Obstetrics and Gynaecology, Máxima Medical Centre, Veldhoven, the Netherlands
- Research School Grow, Maastricht University, Maastricht, the Netherlands
| | - J M Sampat
- Department of Obstetrics and Gynaecology, Máxima Medical Centre, Veldhoven, the Netherlands
- Research School Grow, Maastricht University, Maastricht, the Netherlands
| | - A M F Schreurs
- Department of Reproductive Medicine, Endometriosis Center, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - M van Wely
- Methodology, Department of Obstetrics and Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - J E Bosmans
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, The Netherlands
| | - B de Bie
- Endometriosis Foundation of the Netherlands (Endometriose Stichting), Sittard, The Netherlands
| | - F W Jansen
- Department of Obstetrics and Gynaecology, Leiden University Medical Centre, University of Leiden, Leiden, the Netherlands
| | - E R Klinkert
- Department of Obstetrics and Gynaecology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - A W Nap
- Department of Obstetrics and Gynaecology, Rijnstate Hospital Arnhem, Arnhem, the Netherlands
| | - B W J Mol
- Department of Obstetrics and Gynaecology, Monash Medical Centre Melbourne, Melbourne, Australia
| | - M Y Bongers
- Department of Obstetrics and Gynaecology, Máxima Medical Centre, Veldhoven, the Netherlands
- Research School Grow, Maastricht University, Maastricht, the Netherlands
| | - V Mijatovic
- Department of Reproductive Medicine, Endometriosis Center, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - J W M Maas
- Department of Obstetrics and Gynaecology, Máxima Medical Centre, Veldhoven, the Netherlands
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Ball E, Khan KS. Recent advances in understanding and managing chronic pelvic pain in women with special consideration to endometriosis. F1000Res 2020; 9:F1000 Faculty Rev-83. [PMID: 32089831 PMCID: PMC7001750 DOI: 10.12688/f1000research.20750.1] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/28/2020] [Indexed: 12/26/2022] Open
Abstract
Chronic pelvic pain (CPP) in women is defined variably, but for clinical use it is cyclical or non-cyclical pain of at least 3-6 months' duration. It has major impacts on individuals and society. There are both structural and idiopathic causes. Whereas CPP is not curable in many cases, it is treatable. The most promising approach is multidisciplinary patient-centered care including cause-directed therapy, lifestyle changes, talking therapies, meditation, acupuncture, and physiotherapy (this is not a complete list). One of the most common structural causes for CPP is endometriosis. This review investigates current scientific concepts and recent innovations in this field as well as for CPP in general.
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Affiliation(s)
- Elizabeth Ball
- Department of Obstetrics and Gynaecology, The Royal London Hospital, Barts Health NHS Trust, London, UK
- Women’s Health Research Unit, Yvonne Carter Building, Queen Mary University of London, London, UK
- Centre for Maternal & Child Health Research, School of Health Sciences, City University of London, London, UK
| | - Khalid S Khan
- Department of Public Health, University of Granada, Granada, Spain
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The clinical outcome of Dienogest treatment followed by in vitro fertilization and embryo transfer in infertile women with endometriosis. J Ovarian Res 2019; 12:123. [PMID: 31831028 PMCID: PMC6909621 DOI: 10.1186/s13048-019-0597-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 12/03/2019] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Endometriosis is considered to be the most intractable cause of female infertility. Administering any type of treatment for endometriosis before in vitro fertilization and embryo transfer (IVF-ET) is an important strategy for improving the IVF-ET outcomes for infertile women with endometriosis. In fact, treatment with a gonadotropin-releasing hormone (GnRH) agonist just before IVF-ET has been reported to improve the clinical outcome in endometriosis patients. However, the benefit of Dienogest (DNG), a synthetic progestin, treatment just before IVF-ET remains unclear. METHODS Sixty-eight infertile women with Stage III or IV endometriosis (ovarian endometrial cyst < 4 cm) were recruited for this study. The subjects were divided into 2 groups: a DNG group (n = 33) and a control group (n = 35). DNG was administered orally every day for 12 weeks prior to the conventional IVF-ET cycle in the DNG group. Standard controlled ovarian hyperstimulation with the GnRH agonist long protocol was performed in the control group. The numbers of mature follicles and retrieved oocytes, fertilization rates, implantation rates, and clinical pregnancy rate were compared between the two groups. In addition, the concentrations of inflammatory cytokines, oxidative stress markers, and antioxidants in follicular fluids were also measured. RESULTS The numbers of growing follicles, retrieved oocytes, fertilized oocytes, and blastocysts were significantly lower in the DNG group than in the control group. The fertilization and blastocyst rates were also lower in the DNG group than in the control group. Although there was no significant difference in the implantation rate between the groups, the cumulative pregnancy rate and live birth rate were lower in the DNG group than in the control group. There was no significant difference in the abortion rate. Our results failed to show that DNG reduces the inflammatory cytokine levels and oxidative stress in follicular fluids. CONCLUSIONS Administering DNG treatment just before IVF-ET did not provide any benefits to improve the clinical outcomes for infertile women with endometriosis.
