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Nezhat FR, Cathcart AM, Nezhat CH, Nezhat CR. Pathophysiology and Clinical Implications of Ovarian Endometriomas. Obstet Gynecol 2024; 143:759-766. [PMID: 38626453 PMCID: PMC11090516 DOI: 10.1097/aog.0000000000005587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Revised: 03/12/2024] [Accepted: 03/14/2024] [Indexed: 04/18/2024]
Abstract
Ovarian endometriomas affect many patients with endometriosis and have significant effects on quality of life, fertility, and risk of malignancy. Endometriomas range from small (1-3 cm), densely fibrotic cysts to large (20 cm or greater) cysts with varying degrees of fibrosis. Endometriomas are hypothesized to form from endometriotic invasion or metaplasia of functional cysts or alternatively from ovarian surface endometriosis that bleeds into the ovarian cortex. Different mechanisms of endometrioma formation may help explain the phenotypic variability observed among endometriomas. Laparoscopic surgery is the preferred first-line modality of diagnosis and treatment of endometriomas. Ovarian cystectomy is preferred over cyst ablation or sclerotherapy for enabling pathologic diagnosis, improving symptoms, preventing recurrence, and optimizing fertility outcomes. Cystectomy for small, densely adherent endometriomas is made challenging by dense fibrosis of the cyst capsule obliterating the plane with normal ovarian cortex, whereas cystectomy for large endometriomas can carry unique challenges as a result of adhesions between the cyst and pelvic structures. Preoperative and postoperative hormonal suppression can improve operative outcomes and decrease the risk of endometrioma recurrence. Whether the optimal management, fertility consequences, and malignant potential of endometriomas vary on the basis of size and phenotype remains to be fully explored.
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Affiliation(s)
- Farr R Nezhat
- Weill Cornell Medical College, Cornell University, New York, and NYU Long Island School of Medicine, Mineola, New York; the Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon; the Atlanta Center for Minimally Invasive Surgery and Reproductive Medicine, Atlanta, Georgia; and the Center for Special Minimally Invasive and Robotic Surgery, and Stanford University Medical Center, Palo Alto, and the University of California, San Francisco, San Francisco, California
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Urman B, Ata B, Gomel V. Reproductive surgery remains an essential element of reproductive medicine. Facts Views Vis Obgyn 2024; 16:145-162. [PMID: 38950529 DOI: 10.52054/fvvo.16.2.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/03/2024] Open
Abstract
Background Reproductive surgery has long been neglected and is perceived to be simple surgery that can be undertaken by all gynaecologists. However, given the ever-expanding knowledge in the field, reproductive surgery now comprises surgical interventions on female reproductive organs that need to be carefully planned and executed with consideration given to the individuals symptoms, function of the organ and fertility concerns. Objectives To discuss the different perspectives of reproductive surgeons and other gynaecological surgeons, e.g., gynaecological oncologists, and advanced minimally invasive surgeons, regarding diagnosis and management of pelvic pathology that affects reproductive potential. Furthermore, to highlight the gaps in knowledge and numerous controversies surrounding reproductive surgery, while summarising the current opinion on management. Materials and Methods Narrative review based on literature and the cumulative experience of the authors. Main outcome measures The paper does not address specific research questions. Conclusions Reproductive surgery encompasses all reproductive organs with the aim of alleviating symptoms whilst restoring and preserving function with careful consideration given to alternatives such as expectant management, medical treatments, and assisted reproductive techniques. It necessitates utmost technical expertise and sufficient knowledge of the female genital anatomy and physiology, together with a thorough understanding of and respect to of ovarian reserve, tubal function, and integrity of the uterine anatomy, as well as an up-to-date knowledge of alternatives, mainly assisted reproductive technology. What is new? A holistic approach to infertile women is only possible by focusing on the field of reproductive medicine and surgery, which is unattainable while practicing in multiple fields.
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Agnihotri T, Ghosh A, Lamba A, Ray CE. Endometriosis: An Overview. Semin Intervent Radiol 2023; 40:544-548. [PMID: 38274215 PMCID: PMC10807967 DOI: 10.1055/s-0043-1777748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
Affiliation(s)
- Tanvir Agnihotri
- Department of Radiology, New York University School of Medicine, New York, New York
| | - Abheek Ghosh
- University of Maryland School of Medicine, Baltimore, Maryland
| | - Ashley Lamba
- Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Charles E. Ray
- Department of Radiology, University of Illinois College of Medicine, Chicago, Illinois
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Mechsner S. [Holistic treatment of endometriosis]. Schmerz 2023; 37:437-447. [PMID: 37626190 DOI: 10.1007/s00482-023-00747-0] [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: 12/28/2022] [Revised: 06/26/2023] [Accepted: 07/04/2023] [Indexed: 08/27/2023]
Abstract
BACKGROUND The pain phenomena caused by endometriosis are manifold. In addition to nociceptive pain there is also a nociplastic reaction with central sensitization. Atypical symptoms, such as acyclic lower abdominal pain, radiating pain, nonspecific bladder and intestinal complaints or even depression increasingly occur in addition to the classical cyclic complaints, such as severe dysmenorrhea, cyclic lower abdominal pain, dyspareunia, dysuria and dyschezia. Due to the diffuse range of symptoms, affected patients often consult not just gynecologists but also specialists from other disciplines (internal medicine, gastroenterology, orthopedics, pain therapy, psychology etc.). OBJECTIVE The complexity of endometriosis is presented. The resulting approaches to multimodal interdisciplinary holistic treatment are described. RESULTS Interdisciplinary concepts should be involved in the optimal treatment of endometriosis patients along with hormonal and surgical treatment, mostly under the supervision of a gynecologist and pain management, dietary changes, psychological support and physiotherapeutic management should also be included. This article provides an overview of possible treatment strategies for chronic symptomatic endometriosis. CONCLUSION Based on multimodal treatment strategies and regarding the complex pathophysiological alterations of this disease, the complex complaints that significantly impair the quality of life of endometriosis patients can be greatly improved.
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Affiliation(s)
- Sylvia Mechsner
- Klinik für Gynäkologie, Endometriosezentrum Charité, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Deutschland.
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Hu Y, Xiang Y, Huang W. Endometrial polyps effect on pregnancy outcomes in infertile women with minimal/mild endometriosis: A retrospective study. J Obstet Gynaecol Res 2023; 49:2946-2951. [PMID: 37723936 DOI: 10.1111/jog.15794] [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: 03/09/2023] [Accepted: 09/07/2023] [Indexed: 09/20/2023]
Abstract
OBJECTIVE To assess the pregnancy outcomes and associated influencing factors of pregnancy after hysteroscopy combined with laparoscopy treatment in infertile patients with minimal/mild endometriosis. DESIGN A retrospective study. SETTING West China Second University Hospital of Sichuan University. PATIENTS We enrolled 898 infertile women who had their minimal/mild endometriosis lesions removed by laparoscopy, including 271 patients additionally diagnosed with endometrial polyps who also underwent hysteroscopic polypectomy. METHODS Based on the existence of endometrial polyps, patients with minimal/mild endometriosis were enrolled and divided into polyps group and non-polyps group. MAIN OUTCOME MEASURES Pregnancy outcomes. RESULTS A total of 271 women with minimal/mild endometriosis were included in polyps group while 491 women with minimal/mild endometriosis were included in non-polyps group. The pregnancy rate of polyps group was not statistically significant compared with non-polyp group (60.15% vs. 58.25%). The pregnancy rate was higher among patients with polyps ≥1 cm (76.06%, 54/71) than patients with polyps <1 cm (54.50%, 109/200) or patients without polyps (58.25%, 286/491) (p = 0.006). The pregnancy rate was higher for patients with multiple polyps (67.86%, 95/140) than for patients with single polyp (51.91%, 68/131) or without polyps (p = 0.025). CONCLUSIONS Among women with minimal/mild endometriosis, hysteroscopic polypectomy did significantly increase fertility in infertile patients with multiple polyps or size of polyp ≥1 cm compared with those without endometrial polyps, single polyp, and size of polyp <1 cm. The size and number of polyps were independently associated with the reproductive ability of women with minimal/mild endometriosis.
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Affiliation(s)
- Yuanyuan Hu
- Department of Obstetrics and Gynaecology, West China Second University Hospital of Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Chengdu, Sichuan, China
| | - Yingchun Xiang
- Department of Obstetrics and Gynecology, Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi Clinical College of Wuhan University, Enshi, Hubei, China
| | - Wei Huang
- Department of Obstetrics and Gynaecology, West China Second University Hospital of Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Chengdu, Sichuan, China
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Kalaitzopoulos DR, Zografou M, Nirgianakis K, Daniilidis A, Krentel H, Eberhard M, Samartzis N. Treatment after endometrioma recurrence: a narrative review. Minerva Obstet Gynecol 2023; 75:449-459. [PMID: 37058320 DOI: 10.23736/s2724-606x.23.05249-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/15/2023]
Abstract
INTRODUCTION Ovarian endometrioma is a common subtype of endometriosis with a prevalence between 17 and 44%. The reported average recurrence of endometrioma after surgical management is 21.5% after 2 years and 40-50% after 5 years. The aim of this narrative review was to summarize the existing literature focusing on treatment options after endometrioma recurrence in order to provide an evidence-based approach for the clinical practice. EVIDENCE ACQUISITION Three electronic databases (MEDLINE, EMBASE and Cochrane) were searched until September 2022 for eligible studies. EVIDENCE SYNTHESIS The available studies showed that repeated surgery has a negative impact on ovarian function, without improving the fertility outcomes. Transvaginal aspiration as an alternative option for surgery has a high rate of recurrence, which varies from 8.20 to 43.5% depending on the technique used and on the study population. Pregnancy related outcomes were similar between transvaginal aspiration groups and no intervention groups in patients with endometrioma recurrence. Regarding medical treatments, only four studies were found, showing that progestins reduce the pain and the diameter of the ovarian cyst. CONCLUSIONS Recurrent endometrioma is a challenging condition which could be encountered during the care of women with endometriosis. The decision about the treatment-strategy has to be individualized considering family planning status, age, ovarian reserve and transvaginal ultrasound findings. Well-designed randomized clinical trials are needed to export safer conclusions about the most appropriate treatment in each specific condition after endometrioma recurrence.
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Affiliation(s)
| | - Maria Zografou
- Clinic of Gynecology, Bethesda Hospital, Duisburg, Germany
| | - Konstantinos Nirgianakis
- Center for Gynecologic Surgery, Heraklion, Greece
- University Hospital of Berne, Berne, Switzerland
| | - Angelos Daniilidis
- Second Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Harald Krentel
- Clinic of Gynecology, Bethesda Hospital, Duisburg, Germany
| | - Markus Eberhard
- Department of Obstetrics and Gynecology, Cantonal Hospital Schaffhausen, Schaffhausen, Switzerland
| | - Nicolas Samartzis
- Department of Obstetrics and Gynecology, Cantonal Hospital Schaffhausen, Schaffhausen, Switzerland
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Fujii M, Koshiba A, Ito F, Kusuki I, Kitawaki J, Mori T. Postoperative Pregnancy Outcomes Following Laparoscopic Surgical Management in Women with Stage III/IV Endometriosis: A Single-Center Follow-Up Study. Gynecol Minim Invasive Ther 2023; 12:153-160. [PMID: 37807984 PMCID: PMC10553597 DOI: 10.4103/gmit.gmit_132_22] [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: 11/21/2022] [Revised: 12/08/2022] [Accepted: 12/22/2022] [Indexed: 10/10/2023] Open
Abstract
Objectives The effects of laparoscopic surgical management in women with stage III/IV endometriosis remain controversial. The standard extent of resection for stage III/IV endometriosis with deep endometriosis to treat endometriosis-associated infertility is debatable. This study aimed to assess the postoperative pregnancy outcomes following a routine surgical intervention for stage III/IV endometriosis patients. Materials and Methods Patients with stage III/IV endometriosis who underwent conservative laparoscopic surgery at our hospital between January 2010 and December 2018 were retrospectively analyzed. Statistical analyses were performed to determine the correlations between endometriosis features and postoperative pregnancy outcomes. Results Of 256 patients enrolled, 94 wished to conceive. Exclusion criteria: ≥40 years, adenomyosis, partners with infertility issues. Finally, 71 women were included. The overall postoperative pregnancy rate was 76.1% (n = 54): 49 and five from non-assisted reproductive technology (ART) and ART, respectively. The postoperative pregnancy rate in patients diagnosed with infertility presurgery (40/71) was 70.0% (n = 28): 24 (non-ART) and four (ART). The endometriosis fertility index (EFI) score was higher in the pregnant than in the nonpregnant group (P = 0.03). The EFI score and surgical score of EFI were higher in the non-ART than in the ART group (P = 0.04; P = 0.02); in the infertile group, they were higher in the pregnant than in the nonpregnant group (P = 0.018; P = 0.027). Conclusion Our postoperative pregnancy rate after conservative laparoscopic surgery for patients with stage III/IV endometriosis compared favorably with previous reports. EFI was a significant predictor of postoperative pregnancy. Our surgical approach to maintain a high surgical score of EFI might help treat endometriosis-associated infertility.
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Affiliation(s)
- Maya Fujii
- Department of Obstetrics and Gynecology, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Japan
| | - Akemi Koshiba
- Department of Obstetrics and Gynecology, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Japan
| | - Fumitake Ito
- Department of Obstetrics and Gynecology, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Japan
| | - Izumi Kusuki
- Department of Obstetrics and Gynecology, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Japan
| | - Jo Kitawaki
- Department of Obstetrics and Gynecology, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Japan
| | - Taisuke Mori
- Department of Obstetrics and Gynecology, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Japan
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Pirtea P, de Ziegler D, Ayoubi JM. Endometrial receptivity in adenomyosis and/or endometriosis. Fertil Steril 2023; 119:741-745. [PMID: 36914148 DOI: 10.1016/j.fertnstert.2023.03.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 03/01/2023] [Accepted: 03/03/2023] [Indexed: 03/16/2023]
Abstract
A narrative review of endometrial receptivity in adenomyosis and/or endometriosis revealed that this parameter is difficult to assess in natural conception because both disorders alter natural fertility. Recent data emanating from assisted reproductive technology have allowed the study of endometrial receptivity in women affected by adenomyosis and endometriosis. This has upended our views on the effects of these 2 disorders on embryo implantation. Today, the very existence of altered receptivity in assisted reproductive technology is questioned. In this context, we now know that frozen euploid blastocyst transfers in estradiol and progesterone cycles have unaltered outcomes in both adenomyosis and endometriosis.
