Pain and infertility--a rationale for different treatment approaches

Repeat transvaginal ultrasound-guided aspiration of ovarian endometrioma in infertile women with endometriosis

OBJECTIVE

We sought to investigate the effectiveness of repeated transvaginal ultrasound-guided aspiration of endometriomas in infertile women with endometriosis.

STUDY DESIGN

A retrospective study was performed in our department of reproductive health on 129 infertile women who underwent monthly repeated transvaginal aspiration of endometriomas. The recurrence and pregnancy were monitored during a follow-up period of 24 months.

RESULTS

Recurrences of cysts were found in 118 (91.5%) patients in the first postaspirate month and 86 (66.7%) in the second, 60 (46.5%) in the third, 28 (21.7%) in the fourth, 12 (9.3%) in the fifth, 7 (5.4%) in the sixth, and 36 (27.9%) in the 24th postaspiration month. Mean 3.1 ± 2.8 times of aspirations per patient were performed without any adverse effect. There was a linear regression relationship between the change of times of aspirations and the chance of recurrence of cysts. Overall pregnancy rate of 43.4% (56/129) was obtained.

CONCLUSION

The repetitive aspiration of endometriomas is an effective therapeutic option in patients with endometriosis.

Surgical management of endometriosis-associated pain

General surgical guidelines are reasonable, but treatment frequently must be individualized. Laparoscopic coagulation can be used for many cases of superficial endometriosis. Resection seems to be associated with an increased resolution of endometriosis. Resection increases the difficulty of the procedure, the time of the operation, and the cost, however. When endometriosis is found coincidentally, it may need no treatment because many women have endometriosis as a self-limited disease. Distinguishing patients who need no treatment from patients who need intermediate or extensive treatment can be difficult. Care is needed to attempt to ensure that patients are neither overtreated nor undertreated.

Endometriosis and pain

Endometriosis generally causes pain that is cyclic and generally responds to medication and/or surgery. When endometriosis is found coincidentally, it may need no treatment because many women have endometriosis as a self-limited disease. In other women, the biologic behavior is much more unpredictable. Severe dysmenorrhea, focal pelvic tenderness, and deep dyspareunia are suggestive of endometriosis. Diagnosis at laparoscopy includes concerns about subtle appearance, endometriosis hidden within adhesions, retroperitoneal disease, and intra-ovarian lesions. Negative laparoscopy results do not mean that patients have no endometriosis. In contrast, a response to GnRH agonists can occur in patients with no endometriosis because conditions other than endometriosis are estrogen sensitive. Coexistent disease can confuse the picture at the time of surgery. Some coexistent diseases also can cause pain that is similar to that of endometriosis. Distinguishing those patients who need no treatment from those who need intermediate or extensive treatment can be very difficult. Care is needed to ensure that patients are neither overtreated or undertreated. An integrated approach involving a multidisciplinary team is needed in some. Other patients respond to primary care techniques.

Ultrasound guided aspiration of endometrioma--a new therapeutic modality to improve reproductive outcome

OBJECTIVE

To evaluate the therapeutic efficacy and reproductive outcome following ultrasound guided aspiration (UGA) of endometrioma in infertile patients.

METHOD

This is a prospective non-randomized clinical report of UGA in 22 infertile patients with endometrioma. The aspiration of endometriotic cysts was carried out transvaginally in nine and transabdominally in 13 patients. Following aspiration intranasal buserilin was given to eight and danazol to 14 patients. In the case of recurrence a reaspiration was done. Patients were allowed to conceive following medical therapy. Recurrence of endometrioma and conception rate was recorded and correlated with endometrioma size and volume aspirated.

RESULT

A total of 47 aspirations were done. There were no procedure related complications. Reaspiration was required in six patients and one was operated (total recurrence 7/22--31.8%). During a mean follow-up of 20+/-8.4 months nine patients (40.9%) conceived and eight have already delivered at term. The recurrence risk and the conception rate was not affected by the cyst size or volume aspirated.

CONCLUSION

UGA of endometrioma can be an effective and safe alternative therapeutic procedure in infertile patients with endometrioma to improve their reproductive outcome.

Biases in the endometriosis literature. Illustrated by 20 years of endometriosis research in Leuven

AIM

To review the Leuven data on endometriosis to demonstrate the shifts that occurred over the years in diagnosis of endometriosis, classification of women with endometriosis and thus in interpretation of results.

RESULTS

The contributions to the LUF syndrome, to non-pigmented endometriosis, to cystic ovarian endometriosis, to deep endometriosis, to endometriosis as an immunologic disease and to the development of an animal model of endometriosis, illustrate the persistent interest in endometriosis over 20 years. Using these data it can be shown how progressively the recognition of endometriosis caused important shifts from women who in the beginning of this period were classified as normal, to women who later became classified as having minimal or mild endometriosis. This was caused initially by the active search for small typical lesions and later by the recognition of non-pigmented lesions as endometriosis. The second important shift was caused by the recognition that deep endometriosis is not only a frequent disease, but that these women are predominantly classified as having mild to moderate endometriosis and even as women without endometriosis. The third shift is still ongoing, since the deep lesions reported become progressively smaller, by the "enthusiasm" of the surgeons, and by the introduction of a menstrual clinical exam. A fourth bias in the literature concerns the diagnosis and treatment of cystic ovarian endometriosis. Together with these shifts in recognition and treatment of endometriosis, our understanding of the physiopathology of endometriosis has changed. This is illustrated by the new concepts which have emerged over this period. These are, the focal treatment of cystic ovarian endometriosis, the concept that mild endometriosis could be a normal physiological condition and the endometriotic disease theory.

CONCLUSION

To interpret the data of the literature we should be aware of the shifts that have occurred in the classification of endometriosis over the past 20 years, and which still can hamper the comparison of results between research groups.