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Singh SS, Gude K, Perdeaux E, Gattrell WT, Becker CM. Surgical Outcomes in Patients With Endometriosis: A Systematic Review. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 42:881-888.e11. [PMID: 31718952 DOI: 10.1016/j.jogc.2019.08.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 07/31/2019] [Accepted: 08/01/2019] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Among women treated surgically for endometriosis-associated pain, comprehensive data are lacking on the proportions of patients who experience little or no symptom relief, develop recurrent symptoms, or require further surgical treatment for endometriosis. The aim of this study was to assess the efficacy of surgical procedures used to treat endometriosis-associated pain. METHODS Medline and Embase were searched on October 13, 2016. Articles referring to women undergoing surgery for the treatment of endometriosis-associated pain were screened by two independent investigators. For each included treatment arm, data were extracted for the proportion of patients reporting partial or no improvement after surgery for endometriosis-associated pain, pain recurrence, or requirement for further surgery. RESULTS A total of 38 studies were included. Most studies did not report relevant outcomes to evaluate pain (71.1%) and recurrent surgery (68.4%). Of the women who underwent lesion excision, 11.8% reported no improvement in pain, and 22.6% underwent further surgery. Postoperative pain, recurrent pain, and adverse events were reported by 34.3%, 28.7%, and 14.8%, respectively, of patients who underwent excision or ablation of endometriosis combined with pelvic denervation and in 25.0%, 15.8%, and 8.1% of women who underwent lesion excision alone. Of the patients who were treated surgically for deep endometriosis affecting the bowel and/or bladder, 7.0% experienced recurrent symptoms, and 4.1% underwent further surgery. CONCLUSION This review supports the findings of previous studies and highlights the need for standardized reporting and more detailed follow-up after surgery for endometriosis-associated pain.
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Affiliation(s)
- Sukhbir S Singh
- Department of Obstetrics and Gynecology, The Ottawa Hospital & University of Ottawa, Ottawa, ON.
| | - Kerstin Gude
- Global Pharmacovigilance, Bayer AG, Berlin, Germany
| | | | - William T Gattrell
- Research Evaluation Unit, Oxford PharmaGenesis, Oxford, United Kingdom; Department of Mechanical Engineering and Mathematical Sciences, Oxford Brookes University, Oxford, United Kingdom
| | - Christian M Becker
- Endometriosis Care and Research (CaRe) Centre, Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, United Kingdom
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Ceccaroni M, Bounous VE, Clarizia R, Mautone D, Mabrouk M. Recurrent endometriosis: a battle against an unknown enemy. EUR J CONTRACEP REPR 2019; 24:464-474. [PMID: 31550940 DOI: 10.1080/13625187.2019.1662391] [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] [Indexed: 12/20/2022]
Abstract
Recurrence of endometriosis after conservative surgery is not an uncommon finding. There is no uniformity, however, on what the term 'recurrence' means. Recurrence is variously defined in the literature as the relapse of pain, clinical or instrumental detection of an endometriotic lesion, repeat rise in CA 125 levels, or evidence of recurrence found during repeat surgery. Consequently, the reported recurrence rate varies widely (0-89%) in the different series, depending on its definition and the type of study performed. As endometriosis recurrence seems to be an indeterminate enemy, we set out to examine exactly what we were fighting in our everyday battle. In this narrative review, we aimed to seek an answer to questions related to endometriosis recurrence, some of which are often asked by our patients.