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Affiliation(s)
- Paul Pirtea
- Department of Obstetrics, Gynecology and ART, Hospital Foch, Paris, France.
| | | | - Jean Marc Ayoubi
- Department of Obstetrics, Gynecology and ART, Hospital Foch, Paris, France
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Chen LH, Lo WC, Huang HY, Wu HM. A Lifelong Impact on Endometriosis: Pathophysiology and Pharmacological Treatment. Int J Mol Sci 2023; 24:ijms24087503. [PMID: 37108664 PMCID: PMC10139092 DOI: 10.3390/ijms24087503] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 04/06/2023] [Accepted: 04/16/2023] [Indexed: 04/29/2023] Open
Abstract
Endometriosis is a chronic inflammatory disease associated with bothersome symptoms in premenopausal women and is complicated with long-term systemic impacts in the post-menopausal stage. It is generally defined by the presence of endometrial-like tissue outside the uterine cavity, which causes menstrual disorders, chronic pelvic pain, and infertility. Endometriotic lesions can also spread and grow in extra-pelvic sites; the chronic inflammatory status can cause systemic effects, including metabolic disorder, immune dysregulation, and cardiovascular diseases. The uncertain etiologies of endometriosis and their diverse presentations limit the treatment efficacy. High recurrence risk and intolerable side effects result in poor compliance. Current studies for endometriosis have paid attention to the advances in hormonal, neurological, and immunological approaches to the pathophysiology and their potential pharmacological intervention. Here we provide an overview of the lifelong impacts of endometriosis and summarize the updated consensus on therapeutic strategies.
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Affiliation(s)
- Liang-Hsuan Chen
- Department of Obstetrics and Gynecology, Linkou Medical Center, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan 33305, Taiwan
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
| | - Wei-Che Lo
- Department of Obstetrics and Gynecology, Linkou Medical Center, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan 33305, Taiwan
| | - Hong-Yuan Huang
- Department of Obstetrics and Gynecology, Linkou Medical Center, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan 33305, Taiwan
| | - Hsien-Ming Wu
- Department of Obstetrics and Gynecology, Linkou Medical Center, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan 33305, Taiwan
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
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Chang JC, Yi YC, Chen YF, Guu HF, Kung HF, Chen LY, Chuan ST, Chen MJ. Presence of endometrioma decreased blastocyst formation rate but not impair Assisted Reproductive Technology (ART) outcome. Arch Gynecol Obstet 2023; 307:2011-2020. [PMID: 37067551 DOI: 10.1007/s00404-023-07036-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 04/01/2023] [Indexed: 04/18/2023]
Abstract
PURPOSE This study aims to assess the impact of endometrioma on patients who undergo ART treatment due to endometriosis. METHODS A retrospective study was conducted on women ≤ 40 years of age who underwent ART treatment at an academic medical center between January 2014 and December 2020. Two-hundred-and-eight women had received IVF/ICSI treatment due to endometriosis and there were 89 patients presence of endometrioma. Patients were further divided into primary endometrioma, recurrent endometrioma and those having received cystectomy for endometrioma prior to IVF/ICSI. The control group included 624 infertile women without endometriosis. RESULTS In the endometrioma subgroup (B) the blastocyst formation rate was significantly lower when compared with the endometriosis (A) and control groups (C). The cumulative live birth rates (CLBRs) (60.5% versus 49.4% versus 56.9%, p = 0.194 in A versus B, p = 0.406 in A versus C, p = 0.878 in B versus C) were comparable. Multiple logistic regression analysis revealed that female age, total FSH dose and blastocyst formation rate were the significant variables in predicting CLBR (OR 0.89, CI 0.80-0.99, p < 0.025, OR 0.68 CI 0.53-0.88, p = 0.003 and OR 30.04, CI 9.93-90.9, p < 0.001, respectively). The CLBRs were comparable at 47.1%, 60% and 57.9% in the primary endometrioma, s/p cystectomy and recurrent endometrioma group. CONCLUSION Although the blastocyst formation rate was lower in the endometrioma group, CLBR was not worse than those who were in the endometriosis or control group. Cystectomy for endometrioma did not alter IVF/ICSI outcomes if the ovarian reserve was comparable. Recurrent endometrioma did not worsen IVF/ICSI outcomes than primary endometrioma.
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Affiliation(s)
- Jui-Chun Chang
- Department of Obstetrics and Gynecology and Women's Health, Taichung Veterans General Hospital, No. 1650, Sec. 4, Taiwan Blvd., Xitun Dist, Taichung City, Taiwan
| | - Yu-Chiao Yi
- Department of Obstetrics and Gynecology and Women's Health, Taichung Veterans General Hospital, No. 1650, Sec. 4, Taiwan Blvd., Xitun Dist, Taichung City, Taiwan
- School of Medicine, National Yang-Ming Chiao Tung University, Taipei, Taiwan
- Institute of Biochemistry and Biotechnology, Chung Shan Medical University, Taichung, Taiwan
| | - Ya-Fang Chen
- Department of Obstetrics and Gynecology and Women's Health, Taichung Veterans General Hospital, No. 1650, Sec. 4, Taiwan Blvd., Xitun Dist, Taichung City, Taiwan
| | - Hwa-Fen Guu
- Department of Obstetrics and Gynecology and Women's Health, Taichung Veterans General Hospital, No. 1650, Sec. 4, Taiwan Blvd., Xitun Dist, Taichung City, Taiwan
| | - Hsiao-Fan Kung
- Department of Obstetrics and Gynecology and Women's Health, Taichung Veterans General Hospital, No. 1650, Sec. 4, Taiwan Blvd., Xitun Dist, Taichung City, Taiwan
| | - Li-Yu Chen
- Department of Obstetrics and Gynecology and Women's Health, Taichung Veterans General Hospital, No. 1650, Sec. 4, Taiwan Blvd., Xitun Dist, Taichung City, Taiwan
| | - Shih-Ting Chuan
- Department of Obstetrics and Gynecology and Women's Health, Taichung Veterans General Hospital, No. 1650, Sec. 4, Taiwan Blvd., Xitun Dist, Taichung City, Taiwan
| | - Ming-Jer Chen
- Department of Obstetrics and Gynecology and Women's Health, Taichung Veterans General Hospital, No. 1650, Sec. 4, Taiwan Blvd., Xitun Dist, Taichung City, Taiwan.
- School of Medicine, National Yang-Ming Chiao Tung University, Taipei, Taiwan.
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Candiani M, Ottolina J, Salmeri N, D’Alessandro S, Tandoi I, Bartiromo L, Schimberni M, Ferrari S, Villanacci R. Minimally invasive surgery for ovarian endometriosis as a mean of improving fertility: Cystectomy vs. CO2 fiber laser ablation what do we know so far? Front Surg 2023; 10:1147877. [PMID: 37051570 PMCID: PMC10083313 DOI: 10.3389/fsurg.2023.1147877] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 03/10/2023] [Indexed: 03/29/2023] Open
Abstract
Minimally invasive surgery emerged in the 1980s as a safe and effective technique which requires smaller incisions and, usually, a shorter hospital stay compared to traditional surgery. Since then, minimally invasive surgery has expanded in many surgical specialties. One of its newest application in gynecology stands in the infertility management of young women with unexplained infertility or suspected endometriosis. In these cases, laparoscopy allows to diagnose and treat the disease aiming to increase at best the chances of spontaneous pregnancy or trough assisted reproductive technology. Nowadays, minimally invasive surgical approach of ovarian endometriosis consists of either laparoscopic cystectomy or ablative techniques such as laparoscopic CO2 fiber laser vaporization. Although cystectomy represents the gold standard according to the latest Cochrane review, some endometriosis experts are worried about its detrimental effect on healthy ovarian parenchyma and suggest preferring a less aggressive approach such as CO2 fiber laser vaporization. The aim of this review is to give an overview of the available evidences about the impact of the two surgical procedures on ovarian reserve markers and pregnancy outcome.
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Puscasiu L, Mircea O, Hennetier C, Rubod C, Schmied R, Resch B, Merlot B, Roman H. Pregnancy rate following endometriomas management by ablation using plasma energy, cystectomy and drainage: A three-arm comparative study. Int J Gynaecol Obstet 2023; 160:947-954. [PMID: 36085559 DOI: 10.1002/ijgo.14444] [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: 07/03/2022] [Revised: 08/20/2022] [Accepted: 08/30/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To compare differences in the postoperative pregnancy rate in women seeking to conceive and presenting with endometriomas larger than 3 cm in diameter, which were managed by ablation using plasma energy, cystectomy, or simple drainage. METHODS A retrospective three-arm comparative study based on prospective collection of data evaluating 363 patients, undergoing endometrioma cystectomy, ablation using plasma energy, or simple drainage. RESULTS In this series, 204 (56.2%) patients underwent endometrioma ablation using plasma energy, 121 (33.3%) received cystectomy, and 38 (10.5%) had a simple drainage. Postoperative follow up was 50 ± 26 months. Overall postoperative pregnancy rate was 60.3%. The probability of being pregnant after cystectomy, ablation, and drainage was respectively 27%, 32%, and 16% at 12 months, with a statistically significant difference between pregnancy rates among the three arms (P = 0.015). Simple drainage was associated with a probability of conception over 50% after 2 years, mainly based on postoperative assisted reproductive technology. CONCLUSIONS We reveal good postoperative pregnancy rate after ablation using plasma energy or cystectomy for endometriomas. Surgical management should be carefully considered in women with endometriomas and pregnancy intention, because the postoperative pregnancy rate may be compared with that observed after first-line assisted reproductive technology management.
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Affiliation(s)
- Lucian Puscasiu
- Department of Obstetrics and Gynecology, University of Medicine, Pharmacy, Science and Technology "George Emil Palade" Targu Mures, Targu Mures, Romania
| | - Oana Mircea
- Department of Obstetrics and Gynecology, University of Medicine, Pharmacy, Science and Technology "George Emil Palade" Targu Mures, Targu Mures, Romania
| | - Clotilde Hennetier
- Expert Centre in the Diagnosis and Multidisciplinary Management of Endometriosis, Rouen University Hospital, Rouen, France
| | - Christelle Rubod
- Department of Gynecology and Obstetrics, CHRU Jeanne de Flandre, Lille, France
| | | | - Benoit Resch
- Expert Centre in the Diagnosis and Multidisciplinary Management of Endometriosis, Rouen University Hospital, Rouen, France.,Clinique Mathilde, Rouen, France
| | | | - Horace Roman
- IFEMEndo, Clinique Tivoli-Ducos, Bordeaux, France.,Department of Gynecology and Obstetrics, Aarhus University Hospital, Aarhus, Denmark
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Ethanol Sclerotherapy for Endometrioma: At the Time of Laparoscopy. J Minim Invasive Gynecol 2023; 30:1-2. [PMID: 36372313 DOI: 10.1016/j.jmig.2022.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 11/07/2022] [Indexed: 11/11/2022]
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Crestani A, Merlot B, Dennis T, Chanavaz-Lacheray I, Roman H. Impact of Laparoscopic Sclerotherapy for Ovarian Endometriomas on Ovarian Reserve. J Minim Invasive Gynecol 2023; 30:32-38. [PMID: 36228863 DOI: 10.1016/j.jmig.2022.10.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 08/28/2022] [Accepted: 10/03/2022] [Indexed: 11/08/2022]
Abstract
STUDY Objective: To evaluate the impact of laparoscopic sclerotherapy on the management of endometrioma during surgery for deep infiltrative endometriosis (DIE). DESIGN Observational study. SETTING Tivoli-Ducos Clinic, Bordeaux. PATIENTS Sixty-nine patients underwent laparoscopic sclerotherapy for endometrioma during surgery for DIE. INTERVENTIONS Laparoscopic sclerotherapy with 95% ethanol solution and DIE surgery. MEASUREMENTS AND MAIN RESULTS Antimüllerian hormone (AMH) levels before and at least 6 months after surgery, recurrences, and pregnancies. Mean AMH (ng/mL) levels were 3.4 (2.3) before surgery and 2 (1.7) after surgery (p <.001). Mean difference was 1.29 ng/mL. Preoperative AMH level was the only variable independently associated with an additive decrease in AMH. Mean (standard deviation) follow-up period was 17.5 months (4.6) (range 9-26 months); 18 of 44 patients (40.1%) with pregnancy intent conceived. Of 51 patients who underwent postoperative pelvic ultrasound, 6 (6 of 51, 11.8%) had a recurrence of endometrioma. CONCLUSION Laparoscopic sclerotherapy for endometrioma >40 mm during surgery for DIE sclerotherapy has a low impact on AMH, preserves fertility, and prevents recurrence.