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Affiliation(s)
- Marcello Ceccaroni
- Department of Obstetrics and Gynaecology, Gynaecological Oncology and Minimally Invasive Pelvic Surgery, International School of Surgical Anatomy, Sacred Heart Hospital, Negrar, Verona, Italy
| | - Valentina Elisabetta Bounous
- Department of Surgical Sciences, Unit of Gynaecology and Obstetrics, Mauriziano Umberto I Hospital, University of Turin, Turin, Italy
| | - Roberto Clarizia
- Department of Obstetrics and Gynaecology, Gynaecological Oncology and Minimally Invasive Pelvic Surgery, International School of Surgical Anatomy, Sacred Heart Hospital, Negrar, Verona, Italy
| | - Daniele Mautone
- Department of Obstetrics and Gynaecology, Gynaecological Oncology and Minimally Invasive Pelvic Surgery, International School of Surgical Anatomy, Sacred Heart Hospital, Negrar, Verona, Italy
| | - Mohamed Mabrouk
- Minimally Invasive Pelvic Surgery Unit, Sant'Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
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Benoit L, Boujenah J, Poncelet C, Grynberg M, Carbillon L, Nyangoh Timoh K, Touleimat S, Mathieu D'Argent E, Jayot A, Owen C, Lavoue V, Roman H, Darai E, Bendifallah S. Predicting the likelihood of a live birth for women with endometriosis-related infertility. Eur J Obstet Gynecol Reprod Biol 2019; 242:56-62. [PMID: 31563819 DOI: 10.1016/j.ejogrb.2019.09.011] [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: 06/19/2019] [Revised: 09/04/2019] [Accepted: 09/18/2019] [Indexed: 01/10/2023]
Abstract
OBJECTIVE Endometriosis affects 10% of women in reproductive age and alters fertility. Its management is still debated notably the timing of surgery and ART in infertility. Several tools have been created to guide the practitioner and the couple yet many limitations persist. The objective is to create a nomogram to predict the likelihood of a live birth after surgery followed by assisted reproductive technology (ART) for patients with endometriosis-related infertility. STUDY DESIGN All women in a public university hospital who attempted to conceive by ART after surgery for endometriosis-related infertility from 2004 to 2016 were included. We created a model using multivariable linear regression based on a retrospective database. RESULT Of the 297 women included, 171 (57.6%) obtained a live birth. Age, duration of infertility, number of ICSI-IVF cycles, ovarian reserve and the revised American Fertility Society (rAFS) score were included in the nomogram. The predictive model had an area under the curve (AUC) of 0.77 (95% CI, 0.75-0.79) and was well calibrated. The external validation of the model was achieved with an AUC of 0.71 (95% CI, 0.69-0.73) and calibration was good. The staging accuracy according to AUC criteria for the nomogram compared to the currently used Endometriosis Infertility Index to predict live births were 0.77 (95% CI, 0.75-0.79) and 0.60 (95% CI: 0.57-0.63), respectively. CONCLUSION This simple tool appears to accurately predict the likelihood of a live birth for a patient undergoing ART after surgery for endometriosis-related infertility. It could be used to counsel patients in their choice between spontaneous versus ART conception, or oocyte donation.
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Affiliation(s)
- L Benoit
- Department of Gynecology and Obstetrics, Tenon University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Sorbonne University, Paris, France.
| | - J Boujenah
- Department of Obstetrics, Gynecology and Assisted Reproductive Technologies Centers, Hôpitaux Universitaires Paris Seine Saint-Denis, Assistance Publique-Hôpitaux de Paris, Bondy, France; University of Paris 13, Sorbonne University, Bobigny, France
| | - C Poncelet
- Department of Obstetrics, Gynecology and Assisted Reproductive Technologies Centers, Hôpitaux Universitaires Paris Seine Saint-Denis, Assistance Publique-Hôpitaux de Paris, Bondy, France; University of Paris 13, Sorbonne University, Bobigny, France
| | - M Grynberg
- Department of Gynecology and Obstetrics, Antoine Béclère Hospital, Clamart, France
| | - L Carbillon
- Department of Obstetrics, Gynecology and Assisted Reproductive Technologies Centers, Hôpitaux Universitaires Paris Seine Saint-Denis, Assistance Publique-Hôpitaux de Paris, Bondy, France; University of Paris 13, Sorbonne University, Bobigny, France
| | - K Nyangoh Timoh
- Department of Gynecology and Obstetrics, CHU de Rennes, Hôpital sud, 16 bd de Bulgarie, 35000 Rennes, France
| | - S Touleimat
- Expert Center in the Diagnosis and Multidisciplinary Management of Endometriosis, Rouen University Hospital, 76031 Rouen, France
| | - Emmanuelle Mathieu D'Argent
- Department of Gynecology and Obstetrics, Tenon University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Sorbonne University, Paris, France
| | - Aude Jayot
- Department of Gynecology and Obstetrics, Tenon University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Sorbonne University, Paris, France
| | - Clémentine Owen
- Department of Gynecology and Obstetrics, Tenon University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Sorbonne University, Paris, France
| | - V Lavoue
- Department of Gynecology and Obstetrics, CHU de Rennes, Hôpital sud, 16 bd de Bulgarie, 35000 Rennes, France
| | - H Roman
- Expert Center in the Diagnosis and Multidisciplinary Management of Endometriosis, Rouen University Hospital, 76031 Rouen, France
| | - E Darai
- Department of Gynecology and Obstetrics, Tenon University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Sorbonne University, Paris, France; Groupe de Recherche Clinique 6 (GRC6-UPMC): Centre Expert En Endométriose (C3E), France; UMR_S938, Research Center of Saint Antoine, Sorbonne University, Paris 6, France
| | - S Bendifallah
- Department of Gynecology and Obstetrics, Tenon University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Sorbonne University, Paris, France; Groupe de Recherche Clinique 6 (GRC6-UPMC): Centre Expert En Endométriose (C3E), France; UMR_S938, Research Center of Saint Antoine, Sorbonne University, Paris 6, France
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As-Sanie S, Black R, Giudice LC, Gray Valbrun T, Gupta J, Jones B, Laufer MR, Milspaw AT, Missmer SA, Norman A, Taylor RN, Wallace K, Williams Z, Yong PJ, Nebel RA. Assessing research gaps and unmet needs in endometriosis. Am J Obstet Gynecol 2019; 221:86-94. [PMID: 30790565 DOI: 10.1016/j.ajog.2019.02.033] [Citation(s) in RCA: 159] [Impact Index Per Article: 31.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 02/11/2019] [Accepted: 02/14/2019] [Indexed: 12/29/2022]
Abstract
Endometriosis, a systemic disease that is often painful and chronic, affects ∼10% of reproductive-age women. The disease can have a negative impact on a patient's physical and emotional well-being, quality of life, and productivity. Endometriosis also places significant economic and social burden on patients, their families, and society as a whole. Despite its high prevalence and cost, endometriosis remains underfunded and underresearched, greatly limiting our understanding of the disease and slowing much-needed innovation in diagnostic and treatment options. Due in part to the societal normalization of women's pain and stigma around menstrual issues, there is also a lack of disease awareness among patients, health care providers, and the public. The Society for Women's Health Research convened an interdisciplinary group of expert researchers, clinicians, and patients for a roundtable meeting to review the current state of the science on endometriosis and identify areas of need to improve a woman's diagnosis, treatment, and access to quality care. Comprehensive and interdisciplinary approaches to disease management and increased education and disease awareness for patients, health care providers, and the public are needed to remove stigma, increase timely and accurate diagnosis and treatment, and allow for new advancements.