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Affiliation(s)
- Adrien Crestani
- From the Franco-European Multidisciplinary Endometriosis Institute (IFEMEndo), Clinique Tivoli-Ducos, Bordeaux (Drs. Crestani, Merlot, Dennis, Lacheray, and Roman); and Sorbonne Université, Paris (Dr. Crestani), France.
| | - Benjamin Merlot
- From the Franco-European Multidisciplinary Endometriosis Institute (IFEMEndo), Clinique Tivoli-Ducos, Bordeaux (Drs. Crestani, Merlot, Dennis, Lacheray, and Roman)
| | - Thomas Dennis
- From the Franco-European Multidisciplinary Endometriosis Institute (IFEMEndo), Clinique Tivoli-Ducos, Bordeaux (Drs. Crestani, Merlot, Dennis, Lacheray, and Roman)
| | - Isabella Chanavaz-Lacheray
- From the Franco-European Multidisciplinary Endometriosis Institute (IFEMEndo), Clinique Tivoli-Ducos, Bordeaux (Drs. Crestani, Merlot, Dennis, Lacheray, and Roman)
| | - Horace Roman
- From the Franco-European Multidisciplinary Endometriosis Institute (IFEMEndo), Clinique Tivoli-Ducos, Bordeaux (Drs. Crestani, Merlot, Dennis, Lacheray, and Roman); Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark (Dr. Roman)
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15
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Delli Carpini G, Giannella L, Di Giuseppe J, Montanari M, Fichera M, Pizzagalli D, Meccariello ML, Palazzo P, Valenza C, Francucci A, Ciavattini A. Effect of the mode of delivery on the risk of endometriosis recurrence: a retrospective cohort study. Fertil Steril 2022; 118:1080-1087. [PMID: 36243596 DOI: 10.1016/j.fertnstert.2022.08.849] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 08/18/2022] [Accepted: 08/19/2022] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To evaluate the risk of endometriosis recurrence according to the mode of delivery (cesarean section vs. vaginal birth) in patients who had become pregnant with a live birth after surgery for endometriosis. DESIGN A retrospective cohort study. A Cox proportional-hazards regression was performed to evaluate the risk factors for endometriosis recurrence at 36 months of follow-up after the last pregnancy. SETTING Academic hospital. PATIENT(S) Patients who have had ≥1 pregnancy with a live birth following conservative surgery for ovarian endometriosis performed from January 2009 to December 2016 at our institution. INTERVENTION(S) Patients who underwent ≥1 cesarean section after surgery for endometriosis. MAIN OUTCOME MEASURES The recurrence rate of endometriosis after live-birth pregnancies obtained after the first surgery for endometriosis. RESULTS Patients with a history of ≥1 cesarean section after surgery for endometriosis have a higher risk of endometriosis recurrence than the patients who have had a vaginal birth, with an adjusted hazard ratio of 2.25 (95% confidence interval, 1.27-3.96). CONCLUSION A cesarean section after surgery for endometriosis is associated with a twofold high risk of endometriosis recurrence with respect to vaginal birth. A different follow-up approach may be needed in those patients, and avoiding inappropriate indications for cesarean sections in pregnant patients with a history of surgery for endometriosis is necessary.
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Affiliation(s)
- Giovanni Delli Carpini
- Gynecologic Section, Department of Odontostomatologic and Specialized Clinical Sciences, Università Politecnica delle Marche, Ancona, Italy
| | - Luca Giannella
- Gynecologic Section, Department of Odontostomatologic and Specialized Clinical Sciences, Università Politecnica delle Marche, Ancona, Italy
| | - Jacopo Di Giuseppe
- Gynecologic Section, Department of Odontostomatologic and Specialized Clinical Sciences, Università Politecnica delle Marche, Ancona, Italy
| | - Michele Montanari
- Gynecologic Section, Department of Odontostomatologic and Specialized Clinical Sciences, Università Politecnica delle Marche, Ancona, Italy
| | - Mariasole Fichera
- Gynecologic Section, Department of Odontostomatologic and Specialized Clinical Sciences, Università Politecnica delle Marche, Ancona, Italy
| | - Davide Pizzagalli
- Gynecologic Section, Department of Odontostomatologic and Specialized Clinical Sciences, Università Politecnica delle Marche, Ancona, Italy
| | - Maria Liberata Meccariello
- Gynecologic Section, Department of Odontostomatologic and Specialized Clinical Sciences, Università Politecnica delle Marche, Ancona, Italy
| | - Paola Palazzo
- Gynecologic Section, Department of Odontostomatologic and Specialized Clinical Sciences, Università Politecnica delle Marche, Ancona, Italy
| | - Carmine Valenza
- Gynecologic Section, Department of Odontostomatologic and Specialized Clinical Sciences, Università Politecnica delle Marche, Ancona, Italy
| | - Alessio Francucci
- Gynecologic Section, Department of Odontostomatologic and Specialized Clinical Sciences, Università Politecnica delle Marche, Ancona, Italy
| | - Andrea Ciavattini
- Gynecologic Section, Department of Odontostomatologic and Specialized Clinical Sciences, Università Politecnica delle Marche, Ancona, Italy.
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16
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Daniilidis A, Angioni S, Di Michele S, Dinas K, Gkrozou F, D’Alterio MN. Deep Endometriosis and Infertility: What Is the Impact of Surgery? J Clin Med 2022; 11:jcm11226727. [PMID: 36431203 PMCID: PMC9693611 DOI: 10.3390/jcm11226727] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 10/26/2022] [Accepted: 11/05/2022] [Indexed: 11/16/2022] Open
Abstract
In women with deep endometriosis, the spontaneous fertility rate might range from 2 to 10%. The optimal management of these women is still an area of debate. Therefore, this review aims to explore the literature on the impact of deep endometriosis surgery on reproductive outcomes and pregnancy rates in women with and without prior infertility. A total of 392 articles were identified through database searching. Twenty-three studies were eligible to be included in the review. A total of 1548 women were identified, 814 of whom became pregnant, with a mean pregnancy rate of 52.6% (95% CI 49.7-63%). Our review suggests that surgery may improve fertility outcomes. Due to the variability in the studies, it is impossible to stratify fertility outcomes of surgery by the localization of deep endometriosis. More investigations are needed to determine whether surgical management should be first-intention or limited to the failure of medically assisted reproduction treatment.
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Affiliation(s)
- Angelos Daniilidis
- Department of Obstetrics and Gynecology, Hippokratio Hospital, Aristotle University of Thessaloniki, 546 42 Thessaloniki, Greece
- Correspondence: (A.D.); (M.N.D.); Tel.: +39-07051093399 (M.N.D.)
| | - Stefano Angioni
- Department of Surgical Science, University of Cagliari, Cittadella Universitaria Blocco I, Asse Didattico Medicna P2, Monserrato, 09042 Cagliari, Italy
| | - Stefano Di Michele
- Department of Surgical Science, University of Cagliari, Cittadella Universitaria Blocco I, Asse Didattico Medicna P2, Monserrato, 09042 Cagliari, Italy
| | - Konstantinos Dinas
- Department of Obstetrics and Gynecology, Hippokratio Hospital, Aristotle University of Thessaloniki, 546 42 Thessaloniki, Greece
| | - Fani Gkrozou
- University Clinic in Obstetrics and Gynecology, University of Ioannina, 451 10 Ioannina, Greece
| | - Maurizio Nicola D’Alterio
- Department of Surgical Science, University of Cagliari, Cittadella Universitaria Blocco I, Asse Didattico Medicna P2, Monserrato, 09042 Cagliari, Italy
- Correspondence: (A.D.); (M.N.D.); Tel.: +39-07051093399 (M.N.D.)
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17
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Bonavina G, Taylor HS. Endometriosis-associated infertility: From pathophysiology to tailored treatment. Front Endocrinol (Lausanne) 2022; 13:1020827. [PMID: 36387918 PMCID: PMC9643365 DOI: 10.3389/fendo.2022.1020827] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 10/06/2022] [Indexed: 11/13/2022] Open
Abstract
Despite the clinically recognized association between endometriosis and infertility, the mechanisms implicated in endometriosis-associated infertility are not fully understood. Endometriosis is a multifactorial and systemic disease that has pleiotropic direct and indirect effects on reproduction. A complex interaction between endometriosis subtype, pain, inflammation, altered pelvic anatomy, adhesions, disrupted ovarian reserve/function, and compromised endometrial receptivity as well as systemic effects of the disease define endometriosis-associated infertility. The population of infertile women with endometriosis is heterogeneous, and diverse patients' phenotypes can be observed in the clinical setting, thus making difficult to establish a precise diagnosis and a single mechanism of endometriosis related infertility. Moreover, clinical management of infertility associated with endometriosis can be challenging due to this heterogeneity. Innovative non-invasive diagnostic tools are on the horizon that may allow us to target the specific dysfunctional alteration in the reproduction process. Currently the treatment should be individualized according to the clinical situation and to the suspected level of impairment. Here we review the etiology of endometriosis related infertility as well as current treatment options, including the roles of surgery and assisted reproductive technologies.
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Affiliation(s)
- Giulia Bonavina
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT, United States
| | - Hugh S Taylor
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT, United States
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18
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Bhurke AV, DasMahapatra P, Balakrishnan S, Khan SA, Mortlock S, Das V, Chellamma N, Vadakkathil SC, Srivastava A, Majumdar A, Pasi A, Sachdeva G, Montgomery GW, Gajbhiye RK. Clinical characteristics and surgical management of endometriosis-associated infertility: A multicenter prospective cohort study. Int J Gynaecol Obstet 2022; 159:86-96. [PMID: 35075631 PMCID: PMC7615031 DOI: 10.1002/ijgo.14115] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Revised: 12/26/2021] [Accepted: 01/21/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To study clinical, surgical characteristics and the relationship between endometriosis lesion types and conception rate after surgery in infertile women with endometriosis. METHODS A prospective, multicenter cohort of 204 women (age 20-35 years) with endometriosis was followed up post-surgery between November 2017 and February 2020 at three tertiary-care hospitals. RESULTS Based on the severity of endometriosis lesion type, deep infiltrating endometriosis (DIE) (81/204, 39.7%) was the most common lesion; followed by ovarian endometriosis (OMA) (64/204, 31.4%), and superficial peritoneal endometriosis (SUP) (59/204, 28.9%). Endometriosis patients had a single lesion type (94/204, 46.1%), two lesion types (77/204, 37.7%), or three lesion types (33/204, 16.2%) with significant differences between regions (P < 0.001). Around 40% (37/95) of obese women had SUP (P = 0.003) whereas 78% (14/18) of underweight women had DIE (P < 0.001). Significant differences in mean Endometriosis Fertility Index scores between endometriosis lesion types and patients with one, two, and three types of lesions were observed (P < 0.001). The majority (22/32, 68.8%) of the women conceived naturally after the surgery. Half (16/32; 50%) of the women with a single lesion type conceived after the surgery; of which most (13/16, 81.2%) had SUP, followed by OMA (2/16, 12.5%), and DIE (1/16, 6.3%). CONCLUSION Women with SUP and only one type of endometriotic lesion were more likely to conceive post-surgery.
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Affiliation(s)
- Aishwarya V. Bhurke
- Clinical Research Laboratory, Indian Council of Medical Research–National Institute for Research in Reproductive and Child Health (NIRRCH), Mumbai, India
| | | | - Sheila Balakrishnan
- Department of Reproductive Medicine, Government Medical College, Thiruvananthapuram, India
| | - Shagufta A. Khan
- Clinical Research Laboratory, Indian Council of Medical Research–National Institute for Research in Reproductive and Child Health (NIRRCH), Mumbai, India
| | - Sally Mortlock
- Institute for Molecular Bioscience, The University of Queensland, St. Lucia, Queensland, Australia
| | - Vinita Das
- Department of Obstetrics and Gynecology, King George’s Medical University (KGMU), Lucknow, India
| | - Nirmala Chellamma
- Department of Obstetrics and Gynecology, Sree Avittam Thirunal Hospital, Government Medical College, Thiruvananthapuram, India
| | - Sowmini Cheruvara Vadakkathil
- Department of Obstetrics and Gynecology, Sree Avittam Thirunal Hospital, Government Medical College, Thiruvananthapuram, India
| | - Aarti Srivastava
- Department of Obstetrics and Gynecology, King George’s Medical University (KGMU), Lucknow, India
| | - Amiya Majumdar
- Spectrum Clinic & Endoscopy Research Institute, Kolkata, India
| | | | | | - Grant W. Montgomery
- Institute for Molecular Bioscience, The University of Queensland, St. Lucia, Queensland, Australia
| | - Rahul K. Gajbhiye
- Clinical Research Laboratory, Indian Council of Medical Research–National Institute for Research in Reproductive and Child Health (NIRRCH), Mumbai, India
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19
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Guo C, Zhang C. Platelet-to-Lymphocyte Ratio and CA125 Level as a Combined Biomarker for Diagnosing Endometriosis and Predicting Pelvic Adhesion Severity. Front Oncol 2022; 12:896152. [PMID: 35800055 PMCID: PMC9255667 DOI: 10.3389/fonc.2022.896152] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 05/19/2022] [Indexed: 11/16/2022] Open
Abstract
Adhesion is a significant biological characteristic of endometriosis, and accurate evaluation of the pelvic adhesion is necessary for surgical treatment. Serum CA125 is yet the most common used biomarker in the diagnosis and follow-up of patients with endometriosis despite of its high false-positive rate and low specificity. Herein, we aimed to examine the diagnostic value of the combination of the platelet-to-lymphocyte ratio (PLR) and CA125 for patients with different stages of endometriosis and their correlations with pelvic adhesion. We retrospectively analyzed the clinical data and blood count parameters of patients with both endometriosis and other benign ovarian tumors. The mean level of CA125, the PLR and the combined marker (the CA125 level multiplied by the PLR) in the EMs group were significantly higher than those in the Cyst group (P < 0.05). ROC curve analysis was used to compare the diagnostic values of serum PLR, CA125, and the combined marker in ovarian endometriosis. The cut-off value of the PLR was 176.835, with 28.3% sensitivity and 96.9% specificity. The cut-off value of CA125 was 31.67 U/mL, with 84.1% sensitivity and 87.4% specificity. The cut-off value of the combined marker was 3894.97, with 83.4% sensitivity and 95.8% specificity. It was found that the severity of adhesion in endometriosis was positively correlated with the PLR (r = 0.286, P < 0.01), CA125 (r = 0.276, P < 0.01), and combined marker (r = 0.369, P < 0.01). The combined marker showed the highest AUC value (0.751, 95% CI: 0.666–0.837), with a sensitivity of 56.0% and a specificity of 89.6%, and the cut-off value was 9056.94. Besides, the levels of CA125, PLR, and their combination were significantly elevated in patients with endometriosis. The combined marker was not only positively correlated with pelvic adhesion but also showed a greater diagnostic value and specificity than CA125 alone. These findings indicate that the combined marker may be a potential inflammatory biomarker playing an important role in the diagnosis and assessment of adhesion in endometriosis.