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Tomassetti C, Bafort C, Meuleman C, Welkenhuysen M, Fieuws S, D'Hooghe T. Reproducibility of the Endometriosis Fertility Index: a prospective inter-/intra-rater agreement study. BJOG 2019; 127:107-114. [PMID: 31319445 DOI: 10.1111/1471-0528.15880] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2019] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To evaluate the reproducibility of the Endometriosis Fertility Index (EFI). DESIGN Single-cohort prospective observational study. SETTING University hospital. POPULATION Women undergoing laparoscopic resection of any rASRM-stage endometriosis. METHODS Details of pre- and peroperative findings were collected into a coded research file. EFI scoring was performed en-bloc by three different raters (expert-1 [C.T.], expert-2 [C.M.], junior [C.B.]). Required sample size: 71. Definitions used for agreement: clinical (scores within same range: 0-4, 5-6, 7-10) and numerical (difference ≤1 EFI point). MAIN OUTCOME MEASURES Primary outcome: rate of clinical agreement between two experts. SECONDARY OUTCOMES expert numerical agreement, clinical and numerical agreement between expert-1 and junior, and within expert-1 (intra-observer), agreement of rASRM score and -stage. RESULTS A near 'inter-expert' clinical agreement rate (1.000, 95% CI 0.956-1.000; P = 0.0149) was observed. The numerical agreement between two experts was also high (0.988, 95% CI 0.934-1.000); similarly, high agreement rates were observed for both 'junior-expert' comparisons (clinical 0 .963, 95% CI 0.897-0.992; numerical 0.988, 95% CI 0.934-1.000) and 'intra-expert' comparisons (clinical 0.988, 95% CI 0.934-1.000; numerical 1.000, 95% CI 0.956-1.000). Reasons for disagreements were different scoring of the least-function score and disagreements in rASRM scores. The reproducibility of the rASRM score was clearly inferior to that of the EFI for all comparisons. CONCLUSION The EFI can be reproduced reliably by different raters, further supporting its use in daily clinical practice as the principal clinical tool for postoperative fertility counselling/management of women with endometriosis. TWEETABLE ABSTRACT A study confirming the high reproducibility of the EFI substantiates its use in daily clinical practice.
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Affiliation(s)
- C Tomassetti
- Department of Obstetrics and Gynaecology, Leuven University Fertility Centre, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - C Bafort
- Department of Obstetrics and Gynaecology, Leuven University Fertility Centre, University Hospitals Leuven, Leuven, Belgium
| | - C Meuleman
- Department of Obstetrics and Gynaecology, Leuven University Fertility Centre, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - M Welkenhuysen
- Department of Obstetrics and Gynaecology, Leuven University Fertility Centre, University Hospitals Leuven, Leuven, Belgium
| | - S Fieuws
- Department of Public Health, Interuniversity Centre for Biostatistics and Statistical Bioinformatics, KU Leuven, Leuven, Belgium
| | - T D'Hooghe
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
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Arfi A, Bendifallah S, Mathieu D'argent E, Poupon C, Ballester M, Cohen J, Darai E. Nomogram predicting the likelihood of live-birth rate after surgery for deep infiltrating endometriosis without bowel involvement in women who wish to conceive: A retrospective study. Eur J Obstet Gynecol Reprod Biol 2019; 235:81-87. [PMID: 30831447 DOI: 10.1016/j.ejogrb.2019.02.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 12/12/2018] [Accepted: 02/05/2019] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To study the fertility and live birth (LB) rate in women after surgery for deep infiltrating endometriosis (DIE) without bowel involvement and to evaluate the predictive factors of LB after DIE surgery without bowel involvement. STUDY DESIGN Retrospective cohort study. A total of 118 women who wished to conceive and who underwent surgery for DIE without bowel involvement were analyzed between January 2006 and December 2014. A multivariate logistic regression analysis of selected factors and a nomogram to predict the subsequent LB rate was constructed. RESULTS Thirty-six woman had a LB (30.5%). In multivariate analysis, factors associated with a LB were: age ≤30 years (p = 0.0024), BMI ≤ 25 kg/m2 (p = 0.029) and Enzian grade 1 (p < 0.001). These factors were associated to develop a nomogram. Before and after the bootstrap sampling procedure, the predictive model had an AUC of 0.84 (95% CI, 0.82-0.86) and 0.81 (95% CI, 0.79-83), respectively, and showed a good calibration. CONCLUSIONS This work presents the originality of describing the fertility and the LB rate after surgery for DIE without bowel involvement with a predictive model. Such tools can help clinicians to support the patient in making an informed decision about fertility treatment options, contributing to the decision-making process by defining simple risk factors of poor LB probability that can help identify good candidates for MAR.