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20
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Endometriosis and Infertility: A Long-Life Approach to Preserve Reproductive Integrity. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19106162. [PMID: 35627698 PMCID: PMC9141878 DOI: 10.3390/ijerph19106162] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 05/01/2022] [Accepted: 05/06/2022] [Indexed: 02/04/2023]
Abstract
Laparoscopic surgery was originally considered the gold standard in the treatment of endometriosis-related infertility. Assisted reproductive technology (ART) was indicated as second-line treatment or in the case of male factor. The combined approach of surgery followed by ART proved to offer higher chances of pregnancy in infertile women with endometriosis. However, it was highlighted how pelvic surgery for endometriosis, especially in cases of ovarian endometriomas, could cause iatrogenic damage due to ovarian reserve loss, adhesion formation (scarring), and ischemic damage. Furthermore, in the last few years, the trend to delay the first childbirth, recent technological advances in ultrasound diagnosis, and technological progress in clinical and laboratory aspects of ART have certainly influenced the approach to infertility and endometriosis with, ART assuming a more relevant role. Management of endometriosis should take into account that the disease is chronic and involves the reproductive system. Consequently, treatment and counselling should aim to preserve the chances of pregnancy for the patient, even if it is not associated with infertility. This review will analyse the evolution of the management of infertility associated with endometriosis and propose an algorithm for treatment decision-making based on the most recent acquisitions.
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21
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Infertility workup: identifying endometriosis. Fertil Steril 2022; 118:29-33. [PMID: 35568524 DOI: 10.1016/j.fertnstert.2022.03.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 03/18/2022] [Accepted: 03/18/2022] [Indexed: 12/28/2022]
Abstract
Endometriosis was classically diagnosed during diagnostic laparoscopies, which used to be routinely performed up until a decade ago or so. This practice fitted with the long-held belief that surgery was the gold standard for diagnosing endometriosis. Today, the abandon of routine diagnostic laparoscopies-in favor of assisted reproductive technology-first therapeutic approaches-has created a void for diagnosing endometriosis. Modern-day imaging techniques-ultrasound and magnetic resonance imaging-when used with a systematic approach have offered a reliable replacement option for diagnosing endometriosis. In infertility, endometriosis should be identified or excluded on the basis of past history or confirmation or exclusion suspicion on the basis of history and/or physical examination.
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22
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Mechsner S. Endometriosis, an Ongoing Pain—Step-by-Step Treatment. J Clin Med 2022; 11:jcm11020467. [PMID: 35054161 PMCID: PMC8780646 DOI: 10.3390/jcm11020467] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 01/10/2022] [Accepted: 01/11/2022] [Indexed: 01/27/2023] Open
Abstract
Endometriosis is a disease that is becoming more and more challenging for the medical community. The current therapeutic concepts (surgical therapy and/or hormonal therapies) often do not lead to sufficient pain control, and late diagnosis and high recurrence rates mean that women affected by the disease can suffer for decades before receiving proper treatment. Although the introduction of certified endometriosis centers has created contact points for surgical therapies performed by endometriosis experts, these centers are not sufficient to offer the affected patients the all-encompassing long-term support they need. In recent years, new findings regarding the pathogenesis and correlations of the pain phenomena caused by endometriosis have shown that conventional therapy strategies are not adequate and individual long-term concepts must be developed. Not only can endometriosis cause nociceptive pain, but it can also lead to a nociplastic reaction with central sensitization. Hence, aside from the classic cyclic complaints, patients increasingly suffer from atypical pain. Due to the high number of affected patients who are treated inadequately, it is necessary for gynecologists in private practices to become familiar with multimodal treatment concepts since they are the central point of contact of their patients. The following article will provide an overview of treatment strategies for chronic symptomatic endometriosis.
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Affiliation(s)
- Sylvia Mechsner
- Clinic for Gynecology, Endometriosis Center Charité, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
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23
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Rodrigues DM, de Ávila I, Amorim LVC, Carneiro MM, Ferreira MCF. Endometriosis fertility index predicts pregnancy in women operated on for moderate and severe symptomatic endometriosis. Women Health 2021; 62:3-11. [PMID: 34852729 DOI: 10.1080/03630242.2021.1986458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Endometriosis Fertility Index (EFI) is a clinical staging system created to predict spontaneous pregnancy outcomes in patients with endometriosis. The present study aimed at evaluating the performance of EFI in symptomatic patients, submitted to laparoscopy for moderate and severe endometriosis associated to infertility in a Brazilian population. Seventy-seven women with endometriosis and pelvic pain, who desired to become pregnant, were selected from a tertiary care unit between those operated on between May 2007 and March 2017. All of them were submitted to laparoscopy for the surgical treatment of endometriosis and allowed to attempt natural conception for 36 months or immediately referred to in vitro fertilization (IVF). EFI was calculated according to surgical description and clinical information in medical records. Pregnancy rates and live birth rates after natural conception or IVF are reported and correlated to EFI. Fifty-three women tried natural conception and 24 were referred to IVF. Of the 53 who tried natural conception, 29 achieved pregnancy (54.7%) and 28 had live birth (52.8%). The majority of pregnancies (82.7%) occurred in the first 12 months after surgery and 75% of the patients who became spontaneously pregnant had EFI ≥ 7. Of the 24 patients referred to IVF, 13 became pregnant (54.1%) and 10 had live birth (41.7%). Infertility duration of 36 months or more and the presence of endometrioma increased the probability of having EFI ≤ 5. The overall live birth rate (LBR) for patients with low EFI scores (2-4) was 17% compared with 83.8% for those with higher EFI scores (6-9). EFI predicts pregnancy rates in patients operated on for moderate and severe endometriosis. Scores seem also to predict pregnancy rates after IVF.
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Affiliation(s)
- Daisy Martins Rodrigues
- Department of Obstetrics and Gynecology, Faculty of Medicine, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | | | | | - Marcia Mendonça Carneiro
- Department of Obstetrics and Gynecology, Faculty of Medicine, Federal University of Minas Gerais, Belo Horizonte, Brazil.,Biocor Hospital Belo Horizonte, Belo Horizonte, Brazil
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24
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Santulli P, Bourdon M, Koutchinsky S, Maignien C, Marcellin L, Maitrot-Mantelet L, Pocate Cheriet K, Patrat C, Chapron C. Fertility preservation for patients affected by endometriosis should ideally be carried out before surgery. Reprod Biomed Online 2021; 43:853-863. [PMID: 34649771 DOI: 10.1016/j.rbmo.2021.08.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 08/20/2021] [Accepted: 08/23/2021] [Indexed: 12/20/2022]
Abstract
RESEARCH QUESTION What prognostic factors relate to a high oocyte yield in fertility preservation for women affected by endometriosis? DESIGN Observational cohort study conducted in a tertiary care university hospital between April 2015 and January 2019. Women who had undergone fertility preservation with ovarian stimulation for oocytes and embryo vitrification for endometriosis were included. Prognostic factors associated with the number of oocytes retrieved after the first ovarian stimulation were analysed. RESULTS A total of 146 women who had undergone 258 ovarian stimulation cycles were included; 82 (56.2%) had undergone more than one ovarian stimulation cycle; 72.6% had at least one endometrioma lesion; and 36.3% had previously undergone surgery for endometriosis. After adjustment by multiple linear regression, the factors that significantly reduced the number of oocytes retrieved were previous history of surgery for ovarian endometriosis (coefficient -1.08; 95% CI -2.02 to -0.15; P = 0.024); women's age (-0.21; 95% CI -0.41 to -0.01; P = 0.039); and total dose of gonadotrophin used (-0.01; 95% CI -0.01 to -0.00; P = 0.047). Anti-Müllerian hormone serum level and gravidity positively correlated with an increase in the number of oocytes retrieved (1.65; 95% CI 1.13 to 2.17; P < 0.001 and 3.30; 95% CI 0.91 to 5.68; P = 0.007, respectively) after the first ovarian stimulation cycle. CONCLUSION A history of surgery for ovarian endometriosis was associated with significantly lower oocyte yields. Fertility preservation should be integrated into endometriosis management. Fertility preservation should ideally be made available to the patient before surgery.
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Affiliation(s)
- Pietro Santulli
- Université de Paris, Faculté de Santé, Faculté de Médecine Paris Centre, Paris, France; Service de Gynécologie-Obstétrique II et de Médecine de la Reproduction, AP-HP, Centre Hospitalier Universitaire (CHU) Cochin - Bâtiment Port Royal, 123 Boulevard de Port-Royal 75679 Paris 14, France; Université de Paris, Department 'Infection, Immunity, Inflammation', INSERM U1016, Institut Cochin, Paris, France.
| | - Mathilde Bourdon
- Université de Paris, Faculté de Santé, Faculté de Médecine Paris Centre, Paris, France; Service de Gynécologie-Obstétrique II et de Médecine de la Reproduction, AP-HP, Centre Hospitalier Universitaire (CHU) Cochin - Bâtiment Port Royal, 123 Boulevard de Port-Royal 75679 Paris 14, France; Université de Paris, Department 'Infection, Immunity, Inflammation', INSERM U1016, Institut Cochin, Paris, France
| | - Sonia Koutchinsky
- Université de Paris, Faculté de Santé, Faculté de Médecine Paris Centre, Paris, France; Service de Gynécologie-Obstétrique II et de Médecine de la Reproduction, AP-HP, Centre Hospitalier Universitaire (CHU) Cochin - Bâtiment Port Royal, 123 Boulevard de Port-Royal 75679 Paris 14, France
| | - Chloé Maignien
- Université de Paris, Faculté de Santé, Faculté de Médecine Paris Centre, Paris, France; Service de Gynécologie-Obstétrique II et de Médecine de la Reproduction, AP-HP, Centre Hospitalier Universitaire (CHU) Cochin - Bâtiment Port Royal, 123 Boulevard de Port-Royal 75679 Paris 14, France
| | - Louis Marcellin
- Université de Paris, Faculté de Santé, Faculté de Médecine Paris Centre, Paris, France; Service de Gynécologie-Obstétrique II et de Médecine de la Reproduction, AP-HP, Centre Hospitalier Universitaire (CHU) Cochin - Bâtiment Port Royal, 123 Boulevard de Port-Royal 75679 Paris 14, France; Université de Paris, Department 'Infection, Immunity, Inflammation', INSERM U1016, Institut Cochin, Paris, France
| | - Lorraine Maitrot-Mantelet
- Université de Paris, Faculté de Santé, Faculté de Médecine Paris Centre, Paris, France; Service de Gynécologie-Obstétrique II et de Médecine de la Reproduction, AP-HP, Centre Hospitalier Universitaire (CHU) Cochin - Bâtiment Port Royal, 123 Boulevard de Port-Royal 75679 Paris 14, France
| | - Khaled Pocate Cheriet
- Université de Paris, Faculté de Santé, Faculté de Médecine Paris Centre, Paris, France; Université de Paris, Department 'Infection, Immunity, Inflammation', INSERM U1016, Institut Cochin, Paris, France; Service d'Histologie-Embryologie-Biologie de la Reproduction, AP-HP, Centre Hospitalier Universitaire (CHU) Cochin, Paris 75014, France
| | - Catherine Patrat
- Université de Paris, Faculté de Santé, Faculté de Médecine Paris Centre, Paris, France; Service d'Histologie-Embryologie-Biologie de la Reproduction, AP-HP, Centre Hospitalier Universitaire (CHU) Cochin, Paris 75014, France
| | - Charles Chapron
- Université de Paris, Faculté de Santé, Faculté de Médecine Paris Centre, Paris, France; Service de Gynécologie-Obstétrique II et de Médecine de la Reproduction, AP-HP, Centre Hospitalier Universitaire (CHU) Cochin - Bâtiment Port Royal, 123 Boulevard de Port-Royal 75679 Paris 14, France; Université de Paris, Department 'Infection, Immunity, Inflammation', INSERM U1016, Institut Cochin, Paris, France
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Vatsa R, Sethi A. Impact of endometriosis on female fertility and the management options for endometriosis-related infertility in reproductive age women: a scoping review with recent evidences. MIDDLE EAST FERTILITY SOCIETY JOURNAL 2021. [DOI: 10.1186/s43043-021-00082-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Endometriosis is a chronic inflammatory condition with varied presentation, which ultimately leads to chronic pelvic pain and infertility. It is a psychological and economic burden to the women and their families.
Main body of abstract
The literature search was performed on the following databases: MEDLINE, Google Scholar, Scopus, EMBASE, Global health, the COCHRANE library, and Web of Science. We searched the entirety of those databases for studies published until July 2020 and in English language. The literature search was conducted using the combination of the Medical Subject heading (MeSH) and any relevant keywords for “endometriosis related infertility and management” in different orders. The modalities of treatment of infertility in these patients are heterogeneous and inconclusive among the infertility experts. In this article, we tried to review the literature and look for the evidences for management of infertility caused by endometriosis. In stage I/II endometriosis, laparoscopic ablation leads to improvement in LBR. In stage III/IV, operative laparoscopy better than expectant management, to increase spontaneous pregnancy rates. Repeat surgery in stage III/IV rarely increases fecundability as it will decrease the ovarian reserve, and IVF will be better in these patients. The beneficial impact of GnRH agonist down-regulation in ART is undisputed. Dienogest is an upcoming and new alternative to GnRH agonist, with a better side effect profile. IVF + ICSI may be beneficial as compared to IVF alone. Younger patients planned for surgery due to pain or any other reason should be given the option of fertility preservation.
Short conclusion
In women with endometriosis-related infertility, clinician should individualize management, with patient-centred, multi-modal, and interdisciplinary integrated approach.
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Lee JK, Ahn SH, Kim HI, Lee YJ, Kim S, Han K, Kim MD, Seo SK. Therapeutic Efficacy of Catheter-directed Ethanol Sclerotherapy and Its Impact on Ovarian Reserve in Patients with Ovarian Endometrioma at Risk of Decreased Ovarian Reserve: A Preliminary Study. J Minim Invasive Gynecol 2021; 29:317-323. [PMID: 34469826 DOI: 10.1016/j.jmig.2021.08.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 08/24/2021] [Accepted: 08/25/2021] [Indexed: 10/20/2022]
Abstract
STUDY OBJECTIVE To investigate the therapeutic efficacy of catheter-directed ethanol sclerotherapy (CDS) and its effect on ovarian reserve in patients with endometrioma at risk of decreased ovarian reserve. DESIGN Retrospective study. SETTING Teaching hospital. PATIENTS We evaluated 18 patients with ovarian endometrioma measuring ≥3 cm and preprocedural serum antimüllerian hormone (AMH) levels of <2 ng/mL. INTERVENTIONS An 8.5-F catheter was inserted either transabdominally or transvaginally into the endometrioma. After aspiration, sclerotherapy with 99% ethanol was performed, with a subsequent 20-minute ethanol retention. MEASUREMENTS AND MAIN RESULTS Ultrasonography was performed preprocedurally and 6 months after CDS to evaluate any recurrence or changes in cyst size. Furthermore, serum AMH levels, cancer antigen 125 (CA-125) levels, and the visual analog scale scores for dysmenorrhea were obtained to analyze the ovarian reserve and treatment efficacy, preprocedurally and at 6 months after CDS. The mean cyst size on ultrasonography and serum CA-125 levels decreased 6 months after CDS (p <.001 and p = .001, respectively). All patients reported a decreased visual analog scale score for dysmenorrhea (p <.001). However, the difference in serum AMH levels before and after CDS was statistically insignificant (p = .875). CONCLUSION CDS was efficacious in reducing pain and serum CA-125 levels in patients with low AMH levels without adversely affecting their ovarian reserve.
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Affiliation(s)
- Jae Kyung Lee
- Departments of Obstetrics and Gynecology (Drs. J.K. Lee, Ahn, H.I. Kim, Y.J. Lee, S. Kim, and Seo); Severance Hospital, and Institute of Women's Life Medical Science, (Drs. J.K. Lee, Ahn, H.I. Kim, Y.J. Lee, S. Kim, and Seo), Yonsei University College of Medicine, Seoul, Korea
| | - So Hyun Ahn
- Departments of Obstetrics and Gynecology (Drs. J.K. Lee, Ahn, H.I. Kim, Y.J. Lee, S. Kim, and Seo); Severance Hospital, and Institute of Women's Life Medical Science, (Drs. J.K. Lee, Ahn, H.I. Kim, Y.J. Lee, S. Kim, and Seo), Yonsei University College of Medicine, Seoul, Korea
| | - Hye In Kim
- Departments of Obstetrics and Gynecology (Drs. J.K. Lee, Ahn, H.I. Kim, Y.J. Lee, S. Kim, and Seo); Severance Hospital, and Institute of Women's Life Medical Science, (Drs. J.K. Lee, Ahn, H.I. Kim, Y.J. Lee, S. Kim, and Seo), Yonsei University College of Medicine, Seoul, Korea
| | - Yong Jae Lee
- Departments of Obstetrics and Gynecology (Drs. J.K. Lee, Ahn, H.I. Kim, Y.J. Lee, S. Kim, and Seo); Severance Hospital, and Institute of Women's Life Medical Science, (Drs. J.K. Lee, Ahn, H.I. Kim, Y.J. Lee, S. Kim, and Seo), Yonsei University College of Medicine, Seoul, Korea
| | - Sunghoon Kim
- Departments of Obstetrics and Gynecology (Drs. J.K. Lee, Ahn, H.I. Kim, Y.J. Lee, S. Kim, and Seo); Severance Hospital, and Institute of Women's Life Medical Science, (Drs. J.K. Lee, Ahn, H.I. Kim, Y.J. Lee, S. Kim, and Seo), Yonsei University College of Medicine, Seoul, Korea
| | | | | | - Seok Kyo Seo
- Departments of Obstetrics and Gynecology (Drs. J.K. Lee, Ahn, H.I. Kim, Y.J. Lee, S. Kim, and Seo); Severance Hospital, and Institute of Women's Life Medical Science, (Drs. J.K. Lee, Ahn, H.I. Kim, Y.J. Lee, S. Kim, and Seo), Yonsei University College of Medicine, Seoul, Korea.
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Gruber TM, Mechsner S. Pathogenesis of Endometriosis: The Origin of Pain and Subfertility. Cells 2021; 10:cells10061381. [PMID: 34205040 PMCID: PMC8226491 DOI: 10.3390/cells10061381] [Citation(s) in RCA: 67] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 05/24/2021] [Accepted: 05/27/2021] [Indexed: 01/04/2023] Open
Abstract
Endometriosis (EM) and adenomyosis (AM) are common conditions with pain and infertility as the principal symptoms. The pathophysiology of pain in EM and AM comprises sensory and somatoform pain mechanisms. Over time, these may aggravate and lead to individual complex disease patterns if not diagnosed and treated. Despite the known facts, several years often pass between the onset of symptoms and diagnosis. Chronic pain disorders with changes on a neuronal level frequently arise and are linked to depressive disorders, with the process becoming a vicious cycle. Additionally, women with EM and AM suffer from sub- and infertility. Low fecundity rates are caused by anatomical changes in combination with behavioral changes in the sexual activity of women with chronic pain as well as local proinflammatory factors that not only decrease implantation rates but also promote early abortions.
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Affiliation(s)
- Teresa Mira Gruber
- Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Obstetrics, Augustenburger Platz 1, 13353 Berlin, Germany;
| | - Sylvia Mechsner
- Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Endometriosis Centre Charité, Department of Gynaecology, Augustenburger Platz 1, 13353 Berlin, Germany
- Correspondence:
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Muzii L, DI Tucci C, Galati G, Mattei G, Chinè A, Cascialli G, Palaia I, Benedetti Panici P. Endometriosis-associated infertility: surgery or IVF? Minerva Obstet Gynecol 2021; 73:226-232. [PMID: 33435663 DOI: 10.23736/s2724-606x.20.04765-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Endometriosis is a chronic disease frequently associated with female infertility. The choice of treatment in case of endometriosis is one of the most discussed topics in Reproductive Medicine. The approach to the patient with endometriosis and infertility should be tailored based on different parameters. The localization of the disease, the severity of symptoms and the age of the patient are just some of them. Management options include surgery, in-vitro fertilization (IVF), or a combination of both. Data, mostly uncontrolled, would favor surgery at any stage of endometriosis, increasing the chances of natural conception compared to expectant management. Laparoscopic excision of the ovarian endometrioma should be the treatment of choice when there is associated pain. Surgery should be performed following appropriate techniques to reduce the possible damage to the ovarian reserve. Pregnancy rates around 50% have been consistently reported after surgery, which compare favorably with those obtained with IVF. IVF, on the other hand, may be preferred in case of associated male or tubal factor, in case of a reduced ovarian reserve, or if previous surgery has failed, particularly if there is no associated pain, and when the ultrasonographic features of the ovarian cyst are reassuring. Sometimes IVF may be preceded by surgery, when a difficult access to follicles at pick-up, due to the size and location of the ovarian cyst, or to severe adhesions, is anticipated. Due to the lack of solid evidence in the scenario of endometriosis-associated infertility, robust data from randomized clinical trials (RCTs) are strongly needed.
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Affiliation(s)
- Ludovico Muzii
- Department of Obstetrics and Gynecology, Sapienza University, Rome, Italy -
| | - Chiara DI Tucci
- Department of Obstetrics and Gynecology, Sapienza University, Rome, Italy
| | - Giulia Galati
- Department of Obstetrics and Gynecology, Sapienza University, Rome, Italy
| | - Giulia Mattei
- Department of Obstetrics and Gynecology, Sapienza University, Rome, Italy
| | - Alessandra Chinè
- Department of Obstetrics and Gynecology, Sapienza University, Rome, Italy
| | - Gianluca Cascialli
- Department of Obstetrics and Gynecology, Sapienza University, Rome, Italy
| | - Innocenza Palaia
- Department of Obstetrics and Gynecology, Sapienza University, Rome, Italy
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Mechsner S. [Management of endometriosis pain : Stage-based treatment strategies and clinical experience]. Schmerz 2021; 35:159-171. [PMID: 33704582 DOI: 10.1007/s00482-021-00543-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 01/29/2021] [Accepted: 02/02/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Endometriosis is associated with various types of intense pain. In addition to nociceptive pain, there is also a nociplastic reaction with central sensitization. Atypical symptoms such as acyclic lower abdominal pain, radiating pain, non-specific bladder and intestinal complaints or even depression are frequent as are classic cyclical complaints such as severe dysmenorrhea, cyclical lower abdominal pain, dyspareunia, dysuria and dyschezia. In cases of a diverse range of symptoms, patients often consult not just gynecologists but specialists from other disciplines (e.g., internal medicine, gastroenterology, orthopedics, pain therapy, psychology). AIMS Overview about the pathophysiology and complexity of the disease and the resulting treatment options. A multimodal interdisciplinary concept might be able to take into consideration all aspects of the complex disease. METHODS Interdisciplinary concepts should be involved in the treatment of endometriosis patients along with hormonal and surgical therapy, which are generally under the supervision of a gynecologist. Pain management, dietary changes, psychological support, as well as physiotherapy should be included. The present article is intended to provide an overview of possible treatment strategies for chronic, symptomatic endometriosis. CONCLUSION The use of multimodal treatment strategies regarding the complex pathophysiological aspects of this disease might be helpful in significantly improving the quality of life of endometriosis patients.
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Affiliation(s)
- Sylvia Mechsner
- Klinik für Gynäkologie, Endometriosezentrum Charité, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Deutschland.
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Necula D, Gmuer A, Mathis J. The impact of endometriosis on the outcome of assisted reproductive techniques: role of fertility preservation. Horm Mol Biol Clin Investig 2021; 43:113-121. [PMID: 33691349 DOI: 10.1515/hmbci-2020-0082] [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: 11/22/2020] [Accepted: 02/18/2021] [Indexed: 11/15/2022]
Abstract
Endometriosis is one of the most common diseases associated with infertility. It requires different therapeutic approaches, depending on the type, whether superficial, ovarian or deep endometriotic nodules, clinical presentation, age or origin of infertility. Patients with endometriosis should be considered a group of high-risk for infertility and any intervention should be planned taking this consideration into account. For many years, surgery was the only tool in improving fertility outcomes. Nowadays, it remains the gold standard for the treatment of endometriosis, but it should be carefully used because of its harmful potential, leading to premature ovarian insufficiency and further infertility. With the development of modern assisted reproductive techniques (ART), which can offer better results in terms of fertility, the role of surgery progressively decreased. Nowadays, therapeutic approach is complex and multidisciplinary teams should be guiding individual treatment for each woman. Options include medical treatment, surgery, in vitro fertilization (IVF) or oocytes/embryo/ovarian tissue cryopreservation. There is a constant effort in developing diagnostic scores, in order to predict risk of infertility and create standard of practice, offering a long-term approach in terms of fertility preservation and quality of life.
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Affiliation(s)
- Daniel Necula
- Gynecology and Obstetrics Unit, Biel/Bienne Hospital, Biel, Switzerland
| | - Andrea Gmuer
- Gynecology and Obstetrics Unit, Biel/Bienne Hospital, Biel, Switzerland
| | - Jérôme Mathis
- Gynecology and Obstetrics Unit, Biel/Bienne Hospital, Biel, Switzerland
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31
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Taylor HS, Kotlyar AM, Flores VA. Endometriosis is a chronic systemic disease: clinical challenges and novel innovations. Lancet 2021; 397:839-852. [PMID: 33640070 DOI: 10.1016/s0140-6736(21)00389-5] [Citation(s) in RCA: 373] [Impact Index Per Article: 124.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 08/09/2020] [Accepted: 08/14/2020] [Indexed: 12/14/2022]
Abstract
Endometriosis is a common disease affecting 5-10% of women of reproductive age globally. However, despite its prevalence, diagnosis is typically delayed by years, misdiagnosis is common, and delivery of effective therapy is prolonged. Identification and prompt treatment of endometriosis are essential and facilitated by accurate clinical diagnosis. Endometriosis is classically defined as a chronic, gynaecological disease characterised by endometrial-like tissue present outside of the uterus and is thought to arise by retrograde menstruation. However, this description is outdated and no longer reflects the true scope and manifestations of the disease. The clinical presentation is varied, the presence of pelvic lesions is heterogeneous, and the manifestations of the disease outside of the female reproductive tract remain poorly understood. Endometriosis is now considered a systemic disease rather than a disease predominantly affecting the pelvis. Endometriosis affects metabolism in liver and adipose tissue, leads to systemic inflammation, and alters gene expression in the brain that causes pain sensitisation and mood disorders. The full effect of the disease is not fully recognised and goes far beyond the pelvis. Recognition of the full scope of the disease will facilitate clinical diagnosis and allow for more comprehensive treatment than currently available. Progestins and low-dose oral contraceptives are unsuccessful in a third of symptomatic women globally, probably as a result of progesterone resistance. Oral gonadotropin-releasing hormone (GnRH) antagonists constitute an effective and tolerable therapeutic alternative when first-line medications do not work. The development of GnRH antagonists has resulted in oral drugs that have fewer side-effects than other therapies and has allowed for rapid movement between treatments to optimise and personalise endometriosis care. In this Review, we discuss the latest understanding of endometriosis as a systemic disease with multiple manifestations outside the parameters of classic gynaecological disease.
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Affiliation(s)
- Hugh S Taylor
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT, USA.
| | - Alexander M Kotlyar
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT, USA
| | - Valerie A Flores
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT, USA
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Da Luz CM, Da Broi MG, Plaça JR, Silva WA, Meola J, Navarro PA. Altered transcriptome in cumulus cells of infertile women with advanced endometriosis with and without endometrioma. Reprod Biomed Online 2021; 42:952-962. [PMID: 33736992 DOI: 10.1016/j.rbmo.2021.01.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 01/27/2021] [Accepted: 01/29/2021] [Indexed: 11/28/2022]
Abstract
RESEARCH QUESTION Is the transcriptome of cumulus cells of infertile women with advanced endometriosis (EIII/IV), with and without endometrioma, altered? DESIGN In this prospective case-control study, next-generation RNA sequencing was used to compare the transcript profile of cumulus cells among infertile patients undergoing ovarian stimulation for intracytoplasmic sperm injection with EIII/IV, with (n = 9) and without endometrioma (n = 9), and controls (n = 9). An in-silico enrichment analysis was conducted to establish the possibly altered pathways in cumulus cells of patients with endometriosis. RESULTS Most of the differentially expressed genes (DEG) were found when cumulus cells from women with EIII/IV with endometrioma were compared with controls (DEG, n = 461). In women with EIII/IV without endometrioma, only 66 DEG were verified compared with controls. The enrichment analysis showed that some DEG in cumulus cells of endometriosis are involved in important pathways for the oocyte competence acquisition, such as oxidative phosphorylation, metabolism, mitochondrial function, acetylation and steroid biosynthesis. No DEG were found when cumulus cells from women with EIII/IV with and without endometrioma were compared. CONCLUSION RNA sequencing results suggest that cumulus cells of infertile women with EIII/IV have an altered transcriptome, regardless of endometrioma. The present findings offer a better understanding of the genes and molecular mechanisms that may be involved in endometriosis-related infertility, mostly in the oocyte competence acquisition process.