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Affiliation(s)
- Alexandra Arfi
- Department of Gynaecology and Obstetrics, Tenon University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), University Pierre and Marie Curie, Paris 6, France.
| | - Sofiane Bendifallah
- Department of Gynaecology and Obstetrics, Tenon University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), University Pierre and Marie Curie, Paris 6, France; INSERM UMR_S_707, Epidemiology, Information Systems, Modeling, University Pierre and Marie Curie, Paris 6, France
| | - Emmanuelle Mathieu D'argent
- Department of Gynaecology and Obstetrics, Tenon University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), University Pierre and Marie Curie, Paris 6, France
| | - Clothilde Poupon
- Department of Gynaecology and Obstetrics, Tenon University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), University Pierre and Marie Curie, Paris 6, France
| | - Marcos Ballester
- Department of Gynaecology and Obstetrics, Tenon University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), University Pierre and Marie Curie, Paris 6, France; Groupe de Recherche Clinique 6 (GRC6-UPMC), Centre Expert En Endométriose (C3E), France; UMR_S938 Université Pierre et Marie Curie Paris 6, France
| | - Jonathan Cohen
- Department of Gynaecology and Obstetrics, Tenon University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), University Pierre and Marie Curie, Paris 6, France
| | - Emile Darai
- Department of Gynaecology and Obstetrics, Tenon University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), University Pierre and Marie Curie, Paris 6, France; Groupe de Recherche Clinique 6 (GRC6-UPMC), Centre Expert En Endométriose (C3E), France; UMR_S938 Université Pierre et Marie Curie Paris 6, France
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Yang P, Wang Y, Wu Z, Pan N, Yan L, Ma C. Risk of miscarriage in women with endometriosis undergoing IVF fresh cycles: a retrospective cohort study. Reprod Biol Endocrinol 2019; 17:21. [PMID: 30755216 PMCID: PMC6371538 DOI: 10.1186/s12958-019-0463-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 01/31/2019] [Indexed: 02/10/2023] Open
Abstract
BACKGROUND Endometriosis is thought to affect the effectiveness of ART by an increased risk of miscarriage. We aimed to investigate the impact of endometriosis in women achieving singleton pregnancies through IVF fresh cycles and risk of miscarriage. METHODS This retrospective cohort study included all women undergoing a first IVF cycle and achieving singleton pregnancies after fresh embryo transfer in a tertiary university hospital reproductive medical center between January 2008 and June 2016. Women with endometriosis were compared with women with no endometriosis. Women in the endometriosis group were all with a history of laparoscopy or laparotomy for endometriosis and/or with ovarian endometrioma. The control group was matched 1:2 according to age and study period. RESULTS Among the cohort, we identified 1006 women with endometriosis as study group and 2012 unaffected women matched in a 1:2 ratios as control group. The miscarriage rate between women with and without endometriosis was similar (22.4 and 20.1%, P = 0.085). The odds ratio after adjusting for the risk factors for miscarriage was 1.14 (95% confidence interval 0.95-1.37). In the study group, the women with and without endometrioma did not show a significant risk of miscarriage, (19.8 and 23.8%, P = 0.152, OR 0.79, 95% CI 0.58-1.09). The miscarriage rate in women with endometrioma ≥30 mm (37.3 ± 7.1 mm) and < 30 mm (19.3 ± 5.5 mm) was not significantly different, (24.7 and 18.5%, P = 0.229, OR 1.44, 95% CI 0.79-2.63). After adjustment for risk factors for miscarriage, the presence of endometrioma and the size of endometrioma, regression model confirmed no significant increase for the risk of miscarriage in the subgroup analyses. CONCLUSIONS The risk of miscarriage did not statistically increase in women with endometriosis who achieved pregnancy through IVF fresh cycles.