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Affiliation(s)
- Caroline M Da Luz
- Division of Human Reproduction, Department of Gynecology and Obstetrics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto São Paulo 14049-900, Brazil.
| | - Michele G Da Broi
- Division of Human Reproduction, Department of Gynecology and Obstetrics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto São Paulo 14049-900, Brazil
| | - Jessica R Plaça
- Center for Integrative Systems Biology - CISBi, NAP/USP, Ribeirão Preto São Paulo 14049-900, Brazil
| | - Wilson A Silva
- Center for Integrative Systems Biology - CISBi, NAP/USP, Ribeirão Preto São Paulo 14049-900, Brazil; Center for Medical Genomics, HCFMRP/USP, Ribeirão Preto São Paulo 14049-900, Brazil; Department of Genetics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto São Paulo 14049-900, Brazil
| | - Juliana Meola
- Division of Human Reproduction, Department of Gynecology and Obstetrics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto São Paulo 14049-900, Brazil
| | - Paula A Navarro
- Division of Human Reproduction, Department of Gynecology and Obstetrics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto São Paulo 14049-900, Brazil; National Institute of Hormones and Women's Health, CNPq, Porto Alegre Rio Grande do Sul 90035-003, Brazil
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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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Pais AS, Flagothier C, Tebache L, Almeida Santos T, Nisolle M. Impact of Surgical Management of Endometrioma on AMH Levels and Pregnancy Rates: A Review of Recent Literature. J Clin Med 2021; 10:jcm10030414. [PMID: 33499120 PMCID: PMC7865255 DOI: 10.3390/jcm10030414] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 01/04/2021] [Accepted: 01/18/2021] [Indexed: 01/13/2023] Open
Abstract
Ovarian endometrioma are found in up to 40% of women with endometriosis and 50% of infertile women. The best surgical approach for endometrioma and its impact on pregnancy rates is still controversial. Therefore, we conducted a literature review on surgical management of ovarian endometrioma and its impact on pregnancy rates and ovarian reserve, assessed by anti-Müllerian hormone (AMH) serum levels. Ovarian cystectomy is the preferred technique, as it is associated with lower recurrence and higher spontaneous pregnancy rate. However, ablative approaches and combined techniques are becoming more popular as ovarian reserve is less affected and there are slightly higher pregnancy rates. Preoperative AMH level might be useful to predict the occurrence of pregnancy. In conclusion, AMH should be included in the preoperative evaluation of reproductive aged women with endometriosis. The surgical options for ovarian endometrioma should be individualized. The endometrioma ablation procedure seems to be the most promising treatment.
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Affiliation(s)
- Ana Sofia Pais
- Reproductive Medicine Unit, Centro Hospitalar e Universitário de Coimbra, 3004-561 Coimbra, Portugal;
- Obstetrics Department, Faculty of Medicine, University of Coimbra, 3000-370 Coimbra, Portugal
- Coimbra Institute for Clinical and Biomedical Research (iCBR) Area of Environment Genetics and Oncobiology (CIMAGO), Biophysics Institute of Faculty of Medicine, University of Coimbra, 3000-548 Coimbra, Portugal
- Center for Innovative Biomedicine and Biotechnology (CIBB), University of Coimbra, 3000-548 Coimbra, Portugal
- Clinical Academic Center of Coimbra (CACC), 3000-548 Coimbra, Portugal
- Correspondence:
| | - Clara Flagothier
- Department of Obstetrics and Gynaecology, Hospital CHR Liège, University of Liège, 4000 Liège, Belgium; (C.F.); (L.T.); (M.N.)
| | - Linda Tebache
- Department of Obstetrics and Gynaecology, Hospital CHR Liège, University of Liège, 4000 Liège, Belgium; (C.F.); (L.T.); (M.N.)
| | - Teresa Almeida Santos
- Reproductive Medicine Unit, Centro Hospitalar e Universitário de Coimbra, 3004-561 Coimbra, Portugal;
- Faculty of Medicine, University of Coimbra, 3000-370 Coimbra, Portugal
| | - Michelle Nisolle
- Department of Obstetrics and Gynaecology, Hospital CHR Liège, University of Liège, 4000 Liège, Belgium; (C.F.); (L.T.); (M.N.)
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Vignali M, Solima E, Barbera V, Becherini C, Belloni GM. Approaching ovarian endometrioma with medical therapy. Minerva Obstet Gynecol 2020; 73:215-225. [PMID: 33314904 DOI: 10.23736/s2724-606x.20.04751-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Endometriosis is a chronic inflammatory gynecological disorder associated with pelvic pain symptoms and infertility. Ovarian cysts (endometriomas) are the most common localization of endometriosis in the pelvis. Considering non-invasive methods, transvaginal ultrasound has high sensitivity and specificity for endometrioma diagnosis. Laparoscopic removal of endometrioma is related to a damage to the ovarian reserve and should be limited to patients with suspicious cysts or unresponsive to medical treatment. The main goal of medical therapy of symptomatic endometrioma is the control of pain symptoms, while no benefits have been demonstrated in terms of improving fertility rates of women seeking pregnancy. The aim of medical treatment is the inhibition of ovulation, stop of menstruation and achievement of a stable hypo-hormonal milieu. Estroprogestins and progestins are indicated by guidelines as first line medications for symptomatic patients. Several hormonal treatments have been proposed for the treatment of symptomatic endometriomas. In particular, dienogest, a relatively new progestin, has shown promising results. Medical treatment should be conceived as a long-term treatment. Safety, tolerability, a low percentage of side effects and an easy route of administration are essential for patient acceptance and adherence to therapy.
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Affiliation(s)
- Michele Vignali
- Department of Biomedical Sciences for Health, M. Melloni Hospital, University of Milan, Milan, Italy -
| | - Eugenio Solima
- Department of Biomedical Sciences for Health, M. Melloni Hospital, University of Milan, Milan, Italy
| | - Valeria Barbera
- Department of Biomedical Sciences for Health, M. Melloni Hospital, University of Milan, Milan, Italy
| | - Chiara Becherini
- Department of Biomedical Sciences for Health, M. Melloni Hospital, University of Milan, Milan, Italy
| | - Gaia M Belloni
- Department of Biomedical Sciences for Health, M. Melloni Hospital, University of Milan, Milan, Italy
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Abstract
BACKGROUND Endometriosis is associated with pain and infertility. Surgical interventions aim to remove visible areas of endometriosis and restore the anatomy. OBJECTIVES To assess the effectiveness and safety of laparoscopic surgery in the treatment of pain and infertility associated with endometriosis. SEARCH METHODS This review has drawn on the search strategy developed by the Cochrane Gynaecology and Fertility Group including searching the Cochrane Gynaecology and Fertility Group's specialised register, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, reference lists for relevant trials, and trial registries from inception to April 2020. SELECTION CRITERIA We selected randomised controlled trials (RCTs) that compared the effectiveness and safety of laparoscopic surgery with any other laparoscopic or robotic intervention, holistic or medical treatment, or diagnostic laparoscopy only. DATA COLLECTION AND ANALYSIS Two review authors independently performed selection of studies, assessment of trial quality and extraction of relevant data with disagreements resolved by a third review author. We collected data for the core outcome set for endometriosis. Primary outcomes included overall pain and live birth. We evaluated the quality of evidence using GRADE methods. MAIN RESULTS We included 14 RCTs. The studies randomised 1563 women with endometriosis. Four RCTs compared laparoscopic ablation or excision with diagnostic laparoscopy only. Two RCTs compared laparoscopic excision with diagnostic laparoscopy only. One RCT compared laparoscopic ablation or excision with laparoscopic ablation or excision and uterine suspension. Two RCTs compared laparoscopic ablation and uterine nerve transection with diagnostic laparoscopy only. One RCT compared laparoscopic ablation with diagnostic laparoscopy and gonadotropin-releasing hormone (GnRH) analogues. Two RCTs compared laparoscopic ablation with laparoscopic excision. One RCT compared laparoscopic ablation or excision with helium thermal coagulator with laparoscopic ablation or excision with electrodiathermy. One RCT compared conservative laparoscopic surgery with laparoscopic colorectal resection of deep endometriosis infiltrating the rectum. Common limitations in the primary studies included lack of clearly described blinding, failure to fully describe methods of randomisation and allocation concealment, and poor reporting of outcome data. Laparoscopic treatment versus diagnostic laparoscopy We are uncertain of the effect of laparoscopic treatment on overall pain scores compared to diagnostic laparoscopy only at six months (mean difference (MD) 0.90, 95% confidence interval (CI) 0.31 to 1.49; 1 RCT, 16 participants; very low quality evidence) and at 12 months (MD 1.65, 95% CI 1.11 to 2.19; 1 RCT, 16 participants; very low quality evidence), where a positive value means pain relief (the higher the score, the more pain relief) and a negative value reflects pain increase (the lower the score, the worse the increase in pain). No studies looked at live birth. We are uncertain of the effect of laparoscopic treatment on quality of life compared to diagnostic laparoscopy only: EuroQol-5D index summary at six months (MD 0.03, 95% CI -0.12 to 0.18; 1 RCT, 39 participants; low quality evidence), 12-item Short Form (SF-12) mental health component (MD 2.30, 95% CI -4.50 to 9.10; 1 RCT, 39 participants; low quality evidence) and SF-12 physical health component (MD 2.70, 95% CI -2.90 to 8.30; 1 RCT, 39 participants; low quality evidence). Laparoscopic treatment probably improves viable intrauterine pregnancy rate compared to diagnostic laparoscopy only (odds ratio (OR) 1.89, 95% CI 1.25 to 2.86; 3 RCTs, 528 participants; I2 = 0%; moderate quality evidence). We are uncertain of the effect of laparoscopic treatment compared to diagnostic laparoscopy only on ectopic pregnancy (MD 1.18, 95% CI 0.10 to 13.48; 1 RCT, 100 participants; low quality evidence) and miscarriage (MD 0.94, 95% CI 0.35 to 2.54; 2 RCTs, 112 participants; low quality evidence). There was limited reporting of adverse events. No conversions to laparotomy were reported in both groups (1 RCT, 341 participants). Laparoscopic ablation and uterine nerve transection versus diagnostic laparoscopy We are uncertain of the effect of laparoscopic ablation and uterine nerve transection on adverse events (more specifically vascular injury) compared to diagnostic laparoscopy only (OR 0.33, 95% CI 0.01 to 8.32; 1 RCT, 141 participants; low quality evidence). No studies looked at overall pain scores (at six and 12 months), live birth, quality of life, viable intrauterine pregnancy confirmed by ultrasound, ectopic pregnancy and miscarriage. Laparoscopic ablation versus laparoscopic excision There was insufficient evidence to determine whether there was a difference in overall pain, measured at 12 months, for laparoscopic ablation compared with laparoscopic excision (MD 0.00, 95% CI -1.22 to 1.22; 1 RCT, 103 participants; very low quality evidence). No studies looked at overall pain scores at six months, live birth, quality of life, viable intrauterine pregnancy confirmed by ultrasound, ectopic pregnancy, miscarriage and adverse events. Helium thermal coagulator versus electrodiathermy We are uncertain whether helium thermal coagulator compared to electrodiathermy improves quality of life using the 30-item Endometriosis Health Profile (EHP-30) at nine months, when considering the components: pain (MD 6.68, 95% CI -3.07 to 16.43; 1 RCT, 119 participants; very low quality evidence), control and powerlessness (MD 4.79, 95% CI -6.92 to 16.50; 1 RCT, 119 participants; very low quality evidence), emotional well-being (MD 6.17, 95% CI -3.95 to 16.29; 1 RCT, 119 participants; very low quality evidence) and social support (MD 5.62, 95% CI -6.21 to 17.45; 1 RCT, 119 participants; very low quality evidence). Adverse events were not estimable. No studies looked at overall pain scores (at six and 12 months), live birth, viable intrauterine pregnancy confirmed by ultrasound, ectopic pregnancy and miscarriage. AUTHORS' CONCLUSIONS Compared to diagnostic laparoscopy only, it is uncertain whether laparoscopic surgery reduces overall pain associated with minimal to severe endometriosis. No data were reported on live birth. There is moderate quality evidence that laparoscopic surgery increases viable intrauterine pregnancy rates confirmed by ultrasound compared to diagnostic laparoscopy only. No studies were found that looked at live birth for any of the comparisons. Further research is needed considering the management of different subtypes of endometriosis and comparing laparoscopic interventions with lifestyle and medical interventions. There was insufficient evidence on adverse events to allow any conclusions to be drawn regarding safety.
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Affiliation(s)
- Celine Bafort
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - Yusuf Beebeejaun
- King's Fertility, King's College Hospital NHS Foundation Trust, London, UK
| | - Carla Tomassetti
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - Jan Bosteels
- Academic Centre for General Practice, Cochrane Belgium, Leuven, Belgium
| | - James Mn Duffy
- Institute for Women's Health, University College London, London, UK
- King's Fertility, Fetal Medicine Research Institute, London, UK
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Capezzuoli T, Vannuccini S, Mautone D, Sorbi F, Chen H, Reis FM, Ceccaroni M, Petraglia F. Long-term hormonal treatment reduces repetitive surgery for endometriosis recurrence. Reprod Biomed Online 2020; 42:451-456. [PMID: 33277193 DOI: 10.1016/j.rbmo.2020.09.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 08/05/2020] [Accepted: 09/17/2020] [Indexed: 12/16/2022]
Abstract
RESEARCH QUESTION How effective is medical hormonal treatment in preventing endometriosis recurrence and in improving women's clinical symptoms and quality of life? DESIGN This observational cross-sectional study evaluated the effects of hormonal medical treatment (progestins, gonadotrophin-releasing hormone analogues or continuous oral contraceptives) on endometriosis recurrence, current clinical symptoms and quality of life in three groups of patients: Group A (n = 34), no hormonal treatment either before or after the first endometriosis surgery; Group B (n = 76), on hormonal treatment after the first endometriosis surgery; and Group C (n = 75), on hormonal treatment both before and after the first endometriosis surgery. RESULTS Group C patients were characterized by a lower rate of endometriosis reoperation (P = 0.011) and a lower rate of dysmenorrhoea (P = 0.006). Women who experienced repetitive endometriosis surgery showed worse physical (P = 0.004) and mental (P = 0.012) status than those who received a single surgery, independent of the treatment. CONCLUSION Hormonal treatments represent a valid cornerstone of endometriosis management and may be useful as an alternative to surgery, but also before surgery, to plan better, and after surgery in order to reduce the risk of recurrence. Medical counselling is very helpful in choosing the correct and individualized endometriosis treatment. In fact, the gold standard for modern endometriosis management is the individualized approach and surgery should be considered, depending on the clinical situation and a patient's symptoms.
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Affiliation(s)
- Tommaso Capezzuoli
- Department of Clinical Experimental and Biomedical Sciences, University of Florence Florence, Italy
| | - Silvia Vannuccini
- Obstetrics and Gynecology, Department of Maternity and Infancy, AOU Careggi Florence, Italy; Department of Molecular and Developmental Medicine, University of Siena Siena, Italy
| | - Daniele Mautone
- Gynecology and Obstetrics, Gynecologic Oncology, Minimally-Invasive Pelvic Surgery, International School of Surgical Anatomy, IRCCS Sacro Cuore Don Calabria Hospital, Negar di Valpolicella, Verona, Italy
| | - Flavia Sorbi
- Department of Clinical Experimental and Biomedical Sciences, University of Florence Florence, Italy
| | - Huixi Chen
- International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University Shanghai, China
| | - Fernando M Reis
- Universidade Federal de Minas Gerais, Division of Human Reproduction, Belo Horizonte, Brazil
| | - Marcello Ceccaroni
- Gynecology and Obstetrics, Gynecologic Oncology, Minimally-Invasive Pelvic Surgery, International School of Surgical Anatomy, IRCCS Sacro Cuore Don Calabria Hospital, Negar di Valpolicella, Verona, Italy
| | - Felice Petraglia
- Department of Clinical Experimental and Biomedical Sciences, University of Florence Florence, Italy.
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Focal adenomyosis of the outer myometrium and deep infiltrating endometriosis severity. Fertil Steril 2020; 114:818-827. [PMID: 32741618 DOI: 10.1016/j.fertnstert.2020.05.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 04/28/2020] [Accepted: 05/02/2020] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To determine whether the presence of focal adenomyosis of the outer myometrium (FAOM) at preoperative magnetic resonance imaging is associated with the severity of deep infiltrating endometriosis. DESIGN Observational cross-sectional study involving 255 symptomatic deep infiltrating endometriosis patients. Comparisons were performed according to the presence of FAOM. SETTING University hospital. PATIENT(S) Women with a preoperative magnetic resonance imaging and complete surgical exeresis of endometriotic lesions with histologically documented deep infiltrating endometriosis. INTERVENTION(S) Surgical management for deep infiltrating endometriosis. MAIN OUTCOME MEASURE(S) The presence of multiple deep infiltrating endometriosis lesions, the mean number and location of deep infiltrating endometriosis lesions, and the mean total revised American Society for Reproductive Medicine scores. RESULT(S) The prevalence of FAOM at preoperative magnetic resonance imaging in the 255 patients with deep infiltrating endometriosis was 56.5%. The mean number of deep infiltrating endometriosis lesions was significantly higher in the FAOM(+) group than in the FAOM(-) group: 3.5 ± 2.1 vs. 2.2 ± 1.5. The mean total revised American Society for Reproductive Medicine score was higher in case of FOAM coexisting with deep infiltrating endometriosis. After adjusting for confounding factors, the presence of FAOM was significantly associated with multiple deep lesions. CONCLUSION(S) FAOM was significantly associated with greater deep infiltrating endometriosis severity. This needs to be integrated into the management strategy. Furthermore, a pathogenic link between deep infiltrating endometriosis and FAOM cannot be excluded.
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Fertility Outcome after CO 2 Laser Vaporization versus Cystectomy in Women with Ovarian Endometrioma: A Comparative Study. J Minim Invasive Gynecol 2020; 28:34-41. [PMID: 32712323 DOI: 10.1016/j.jmig.2020.07.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 07/07/2020] [Accepted: 07/20/2020] [Indexed: 12/11/2022]
Abstract
STUDY OBJECTIVE To assess the postoperative likelihood of conception in patients with endometriomas managed by either CO2 laser vaporization or cystectomy. DESIGN A retrospective study with prospective recording of data. SETTING University hospital. PATIENTS One hundred and forty-two patients with symptomatic endometriomas. INTERVENTIONS Patients underwent a standardized laparoscopic stripping technique (Group 1) or cyst vaporization with CO2 fiber laser (Group 2). Patients wishing to become pregnant were allowed to attempt a spontaneous conception after surgery. If spontaneous conception failed, patients were referred for in vitro fertilization (IVF). MEASUREMENTS AND MAIN RESULTS The primary objective was to compare pregnancy rates between the 2 groups. The secondary objective was the identification of independent predictors of pregnancy. Thirty-nine women in Group 1 (53.4%) and 39 women in Group 2 (56.5%) desired to conceive after surgery. Three patients (7.7%) in Group 1 became pregnant following donor-IVF and were excluded. Pregnancies were recorded in 72.2% of patients treated with cystectomy and in 74.3% of those managed with CO2 fiber laser (p = .83). Twenty patients (55.6%) in Group 1 and 14 patients (35.9%) in Group 2 conceived spontaneously (p = .08). Among patients who failed spontaneous conception, 21 patients (28%) achieved pregnancy through IVF (Group 1: n = 6, 16.7%; Group 2: n = 15, 38.5%; p = .08). Twenty patients (26.7%) never became pregnant. Age at the time of surgery (odds ratio (OR) = 0.86; 95% Confidence intervals (CI): 0.78-0.96, p = .002) and duration of infertility (OR=0.80; 95% CI: 0.69-0.92, p = .006) were identified as independent indicators for pregnancy. CONCLUSION CO2 laser-treated endometrioma is associated with pregnancy rates equal to those observed after cystectomy and favorable IVF outcomes. The one step CO2 fiber laser technique may represent a viable alternative to cystectomy.
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Günther V, von Otte S, Maass N, Alkatout I. Endometrial "Scratching" An update and overview of current research. J Turk Ger Gynecol Assoc 2020; 21:124-129. [PMID: 32517438 PMCID: PMC7294834 DOI: 10.4274/jtgga.galenos.2020.2019.0175] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
About one in every six couples is affected by sterility. Assisted reproduction procedures are currently the treatment of choice for a number of patients who desire children. Many causes of sterility can be overcome with the aid of in vitro fertilization, but successful implantation of the embryos is the major limiting factor. Failure of implantation may occur repetitively. In the treatment of sterility, many approaches have been used to overcome the barrier of implantation failure and improve the chances of successful nidation. Scratching the endometrium prior to embryo transfer has been suggested as one means of enhancing the likelihood of implantation. The current literature was examined to investigate if there was any possible benefit from endometrial scratching. The studies were divided according to whether the women suffered from recurrent implantation failure or not. In summary, it was found that unselected subfertile women generally benefit less from endometrial scratching, but scratching appears to be successful in women who have experienced repeated implantation failure. Although the heterogeneous body of data on the subject deserves further clarification. The latest data presented at “European Society of Human Reproduction and Embryology” 2018 in Barcelona suggested that the method should be abandoned.
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Affiliation(s)
- Veronika Günther
- Clinic for Obstetrics and Gynecology, UKSH Campus Kiel, Kiel, Germany.,University Fertility Center, Ambulanzzentrum des UKSH gGmbH, Kiel, Germany
| | - Sören von Otte
- University Fertility Center, Ambulanzzentrum des UKSH gGmbH, Kiel, Germany
| | - Nicolai Maass
- Clinic for Obstetrics and Gynecology, UKSH Campus Kiel, Kiel, Germany
| | - Ibrahim Alkatout
- Clinic for Obstetrics and Gynecology, UKSH Campus Kiel, Kiel, Germany
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Mikhaleva LM, Davydov AI, Patsap OI, Mikhaylenko EV, Nikolenko VN, Neganova ME, Klochkov SG, Somasundaram SG, Kirkland CE, Aliev G. Malignant Transformation and Associated Biomarkers of Ovarian Endometriosis: A Narrative Review. Adv Ther 2020; 37:2580-2603. [PMID: 32385745 PMCID: PMC7467438 DOI: 10.1007/s12325-020-01363-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Indexed: 02/07/2023]
Abstract
This review focuses on pathogenesis of endometriosis, its possible biomarkers and role in endometriosis-associated ovarian cancer. We analyzed various databases to obtain new insights, theories, and biomarkers associated with endometriosis. There are several theories of endometriosis development and biomarker changes including atypical forms. A number of studies have attempted to establish specific, reliable biomarkers to help diagnose endometriosis and endometriosis-associated diseases on the basis of different pathogenetic pathways. Nevertheless, despite intensive research extending even to the molecular level, the origin, natural history, malignant transformation, and laboratory management of endometriosis and related diseases are not yet clearly defined. Therefore, early laboratory diagnoses of endometriosis, its atypical form, and endometriosis-associated ovarian tumors are important problems that require further study in the context of advanced therapeutic strategies to provide maximal health benefits to patients.
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Affiliation(s)
- Liudmila M Mikhaleva
- Department of Clinical Pathology, Federal State Budgetary Institution "Research Institute of Human Morphology", 3, Tsyurupy Str, Moscow, 117418, Russian Federation
| | - Aleksandr I Davydov
- Department of Obstetrics, Gynecology and Perinatology, Institute of Clinical Medicine, I.M. Sechenov First Moscow State Medical University (Sechenov University), 8/2, Trubetskaya Str., Moscow, 119991, Russian Federation
- Department of Pathology, City Clinical Hospital After Named S.S. Udina, 4, Bld., 3, Kolomensky Passage, Moscow, 115446, Russian Federation
| | - Olga I Patsap
- Department of Pathology, City Clinical Hospital After Named S.S. Udina, 4, Bld., 3, Kolomensky Passage, Moscow, 115446, Russian Federation
| | - Elizaveta V Mikhaylenko
- I. M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), 8/2 Trubetskaya Str, Moscow, 119991, Russia
| | - Vladimir N Nikolenko
- I. M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), 8/2 Trubetskaya Str, Moscow, 119991, Russia
- Department of Normal and Topographic Anatomy, M.V. Lomonosov Moscow State University, Leninskie Gory, 1, Moscow, 119991, Russia
| | - Margarita E Neganova
- Institute of Physiologically Active Compounds, Russian Academy of Sciences, 1 Severny pr, Chernogolovka, Moscow Region, 142432, Russia
| | - Sergey G Klochkov
- Institute of Physiologically Active Compounds, Russian Academy of Sciences, 1 Severny pr, Chernogolovka, Moscow Region, 142432, Russia
| | | | - Cecil E Kirkland
- Department of Biological Sciences, Salem University, Salem, WV, 26426, USA
| | - Gjumrakch Aliev
- Department of Clinical Pathology, Federal State Budgetary Institution "Research Institute of Human Morphology", 3, Tsyurupy Str, Moscow, 117418, Russian Federation.
- I. M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), 8/2 Trubetskaya Str, Moscow, 119991, Russia.
- Institute of Physiologically Active Compounds, Russian Academy of Sciences, 1 Severny pr, Chernogolovka, Moscow Region, 142432, Russia.
- GALLY International Research Institute, 7733 Louis Pasteur Drive, #330, San Antonio, TX, 78229, USA.
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Parry JP. The solution to endometriosis isn't always in vitro fertilization. Fertil Steril 2020; 113:1171. [PMID: 32387280 DOI: 10.1016/j.fertnstert.2020.02.101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 02/17/2020] [Indexed: 11/18/2022]
Affiliation(s)
- J Preston Parry
- Parryscope and Positive Steps Fertility, Madison, Mississippi; Department of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson, Mississippi
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43
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Is early initiation of infertility treatment justified in women over the age of 35 years? Reprod Biomed Online 2020; 40:393-398. [DOI: 10.1016/j.rbmo.2019.12.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Revised: 11/12/2019] [Accepted: 12/10/2019] [Indexed: 12/14/2022]
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Maignien C, Santulli P, Bourdon M, Korb D, Marcellin L, Lamau MC, Chapron C. Deep Infiltrating Endometriosis: a Previous History of Surgery for Endometriosis May Negatively Affect Assisted Reproductive Technology Outcomes. Reprod Sci 2020; 27:545-554. [DOI: 10.1007/s43032-019-00052-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 07/23/2019] [Indexed: 11/29/2022]
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Larraín D, Buckel H, Prado J, Abedrapo M, Rojas I. Multidisciplinary laparoscopic management of deep infiltrating endometriosis from 2010 to 2017: A retrospective cohort study. Medwave 2019; 19:e7750. [PMID: 31999675 DOI: 10.5867/medwave.2019.11.7750] [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: 06/29/2019] [Accepted: 10/25/2019] [Indexed: 11/27/2022] Open
Abstract
Background Laparoscopy has become the standard of care in the surgical management of deep infiltrating endometriosis (DIE). However, it is a challenging procedure with a high complication rate. Despite the benefits of the minimally invasive approach, DIE resection is often performed by surgeons without adequate training, especially in developing countries like Chile. Objective To asses our experience in the diagnosis and laparoscopic management of DIE during seven years. Methods A retrospective cohort study of data including 137 patients with pathology-proven DIE. Surgical and fertility outcomes were evaluated. Results All procedures were performed laparoscopically without conversion. Dysmenorrhea and dyspareunia were the most common symptoms in 85.4% and 56.9%, respectively. Uterosacral ligaments were the most common DIE location. Endometrioma was present in 48.9% of cases. Median operative time was 140 minutes; however, it was longer in cases requiring bowel surgery (p < 0.0001). The complication rate was 10.9%. Median follow-up was 24.5 months. The pregnancy rate was 58.1% and 90% of patients reported significant symptom relief after surgery. Conclusion Laparoscopic surgical management of DIE is effective and safe but it must be performed in tertiary centers with the availability of multidisciplinary teams.