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Affiliation(s)
- Puyu Yang
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Haidian district, North garden road, No 49, Beijing, People's Republic of China
- National Clinical Research Center for Obstetrics and Gynecology, Beijing, 100191, China
- Key Laboratory of Assisted Reproduction (Peking University), Ministry of Education, Beijing, 100191, China
| | - Yang Wang
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Haidian district, North garden road, No 49, Beijing, People's Republic of China
- National Clinical Research Center for Obstetrics and Gynecology, Beijing, 100191, China
| | - Zhangxin Wu
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Haidian district, North garden road, No 49, Beijing, People's Republic of China
- National Clinical Research Center for Obstetrics and Gynecology, Beijing, 100191, China
| | - Ningning Pan
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Haidian district, North garden road, No 49, Beijing, People's Republic of China
- National Clinical Research Center for Obstetrics and Gynecology, Beijing, 100191, China
| | - Liying Yan
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Haidian district, North garden road, No 49, Beijing, People's Republic of China
- National Clinical Research Center for Obstetrics and Gynecology, Beijing, 100191, China
- Key Laboratory of Assisted Reproduction (Peking University), Ministry of Education, Beijing, 100191, China
| | - Caihong Ma
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Haidian district, North garden road, No 49, Beijing, People's Republic of China.
- National Clinical Research Center for Obstetrics and Gynecology, Beijing, 100191, China.
- Key Laboratory of Assisted Reproduction (Peking University), Ministry of Education, Beijing, 100191, China.
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Gordts S, Campo R. Modern approaches to surgical management of endometrioma. Best Pract Res Clin Obstet Gynaecol 2019; 59:48-55. [PMID: 30709745 DOI: 10.1016/j.bpobgyn.2018.12.013] [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: 11/13/2018] [Revised: 12/29/2018] [Accepted: 12/31/2018] [Indexed: 11/17/2022]
Abstract
Formation of the ovarian endometrioma consists of implantation, invagination of the ovarian cortex, and adhesion formation. Progression is characterized by repeated injury and repair with degenerative changes. Already with a partially deprived ovarian reserve, resulting from the disease, surgical treatment carries a potential risk of further follicular deprivation. Surgery should therefore be performed with microsurgical precision by experienced hands. Early treatment can possibly prevent further progression. The adverse impact on ovarian reserve of the ablative approach has to be balanced against a lower recurrence rate of a cystectomy. Adapted surgical approaches like a two-step approach or a combination of excisional and ablative surgery has to be considered in case of a large endometrioma. Further studies on the possibility and advantages of sclerotherapy are warranted. Fertility preservation by cryopreservation of ovarian cortex should be part of the informed consent with the patient.
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Affiliation(s)
- S Gordts
- Leuven Institute for Fertility & Embryology, Schipvaartstraat 4, 3000 Leuven, Belgium.
| | - R Campo
- Leuven Institute for Fertility & Embryology, Schipvaartstraat 4, 3000 Leuven, Belgium
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Lee JH, Lee BS. Updated guideline for clinical evaluation and management of endometriosis. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2019. [DOI: 10.5124/jkma.2019.62.10.525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Jae Hoon Lee
- Department of Obstetrics and Gynecology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Byung Seok Lee
- Department of Obstetrics and Gynecology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Ovarian endometriosis and infertility: in vitro fertilization (IVF) or surgery as the first approach? Fertil Steril 2018; 110:1218-1226. [DOI: 10.1016/j.fertnstert.2018.10.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 10/02/2018] [Indexed: 01/01/2023]
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Clinical evaluation and management of endometriosis: guideline for Korean patients from Korean Society of Endometriosis. Obstet Gynecol Sci 2018; 61:553-564. [PMID: 30254991 PMCID: PMC6137012 DOI: 10.5468/ogs.2018.61.5.553] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 03/30/2018] [Accepted: 04/24/2018] [Indexed: 12/04/2022] Open
Abstract
Endometriosis is one of the most common diseases in reproductive ages, and it affects patients' quality of life and fertility. However, few Korean guidelines are available for the evaluation and management of endometriosis. Korean Society of Endometriosis reviewed various literatures and trials, and to provide seventy-one evidence-based recommendations. This review presents guidelines for the diagnosis and management of endometriosis with emphasis on: it's role in infertility, treatment of recurrence, asymptomatic women, endometriosis in adolescents and menopausal women, and possible association of endometriosis with cancer.
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Andres MP, Borrelli GM, Abrão MS. Endometriosis classification according to pain symptoms: can the ASRM classification be improved? Best Pract Res Clin Obstet Gynaecol 2018; 51:111-118. [DOI: 10.1016/j.bpobgyn.2018.06.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 06/07/2018] [Indexed: 11/15/2022]
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