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Affiliation(s)
- Demetrio Larraín
- Unidad de Endometriosis, Servicio de Obstetricia y Ginecología, Clínica Santa María, Santiago, Chile. Address: Santa María 0500, Providencia, RM, Chile, Código Postal 7500000. . ORCID: 0000-0002-4161-0513
| | - Hans Buckel
- Unidad de Endometriosis, Servicio de Obstetricia y Ginecología, Clínica Santa María, Santiago, Chile
| | - Jaime Prado
- Unidad de Endometriosis, Servicio de Obstetricia y Ginecología, Clínica Santa María, Santiago, Chile
| | - Mario Abedrapo
- Servicio de Cirugía, Clínica Santa María, Santiago, Chile
| | - Iván Rojas
- Unidad de Endometriosis, Servicio de Obstetricia y Ginecología, Clínica Santa María, Santiago, Chile
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Chapron C, Marcellin L, Borghese B, Santulli P. Rethinking mechanisms, diagnosis and management of endometriosis. Nat Rev Endocrinol 2019; 15:666-682. [PMID: 31488888 DOI: 10.1038/s41574-019-0245-z] [Citation(s) in RCA: 437] [Impact Index Per Article: 87.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/18/2019] [Indexed: 02/08/2023]
Abstract
Endometriosis is a chronic inflammatory disease defined as the presence of endometrial tissue outside the uterus, which causes pelvic pain and infertility. This disease should be viewed as a public health problem with a major effect on the quality of life of women as well as being a substantial economic burden. In light of the considerable progress with diagnostic imaging (for example, transvaginal ultrasound and MRI), exploratory laparoscopy should no longer be used to diagnose endometriotic lesions. Instead, diagnosis of endometriosis should be based on a structured process involving the combination of patient interviews, clinical examination and imaging. Notably, a diagnosis of endometriosis often leads to immediate surgery. Therefore, rethinking the diagnosis and management of endometriosis is warranted. Instead of assessing endometriosis on the day of the diagnosis, gynaecologists should consider the patient's 'endometriosis life'. Medical treatment is the first-line therapeutic option for patients with pelvic pain and no desire for immediate pregnancy. In women with infertility, careful consideration should be made regarding whether to provide assisted reproductive technologies prior to performing endometriosis surgery. Modern endometriosis management should be individualized with a patient-centred, multi-modal and interdisciplinary integrated approach.
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Affiliation(s)
- Charles Chapron
- Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, Paris, France.
- Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, Department of Gynecology Obstetrics II and Reproductive Medicine, Paris, France.
- Department 'Development, Reproduction and Cancer', Institut Cochin, INSERM U1016, Université Paris Descartes, Paris, France.
| | - Louis Marcellin
- Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, Paris, France
- Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, Department of Gynecology Obstetrics II and Reproductive Medicine, Paris, France
- Department 'Development, Reproduction and Cancer', Institut Cochin, INSERM U1016, Université Paris Descartes, Paris, France
| | - Bruno Borghese
- Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, Paris, France
- Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, Department of Gynecology Obstetrics II and Reproductive Medicine, Paris, France
- Department 'Development, Reproduction and Cancer', Institut Cochin, INSERM U1016, Université Paris Descartes, Paris, France
| | - Pietro Santulli
- Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, Paris, France
- Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, Department of Gynecology Obstetrics II and Reproductive Medicine, Paris, France
- Department 'Development, Reproduction and Cancer', Institut Cochin, INSERM U1016, Université Paris Descartes, Paris, France
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Zhou Y, Chen C, Hu C, Wang Y, Zhang X, Wu R. Predictive value of the serum anti-Müllerian level for spontaneous pregnancy in women after endometriosis surgery. J Int Med Res 2019; 47:5643-5649. [PMID: 31554444 PMCID: PMC6862891 DOI: 10.1177/0300060519861171] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective This study was performed to assess the predictive value of the anti-Müllerian hormone (AMH) serum level for spontaneous pregnancy in women after endometriosis surgery. Methods In total, 124 patients with suspected ovarian endometrioma planning to undergo laparoscopic ovarian cystectomy were divided into a high AMH group (AMH > 2 ng/mL) and low AMH group (AMH ≤ 2 ng/mL) according to their preoperative AMH levels. The postoperative AMH levels were also measured, and pregnancy outcomes were followed up. Results Twenty-one patients were excluded, and 52 pregnancies were registered in the remaining 103 patients diagnosed with endometriosis. The pregnancy rate was significantly greater in the high than low AMH group. Receiver operator characteristics analysis of preoperative AMH, postoperative AMH, and the AMH decline rate showed that preoperative AMH was associated with the greatest area under the curve. Kaplan–Meier curves showed that women in the high AMH group had a significantly higher cumulative pregnancy rate than those in the low AMH group. Conclusion The preoperative AMH level might be a useful marker to predict the occurrence of natural pregnancy and could be offered as part of the fertility strategy to women who desire pregnancy after endometriosis surgery.
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Affiliation(s)
- Yong Zhou
- Women's Hospital Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, People's Republic of China
| | - Chaolu Chen
- Women's Hospital Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, People's Republic of China
| | - Changchang Hu
- Women's Hospital Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, People's Republic of China
| | - Yuan Wang
- Women's Hospital Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, People's Republic of China
| | - Xian Zhang
- Women's Hospital Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, People's Republic of China
| | - Ruijin Wu
- Women's Hospital Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, People's Republic of China
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Marcellin L, Leconte M, Gaujoux S, Santulli P, Borghese B, Chapron C, Dousset B. Associated ileocaecal location is a marker for greater severity of low rectal endometriosis. BJOG 2019; 126:1600-1608. [DOI: 10.1111/1471-0528.15901] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2019] [Indexed: 12/23/2022]
Affiliation(s)
- L Marcellin
- Département de Gynécologie Obsétrique II et Médecine de la Reproduction (Professeur Chapron) Assistance Publique‐Hôpitaux de Paris (AP‐HP) Centre Hospitalier Universitaire (CHU) Cochin Hôpital Universitaire Paris Centre (HUPC) Paris France
- Université Paris Descartes Sorbonne Paris Cité Paris France
| | - M Leconte
- Université Paris Descartes Sorbonne Paris Cité Paris France
- Service de Chirurgie Digestive Hépato‐biliaire et Endocrinienne Assistance, Publique‐Hôpitaux de Paris (AP‐HP) Centre Hospitalier Universitaire (CHU) Cochin Hôpital Universitaire, Paris Centre (HUPC) Paris France
| | - S Gaujoux
- Université Paris Descartes Sorbonne Paris Cité Paris France
- Service de Chirurgie Digestive Hépato‐biliaire et Endocrinienne Assistance, Publique‐Hôpitaux de Paris (AP‐HP) Centre Hospitalier Universitaire (CHU) Cochin Hôpital Universitaire, Paris Centre (HUPC) Paris France
| | - P Santulli
- Département de Gynécologie Obsétrique II et Médecine de la Reproduction (Professeur Chapron) Assistance Publique‐Hôpitaux de Paris (AP‐HP) Centre Hospitalier Universitaire (CHU) Cochin Hôpital Universitaire Paris Centre (HUPC) Paris France
- Université Paris Descartes Sorbonne Paris Cité Paris France
| | - B Borghese
- Département de Gynécologie Obsétrique II et Médecine de la Reproduction (Professeur Chapron) Assistance Publique‐Hôpitaux de Paris (AP‐HP) Centre Hospitalier Universitaire (CHU) Cochin Hôpital Universitaire Paris Centre (HUPC) Paris France
- Université Paris Descartes Sorbonne Paris Cité Paris France
| | - C Chapron
- Département de Gynécologie Obsétrique II et Médecine de la Reproduction (Professeur Chapron) Assistance Publique‐Hôpitaux de Paris (AP‐HP) Centre Hospitalier Universitaire (CHU) Cochin Hôpital Universitaire Paris Centre (HUPC) Paris France
- Université Paris Descartes Sorbonne Paris Cité Paris France
| | - B Dousset
- Université Paris Descartes Sorbonne Paris Cité Paris France
- Service de Chirurgie Digestive Hépato‐biliaire et Endocrinienne Assistance, Publique‐Hôpitaux de Paris (AP‐HP) Centre Hospitalier Universitaire (CHU) Cochin Hôpital Universitaire, Paris Centre (HUPC) Paris France
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Abesadze E, Sehouli J, Mechsner S, Chiantera V. Possible Role of the Posterior Compartment Peritonectomy, as a Part of the Complex Surgery, Regarding Recurrence Rate, Improvement of Symptoms and Fertility Rate in Patients with Endometriosis, Long-Term Follow-Up. J Minim Invasive Gynecol 2019; 27:1103-1111. [PMID: 31449906 DOI: 10.1016/j.jmig.2019.08.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 08/12/2019] [Accepted: 08/16/2019] [Indexed: 12/18/2022]
Abstract
STUDY OBJECTIVE Beside the pain, there are 2 further problems in the management of endometriosis: the high recurrence rate (10% per year) and the high rate of impaired fertility. The objective of this study was to investigate the pathogenesis of these 2 factors. DESIGN This is a retrospective cohort study, and the aim is to evaluate the complete excision of endometriotic lesions, including the posterior compartment of the peritoneum, with regard to postoperative outcome, focusing on relieving pain, increasing fertility rate, and decreasing recurrence rate. SETTING Charité-University Clinic, Department of Gynaecology, Endometriosis research Centre. PATIENTS Fifty-four patients were enrolled in this study, with severe deep infiltrating endometriosis (scored by ENZIAN) and superficial endometriosis, as well as endometriomas (revised American Society for Reproductive Medicine [rASRM] I = 3; II = 15; III = 10; and IV = 26). INTERVENTIONS Posterior compartment peritonectomy (visible endometriotic lesions and inflamed altered peritoneum) was performed in all patients as part of a complex surgery: complete excision of endometriosis. MEASUREMENTS AND MAIN RESULTS Postoperative outcomes were evaluated, based on the postoperative follow-up (up to 5 years) of 54 investigated patients. In 36 women (66%) preoperative complaints were eliminated. Furthermore, of 28 women seeking improved fertility, pregnancy was reported in 13 cases (46%). In 7 (54%) cases pregnancy occurred spontaneously, and in the remainder with assisted fertilization. In addition, long-term follow-up demonstrated a recurrence rate in 1.8% of patients. CONCLUSION Overall, the number of complaints was significantly reduced. Only in the case of reproductive-aged women with ongoing postoperative complaints was it important to preserve the uterus. Although this pilot study on systematic posterior peritonectomy showed improvement in recurrence and fertility rate, the main question remains: will this surgical technique achieve better results and outcomes in the future? This has to be addressed in a prospective randomized study.
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Affiliation(s)
- Elene Abesadze
- Endometriosis Centre Charité, Department of Gynaecology, Charité, Campus Virchow Clinic, Berlin, Germany (Drs. Abesadze, Sehouli, Mechsner, and Chiantera)
| | - Jalid Sehouli
- Endometriosis Centre Charité, Department of Gynaecology, Charité, Campus Virchow Clinic, Berlin, Germany (Drs. Abesadze, Sehouli, Mechsner, and Chiantera)
| | - Sylvia Mechsner
- Endometriosis Centre Charité, Department of Gynaecology, Charité, Campus Virchow Clinic, Berlin, Germany (Drs. Abesadze, Sehouli, Mechsner, and Chiantera).
| | - Vito Chiantera
- Endometriosis Centre Charité, Department of Gynaecology, Charité, Campus Virchow Clinic, Berlin, Germany (Drs. Abesadze, Sehouli, Mechsner, and Chiantera); University of Palermo, Palermo, Italy (Dr. Chiantera)
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50
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Vercellini P, Viganò P, Frattaruolo MP, Borghi A, Somigliana E. Bowel surgery as a fertility-enhancing procedure in patients with colorectal endometriosis: methodological, pathogenic and ethical issues. Hum Reprod 2019; 33:1205-1211. [PMID: 29741687 DOI: 10.1093/humrep/dey104] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Accepted: 04/12/2018] [Indexed: 12/12/2022] Open
Abstract
Bowel surgery for colorectal endometriosis is being promoted to infertile women without severe sub-occlusive symptoms, with the objective of improving the likelihood of conception. Contrary to rectal shaving, bowel surgery involving full-thickness disk excision and segmental resection entails opening of the intestinal lumen thus increasing the risk of postoperative infectious complications. About 1 in 10 patients undergoing colorectal resection for intestinal endometriosis will experience severe sequelae, including anastomotic dehiscence, rectovaginal fistula formation, and bladder and bowel denervation. Similar to other surgical procedures aiming at enhancing fertility in women with endometriosis, bowel surgery has been introduced into clinical practice without adequate evaluation through randomized controlled trials. According to systematic literature reviews based mainly on case series, the incremental gain of adding bowel procedures to standard surgery appears uncertain in terms of pregnancy rate after both natural attempts and IVF. Considering the methodological drawbacks and the high risk of bias in the available observational studies, it is not possible to exclude the suggestion that the benefit of colorectal surgery has been overestimated. Given the risk of harms to women's health and the important ethical implications, less emphasis should be put on strict statistical significance and more emphasis should be placed on the magnitude of the effect size. In this regard, the published data may not be generalizable, as the surgeons publishing their results may not be representative of all surgeons. Until the results of adequately designed and conducted RCTs are available, colorectal surgery with the sole intent of improving the reproductive performance of infertile patients with intestinal endometriosis should be performed exclusively within research settings and by highly experienced surgeons. Women should be informed about the uncertainties regarding the harms and benefits of bowel surgery in different clinical conditions, and preoperative counselling must be conducted impartially with the objective of achieving a truly shared medical decision.
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Affiliation(s)
- Paolo Vercellini
- Gynaecological Surgery and Endometriosis Departmental Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, Via Commenda 12, Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Via Festa del Perdono 7, Milan, Italy
| | - Paola Viganò
- Reproductive Sciences Laboratory, Division of Genetics and Cell Biology, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, Milan, Italy
| | - Maria Pina Frattaruolo
- Gynaecological Surgery and Endometriosis Departmental Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, Via Commenda 12, Milan, Italy
| | - Alessandra Borghi
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Via Festa del Perdono 7, Milan, Italy
| | - Edgardo Somigliana
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Via Festa del Perdono 7, Milan, Italy.,Infertility Departmental Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Via Fanti 6, Milan, Italy
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